Children with special physical health care needs: restraint use and injury risk in motor vehicle crashes.

Physical disabilities may affect a child passenger's fit within a conventional motor vehicle restraint. The aim of this study is to describe and compare injury risk in motor vehicle crashes (MVC) among children with and without special physical health care needs (SPHCN). This analysis, conducted in 2007-2008, utilizes data collected between December 1998 and November 2002 in a cross-sectional study of children ≤15 years old involved in crashes of State-Farm insured vehicles in 15 states and the District of Columbia. Parent reports via telephone survey were used to define pre-crash SPHCN, restraint status, and occurrence of significant injuries using a validated survey. Complete data were collected for 18,852 children aged 0-15 years; 159 children were reported to have a SPHCN (0.8% and 0.7% of children aged 0-8 and 9-15 years, respectively). A greater proportion of children with SPHCN aged 0-8 years were appropriately restrained (P < 0.001), but there was no significant difference in restraint use among children with and without SPHCN aged 9-15 years. There was no significant association between the presence of a SPHCN and injury risk in either age group, after adjustment for child/driver characteristics (children aged 0-8 years: OR 1.27, 95% CI: 0.48-3.33; children aged 9-15 years: OR 1.51, 95% CI: 0.38-6.11). Children with and without SPHCN have similar injury risk in MVC, despite increased age-appropriate restraint usage among children aged 0-8 years. When counseling families about vehicle safety, practitioners should consider the fit of a child with SPHCN in a restraint system.

Comparison of Motor Vehicle Crashes, Traffic Violations, and License Suspensions Between Autistic and Non-Autistic Adolescent and Young Adult Drivers.

OBJECTIVE: One-third of autistic individuals obtain a driver's license by age 21 years; however, prior studies suggest they may be at heightened risk for motor vehicle crashes. We compared objective rates of crashes, traffic violations, and license suspensions for newly licensed autistic and non-autistic adolescents. METHOD: This retrospective cohort study included New Jersey residents born from 1987 through 2000 who were patients of the Children's Hospital of Philadelphia health care network. Electronic health records were linked with statewide driver licensing and crash databases. Autism status was classified via International Classification of Diseases (ICD) diagnostic codes; individuals with intellectual disability were excluded. We compared rates among 486 autistic and 70,990 non-autistic licensed drivers over their first 48 months of driving. Furthermore, we examined the proportion of crashes attributed to specific driver actions and crash types. RESULTS: Compared with non-autistic drivers, autistic drivers were estimated to have lower average monthly rates of crash involvement (adjusted rate ratio (adjRR) = 0.89, 95% CI = 0.75-1.05), moving violations (adjRR = 0.56, 95% CI = 0.48-0.67), and suspensions (adjRR = 0.32, 95% CI = 0.18-0.58). Among drivers involved in a crash, autistic drivers were half as likely to crash because of unsafe speed, but substantially more likely to crash because of their failure to yield to a vehicle/pedestrian and while making left-turns or U-turns. CONCLUSION: Newly licensed autistic adolescent drivers have similar to lower estimated rates of adverse driving outcomes; the extent to which these can be attributed to different driving patterns is a critical point for future investigation. There were several notable differences in the characteristics of these crashes, which directly inform interventions to improve driving safety of autistic adolescent drivers.

Longitudinal study of driver licensing rates among adolescents and young adults with autism spectrum disorder.

Driving may increase mobility and independence for adolescents with autism without intellectual disability (autism spectrum disorder); however, little is known about rates of licensure. To compare the proportion of adolescents with and without autism spectrum disorder who acquire a learner's permit and driver's license, as well as the rate at which they progress through the licensing system, we conducted a retrospective cohort study of 52,172 New Jersey residents born in the years 1987-1995 who were patients of the Children's Hospital of Philadelphia healthcare network ⩾12 years of age; 609 (1.2%) had an autism spectrum disorder diagnosis. Electronic health records were linked to New Jersey's driver licensing database (2004-2012). Kaplan-Meier curves and log-binomial regression models were used to determine the age at and rate of licensure, and estimate adjusted risk ratios. One in three adolescents with autism spectrum disorder acquired a driver's license versus 83.5% for other adolescents and at a median of 9.2 months later. The vast majority (89.7%) of those with autism spectrum disorder who acquired a permit and were fully eligible to get licensed acquired a license within 2 years. Results indicated that a substantial proportion of adolescents with autism spectrum disorder do get licensed and that license-related decisions are primarily made prior to acquisition of a permit instead of during the learning-to-drive process.

