015 AAP Transporting Children With Special Health Care Needs

User Manual: 015-AAP-Transporting-Children-with-Special-Health-Care-Needs

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AMERICAN ACADEMY OF PEDIATRICS
Committee on Injury and Poison Prevention

School Bus Transportation of Children With Special Health Care Needs
ABSTRACT. School systems are responsible for ensuring that children with special needs are safely transported on all forms of federally approved transportation
provided by the school system, and a plan should be
developed to provide the most current and proper support to children with special transportation requirements. This statement provides current guidelines for the
protection of child passengers with specific health care
needs, including those with a tracheostomy, those requiring use of car seats, or those transported in wheelchairs.
Guidelines that apply to general school transportation
should be followed, including the training of staff, provision of nurses or aides if needed, establishment of a
written emergency evacuation plan, and a comprehensive infection control program.
Research provides the basis for recommendations concerning occupant securement for children in wheelchairs
and children with other special needs who are transported on a school bus. Pediatricians can help their patients by being aware of guidelines for restraint systems
for children with special needs and by remaining informed of new resources. Pediatricians can also play an
important role at the state and local level in the development of school bus specifications.
ABBREVIATIONS. FMVSS, Federal Motor Vehicle Safety Standards; IEP, Individual Education Plan; IFSP, Individual Family
Service Plan; OSHA, Occupational Safety and Health Administration.

INTRODUCTION

M

any preschool-aged and school-aged children with special needs are transported in
school buses. The Individuals With Disabilities Education Act 1997 (Public Law 105-17) has
established requirements for preschool children ages
3 to 5 to have access to related services (ie, audiology
and occupational therapy). It also requires that infants and toddlers (birth to 3 years of age) have
access to these same services; however, it does not
specify how these children are to be transported to
these services if they are to be conducted outside of
the child’s natural home or school environment. Although the provider could vary from state to state, it
is often the responsibility of the school systems to
provide these related services to infants and toddlers.
The Federal Motor Vehicle Safety Standards and
Regulations (FMVSS) 222 (School Bus Passenger
Seating and Crash Protection) established safety reThe recommendations in this statement do not indicate an exclusive course
of treatment or serve as a standard of medical care. Variations, taking into
account individual circumstances, may be appropriate.
PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Academy of Pediatrics.

516

PEDIATRICS Vol. 108 No. 2 August 2001

quirements for school bus interiors, but it applied
only to able-bodied children. However, a 1994
amendment to FMVSS 222 applied to the securement
of wheelchairs and their occupants in school buses.1
National recommended standards for special education school buses were revised in May 1995 by the
Twelfth National Standards Conference on School
Transportation.2
Wheelchairs are the primary mode of transport on
the school bus for many children with special needs.
Most wheelchairs have not been developed as certified transit devices and are not currently subjected to
any crash-testing requirements. A certified transit
wheelchair is one that meets voluntary design and
performance requirements for use as a seat by their
occupant when traveling in a motor vehicle. Rehabilitation therapists can help identify products that
are certified by the manufacturer to meet this standard. Whenever possible a certified transit wheelchair should be used for school bus transportation.3
Research has provided a basis for recommendations
concerning occupant securement for children who
must ride in a wheelchair or children with other
special needs who are transported on a school
bus.1,4 – 6
RECOMMENDATIONS

1. Any child who can assist with transfer or be
reasonably moved from a wheelchair, stroller, or
special seating device to a seat belt or child restraint system complying with FMVSS 213 (Child
Restraint Systems) should be so transferred for
transportation. The vehicle seat should be forward facing, equipped with dynamically tested
occupant restraints, and provided for the vehicle
at the point of manufacture. The unoccupied
wheelchair also should be secured adequately in
the vehicle to prevent it from becoming a dangerous projectile in the event of a sudden stop or
crash.7
2. Passenger seats that have a seat belt or child
restraint system attached should have a reinforced frame and meet the requirements of
FMVSS 208 (Occupant Crash Protection),
FMVSS 209 (Seat Belt Assemblies), and FMVSS
210 (Seatbelt Anchorages). The manufacturer of
the school bus should be consulted regarding the
noted requirements when ordering or retrofitting an existing school bus.8
3. All children weighing less than 50 lb should
be secured in an appropriate child restraint or
safety vest meeting the requirements of FMVSS
213.8

