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Driving and not driving after traumatic brain injury Lisa J' Rapport Department of Psychology, Wayne

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Title: Driving and not driving after traumatic brain injury Lisa J' Rapport Department of Psychology, Wayne


1
Driving (and not driving) after traumatic brain
injuryLisa J. RapportDepartment of Psychology,
Wayne State UniversityDetroit, Michigan

2
Driving (and not driving) after traumatic brain
injury
Rapport
Southeastern Michigan Traumatic Brain Injury
Model System (SEMTBIS)
Supported by the US Department of
Education National Institute on Disability
Research Rehabilitation (H133A970021)
Many thanks Renee Coleman Bryer, Robin Hanks,
Carole Koviak, Cynthia Burt, Rob Kotasek,
Joseph Pellerito, Jr.
3
Why study driving?
  • Fundamental activity of daily living
  • Functional independence
  • Community integration
  • Caregiver and family burden
  • Psychological and physical morbidity
  • Quality of life driving rated highest
  • Ensuring safety of TBI survivors and other
    persons on the road

4
Driving after TBI
  • 40 to 60 of persons with severe acquired brain
    damage return to driving
  • Current study (N 237) 45
  • Rapport, Hanks, Coleman Bryer (2006) 39
  • Coleman (Bryer), Rapport, Ergh, Hanks, Millis,
    Ricker (2002) 46

5
Driving after TBI
  • TBI survivors have a lower rate of relicensure as
    compared to other physically impaired groups.
  • TBI survivors who complete formal driving
    evaluations reintegrate into the driving
    community without increased risk of accident.

6
Possible Outcomes
  • Nondrivers
  • Not competent to resume driving safely
  • Competent to drive but do not resume driving
  • Could become competent to resume driving
  • Drivers
  • Resume driving without increased risk
  • Drive despite safety risks

7
Driving research perspectives
  • Occupational therapists
  • Clinical neuropsychologists
  • Rehabilitation psychologists
  • Physicians
  • Other (predominantly non-clinical)
  • Transportation industry
  • Transportation research specialists (e.g., human
    factors, engineering, etc.)
  • Military

8
Driving Outcomes
  • Driving status driver/non-driver
  • Miles driven
  • Adverse incidents (DMV records and/or
    self-report)
  • Accidents
  • Violations
  • Follow-up data on driving status and community
    integration

9
Theoretical Models of Driving and Driving Fitness
  • Hierarchical Model of Driving (Michon, 1979)
  • Cybernetic Model (Galski et al., 1990)
  • Generally skill focused neglect higher-order
    cognitive and motivational factors
  • No model integrating components of driving on
    which an evaluation should focus and appropriate
    criterion has been widely accepted or rigorously
    tested.

10
Spectrum of driving assessment
  • Initial referral/screening process
  • Clinical evaluation
  • On-road driving evaluation
  • Off-road driving evaluation (e.g., simulation
    paradigms)
  • Psychoeducation
  • Long-term follow up

11
Initial referral/screening
  • Readiness to participate in comprehensive driving
    evaluation
  • National Highway Traffic Safety Administration
    Model driver screenings for
  • Driver licensing agency staff Gross Impairments
    Screening Battery (GRIMPS)
  • Physicians Assessment of Driving-Related Skills
    Battery
  • Designed for older drivers

12
Clinical evaluation
  • Association for Driver Rehabilitation Specialists
    (ADED) Best Practices
  • Components of the clinical evaluation
  • Interview and medical history
  • Physical assessment
  • Visual assessment
  • Cognitive Assessment

13
Cognitive assessment
  • Motor-Free Visual Perception
  • Judgment of Line Orientation (JOLO)
  • Visual Form Discrimination
  • Visual Retention Test
  • Picture Completion
  • Block Design
  • Rey-Osterrieth Complex Figure (copy and recall)
  • Useful Field of View (UFOV)
  • Brake Reaction time
  • Trail Making
  • Digit Symbol/Symbol Digit
  • Stroop
  • Sign reading/Road knowledge
  • Cognitive Behavioral Driver's Inventory (CBDI)
  • Coorabel Program
  • DRIVINGHEALTH Inventory

14
Cognitive assessmentSpecial role of executive
function
  • Risk for accident is moderated by higher-order
    cognitive abilities
  • Self-monitoring, self-assessment, awareness of
    deficit
  • Anticipatory behavior, problem-solving
  • Multi-tasking, mental flexibility
  • Affects functional capacity of other cognitive
    and motor functions

15
Cognitive assessmentSpecial role of executive
function
  • Awareness and compensatory strategies
  • Awareness of deficit may play an essential role
    in self-judgment regarding fitness to drive
  • Link between awareness and driving safety or
    driving status has been largely ignored

16
Driving evaluation after TBI
  • TBI survivors who receive formal driving
    evaluations
  • Current data 21
  • Rapport et al. (2006) 24
  • Fisk et al. (1998) 37 (broadly defined as
    professionally evaluated)

17
Southeastern Michigan TBIMS (SEMTBIS)
  • Preliminary data N 237 TBI survivors
  • Median time post injury 4.6 years (range 6
    months to 15 years)
  • Mean age 45 years (SD 13.3)
  • Mean education 12.0 years (SD 2.1, range 6 to
    18 years).
  • 83 men, 17 women
  • On-road evaluation N 104

