Driving Skills at Licensure and Time to First Crash

BACKGROUND AND OBJECTIVES

Young drivers are overrepresented in crashes, and newly licensed drivers are at high risk, particularly in the months immediately post-licensure. Using a virtual driving assessment (VDA) implemented in the licensing workflow in Ohio, this study examined how driving skills measured at the time of licensure contribute to crash risk post-licensure in newly licensed young drivers.

METHODS

This study examined 16 914 young drivers (<25 years of age) in Ohio who completed the VDA at the time of licensure and their subsequent police-reported crash records. By using the outcome of time to first crash, a Cox proportional hazard model was used to estimate the risk of a crash during the follow-up period as a function of VDA Driving Class (and Skill Cluster) membership.

RESULTS

The best performing No Issues Driving Class had a crash risk 10% lower than average (95% confidence interval [CI] 13% to 6%), whereas the Major Issues with Dangerous Behavior Class had a crash risk 11% higher than average (95% CI 1% to 22%). These results withstood adjusting for covariates (age, sex, and tract-level socioeconomic status indicators). At the same time, drivers licensed at age 18 had a crash risk 16% higher than average (95% CI 6% to 27%).

CONCLUSIONS

This population-level study reveals that driving skills measured at the time of licensure are a predictor of crashes early in licensure, paving the way for better prediction models and targeted, personalized interventions. The authors of future studies should explore time- and exposure-varying risks.

Financial status and travel time to driving schools as barriers to obtaining a young driver license in a state with comprehensive young driver licensing policy

The highest lifetime risk for a motor vehicle crash is immediately after the point of licensure, with teen drivers most at risk. Comprehensive teen driver licensing policies that require completion of driver education and behind-the-wheel training along with Graduated Driver Licensing (GDL) are associated with lower young driver crash rates early in licensure. We hypothesize that lack of financial resources and travel time to driving schools reduce the likelihood for teens to complete driver training and gain a young driver's license before age 18. We utilize licensing data from the Ohio Bureau of Motor Vehicles on over 35,000 applicants between 15.5 and 25 years old collected between 2017 and 2019. This dataset of driving schools is maintained by the Ohio Department of Public Safety and is linked with Census tract-level socioeconomic data from the U.S. Census. Using logit models, we estimate the completion of driver training and license obtainment among young drivers in the Columbus, Ohio metro area. We find that young drivers in lower-income Census tracts have a lower likelihood to complete driver training and get licensed before age 18. As travel time to driving schools increases, teens in wealthier Census tracts are more likely to forgo driver training and licensure than teens in lower-income Census tracts. For jurisdictions aspiring to improve safe driving for young drivers, our findings help shape recommendations on policies to enhance access to driver training and licensure especially among teens living in lower-income Census tracts.

An event-based magnetoencephalography study of simulated driving: Establishing a novel paradigm to probe the dynamic interplay of executive and motor function

Magnetoencephalography (MEG) is particularly well-suited to the study of human motor cortex oscillatory rhythms and motor control. However, the motor tasks studied to date are largely overly simplistic. This study describes a new approach: a novel event-based simulated drive made operational via MEG compatible driving simulator hardware, paired with differential beamformer methods to characterize the neural correlates of realistic, complex motor activity. We scanned 23 healthy individuals aged 16-23 years (mean age = 19.5, SD = 2.5; 18 males and 5 females, all right-handed) who completed a custom-built repeated trials driving scenario. MEG data were recorded with a 275-channel CTF, and a volumetric magnetic resonance imaging scan was used for MEG source localization. To validate this paradigm, we hypothesized that pedal-use would elicit expected modulation of primary motor responses beta-event-related desynchronization (B-ERD) and movement-related gamma synchrony (MRGS). To confirm the added utility of this paradigm, we hypothesized that the driving task could also probe frontal cognitive control responses (specifically, frontal midline theta [FMT]). Three of 23 participants were removed due to excess head motion (>1.5 cm/trial), confirming feasibility. Nonparametric group analysis revealed significant regions of pedal-use related B-ERD activity (at left precentral foot area, as well as bilateral superior parietal lobe: p < .01 corrected), MRGS (at medial precentral gyrus: p < .01 corrected), and FMT band activity sustained around planned braking (at bilateral superior frontal gyrus: p < .01 corrected). This paradigm overcomes the limits of previous efforts by allowing for characterization of the neural correlates of realistic, complex motor activity in terms of brain regions, frequency bands and their dynamic temporal interplay.

