Trial of Training to Reduce Driver Inattention in Teens with ADHD.

BACKGROUND: Teens with attention deficit-hyperactivity disorder (ADHD) are at increased risk for motor vehicle collisions. A computerized skills-training program to reduce long glances away from the roadway, a contributor to collision risk, may ameliorate driving risks among teens with ADHD. METHODS: We evaluated a computerized skills-training program designed to reduce long glances (lasting ≥2 seconds) away from the roadway in drivers 16 to 19 years of age with ADHD. Participants were randomly assigned in a 1:1 ratio to undergo either enhanced Focused Concentration and Attention Learning, a program that targets reduction in the number of long glances (intervention) or enhanced conventional driver's education (control). The primary outcomes were the number of long glances away from the roadway and the standard deviation of lane position, a measure of lateral movements away from the center of the lane, during two 15-minute simulated drives at baseline and at 1 month and 6 months after training. Secondary outcomes were the rates of long glances and collisions or near-collisions involving abrupt changes in vehicle momentum (g-force event), as assessed with in-vehicle recordings over the 1-year period after training. RESULTS: During simulated driving after training, participants in the intervention group had a mean of 16.5 long glances per drive at 1 month and 15.7 long glances per drive at 6 months, as compared with 28.0 and 27.0 long glances, respectively, in the control group (incidence rate ratio at 1 month, 0.64; 95% confidence interval [CI], 0.52 to 0.76; P<0.001; incidence rate ratio at 6 months, 0.64; 95% CI, 0.52 to 0.76; P<0.001). The standard deviation of lane position (in feet) was 0.98 SD at 1 month and 0.98 SD at 6 months in the intervention group, as compared with 1.20 SD and 1.20 SD, respectively, in the control group (difference at 1 month, -0.21 SD; 95% CI, -0.29 to -0.13; difference at 6 months, -0.22 SD; 95% CI, -0.31 to -0.13; P<0.001 for interaction for both comparisons). During real-world driving over the year after training, the rate of long glances per g-force event was 18.3% in the intervention group and 23.9% in the control group (relative risk, 0.76; 95% CI, 0.61 to 0.92); the rate of collision or near-collision per g-force event was 3.4% and 5.6%, respectively (relative risk, 0.60, 95% CI, 0.41 to 0.89). CONCLUSIONS: In teens with ADHD, a specially designed computerized simulated-driving program with feedback to reduce long glances away from the roadway reduced the frequency of long glances and lessened variation in lane position as compared with a control program. During real-world driving in the year after training, the rate of collisions and near-collisions was lower in the intervention group. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT02848092.).

Examining Patterns and Predictors of ADHD Teens' Skill-Learning Trajectories During Enhanced FOrward Concentration and Attention Learning (FOCAL+) Training.

OBJECTIVE: Examine patterns and predictors of skill learning during multisession Enhanced FOrward Concentration and Attention Learning (FOCAL+) training. BACKGROUND: FOCAL+ teaches teens to reduce the duration of off-road glances using real-time error learning. In a randomized controlled trial, teens with ADHD received five sessions of FOCAL+ training and demonstrated significant reductions in extended glances (>2-s) away from the roadway (i.e., long-glances) and a 40% reduced risk of a crash/near-crash event. Teens' improvement in limiting long-glances as assessed after each FOCAL+ training session has not been examined. METHOD: Licensed teen (ages 16-19) drivers with ADHD (n = 152) were randomly assigned to five sessions of either FOCAL+ or modified standard driver training. Teens completed driving simulation assessments at baseline, after each training session, and 1 month and 6 months posttraining. Naturalistic driving was monitored for one year. RESULTS: FOCAL+ training produced a 53% maximal reduction in long-glances during postsession simulated driving. The number of sessions needed to achieve maximum performance varied across participants. However, after five FOCAL+ training sessions, number of long-glances was comparable irrespective of when teens achieved their maximum performance. The magnitude of reduction in long-glances predicted levels of long-glances during simulated driving at 1 month and 6 months posttraining but not naturalistic driving outcomes. FOCAL+ training provided the most benefit during training to teens who were younger and had less driving experience. CONCLUSION: FOCAL+ training significantly reduces long-glances beginning at the 1st training session. APPLICATION: Providing five FOCAL+ training sessions early on during teen driving may maximize benefit.

The Challenge of New Forms of Work, Innovative Technologies, and Aging on Decent Work: Opportunities for Occupational Safety and Health.

