Miriam Monahan

Evidence-Based Review on Interventions and Determinants of Driving Performance in Teens with Attention Deficit Hyperactivity Disorder or Autism Spectrum Disorder

Objective: We conducted an evidence-based review of intervention studies and predictor studies related to driving outcomes in teens with attention deficit–hyperactivity disorder (ADHD) or autism spectrum disorder (ASD). Methods: Ten primary studies were classified using the American Academy of Neurologys criteria (class I–IV, I = highest level of evidence). We provided recommendations including Level A: intervention/factors are effective/predictive or not; Level B: probably effective/predictive or not; Level C: possibly effective/predictive or not; Level U: no recommendations. Results: For the intervention studies we identified 1 Class II and 1 Class III study; for predictor studies, we identified 7 ADHD studies consisting of 1 Class II and 6 Class III studies. Only 1 Class III ASD study was found. In synopsizing the evidence, the following recommendations are made for the intervention studies pertaining to on-road performance in teens with ADHD: a multimodal intervention is possibly effective in improving driving performance (Level C); stimulants possibly do not affect driving negatively (Level C); no recommendations can be made for hazard perception training in ADHD or ASD (Level U). Consider the following recommendations useful for simulated driving performance: Stimulants possibly improve driving performance (Level C); ADHD diagnosis and being unmedicated possibly worsen driving performance (Level C); no recommendations for driving in low-stimulus conditions (Level U). From self-/proxy report, no recommendations can be made related to gender or ADHD subtype affecting adverse driving outcomes (Level U). Conclusion: Class I studies with Level A recommendations, currently lacking in the literature, are urgently needed to make clear the mechanism underlying driving performance outcomes in ADHD and ASD. Supplementary materials are available for this article. Go to the publishers online edition of Traffic Injury Prevention for the following supplemental resource: Table: Evidence-based Synopsis of ADHD, ASD and Driving Performance: Variables, Sample, Findings & Rationale

Driving errors in Parkinson's disease: moving closer to predicting on-road outcomes

Age-related medical conditions such as Parkinsons disease (PD) compromise driver fitness. Results from studies are unclear on the specific driving errors that underlie passing or failing an on-road assessment. In this study, we determined the between-group differences and quantified the on-road driving errors that predicted pass or fail on-road outcomes in 101 drivers with PD (mean age = 69.38 ± 7.43) and 138 healthy control (HC) drivers (mean age = 71.76 ± 5.08). Participants with PD had minor differences in demographics and driving habits and history but made more and different driving errors than HC participants. Drivers with PD failed the on-road test to a greater extent than HC drivers (41% vs. 9%), χ²(1) = 35.54, HC N = 138, PD N = 99, p < .001. The driving errors predicting on-road pass or fail outcomes (95% confidence interval, Nagelkerke R² =.771) were made in visual scanning, signaling, vehicle positioning, speeding (mainly underspeeding, t(61) = 7.004, p < .001, and total errors. Although it is difficult to predict on-road outcomes, this study provides a foundation for doing so.

Indicators of Simulated Driving Skills in Adolescents with Autism Spectrum Disorder

Adolescents are at high risk for motor vehicle crashes (MVCs). Teens with autism spectrum disorder (ASD) may have an even greater risk for MVCs due to impaired visual, cognitive, and motor skills critical for driving. This prospective two group study demonstrated the demographic, clinical, and simulated driving skill differences of seven adolescents with ASD (mean age = 15.14, SD ±1.22) compared to 22 healthy controls (HC) (mean age = 14.32, SD ±.72) through a comprehensive driving evaluation (CDE) conducted by an occupational therapist certified driving rehabilitation specialist (OT-CDRS). Adolescents with ASD performed poorer on right eye acuity (Fischer’s (F) = 13.44, p = .003), cognition (Mann-Whitney Statistic (U) = 29.00, p = .01), visual motor integration (U = 27.50, p = .01), motor coordination (U = 5.00, p = .001), operational skills for managing simulator controls (U = 4.00, pU = 30.50, p = .02), speed regulation (U = 13.50, p = .001), lane maintenance (U = 34.00, p = .03), signaling (U = 38.50, p = .03), and adjustment to stimuli (U = 9.00, pU = 5.00, pConclusion). Compared to the HC, adolescents with ASD performed worse on visual, cognitive, motor, simulator operational, and fitness to drive skills, suggesting that an OT-CDRS may play an important role in assessing teens with ASD before they pursue traditional driver’s education.