Using human factors principles to redesign a 3D lab workflow during the COVID-19 pandemic

Background

Like most hospitals, our hospital experienced COVID-19 pandemic-related supply chain shortages. Our additive manufacturing lab’s capacity to offset these shortages was soon overwhelmed, leading to a need to improve the efficiency of our existing workflow. We undertook a work system analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) construct which is based on human factors and quality improvement principles. Our objective was to understand the inefficiencies in project submission, review, and acceptance decisions, and make systematic improvements to optimize lab operations.

Methods

Contextual inquiry (interviews and workflow analysis) revealed suboptimal characteristics of the system, specifically, reliance on a single person to facilitate work and, at times, fractured communication with project sponsors, with root causes related to the project intake and evaluation process as identified through SEIPS tools. As interventions, the analysis led us to: 1) enhance an existing but underused project submission form, 2) design and implement an internal project scorecard to standardize evaluation of requests, and 3) distribute the responsibility of submission evaluation across lab members. We implemented these interventions in May 2021 for new projects and compare them to our baseline February 1, 2018 through – April 30, 2021 performance (1184 days).

Results

All project requests were submitted using the enhanced project submission form and all received a standardized evaluation with the project scorecard. Prior to interventions, we completed 35/79 (44%) of projects, compared to 12/20 (60%) of projects after interventions were implemented. Time to review new submissions was reduced from an average of 58 days to 4 days. A more distributed team responsibility structure permitted improved workflow with no increase in staffing, allowing the Lab Manager to devote more time to engineering rather than administrative/decision tasks.

Conclusions

By optimizing our workflows utilizing a human factors approach, we improved the work system of our additive manufacturing lab to be responsive to the urgent needs of the pandemic. The current workflow provides insights for labs aiming to meet the growing demand for point-of-care manufacturing.

Examining virtual driving test performance and its relationship to individuals with HIV-associated neurocognitive disorders

Significance

Existing screening tools for HIV-associated neurocognitive disorders (HAND) are often clinically impractical for detecting milder forms of impairment. The formal diagnosis of HAND requires an assessment of both cognition and impairment in activities of daily living (ADL). To address the critical need for identifying patients who may have disability associated with HAND, we implemented a low-cost screening tool, the Virtual Driving Test (VDT) platform, in a vulnerable cohort of people with HIV (PWH). The VDT presents an opportunity to cost-effectively screen for milder forms of impairment while providing practical guidance for a cognitively demanding ADL.

Objectives

We aimed to: (1) evaluate whether VDT performance variables were associated with a HAND diagnosis and if so; (2) systematically identify a manageable subset of variables for use in a future screening model for HAND. As a secondary objective, we examined the relative associations of identified variables with impairment within the individual domains used to diagnose HAND.

Methods

In a cross-sectional design, 62 PWH were recruited from an established HIV cohort and completed a comprehensive neuropsychological assessment (CNPA), followed by a self-directed VDT. Dichotomized diagnoses of HAND-specific impairment and impairment within each of the seven CNPA domains were ascertained. A systematic variable selection process was used to reduce the large amount of VDT data generated, to a smaller subset of VDT variables, estimated to be associated with HAND. In addition, we examined associations between the identified variables and impairment within each of the CNPA domains.

Results

More than half of the participants (N = 35) had a confirmed presence of HAND. A subset of twenty VDT performance variables was isolated and then ranked by the strength of its estimated associations with HAND. In addition, several variables within the final subset had statistically significant associations with impairment in motor function, executive function, and attention and working memory, consistent with previous research.

Conclusion

We identified a subset of VDT performance variables that are associated with HAND and assess relevant functional abilities among individuals with HAND. Additional research is required to develop and validate a predictive HAND screening model incorporating this subset.