Occupational Safety and Health (OSH) can be relevant in achieving the United Nation's Sustainable Development Goal of decent work by 2030. However, further OSH actions are needed. This paper identifies the role of OSH in addressing two of many determinants of decent work: new forms of work/innovative technologies and worker aging. The authors conducted a discursive analysis of the two determinants and provided examples for consideration. New forms of work/innovative technologies can not only promote but also undermine the future of decent work, and unhealthy aging impedes longer working lives. With a focus on the OSH aspects of new forms of work/innovative technologies and aging, decent work is more likely to be achieved.

Booster Dose of Attention Training Program for Young Novice Drivers: A Longitudinal Driving Simulator Evaluation Study.

OBJECTIVE: We examined the effectiveness of a second exposure to ACCEL, a novel driving training program, on latent hazard anticipation (HA) performance several months after their first exposure. BACKGROUND: Past research has demonstrated that PC-based driver training programs can improve latent HA performance in young novice drivers, but these improvements are below the ceiling level. METHOD: Twenty-five participants were randomly assigned to either the Placebo group, the ACCEL-1 group, or the ACCEL-2 group. Following the completion of the assigned training program, participants drove a series of eighteen scenarios incorporating latent hazards in a high-fidelity driving simulator with their eyes tracked. Participants returned two to six months following the first session and completed either the placebo program (ACCEL-1 and Placebo groups), or a second dose of training program (ACCEL-2 group), again followed by simulated evaluation drives. RESULTS: The ACCEL-2 group showed improved HA performance compared to the ACCEL-1 and Placebo groups in the second evaluation. CONCLUSION: ACCEL enhances young novice drivers' latent HA performance. The effectiveness of ACCEL is retained up to 6 months, and a second dose further improves HA performance. APPLICATION: Policy makers should consider requiring such training before the completion of graduate driver license programs. Young novice drivers that do not show successful latent HA performance could be required to complete additional training before being allowed to drive without restrictions.

SPIDER: A Framework for Understanding Driver Distraction.

OBJECTIVE: The objective was to identify key cognitive processes that are impaired when drivers divert attention from driving. BACKGROUND: Driver distraction is increasingly recognized as a significant source of injuries and fatalities on the roadway. METHOD/RESULTS: A "SPIDER" model is developed that identifies key cognitive processes that are impaired when drivers divert attention from driving. SPIDER is an acronym standing for scanning, predicting, identifying, decision making, and executing a response. CONCLUSION: When drivers engage in secondary activities unrelated to the task of driving, SPIDER-related processes are impaired, situation awareness is degraded, and the ability to safely operate a motor vehicle may be compromised. APPLICATION: The pattern of interference helps to illuminate the sources of driver distraction and may help guide the integration of new technology into the automobile.

Cognitive Distraction in the Wild: Next Steps-Addressing a Not-So-Humdrum Conundrum.

Strayer et al. in this volume show that increases in cognitive workload caused by drivers' involvement in distracting activities that allow them to keep their eyes on the road lead to decrements in indices of safe driving performance. Although there is agreement that in-vehicle tasks that require drivers to take their eyes off the road increase crash risk, there is mounting controversy about whether in-vehicle tasks that do not require drivers to take their eyes off the forward roadway increase crash risk-thus the conundrum: How can there be an abundance of cognitively distracting activities and controversy about whether such activities increase crash risk?

Evaluation of a Risk Awareness Perception Training Program on Novice Teen Driver Behavior at Left-Turn Intersections.

Collisions at left turn intersections are among the most prevalent types of teen driver serious crashes, with inadequate surveillance as a key factor. Risk awareness perception training (RAPT) has shown effectiveness in improving hazard anticipation for latent hazards. The goal of this study was to determine if RAPT version 3 (RAPT-3) improved intersection turning behaviors among novice teen drivers when the hazards were not latent and frequent glancing to multiple locations at the intersection was needed. Teens aged 16-18 with ≤180 days of licensure were randomly assigned to: 1) an intervention group (n=18) that received RAPT-3 (Trained); or 2) a control group (n=19) that received no training (Untrained). Both groups completed RAPT-3 Baseline Assessment and the Trained group completed RAPT-3 Training and RAPT-3 Post Assessment. Training effects were evaluated on a driving simulator. Simulator (gap selection errors and collisions) and eye tracker (traffic check errors) metrics from six left-turn stop sign controlled intersections in the Simulated Driving Assessment (SDA) were analyzed. The Trained group scored significantly higher in RAPT-3 Post Assessment than RAPT-3 Baseline Assessment (p< 0.0001). There were no significant differences in either traffic check and gap selection errors or collisions among Trained and Untrained teens in the SDA. Though Trained teens learned about hazard anticipation related to latent hazards, learning did not translate to performance differences in left-turn stop sign controlled intersections where the hazards were not latent. Our findings point to further research to better understand the challenges teens have with left turn intersections.