4. Child safety seats or safety vests must be secured
to the bus seat in a manner prescribed and approved by the manufacturer of the safety device.
The child restraint should not be secured on a
school bus seat adjacent to an emergency exit.
5. Child safety seats used to transport children who
weigh less than 20 lb or are younger than 1 year
should be attached to the school bus seat in a
rear-facing position. A child restraint that is approved for rear facing for greater weights should
be considered for a child who weighs 20 lb before
1 year of age.
6. Occupied wheelchairs should be secured in a
forward-facing position.
7. Three-wheeled, cart-type units and other wheelchair or stroller-type devices should not be permitted for occupied transport in a school bus
unless results of impact tests demonstrate that
the device can be secured under impact loading
conditions. Any wheelchair or stroller-type unit
designed and approved by a manufacturer for
transportation must be used according to manufacturer’s instructions.
8. Wheelchairs should be secured with fastening
devices that are attached to the floor. Any occupied wheelchairs should be secured with 4point tie-down devices. These tie-down systems
should be dynamically tested with a dummy the
size of a 50th percentile adult male or with a
dummy at the appropriate size for the type of
wheelchair used. They must have demonstrated
capabilities for restraining the wheelchair during
a frontal impact with force conditions of 30 mph
and 20g. The wheelchair securement system
must not apply restraint to the occupant and
should attach to the frame of the wheelchair
rather than to the wheels. The occupant should
be restrained to the wheelchair with a separate
device.
9. Lap boards and metal or plastic trays attached to
the wheelchair or to adaptive equipment should
be removed before loading and should be secured separately for transport.
10. An occupant restraint system that has been
tested at force conditions of 30 mph and 20g for
upper torso restraint (ie, shoulder harness) and
lower torso restraint (ie, lap belt over pelvis)
should be provided for each wheelchair-seated
occupant.
11. Any liquid oxygen transported in a school bus
should be securely mounted and fastened to prevent damage and exposure to intense heat. An
appropriate sign indicating that oxygen is in use
should be placed in the school bus.
ADDITIONAL CONSIDERATIONS FOR PASSENGER
TRANSPORTATION

The following considerations should be incorporated into the school system plan for the transportation requirements of children with special needs:
1. In accordance with state laws and regulations, a
nurse or an aide with appropriate medical training can provide necessary on-board assistance

2.

3.

4.

5.

6.

7.

and support to most children with tracheostomies
who may require suctioning or emergency care
during school bus transport. School systems
should consider providing nurses or aides when
medically necessary to help reduce the potential
for respiratory and other related problems occurring while the children are on the school bus. This
assistance should be included where appropriate
in the child’s Individual Education Plan (IEP) or
the family’s Individual Family Service Plan (IFSP).
School transportation staff should participate in
the development of the transportation portion of
the IEP or IFSP for children who may need special
transportation requirements and medical procedures.
School bus transportation staff should have annual access to training programs and resource
material in special needs transportation to ensure
that they can provide the most current and proper
support to children with special transportation
requirements. Transportation staff who work with
children with special needs can carry out their
daily responsibilities when provided with documented training from a team of professionals, including therapists, nurses, and certified child passenger safety technicians that ensures consistent
and proper restraint for children with special
needs on school buses.9,10
The caregiver (family, guardian, foster parent) of a
child with special needs should be informed of the
importance of incorporating appropriate and safe
transportation specifications in the child’s IEP or
IFSP.
The caregiver of a child with special needs and
the designated bus driver for the child’s bus route
should share information addressing the specific needs of the child transported before and
during the school year. An emergency medical
information card should be kept on the bus for
each student transported. Transportation personnel should adhere to the school district’s policy
regarding confidentiality of student information.
School systems can help ensure optimum protection for children with special needs during school
bus transport by establishing a written plan that
outlines procedures for emergency evacuation for
each child and by requiring, at the minimum, an
evacuation drill for each school year that enables
the transportation staff to practice evacuating children under their care. Local emergency response
personnel should be invited to participate in evacuation drills.
Children who are supported by technology may
be at increased risk of acquiring infectious diseases. All caregivers should wash their hands before and after providing direct care for students
including toileting, tracheostomy, or gastrostomy
care. Standard (universal) precautions should be
used when caring for all children when exposed
to blood or blood-containing body fluids. Schools
should follow the legal requirements of their
states or the Occupational Safety and Health Administration (OSHA) with respect to all immunizations, including hepatitis B immunization. ChilAMERICAN ACADEMY OF PEDIATRICS