Novel use of a virtual driving assessment to classify driver skill at the time of licensure

Motor vehicle crash rates are highest immediately after licensure, and driver error is one of the leading causes. Yet, few studies have quantified driving skills at the time of licensure, making it difficult to identify at-risk drivers before independent driving. Using data from a virtual driving assessment implemented into the licensing workflow in Ohio, this study presents the first population-level study classifying degree of skill at the time of licensure and validating these against a measure of on-road performance: license exam outcomes. Principal component and cluster analysis of 33,249 virtual driving assessments identified 20 Skill Clusters that were then grouped into 4 major summary "Driving Classes"; i) No Issues (i.e. careful and skilled drivers); ii) Minor Issues (i.e. an average new driver with minor vehicle control skill deficits); iii) Major Issues (i.e. drivers with more control issues and who take more risks); and iv) Major Issues with Aggression (i.e. drivers with even more control issues and more reckless and risk-taking behavior). Category labels were determined based on patterns of VDA skill deficits alone (i.e. agnostic of the license examination outcome). These Skill Clusters and Driving Classes had different distributions by sex and age, reflecting age-related licensing policies (i.e. those under 18 and subject to GDL and driver education and training), and were differentially associated with subsequent performance on the on-road licensing examination (showing criterion validity). The No Issues and Minor Issues classes had lower than average odds of failing, and the other two more problematic Driving Classes had higher odds of failing. Thus, this study showed that license applicants can be classified based on their driving skills at the time of licensure. Future studies will validate these Skill Cluster classes in relation to their prediction of post-licensure crash outcomes.

Licensing Examination and Crash Outcomes Postlicensure in Young Drivers

IMPORTANCE

Despite US graduated driver licensing laws, young novice driver crash rates remain high. Study findings suggest comprehensive license policy that mandates driver education including behind-the-wheel (BTW) training may reduce crashes postlicensure. However, only 15 states mandate BTW training.

OBJECTIVE

To identify differences in licensing and crash outcomes for drivers younger than 18 years who are subject to comprehensive licensing requirements (graduated driver licensing, driver education, and BTW training) vs those aged 18 to 24 years who are exempt from these requirements.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, population-based cohort study used Ohio licensing data to define a cohort of 2018 license applicants (age 16-24 years, n = 136 643) and tracked licensed driver (n = 129 897) crash outcomes up to 12 months postlicensure. The study was conducted from January 1, 2018, to December 31, 2019, and data analysis was performed from October 7, 2019, to February 11, 2022.

MAIN OUTCOMES AND MEASURES

Licensing examination performance and population-based, police-reported crash rates in the first 2 months and 12 months postlicensure across age groups, sex, and census tract-level sociodemographic variables were measured. Poisson regression models compared newly licensed driver crash rates, with reference to individuals licensed at 18 years, while controlling for census tract-level sociodemographic factors, time spent in the learner permit period, and licensing examination performance measures.

RESULTS

Of 136 643 novice drivers, 69 488 (50.9%) were male and 67 152 (49.1%) were female. Mean (SD) age at enrollment (age at first on-road examination) was 17.7 (2.1) years. License applicants aged 16 and 17 years performed best on license examinations (15 466 [21.6%] and 5112 [30.9%] failing vs 7981 [37.5%] of applicants aged 18 years). Drivers licensed at 18 years had the highest crash rates of all those younger than 25 years. Compared with drivers licensed at 18 years, crash rates were 27% lower in individuals aged 16 years and 14% lower in those aged 17 years during the first 2 months postlicensure when controlling for socioeconomic status, time spent in learner permit status, and license examination performance measures (adjusted relative risk [aRR] at age 16 years: 0.73; 95% CI, 0.67-0.80; age 17 years: aRR, 0.86; 95% CI, 0.77-0.96). At 12 months postlicensure, crash rates were 19% lower for individuals licensed at age 16 years (aRR, 0.81; 95%, CI, 0.77-0.85) and 6% lower at age 17 years (aRR, 0.94; 95% CI, 0.89-0.99) compared with individuals aged 18 years.

CONCLUSIONS AND RELEVANCE

In Ohio, drivers younger than 18 years who are subject to graduated driver licensing and driver education, including BTW training requirements, had lower crash rates in the first year postlicensure compared with those aged 18 years, with controls applied. These findings suggest that it may be fruitful for future work to reconsider the value of mandated driver license policies, including BTW training, and to examine reasons for delayed licensure and barriers to accessing training.

Scaling and Disseminating Brief Bullying Prevention Programming: Strengths, Challenges, & Considerations

Peer bullying occurs frequently among middle school youth, negatively impacting students and the broader school climate. However, during these years there is a gap in translating empirically supported prevention science into school-based practices. This paper describes how the evidence-based Free2B bullying prevention multi-media assembly was disseminated by a team of educators, researchers, and technologists to over 14,000 students in 40 middle schools across the state. This dissemination and scaling effort was conducted in partnership with the state's government officials and Office of Safe Schools in order to ensure that each school and district across the state had equal access in applying for the programming. Over half of participating students expressed concerns about school bullying, with 36% reporting victimization and 17% reporting perpetration of bullying in the past month. Significant improvements were found in problem-solving knowledge, confidence in being a positive bystander, and sympathy for peer victims. We discuss gender and community setting differences (urban, suburban, rural) in the findings, implications for dissemination and implementation science, and school psychologists' role in disseminating bullying prevention practices.