Design of an experimental protocol to examine medication non-adherence among young drivers diagnosed with ADHD: A driving simulator study.

The diagnosis of ADHD among teens and young adults has been associated with a higher likelihood of motor vehicle crashes. Some studies suggest a beneficial effect of ADHD medication but the exact efficacy is still being debated. Further, medication adherence, which is low in this age group, can further reduce effectiveness. Our long-term objective is to reduce unsafe driving among drivers with ADHD by detecting medication non-adherence through driver behavior modeling and monitoring. As a first step, we developed the described lab study protocol to obtain reliable driver behavior data that will then be used to design and train behavior models built through machine learning. This experimental study protocol was developed to systematically compare driving behaviors under two medication conditions (before and after intake of medication) among young adults with ADHD and a control group of non-ADHD. A driving simulator was used to examine driving behaviors and interactions with traffic. The primary outcome was speed management for two comparisons (ADHD vs. non-ADHD and before vs. after medication), and secondary objectives involved understanding differences among the participants utilizing self-reported surveys about ADHD symptoms, drivers' knowledge, and perception about safety. The study protocol was designed to maximize participant safety and efficiency of data collection, as multiple measures were collected over two 2-h study visits. The sampled ADHD drivers were demographically and psychosocially similar but clinically different from the non-ADHD group. Overall, this protocol was effective in participant recruitment and retention, allowed staggered data collection, and can be incorporated in a subsequent clinical trial that examines the efficacy of a machine-learning based driver monitoring intervention.

Variations in nurse practitioner use in Veterans Affairs primary care practices.

BACKGROUND: Increasingly, primary care practices include nurse practitioners (NPs) in their staffing mix to contain costs and expand primary care. To achieve these aims in U.S. Department of Veterans Affairs medical centers (VAMCs), national policy endorsed involvement of NPs as primary care (PC) providers. OBJECTIVES: To evaluate the degree to which VAMCs incorporated NPs into PC practices between 1996 and 1999, and to identify the internal and external practice environment features associated with NP use. STUDY DESIGN: We surveyed 131 PC directors of all VAMCs in 1996 and 1999 to ascertain the staffing and characteristics of the PC practice and parent organization (e.g., academic affiliation, level of physician staffing, use of managed care arrangements), and drew on previously published studies and HRSA State Health Workforce Profiles to characterize each practice's regional health care environment (e.g., geographic region, state NP practice laws, state managed care penetration). Using multivariate linear regression, we evaluate the contribution of these environmental and organizational factors on the number of NPs/10,000 PC patients in 1999, controlling for the rate of NP use in 1996. PRINCIPAL FINDINGS: From 1996-1999, NP use increased from 75 percent to 90 percent in VA PC practices. The mean number of NPs per practice increased by about 60 percent (2.0 versus 3.2; p<.001), while the rate of NPs/10,000 PC patients trended upward (2.2 versus 2.7; p=.09). Staffing of other primary care clinicians (e.g., physicians and physician assistants per practice) remained stable, while the NP-per-physician rate increased (0.2 versus 0.4; p<.001). After multivariate adjustment, greater reliance on managed-care-oriented provider education programs (p=.02), the presence of NP training programs (p=.05), and more specialty-trained physicians/10,000 PC patients (p=.09) were associated with greater NP involvement in primary care. CONCLUSIONS: Staffing models in VA PC practices have, in fact, changed, with NPs having a greater presence. However, we found substantial practice-based variations in their use, suggesting that more research is needed to better understand how they have been integrated into practice and what impact their involvement has had on the VA's ability to achieve its restructuring goals.