Evaluation of a 3M (mistakes, mentoring, and mastery) training program for transfer of control situations in a level 2 automated driving system.

Drivers must actively supervise automation as it can only function in limited conditions. A failure to supervise the system has negative consequences in terms of missed requests to take over control and may cause crashes or jeopardize safety. The objective of this study is to determine the effect of a novel, 3M (Mistakes, Mentoring, and Mastery) training program on drivers' behavior while using level 2 driving automation systems. To achieve this, 36 participants were assigned randomly to three different training programs (3M training, User manual, and Placebo) and drove through scenarios on a fixed-based driving simulator. The results showed that drivers in the 3M training group took back control more effectively when the driving automation system reached its limits compared to drivers who received User manual or Placebo training. Drivers in the 3M training Group also had higher situation awareness and improved trust in automation. The results indicate that an interactive approach to training with regards to vehicle automation can help drivers more safely interact with automation systems.

Novice driver crashes: The relation between putative causal factors, countermeasures, real world implementations, and policy - A case study in simple, scalable solutions.

Novice drivers are at a greatly inflated risk of crashing. This led in the 20th century to numerous attempts to develop training programs that could reduce their crash risk. Yet, none proved effective. Novice drivers were largely considered careless, not clueless. This article is a case study in the United States of how a better understanding of the causes of novice driver crashes led to training countermeasures targeting teen driving behaviors with known associations with crashes. These effects on behaviors were large enough and long-lasting enough to convince insurance companies to develop training programs that they offered around the country to teen drivers. The success of the training programs at reducing the frequency of behaviors linked to crashes also led to several large-scale evaluations of the effect of the training programs on actual crashes. A reduction in crashes was observed. The cumulative effect has now led to state driver licensing agencies considering as a matter of policy both to include items testing the behaviors linked to crashes on licensing exams and to require training on safety critical behaviors. The effort has been ongoing for over a quarter century and is continuing. The case study highlights the critical elements that made it possible to move from a paradigm shift in the understanding of crash causes to the development and evaluation of crash countermeasures, to the implementation of those crash countermeasures, and to subsequent policy changes at the state and federal level. Key among these elements is the development of simple, scalable solutions.

Furthering decent work by expanding the role of occupational safety and health.

BACKGROUND: The International Labour Organization (ILO) and the United Nations (UN) have promoted the concept of decent work as a Sustainable Development Goal for 2030 to address critical global problems. Occupational safety and health (OSH) are components of decent work, primarily through the ILO social protection objective of the goal, and are linked to various other objectives. OBJECTIVE: This Commentary applies a previously published staging framework to stimulate thinking about how the OSH field can contribute further to the achievement of decent work. METHODS: To advance the contribution of the framework, the different functions of OSH (research, practice, advocacy, governance, and professional education) were used to identify impediments to achieving decent work and develop recommendations for each determinant in the framework. RESULTS: Promoting and achieving decent work are complex issues that require a multifactorial approach. Numerous recommendations supporting systems thinking and transdisciplinary approaches are provided. CONCLUSIONS: The OSH field can expand to further address decent work.

Comparing the Glance Patterns of Older versus Younger Experienced Drivers: Scanning for Hazards while Approaching and Entering the Intersection.

Older drivers are known to look less often for hazards when turning at T-intersections or at four way intersections. The present study is an extension of Romoser & Fisher (2009) and attempts to further analyze the differences in scanning behavior between older and experienced younger drivers in intersections. We evaluated four hypotheses that attempt to explain the older drivers' failure to properly scan in intersections: difficulty with head movements, decreases in working memory capacity, increased distractibility, and failure to recall specific scanning patterns. To test these hypotheses, older and younger experienced drivers' point-of-gaze was monitored while they drove a series of simulated intersections with hidden hazards outside of the turning path. Our results suggest that none of these hypotheses can fully explain our finding that older adults are more likely to remain fixated on their intended path of travel and look less than younger drivers towards other areas where likely hazards might materialize. Instead, the results support a complementary hypothesis that at least some of the difficulties older adults have scanning intersections are due to a specific attentional deficit in the older drivers' ability to inhibit what has become their prepotent goal of monitoring the vehicle's intended path of travel, thereby causing older drivers to fail to scan hazardous areas outside this intended path of travel.