18
Predictors of On-road Performance
  • 60 pass rate
  • Age, education, gender small (r lt .10)
  • Months post injury modest
  • Pass/fail (eta .25)
  • On-road total (r .31)
  • Road knowledge/sign reading small
  • Pass/fail (eta .08)
  • On-road total (r .22)

19
Predictors of On-road Performance
  • Strongest correlates of driving total (r)
  • Symbol Digit Modalities .67
  • Trails B .67
  • Brake Reaction time .54
  • UFOV-3 .48
  • Strongest correlates of pass/fail (eta)
  • Symbol Digit Modalities .54
  • Brake Reaction time .52
  • Trails B .46
  • Matrix Reasoning .43
  • UFOV-3 .41

20
Predictors of On-road Performance
?
21
Predictors of Driving Status
  • Unfortunately, predictors of driving status (who
    returns to driving) differ from objective
    predictors of driving fitness.
  • Survivors who obtain a formal driving evaluation
    are more likely to resume driving than those who
    do not,
  • X2(1) 30.98, p lt .001.

22
Predictors of Driving Status
  • Caregivers hold the keys to the car
  • Caregiver perceptions/opinions about survivor
    fitness to drive strongest predictor of survivor
    driving status and miles driven
  • Caregiver perceptions not strongly related to
    objective indices for survivor
  • Survivor perspective Social barriers as main
    reason for cessation of driving

23
Self-report of barriers to resumption of driving
Group x domain F(8, 430) 4.31, p lt .001,
partial eta2 .07.
24
Predictors of Driving Status
  • Relation between survivors perceptions of their
    restrictions and actual contraindications to
    driving is weak
  • Correlation between self-ratings of driving
    ability and neuropsychological functioning r
    .08
  • Self-rating as fit to drive (average or better
    driver)
  • Survivor drivers 96
  • Survivor nondrivers 75
  • Self-ratings of current driving ability as
    better than average or excellent
  • Survivor drivers 65
  • Survivor nondrivers 45

25
Not Driving after TBI
  • We know less about the sequelae of driving
    cessation than we know about resumption of
    driving after TBI.
  • Domains of interest
  • Community integration
  • Moderating/mediating factors
  • Compensatory interventions

26
Driving Community Integration
Subjective Community Integration
Objective Community Integration
Connectedness
Social Mobility
Social Integration
Occupation (vocation)
27
Driving Community Integration
  • Drivers gt non-drivers in objective community
    integration, even after accounting for
  • Injury severity
  • Social support
  • Negative affectivity
  • Use of alternative transportation

28
Driving Community Integration
Subjective Community Integration
Objective Community Integration
Connectedness
Social Mobility
Social Mobility
Connectedness
Social Integration
Social Integration
Occupation (vocation)
Occupation (vocation)
  • Unadjusted effect eta2 .14
  • Adjusted for significant covariates eta2 .12
  • Unadjusted effect eta2 .18
  • Adjusted for significant covariates eta2 .16
  • Unadjusted effect eta2 .03
  • Adjusted for significant covariates eta2 .02
  • Unadjusted effect eta2 n.s.
  • Adjusted for significant covariates eta2 n.s.

29
Use of Alternative Transportation
  • Use of alternative transportation fairly common
  • Endorsed use quite a bit or more
  • Public transportation 31 - 37
  • Private transportation 27.5 - 47
  • Taxis 15 - 19
  • Friends/family drive 52 54

30
Alternative Transportation
  • Non-drivers use alternative transportation more
    than drivers.
  • Modest to strong relation between use of
    alternative transportation and barriers to
    driving (r .39)
  • However, use of alternative transportation
    unrelated to community integration outcomes
    Social mobility, occupation/vocation, social
    integration, or connectedness.

31
Importance of Psychoeducation
  • Valid decisions about driving after TBI require
    knowledge of characteristics that do and do not
    affect fitness to drive
  • TBI survivors who wish to resume driving should
    obtain a driving evaluation
  • To locate Driver Rehabilitation Specialists in
    the United States www.aded.net

32
Current problems
  • Lack of standardization and consensus regarding
    what constitutes a driving evaluation
  • Low rate of referrals for driving evaluation by
    health care professionals
  • Limited knowledge of clinicians and consumers
    about driving assessment
  • Limited TBI-specific research

33
Current problems
  • Current knowledge driving after TBI
  • Predictors of driving status
  • Predictors of driving fitness
  • Predictors of adverse outcomes
  • Very limited knowledge not driving after TBI
  • Long-term consequences of driving cessation to
    community integration
  • Compensatory strategies after cessation
  • Resources availability, effectiveness,
    facilitation, best practices in rehabilitation

34
Challenges/Gaps
  • Criteria for evaluation of fitness to drive
    (reliable and valid methodologies)
  • relevant driving outcomes
  • Focus on sequelae of driving cessation
  • Community integration
  • Moderating/mediating factors
  • Social support
  • Other compensatory resources
  • Identifying invalid barriers to driving
  • Influencing policy and legislation
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