Evidence-Based Review of Interventions for Medically At-Risk Older Drivers

OBJECTIVE. To conduct an evidence-based review of intervention studies of older drivers with medical conditions. METHOD. We used the American Occupational Therapy Associations classification criteria (Levels I-V, I = highest level of evidence) to identify driving interventions. We classified studies using letters to represent the strength of recommendations: A = strongly recommend the intervention; B = recommend intervention is provided routinely; C = weak evidence that the intervention can improve outcomes; D = recommend not to provide the intervention; I = insufficient evidence to recommend for or against the intervention. RESULTS. For clients with stroke, we recommend a graded simulator intervention (A) and multimodal training in traffic theory knowledge and on-road interventions (B); we make no recommendation for or against Dynavision, Useful Field of View, or visual-perceptual interventions (I). For clients with visual deficits, we recommend educational intervention (A) and bioptic training (B); we make no recommendation for or against prism lenses (I). For clients with dementia, we recommend driving restriction interventions (C) and make no recommendation for or against use of compensatory driving strategies (I). CONCLUSION. Level I studies are needed to identify effective interventions for medically at-risk older drivers.

Driving Characteristics of Teens With Attention Deficit Hyperactivity and Autism Spectrum Disorder

Vehicle crashes are a leading cause of death among teens. Teens with attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), or both (ADHD-ASD) may have a greater crash risk. We examined the between-groups demographic, clinical, and predriving performance differences of 22 teens with ADHD-ASD (mean age = 15.05, standard deviation [SD] = 0.95) and 22 healthy control (HC) teens (mean age = 14.32, SD = 0.72). Compared with HC teens, the teens with ADHD-ASD performed more poorly on right-eye visual acuity, selective attention, visual-motor integration, cognition, and motor performance and made more errors on the driving simulator pertaining to visual scanning, speed regulation, lane maintenance, adjustment to stimuli, and total number of driving errors. Teens with ADHD-ASD, compared with HC teens, may have more predriving deficits and as such require the skills of a certified driving rehabilitation specialist to assess readiness to drive.

Pre-driving evaluation of a teen with attention deficit hyperactivity disorder and autism spectrum disorder:

Background. Vehicle crashes are the leading cause of death among teens, and those teens with attention-deficit/hyperactivity disorder and autism spectrum disorder (ADHD/ASD) may have a greater crash risk. Purpose. This case study compared the pre-driving skills of a teen with ADHD/ASD to an age- and gender-matched healthy control (HC). Method. Data were collected from performance on clinical tests and on a driving simulator. Findings. The main impairments of the teen with ADHD/ASD were the ability to shift attention, perform simple sequential tasks, integrate visual-motor responses, and coordinate motor responses, whereas the HC demonstrated intact skills in these abilities. The teen with ADHD/ASD made 44 driving errors during the drive, and the HC made 17. The teen with ADHD/ASD had more lane maintenance, visual scanning, and speeding errors compared to the HC. Implications. Teens with ADHD/ASD may have more pre-driving deficits and may require a certified driving rehabilitation specialist to assess readiness to drive, but a larger study is needed to confirm this.

Driving indicators in teens with attention deficit hyperactivity and/or autism spectrum disorder