A simulator evaluation of the effects of attention maintenance training on glance distributions of younger novice drivers inside and outside the vehicle.

Driver distraction inside and outside the vehicle is increasingly a problem, especially for younger drivers. In many cases the distraction is associated with long glances away from the forward roadway. Such glances have been shown to be highly predictive of crashes. Ideally, one would like to develop and evaluate a training program which reduced these long glances. Thus, an experiment was conducted in a driving simulator to test the efficacy of a training program, FOCAL, that was developed to teach novice drivers to limit the duration of glances that are inside the vehicle while performing an in-vehicle task, such as looking for a CD or finding the 4-way flashers. The test in the simulator showed that the FOCAL trained group performed significantly better than the placebo trained group on several measures, notably on the percentage of within-vehicle glances that were greater than 2, 2.5, and 3 s. However, the training did not generalize to glances away from the roadway (e.g., when drivers were asked to attend to a sign adjacent to the roadway, both trained and untrained novice drivers were equally likely to make especially long glances at the sign).

Executive Functioning as a Predictor of Adverse Driving Outcomes in Teen Drivers With ADHD.

OBJECTIVE: The present study examined the association between executive functioning (EF) and risky driving behaviors in teens with ADHD. METHOD: Teens diagnosed with ADHD (n = 179; Mage = 17.4 years) completed two 15-min drives in a fixed-base driving simulator. EF was assessed using parent- and self-report Behavior Rating Inventory of Executive Functioning (BRIEF-2), a temporal reproduction task, and a Go/No-Go task (GNG). Driving outcomes included known predictors of crashes: count of long (>2 s) off-road glances, standard deviation (SD) of lane position (SDLP), mean speed, and SD speed. Generalized linear mixed models, controlling for intelligence and driving experience, were conducted. RESULTS: Higher rates of GNG commission errors predicted higher rates of long off-road glances. Lower parent-rated EF and increased rates of GNG omission errors predicted SDLP. Higher rates of GNG commission errors also predicted faster average driving speed. CONCLUSION: Heterogeneity in EF is associated with differences in teen ADHD risky driving behaviors.

Bar-code verification: reducing but not eliminating medication errors.

Using observation, eye tracking, and clinical simulation with embedded errors, we studied the impact of bar-code verification on error identification and recovery during medication administration. Data supported that bar-code verification may reduce but does not eliminate patient identification (ID) and medication errors during clinical simulation of medication administration.

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.

Do Crashes and Near Crashes in Simulator-Based Training Enhance Novice Drivers' Visual Search for Latent Hazards?

Young drivers (younger than 25 years of age) are overrepresented in crashes. Research suggests that a relevant cause is inadequate visual search for possible hazards that are hidden from view. The objective of this study was to develop and evaluate a low-cost, fixed-base simulator training program that would address this failure. It was hypothesized that elicited crashes in the simulator training would result in better scanning for latent hazards in scenarios that were similar to the training scenarios but situated in a different environment (near transfer), and, to a lesser degree, would result in better scanning in scenarios that had altogether different latent hazards than those contained in the training scenarios (far transfer). To test the hypotheses, 18 trained and 18 untrained young novice drivers were evaluated on an advanced driving simulator (different from the training simulator). The eye movements of both groups were measured. In near transfer scenarios, trained drivers fixated the hazardous region 84% of the time, compared with only 57% of untrained drivers. In far transfer scenarios, trained drivers fixated the hazardous region 71 % of the time, compared with only 53% of untrained drivers. The differences between trained and untrained drivers in both the near transfer scenarios and the far transfer scenarios were significant, with a large effect size in the near transfer scenarios and a medium effect size in the far transfer scenarios [respectively: U = 63.00, p(2-tailed) < .01, r = -.53, and U = 88.00, p(2-tailed)<.05,r = -.39].

Do Advance Yield Markings Increase Safe Driver Behaviors at Unsignalized, Marked Midblock Crosswalks? Driving Simulator Study.