Factors associated with driving in teens with autism spectrum disorders.

OBJECTIVE: To compare the characteristics of driving and nondriving teens and explore the driving outcomes for teens with higher functioning autism spectrum disorders. METHODS: Parents of teens aged 15 to 18 years with a parent-reported diagnosis of an autism spectrum disorder enrolled in Interactive Autism Network, an online research registry, were eligible for this cross-sectional study. An online survey was used for data collection. RESULTS: A total of 297 parents completed the survey. Sixty-three percent of teens currently drive or plan to drive. Twenty-nine percent of the teens who are age-eligible to drive currently drive. Compared with age-eligible but nondriving teens, a greater proportion of driving teens were in full-time regular education (p < .005), planned to attend college (p < .001), and held a paid job (p = .008). A greater proportion of parents of driving teens had taught ≥1 teen to drive previously (p < .001). There were no differences in gender, autism subtype, attention deficit/hyperactivity disorder diagnosis, parental age or education, or access to public transportation. Driving predictors included individualized education plans with driving goals, indicators of functional status (classroom placement, college aspiration, and job experience), and parent experience with teaching teens to drive. Twelve percent of teens received driving citations, and 12% of teens had been involved in a motor vehicle crash. CONCLUSIONS: Although a significant proportion of teens with higher functioning autism spectrum disorders were driving or learning to drive, the fact that most driving teens' individualized education plans did not include driving goals suggests an area of opportunity for improvement in transition planning. Driving teens were more frequently in regular education settings with college aspirations, which could help schools identify potential drivers.

Children with special health care needs: patterns of safety restraint use, seating position, and risk of injury in motor vehicle crashes.

OBJECTIVES: Special health care needs associated with behavioral conditions may influence a child's safety in motor vehicle crashes. The aim of this study was to describe and compare variation in restraint use, seating position, and injury risk in motor vehicle crashes among children with and without special health care needs likely to affect behavior. PATIENTS AND METHODS: This study uses data collected between December 1, 1998, and November 30, 2002, in a cross-sectional study of children <16 years of age who were involved in crashes of State Farm-insured vehicles in 15 states. Parent reports via a validated telephone survey were used to define precrash special health care needs, restraint status, seating position, and the occurrence of clinically significant injuries by using a previously validated survey instrument. RESULTS: Complete data were collected for 14654 children aged 4 to 15 years, representing 171633 children in crashes. Of these, 152 children were reported to have a special need likely to affect behavior, representing 1883 children. A greater proportion of children with special needs likely to affect behavior were appropriately restrained, particularly among children aged 4 to 8 years. Drivers of children with special needs likely to affect behavior were more often restrained and more often were the child passenger's parent. There were no differences in the rates of front-row seating. There was no significant association between the presence of a special need likely to affect behavior and risk of injury, after adjustment for child/driver characteristics and crash severity. CONCLUSIONS: Despite a greater proportion of children with special needs likely to affect behavior using proper vehicle restraint, their injury risk was similar to that of children without these special needs. Primary care pediatricians providing best practices for vehicle safety should consider the unique riding experience and risk of injury among children with special health care needs likely to affect behavior.

Acoustical analysis and model-based sound synthesis of the kantele.

The five-string Finnish kantele is a traditional folk music instrument that has unique structural features, resulting in a sound of bright and reverberant timbre. This article presents an analysis of the sound generation principles in the kantele, based on measurements and analytical formulation. The most characteristic features of the unique timbre are caused by the bridgeless string termination around a tuning pin at one end and the knotted termination around a supporting bar at the other end. These result in prominent second-order nonlinearity and strong beating of harmonics, respectively. A computational model of the instrument is also formulated and the algorithm is made efficient for real-time synthesis to simulate these features of the instrument timbre.