Background. Motor vehicle crashes are leading causes of death among teens. Those teens with attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), or a dual diagnosis of ADHD/ASD have defining characteristics placing them at a greater risk for crashes. Purpose. This study examined the between-group demographic, clinical, and simulated driving differences in teens, representing three diagnostic groups, compared to healthy controls (HCs). Method. In this prospective observational study, we used a convenience sample of teens recruited from a variety of community settings. Findings. Compared to the 22 HCs (mean age = 14.32, SD = ±.72), teen drivers representing the diagnostic groups (ADHD/ASD, n = 6, mean age = 15.00, SD = ±.63; ADHD, n = 9, mean age = 15.00, SD = ±1.00; ASD, n = 7, mean age = 15.14, SD = ±.1.22) performed poorer on visual function, visual-motor integration, cognition, and motor performance and made more errors on the driving simulator. Implications. Teens from diagnostic groups have more deficits driving on a driving simulator and may require a comprehensive driving evaluation. Description. Les accidents de la route sont les principales causes de décès chez les jeunes. Les jeunes ayant un trouble du déficit de l’attention avec hyperactivité (TDAH), un trouble du spectre autistique (TSA) ou un double diagnostic ont des caractéristiques déterminantes qui les exposent à de plus grands risques d’accidents. But. Cette étude examinait les différences démographiques, cliniques et simulées en matière de conduite automobile entre des adolescents représentant trois groupes de diagnostics et des témoins sains. Méthodologie. Dans cette étude prospective fondée sur l’observation, nous avons utilisé un échantillon de commodité composé d’adolescents recrutés dans divers milieux communautaires. Résultats. Comparativement aux 22 sujets sains (âge moyen = 14,32, É-T = ± 0,72), les conducteurs adolescents représentant les groupes de diagnostics (TDAH/TSA n = 6, âge moyen = 15,00, É-T = ± 0,63; TDAH n = 9, âge moyen = 15,00, É-T = ±1,00; TSA n = 7, âge moyen = 15,14, É-T = ±1,22) ont obtenu un rendement plus faible en ce qui a trait à la fonction visuelle, l’intégration visuo-motrice, la cognition et le rendement moteur; ils ont aussi fait plus d’erreurs lors de l’utilisation du simulateur de conduite. Conséquences. Les adolescents des groupes de diagnostics ont plus de déficits lorsqu’ils conduisent le simulateur de conduite et il serait sans doute judicieux de leur faire passer une évaluation complète de la conduite automobile.

Utility of an occupational therapy driving intervention for a combat veteran

Many combat veterans are injured in motor vehicle crashes shortly after returning to civilian life, yet little evidence exists on effective driving interventions. In this single-subject design study, we compared clinical test results and driving errors in a returning combat veteran before and after an occupational therapy driving intervention. A certified driving rehabilitation specialist administered baseline clinical and simulated driving assessments; conducted three intervention sessions that discussed driving errors, retrained visual search skills, and invited commentary on driving; and administered a postintervention evaluation in conditions resembling those at baseline. Clinical test results were similar pre- and postintervention. Baseline versus postintervention driving errors were as follows: lane maintenance, 23 versus 7; vehicle positioning, 5 versus 1; signaling, 2 versus 0; speed regulation, 1 versus 1; visual scanning, 1 versus 0; and gap acceptance, 1 versus 0. Although the intervention appeared efficacious for this participant, threats to validity must be recognized and controlled for in a follow-up study.

Development and Validity of Western University’s On-Road Assessment:

Although used across North America, many on-road studies do not explicitly document the content and metrics of on-road courses and accompanying assessments. This article discusses the development of the University of Western Ontario’s on-road course, and elucidates the validity of its accompanying on-road assessment. We identified main components for developing an on-road course and used measurement theory to establish face, content, and initial construct validity. Five adult volunteer drivers and 30 drivers with multiple sclerosis participated in the study. The road course had face and content validity, representing 100% of roadway components determined through a content validity matrix and index. The known-groups method showed that debilitated drivers (vs. not debilitated), made more driving errors (W = 463.50, p = .03), and failed the on-road course, indicating preliminary construct validity of the on-road assessment. This research guides and empirically supports a process for developing a road course and its assessment.

Interrater reliability of Western University's on-road assessment.

Background. Little empirical support exists for interrater reliability between evaluators from different backgrounds when assessing on-road outcomes of drivers. Purpose. We quantified interrater reliability of on-road outcomes between a certified driving school instructor (DI) and an occupational therapist and certified driver rehabilitation specialist (CDRS). Method. Both raters used the Global Rating Score (GRS) with two levels (pass, fail), the GRS with four levels (pass, pass with recommendations, fail remediable, fail), and the priority error rating score (PERS; most frequently occurring on-road errors in priority order) to assess 35 drivers (age, M = 48.31 years, SD = 9.76 years; 40% male; 86% with multiple sclerosis). Findings. The DI and occupational therapist CDRS had excellent agreement on the GRS with two levels (κ = .892, p < .0001), GRS with four levels (κ = .952, p < .0001), and the PERS (κ = .847–.902, p < .0001), indicating interrater reliability. Implications. This research contributes to empirical support for the on-road assessment.