Catherine C. McDonald

The Relationship Between Community Violence Exposure and Mental Health Symptoms in Urban Adolescents

Urban adolescents are exposed to a substantial amount of community violence which has the potential to influence psychological functioning. To examine the relationship between community violence exposure and mental health symptoms in urban adolescents, a literature review using MEDLINE, CINAHL, PubMed, PsycINFO, CSA Social Services and CSA Sociological Abstracts was conducted. Search terms included adolescent/adolescence, violence, urban, mental health, well-being, emotional distress, depression, anxiety, posttraumatic stress disorder and aggression. Twenty-six empirical research articles from 1997 to 2007 met inclusion criteria for review. Findings indicate an influence of community violence exposure on mental health symptoms, particularly posttraumatic stress and aggression. Mediators and moderators for community violence exposure and mental health symptoms help explain relationships. Limitations in the literature are the lack of consistency in measurement and analysis of community violence exposure, including assessment of proximity and time frame of exposure, and in analysis of victimization and witnessing of community violence. Knowledge about identification of urban adolescents exposed to chronic community violence and who experience mental health symptoms is critical to mental health nursing practice and research.

Adolescence, Attention Allocation, and Driving Safety

Motor vehicle crashes are the leading source of morbidity and mortality in adolescents in the United States and the developed world. Inadequate allocation of attention to the driving task and to driving hazards are important sources of adolescent crashes. We review major explanations for these attention failures with particular focus on the roles that brain immaturity and lack of driving experience play in causing attention problems. The review suggests that the potential for overcoming inexperience and immaturity with training to improve attention to both the driving task and hazards is substantial. Nevertheless, there are large individual differences in both attentional abilities and risky driving tendencies that pose challenges to novice driver policies. Research that can provide evidence-based direction for such policies is urgently needed.

Emergency Department-Based Brief Intervention to Reduce Risky Driving and Hazardous/Harmful Drinking in Young Adults: A Randomized Controlled Trial

BACKGROUND Risky driving and hazardous drinking are associated with significant human and economic costs. Brief interventions for more than one risky behavior have the potential to reduce health-compromising behaviors in populations with multiple risk-taking behaviors such as young adults. Emergency department (ED) visits provide a window of opportunity for interventions meant to reduce both risky driving and hazardous drinking. METHODS We determined the efficacy of a Screening, Brief Intervention, and Referral to Treatment (SBIRT) protocol addressing risky driving and hazardous drinking. We used a randomized controlled trial design with follow-ups through 12 months. ED patients aged 18 to 44 who screened positive for both behaviors (n = 476) were randomized to brief intervention (BIG), contact control (CCG), or no-contact control (NCG) groups. The BIG (n = 150) received a 20-minute assessment and two 20-minute interventions. The CCG (n = 162) received a 20-minute assessment at baseline and no intervention. The NCG (n = 164) were asked for contact information at baseline and had no assessment or intervention. Outcomes at 3, 6, 9, and 12 months were self-reported driving behaviors and alcohol consumption. RESULTS Outcomes were significantly lower in BIG compared with CCG through 6 or 9 months, but not at 12 months: Safety belt use at 3 months (adjusted odds ratio [AOR], 0.22; 95% confidence interval [CI], 0.08 to 0.65); 6 months (AOR, 0.13; 95% CI, 0.04 to 0.42); and 9 months (AOR, 0.18; 95% CI, 0.06 to 0.56); binge drinking at 3 months (adjusted rate ratio [ARR] 0.84; 95% CI, 0.74 to 0.97) and 6 months (ARR, 0.81; 95% CI, 0.67 to 0.97); and ≥5 standard drinks/d at 3 months (AOR, 0.43; 95% CI, 0.20 to 0.91) and 6 months (AOR, 0.41; 95% CI, 0.17 to 0.98). No substantial differences were observed between BIG and NCG at 12 months. CONCLUSIONS Our findings indicate that SBIRT reduced risky driving and hazardous drinking in young adults, but its effects did not persist after 9 months. Future research should explore methods for extending the intervention effect.