In the United States, 78% of pedestrian crashes occur at noninter-section crossings. As a result, unsignalized, marked midblock crosswalks are prime targets for remediation. Many of these crashes occur under sight-limited conditions in which the view of critical information by the driver or pedestrian is obstructed by a vehicle stopped in an adjacent travel or parking lane on the near side of the crosswalk. Study of such a situation on the open road is much too risky, but study of the situation in a driving simulator is not. This paper describes the development of scenarios with sight limitations to compare potential vehicle-pedestrian conflicts on a driving simulator under conditions with two different types of pavement markings. Under the first condition, advance yield markings and symbol signs (prompts) that indicated "yield here to pedestrians" were used to warn drivers of pedestrians at marked, midblock crosswalks. Under the second condition, standard crosswalk treatments and prompts were used to warn drivers of these hazards. Actual crashes as well as the drivers' point of gaze were measured to determine if the drivers approaching a marked midblock crosswalk looked for pedestrians in the crosswalk more frequently and sooner in high-risk scenarios when advance yield markings and prompts were present than when standard markings and prompts were used. Fewer crashes were found to occur with advance yield markings. Drivers were also found to look for pedestrians much more frequently and much sooner with advance yield markings. The advantages and limitations of the use of driving simulation to study problems such as these are discussed.

Glancing and Stopping Behavior of Motorcyclists and Car Drivers at Intersections.

For the past decade, motorcycle fatalities have risen while other motor vehicle fatalities have declined. Many motorcycle fatalities occurred within intersections after a driver failed to see a motorcyclist. However, little is known about the behavior of motorcyclists when they negotiate an intersection. A study was undertaken to compare the behavior at intersections of an experienced group of motorcyclists when they were operating a motorcycle with their behavior when they were driving a car. Each participant navigated a course through low-volume, open roads. Participants wore eye-tracking equipment to record eye-glance information, and the motorcycle and car were instrumented with an onboard accelerometer and Global Positioning System apparatus. Results showed that participants were more likely to make last glances toward the direction of the most threatening traffic before they made a turn when they were driving a car than when they were riding a motorcycle. In addition, motorcyclists were less likely to come to a complete stop at a stop sign than car drivers. These results suggested that motorcyclists were exposing themselves to unnecessary risk. Specifically, motorcyclists frequently failed to make proper glances and practice optimal riding techniques. The behavior of the motorcyclists was compared with the current Motorcycle Safety Foundation curriculum. The results suggested that threat-response and delayed-apex techniques should be added to the training curriculum.

Predicting Route Choices of Drivers Given Categorical and Numerical Information on Delays Ahead: Effects of Age, Experience, and Prior Knowledge.

In recent years there has been a considerable increase in the systems used to provide real-time traffic information to motorists. Examples of such systems include dynamic message signs and 511 travel information systems. However, such systems can be used to reduce congestion-one of their primary purposes-only if one can predict the route choices of drivers as a function of the information displayed. This simulator study looks at the diversion pattern that occurs when delays are reported ahead on the main route and how these diversion patterns vary as a function of delay times (for numerical delay signs), message content (for categorical delay signs), use of 511, and drivers' familiarity with the alternative route travel times across two different age groups. For numerical delay signs, the study shows that one can reliably predict the diversion frequencies at the different delays and across the different ages; then it is possible for traffic engineers to know ahead of time how likely it is for drivers to take an alternative route. For categorical delay signs, the findings indicate that drivers' knowledge of the alternative route travel time affects the choices of older versus younger or middle-aged adults differently. When the times are not known, the two groups behave differently; when the times are known, the groups behave similarly. This finding suggests that traffic engineers should try where possible to present the alternative route travel times as well as the delays on the main route.

Impact of L2 automated systems on hazard anticipation and mitigation behavior of young drivers with varying levels of Attention Deficit Hyperactivity Disorder symptomatology.

Level 2 (L2) driving automation systems that maintain latitudinal and longitudinal control of the vehicle decrease mental workload and result in drivers failing to monitor and respond to potential roadway hazards. This issue is potentially important for young drivers with symptoms of Attention Deficit Hyperactivity Disorder (ADHD) since they have known difficulties anticipating and mitigating potential hazards on the road, a skill which requires attention. The objective of this study is to investigate how the use of partially automated (L2) systems and manual systems impacts hazard anticipation and mitigation among young drivers with varying levels of ADHD symptomatology. Sixty-eight drivers, classified into two groups - high and low ADHD symptomatology-navigated twice through three scenarios on a driving simulator, once with an L2 and once with a manual system. The results indicated that: (i) the hazard anticipation skills of drivers with both high and low ADHD symptomatology were depressed in the L2 condition relative to the manual condition; (ii) the hazard mitigations skills of drivers with both high and low ADHD symptomatology were depressed in the L2 condition relative to the manual condition on two measures, but improved on a third measure; and (iii) the hazard anticipation and mitigation skills of drivers with high and low ADHD symptomatology were differentially impacted, both within and across the two levels of automation. Taken together, the results indicate the pernicious and often hard to predict consequences of higher levels of automation for different populations of younger drivers.