517

dren and adults who are in the recommended
categories should receive yearly influenza immunization.11,12 Transportation staff should be provided with training and supplies that prepare
them to carry out universal precaution practices
and procedures.10
The American Academy of Pediatrics encourages
states to address and support the transportation requirements of children with special needs. Pediatricians can help their patients by being aware of general guidelines for evaluating restraint systems for
children with special needs and remaining informed
of new resources as they become available. Periodically updated information on specific restraint systems for children with special needs can be obtained
through the Academy.13 In addition, pediatricians
can play important roles at local and state levels to
assist in the evaluation and development of school
bus specifications responsive to the safe transportation requirements of children with special needs.
Committee on Injury and Poison Prevention,
2000 –2001
Marilyn J. Bull, MD, Chairperson
Phyllis Agran, MD, MPH
H. Garry Gardner, MD
Danielle Laraque, MD
Susan H. Pollack, MD
Gary A. Smith, MD, DrPH
Howard R. Spivak, MD
Milton Tenenbein, MD
Liaisons
Ruth A. Brenner, MD, MPH
National Institute of Child Health and Human
Development
Stephanie Bryn, MPH
Health Resources and Services
Administration/Maternal and Child Health Bureau
Cheryl Neverman, MS
National Highway Traffic Safety Administration
Richard A. Schieber, MD, MPH
Centers for Disease Control and Prevention
Richard Stanwick, MD
Canadian Paediatric Society

518

Deborah Tinsworth
US Consumer Product Safety Commission
Section Liaisons
Victor Garcia, MD
Section on Surgery
Robert R. Tanz, MD
Section on Injury and Poison Prevention
Consultants
Murray L. Katcher, MD, PhD
Larry K. Pickering, MD, FAAP
Staff
Heather Newland
REFERENCES
1. National Highway Traffic Safety Administration Web site. Available at:
http://www.nhtsa.dot.gov/cars/rules/standards/safstanz.htm
2. National Standards for School Buses and National Standards for School Bus
Operations. Warrensburg, MO: Missouri Safety Center; 1995
3. WC-19 Voluntary Standard. Washington, DC: American National Standards Institute/Rehabilitation Engineering and Assistive Technology
Society of North America; 1999
4. Schneider LW. Protection for the Severely Disabled: A New Challenge in
Occupant Restraint. Proceedings of the International Symposium on
Occupant Restraint. Morton Grove, IL: American Association for Automotive Medicine; 1981:217–231
5. Schneider LW. Impact Sled Test Evaluation of Restraint Systems Used in
Transportation of Handicapped Children. Warrendale, PA: Society of Automotive Engineers; 1979. Technical Paper 790074
6. Wheelchair occupant restraint assemblies for use in motor vehicles.
Standards Australia Amendment No. 1 to AS 2942–1994 (July 5, 1998)
7. Vehicles for transporting the handicapped. Indiana Code IAC No. 1–5.5
(February 1990)
8. Guideline for the Safe Transportation of Pre-school Age Children in School
Buses. Washington, DC: National Highway Traffic Safety
Administration; 1999
9. Stephens LL, Beekman LE, Munk LG, Stefans VA. Study of Transportation of Medically Fragile Children: Core Curriculum for Special Education
Transportation Health Care. Lansing, MI: Michigan Department of
Education; 1989:4
10. Standardized Child Passenger Safety Training Program Participant Manual.
Washington, DC: National Highway Traffic Safety Administration;
2001. In press
11. American Academy of Pediatrics. In: Pickering LK, ed. 2000 Red Book:
Report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village,
IL: American Academy of Pediatrics; 2000:119 –131
12. American Academy of Pediatrics, Committee on Infectious Diseases
and Committee on Practice and Ambulatory Medicine. Infection control
in physicians’ offices. Pediatrics. 2000;105:1361–1369
13. American Academy of Pediatrics. Car Seat Shopping Guide For Children
With Special Needs: Guidelines for Parents. Elk Grove Village, IL: American Academy of Pediatrics; 1998

SCHOOL BUS TRANSPORTATION OF CHILDREN WITH SPECIAL NEEDS



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