Comparison of teen and adult driver crash scenarios in a nationally representative sample of serious crashes

Motor vehicle crashes are the leading cause of death and acquired disability during the first four decades of life. While teen drivers have the highest crash risk, few studies examine the similarities and differences in teen and adult driver crashes. We aimed to: (1) identify and compare the most frequent crash scenarios-integrated information on a vehicles movement prior to crash, immediate pre-crash event, and crash configuration-for teen and adult drivers involved in serious crashes, and (2) for the most frequent scenarios, explore whether the distribution of driver critical errors differed for teens and adult drivers. We analyzed data from the National Motor Vehicle Crash Causation Survey, a nationally representative study of serious crashes conducted by the U.S. National Highway Traffic Safety Administration from 2005 to 2007. Our sample included 642 16- to 19-year-old and 1167 35- to 54-year-old crash-involved drivers (weighted n=296,482 and 439,356, respectively) who made a critical error that led to their crashs critical pre-crash event (i.e., event that made the crash inevitable). We estimated prevalence ratios (PR) and 95% confidence intervals (CI) to compare the relative frequency of crash scenarios and driver critical errors. The top five crash scenarios among teen drivers, accounting for 37.3% of their crashes, included: (1) going straight, other vehicle stopped, rear end; (2) stopped in traffic lane, turning left at intersection, turn into path of other vehicle; (3) negotiating curve, off right edge of road, right roadside departure; (4) going straight, off right edge of road, right roadside departure; and (5) stopped in lane, turning left at intersection, turn across path of other vehicle. The top five crash scenarios among adult drivers, accounting for 33.9% of their crashes, included the same scenarios as the teen drivers with the exception of scenario (3) and the addition of going straight, crossing over an intersection, and continuing on a straight path. For two scenarios ((1) and (3) above), teens were more likely than adults to make a critical decision error (e.g., traveling too fast for conditions). Our findings indicate that among those who make a driver critical error in a serious crash, there are few differences in the scenarios or critical driver errors for teen and adult drivers.

Self-mutilation in adolescents

Self-mutilation is not a new trend or phenomenon in adolescents. Self-mutilation can be divided into three categories: major, stereotypic, and moderate/superficial. Moderate/superficial self-mutilation is the most common type in adolescents and includes cutting, burning, and carving. School nurses are positioned to identify, to assist, and to educate adolescents who are self-mutilating, as well as those who may be at risk. A crucial intervention by school nurses is referral of students who are self-mutilating, because it is a gateway to treatment. Treatment, which includes therapy and medication, may be a difficult and lengthy process. The adolescent who self-mutilates may find the school environment difficult during treatment. School nurses must become educated about adolescent self-mutilation in order to care for those who engage in this behavior. Prevention of self-mutilation should focus on increasing coping mechanisms, facilitating decision-making strategies, encouraging positive relationships, and cultivating self-esteem.

Teen Drivers’ Perceptions of Inattention and Cell Phone Use While Driving

Objective: Inattention to the roadway, including cell phone use while driving (cell phone calls, sending and reading texts, mobile app use, and Internet use), is a critical problem for teen drivers and increases risk for crashes. Effective behavioral interventions for teens are needed in order to decrease teen driver inattention related to cell phone use while driving. However, teens’ perceptions of mobile device use while driving is a necessary component for theoretically driven behavior change interventions. The purpose of this study was to describe teen drivers’ perceptions of cell phone use while driving in order to inform future interventions to reduce risky driving. Methods: We conducted 7 focus groups with a total of 30 teen drivers, ages 16–18, licensed for ≤1 year in Pennsylvania. The focus group interview guide and analysis were based on the Theory of Planned Behavior, identifying the attitudes, perceived behavioral control, and norms about inattention to the roadway. Directed descriptive content analysis was used to analyze the focus group interviews. All focus groups were coded by 2 research team members and discrepancies were reconciled. Themes were developed based on the data. Results: Teens had a mean age of 17.39 (SD = 0.52), mean length of licensure of 173.7 days (SD = 109.2; range 4–364), were 50% male and predominately white (90%) and non-Hispanic (97%). From the focus group data, 3 major themes emerged: (1) Recognizing the danger but still engaging; (2) Considering context; and (3) Formulating safer behaviors that might reduce risk. Despite recognizing that handheld cell phone use, texting, and social media app use are dangerous and distracting while driving, teens and their peers often engaged in these behaviors. Teens described how the context of the situation contributed to whether a teen would place or answer a call, write or respond to a text, or use a social media app. Teens identified ways in which they controlled their behaviors, although some still drew attention away from the roadway. Conclusions: Cell phone use while driving is a contributor to motor vehicle crashes in teens, and effective interventions to decrease risks are needed. Teens viewed some types of cell phone use as unsafe and describe methods in which they control their behaviors. However, some of their methods still take attention off the primary task of driving. Teens could benefit from behavior change interventions that propose strategies to promote focused attention on the roadway at all times during the driving trip.

