Rater-Reliability of Assessing Driving Errors with a DriveSafety 250 Simulator.

This study aimed to establish inter-rater reliability among three raters while training new driver rehabilitation specialists to correctly identify driving errors on a DriveSafety 250 driving simulator. Five participants completed adaptation, residential and suburban, and city and highway scenarios. Intraclass correlation coefficients indicated scores between .623-.877 (p = .003-.122) for the total driving errors recorded in the two scenario drives with rater agreement initially ranging between 7-8%. When analyzing the data for types of driving errors, the intraclass correlation coefficients ranged from .556-.973 (p < .05) and rater agreement between 15-100%. Through proper training and strategy development, raters reached 100% consensus on all aspects of inter-rater reliability while assessing driving errors.

Clinical predictors of driving simulator performance in drivers with multiple sclerosis.

BACKGROUND: Drivers with multiple sclerosis (MS) may experience visual-cognitive impairment that affects their fitness to drive. Due to limitations associated with the on-road assessment, an alternative assessment that measures driving performance is warranted. Whether clinical indicators of on-road outcomes can also predict driving performance outcomes on a driving simulator are not fully understood. OBJECTIVE: This study examined if deficits in immediate verbal/auditory recall (California Verbal Learning Test-Second Edition; CVLT2-IR) and/or slower divided attention (Useful Field of View™; UFOV2) predicted deficits in operational, tactical, or strategic maneuvers assessed on a driving simulator, in drivers with and without MS. METHODS: Participants completed the CVLT2-IR, UFOV2, and a driving simulator assessment of operational, tactical, and strategic maneuvers. RESULTS: Deficits in immediate verbal/auditory recall and slower divided attention predicted adjustment to stimuli errors, pertaining to tactical maneuvers only, in 36 drivers with MS (vs 20 drivers without MS; F(3, 51) = 6.1, p = 0.001, R2 = 0.3, Radj2=0.2). CONCLUSION: The CVLT2-IR and UFOV2 capture the visual and verbal/auditory recall, processing speed, and divided attention required to appropriately adjust to stimuli in a simulated driving environment. Clinicians may use the CVLT2-IR and UFOV2 as precursors to driving performance deficits in drivers with MS.

On-road assessment of fitness-to-drive in persons with MS with cognitive impairment: A prospective study.

BACKGROUND: Cognitive impairment is common in multiple sclerosis (MS). In other populations, cognitive impairment is known to affect fitness-to-drive. Few studies have focused on fitness-to-drive in MS and no studies have solely focused on the influence of cognitive impairment. OBJECTIVE: To assess fitness-to-drive in persons with MS with cognitive impairment and low physical disability. METHODS: Persons with MS, aged 18-59 years with EDSS ⩽ 4.0, impaired processing speed, and impairment on at least one measure of memory or executive function, were recruited. Cognition was assessed using the Minimal Assessment of Cognitive Function battery. A formal on-road driving assessment was conducted. Chi-square analysis examined the association between the fitness-to-drive (pass/fail) and the neuropsychological test results (normal/impaired). Bayesian statistics predicting failure of the on-road assessment were calculated. RESULTS: Of 36 subjects, eight (22.2%) were unfit to drive. Only the BVMTR-IR, measuring visual-spatial memory, predicted on-road driving assessment failure ( X2 ( df = 1, N = 36) = 3.956; p = 0.047) with a sensitivity of 100%, but low specificity (35.7%) due to false positives (18/25). CONCLUSION: In persons with MS and impaired processing speed, impairment on the BVMTR-IR should lead clinicians to address fitness-to-drive.

Efficacy of an occupational therapy driving intervention for returning combat veterans.

Polytrauma, including mild traumatic brain injury, posttraumatic stress disorder, and orthopedic conditions, is common among combat veterans (CVs) from Operations Enduring Freedom and Iraqi Freedom. Medical conditions, coupled with deployment-related training, may affect CVs' fitness to drive and contribute to post-deployment crash and injury risks. However, empirical interventions are lacking. Therefore, the study purpose was to examine the efficacy of an occupational therapy driving intervention (OT-DI) with pre and post testing of CVs. Using a DriveSafety 250 simulator, Occupational Therapy-Driver Rehabilitation Specialists recorded driving errors. Eight CVs (mean age = 39.83, SD = 7.80) received three OT-DI sessions, which incorporated strategies to address driving errors and visual search retraining. We determined baseline driving errors (mean = 31.63, SD = 8.96) were double the number of posttest errors (mean = 15.38, SD = 9.71). At posttesting, a significant (p < 0.05) decrease was noted for total errors and lane maintenance. Despite study constraints, preliminary data support the efficacy of the OT-DI.