Using Crash Data to Develop Simulator Scenarios for Assessing Novice Driver Performance

Teenage drivers are at their highest crash risk in their first 6 months or first 1,000 mi of driving. Driver training, adult-supervised practice driving, and other interventions are aimed at improving driving performance in novice drivers. Previous driver training programs have enumerated thousands of scenarios, with each scenario requiring one or more skills. Although there is general agreement about the broad set of skills needed to become a competent driver, there is no consensus set of scenarios and skills to assess whether novice drivers are likely to crash or to assess the effects of novice driver training programs on the likelihood of a crash. The authors propose that a much narrower, common set of scenarios can be used to focus on the high-risk crashes of young drivers. Until recently, it was not possible to identify the detailed set of scenarios that were specific to high-risk crashes. However, an integration of police crash reports from previous research, a number of critical simulator studies, and a nationally representative database of serious teen crashes (the National Motor Vehicle Crash Causation Survey) now make identification of these scenarios possible. In this paper, the authors propose this novel approach and discuss how to create a common set of simulated scenarios and skills to assess novice driver performance and the effects of training and interventions as they relate to high-risk crashes.

Risky driving, mental health, and health-compromising behaviours: risk clustering in late adolescents and adults

Background Health-compromising behaviours in adolescents and adults co-occur. Because motor vehicle crashes are the leading cause of death and disability for these age groups, understanding the association between risky driving and other health-compromising behaviours is critical. Methods We performed a secondary analysis of data from a randomised controlled trial of an intervention for participants who screened positive for risky driving and problem drinking. Using baseline data, we examined relationships among conduct behaviour problems before and after age 15 years, depressive symptoms, sleep, problem drinking, and risky driving (hostile, reckless and drinking and driving) in late adolescents ages 18–24 (n=110) years, and adults ages 25–44 (n=202) years. We developed a measurement model for the entire sample using confirmatory factor analysis, which was then specified as a multigroup structural equation model. Results Late adolescents and adults had some similar associations for pathways through problem drinking to drinking and driving; depression to reckless driving; and conduct behaviour problems after 15 years of age to hostile driving. Late adolescents, however, had more complex relationships: depressive symptoms and conduct behaviour problems before 15 years of age were associated with more risky driving behaviours through multiple pathways, and males reported more risky driving. Conclusions Risky driving is associated with other health-compromising behaviours and mental health factors. It is a multidimensional phenomenon more pronounced in late adolescence than adulthood. In order to promote safe driving, the findings support the need to consider behaviours that are a health threat in the late adolescent population during driving training and licensure. Trial registration number: NCT00164294.

Are we doing enough to prevent the perfect storm?: novice drivers, ADHD, and distracted driving.

Motor vehicle crashes, the leading cause of teen deaths in the United States, pose a major public health threat for teen drivers, their passengers, and others on the road.1 Yet only one implemented intervention has proven effective in reducing fatal teen crashes—3-stage graduated driver licensing (GDL) systems.2 Recognizing that the first 6 months of solo driving pose the highest crash risk, GDL restricts new drivers to lower risk driving situations, progressively allowing increased exposure to higher risk situations with experience. Substantial and sustained reductions in teen deaths have been realized by the states that have instituted GDL, but GDL alone is not sufficient to address the epidemic of teen crashes. Some teen drivers possess characteristics (eg, attention-deficit/hyperactivity disorder [ADHD]) and/or perform risky driving behaviors (eg, texting while driving) that could put them at heightened risk for the perfect storm, a serious crash. There is an urgent health need to build on the foundation of GDL with additional effective interventions to reduce teen driver crashes. A growing scientific foundation for teen crashes is informing development of new interventions focused on novice teen drivers,3-7 but teens with heightened risk might require tailored approaches. More work is needed to understand how to reduce risk (eg, impaired and distracted driving and driving inexperience) and promote protective factors (eg, parent involvement and invehicle monitoring) for a specific teen at a developmental stage (cognitive, social, and emotional) with individual characteristics (eg, medical, psychological, social, and environmental factors).8 Borrowing from the Institute of Medicine’s framework for preventive health services to address major health problems,9 interventions should be placed within a tiered clinical and public health prevention strategy to reduce teen driver risk (universal-, selective-, and indicated-level interventions) that matches the level of intervention to the risk level of the target population, and matches effective interventions to specific risks and problem behaviors. Graduated driver licensing is a universal-level intervention (ie, targeting all novice teen drivers, regardless of individual risk), but some teens may need more. Just as teens vary in risk for behavioral health problems, teens vary in their risk for unsafe driving behaviors and crashes. In this month’s JAMA Pediatrics, Narad et al10 add to the scientific foundation for an important but understudied area: the combined effects of a known driving risk factor—driving while distracted by cell phone conversations and text messaging—with a known individual difference risk factor— ADHD—on novice teen driver performance. Recognizing potential study risks with placing teens in on-road hazardous situations, this study was conducted in a low-fidelity, simulated driving environment and should inspire future work examining the clinical relevance of their simulator findings regarding real-world driving and crash risk, the etiology of risk, and the development and evaluation of interventions to mitigate risks. To inform this future research agenda, this editorial summarizes current knowledge and research on distraction and ADHD among novice teen drivers, provides an introduction to driving research methods, and poses a vision for a comprehensive clinical and public health approach to reduce crashes associated with distraction and ADHD among novice teen drivers. Distracted driving has become nearly synonymous with the use of cell phones while driving, but, in fact, distraction from cell phone use represents a fraction of the distractions resulting in teen driver crashes.11 A multitude of factors in and out of the vehicle cause distraction, which the National Highway Traffic Safety Administration12 defines as “a form of driving inattention that occurs when drivers divert their attention away from the driving task to focus on another activity instead.”12(p13) Such diverted attention can result from visual, auditory, cognitive, or manual distraction (tasks that involve the driver looking at, speaking/listening to, or thinking about something other than the driving task or where the driver’s fingers are manipulating a device). Based on this common definition, a driver reading or responding to a text message might be highly distracted visually, manually, and cognitively and is at risk for crashes. Further complicating this, most drivers underestimate their level of distraction and do not recognize the personal relevance of distraction on their driving performance.13 Therefore, interventions to reduce distracted driving need to address a broad array of activities, as well as the driver’s intentions and motivations to engage in them while driving. Jerome et al14 demonstrated ADHD as an important risk factor for negative driving outcomes but did not exclusively focus on teens. The compounded effects of ADHD on immaturity and driving inexperience in teens likely result in higher ADHD-related crash risk in teens, but a recent systematic review by Classen and Monahan15 points to the low level of evidence supporting current interventions to improve driving performance for teen drivers with ADHD. Advances are needed in evidence-based, rigorously evaluated assessments of risk and targeted interventions for teens with ADHD that take into account factors such as the subtypes of ADHD, comorbid diRelated article page 933 and JAMA Pediatrics Patient Page page 984 Opinion

EMERGENCY BRAKING IN ADULTS VERSUS NOVICE TEEN DRIVERS: RESPONSE TO SIMULATED SUDDEN DRIVING EVENTS.

Motor vehicle crashes remain the leading cause of death of teens in the United States. Newly licensed drivers are the group most at risk for such crashes. The driving skills of teen drivers are new and still often untested; therefore, their ability to react properly in an emergency situation remains a subject for research. Because it is not possible to expose human subjects to critical life-threatening driving scenarios, researchers increasingly have been using driving simulators to assess driving skills. This paper summarizes the results of a driving scenario in a study that compared the driving performance of novice teen drivers (n = 21) 16 to 17 years old with 90 days of provisional licensure with that of experienced adult drivers (n = 17) 25 to 50 years old with at least 5 years of Pennsylvania licensure who drove at least 100 mi per week and had experienced no self-reported collisions in the previous 3 years. As part of a 30 to 35 mph simulated drive that encompassed the most common scenarios that result in serious crashes, participants were exposed to a sudden car event. As the participant drove on a suburban road, a car surged from a driveway hidden by a fence on the right-hand side of the road. To avoid the crash the participant had to brake hard and demonstrate dynamic control over both attentional and motor resources. The results showed significant differences between the experienced adult and the novice teen drivers in the amount of brake pressure applied. When placed in the same situation, the novice teens decelerated on average 50% less than the experienced adults (p < .01).