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.

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 Association's 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 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.

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.

Evaluating driving as a valued instrumental activity of daily living.

The purpose of this translational research article is to illustrate how general practice occupational therapists have the skills and knowledge to address driving as a valued occupation using an algorithm based on the Occupational Therapy Practice Framework: Domain and Process (2nd ed.; American Occupational Therapy Association, 2008b). Evidence to support the model is offered by a research study. Participants were compared on their performance of complex instrumental activities of daily living (IADLs) and a behind-the-wheel driving assessment. A significant relationship was found between the process skills from the performance assessment and whether the driver passed, failed, or needed restrictions as indicated by the behind-the-wheel assessment. The evidence suggests that occupational therapists using observational performance evaluation of IADLs can assist in determining who might be an at-risk driver. The algorithm addresses how driver rehabilitation specialists can be used most effectively and efficiently with general practice occupational therapy practitioners meeting the needs of senior drivers.

Visual Correlates of Fitness to Drive in Adults With Multiple Sclerosis.

The impact of visual and visual-cognitive impairments on fitness to drive in persons with multiple sclerosis (PwMS) are not well studied. We quantified visual correlates of fitness to drive in 30 PwMS. PwMS completed visual ability and visual attention assessments, and a standardized on-road assessment, and were compared with 145 older volunteer drivers. PwMS (vs. older volunteer drivers) made more total ( W = 12,139, p = .03) and critical driving errors (predictive of crashes) in adjustment to stimuli ( W = 11,352, p < .0001), vehicle positioning ( W = 11,449, p < .0001), and wide lane turns ( W = 9,932, p < .0001). PwMS who failed (vs. passed) made more total ( W = 325, p = .04), adjustment to stimuli ( W = 321.5, p = .02), and gap acceptance errors ( W = 333, p = .03). For PwMS, adjustment to stimuli errors moderately correlated with visual acuity (ρ = .50, p = .006), and gap acceptance errors moderately correlated with visual processing speed (ρ = .40, p = .03). Visual-cognitive impairments may be indicative of critical driving errors and help identify PwMS at-risk for fitness to drive.

Driving Errors That Predict On-Road Outcomes in Adults With Multiple Sclerosis.

Driving errors that predict on-road outcomes for persons with multiple sclerosis (PwMS) are not well studied. The objective of this study was to determine whether adjustment-to-stimuli and gap acceptance errors significantly predict passing/failing a standardized on-road assessment of PwMS. Thirty-seven participants completed visual ability and visual attention assessments, and participated in an on-road assessment, where seven types of driving errors and pass/fail outcomes were determined. Adjustment-to-stimuli (No.) and gap acceptance errors (commit/did not commit) significantly predicted passing/failing the on-road assessment, with an area under the curve of 91.6% ( p < .0001). With no gap acceptance errors committed, five adjustment-to-stimuli errors optimally determined pass/fail outcomes in PwMS. Furthermore, with no adjustment to stimuli errors committed, committing any gap acceptance errors also optimally determined pass/fail outcomes in PwMS. Further research may focus on visual, cognitive, and/or motor impairments underlying adjustment-to-stimuli and gap acceptance errors for eventual development of rehabilitation strategies for PwMS.

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.

Driving Intervention for Returning Combat Veterans.

Increased crash incidence following deployment and veterans' reports of driving difficulty spurred traffic safety research for this population. We conducted an interim analysis on the efficacy of a simulator-based occupational therapy driving intervention (OT-DI) compared with traffic safety education (TSE) in a randomized controlled trial. During baseline and post-testing, OT-Driver Rehabilitation Specialists and one OT-Certified Driver Rehabilitation Specialist measured driving performance errors on a DriveSafety CDS-250 high-fidelity simulator. The intervention group ( n = 13) received three OT-DI sessions addressing driving errors and visual-search retraining. The control group ( n = 13) received three TSE sessions addressing personal factors and defensive driving. Based on Wilcoxon rank-sum analysis, the OT-DI group's errors were significantly reduced when comparing baseline with Post-Test 1 ( p < .0001) and comparing the OT-DI group with the TSE group at Post-Test 1 ( p = .01). These findings provide support for the efficacy of the OT-DI and set the stage for a future effectiveness study.

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.

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

Age-related medical conditions such as Parkinson's 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.

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 Neurology's 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 publisher's 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 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.