Understanding clinician strategies for discussing driving fitness with patients: An initiative to improve provider-patient discussions about safe driving

Objective: A frequently overlooked factor contributing to traffic crashes is driver medical conditions, including cognitive and physical impairments, which can compromise individuals' ability to drive safely. Clinicians are in a critical position (and often legally mandated) to identify patients with impairments that may affect their driving ability and counsel them on appropriate next steps. However, prior studies revealed that provider-patient discussions about driving occurred relatively infrequently and that clinician recommendations about when patients could resume driving varied substantially (Chen et al. 2008; Drazkowski et al. 2010). This research aimed to document current driver fitness assessment practices among neurology and neurosurgery clinicians at an academic medical center, with the overall purpose of informing quality improvement efforts.Methods: A cross-sectional, anonymous survey was distributed to physicians and advanced practice providers working in the neurosurgery and neurology departments of a large, Pennsylvania-based academic medical center. Survey question domains included: 1) frequency of discussions about driving, 2) comfort discussing driving with patients, 3) criteria used to assess patient fitness to drive, 4) driver rehabilitation program referral practices, and 5) Pennsylvania Department of Transportation (PennDOT) reporting.Results: The survey revealed that although most providers (68%) had high levels of perceived responsibility for counseling patients about driving, a minority regularly discussed driving issues with their patients (19% prior to discharge, 49% during clinic visits). In addition, only about half (54%) of providers reported having ever filed a report about a patient with the PennDOT, despite Pennsylvania's mandatory driver reporting law. Likelihood of PennDOT reporting was found to be strongly associated with provider knowledge of Pennsylvania unsafe driver reporting laws (p < 0.001).Conclusions: These findings highlight a need to enhance standard of care practices related to driver screening, counseling, and reporting. Overall, providers recognized the importance of their role in advising patients about safe driving and desired standardized protocols for guiding conversations about driving with patients, PennDOT reporting, and referring patients to driver rehabilitation services.

SPRINTing to Innovation: Children's Hospital of Philadelphia's Strategic Approach to Discovering Its Untapped Innovation Potential

PROBLEM

There is a clear and urgent need for health care innovation in the United States. Hospital employees routinely recognize pain points that affect care delivery and are in a unique position to propose innovative and practical solutions, yet leaders rarely solicit ideas for investment and development from frontline providers and staff, revealing an untapped resource with innovation potential.

APPROACH

To address these deficiencies, the Children's Hospital of Philadelphia expanded its innovation infrastructure with the competition-based SPRINT program in 2015. All hospital employees are encouraged to apply with early-stage innovative ideas, and if selected, are provided with business, legal, technical, and scientific project management support to help accelerate their projects toward commercial viability. SPRINT was modeled around 4 core tenets: (1) small, dynamic, and attentive project manager-led teams; (2) low barriers to entry; (3) emphasis on outreach; and (4) fostering innovators.

OUTCOMES

Over its first 4 cycles from 2015 to 2018, 271 innovative teams applied to the SPRINT program, which led to support for 30 projects (11% acceptance rate). About a quarter of the projects each year were submitted by physician-led teams (mean 23%), a third by nonphysician clinical providers (mean 33%), and almost half were submitted by employees without direct patient contact (mean 44%). Nurses have emerged as the largest applicant group. Eleven of the SPRINT-supported projects (37%) resulted in commercial endpoints.

NEXT STEPS

SPRINT has proven to be an effective model for supporting institution-wide, employee-driven health care innovation, especially among frontline clinical and nonclinical personnel. Critical next steps for the program include a formal cost-benefit analysis and the earlier participation of technology transfer and intellectual property experts to improve the commercialization roadmap for many SPRINT projects.

A Novel Health-Transportation Partnership Paves The Road For Young Driver Safety Through Virtual Assessment

Motor vehicle crashes remain the leading cause of adolescent mortality and injury in the United States. For young drivers, crash risk peaks immediately after licensure and declines during the next two years, making the point of licensure an important safety intervention opportunity. Legislation in Ohio established a unique health-transportation partnership among the State of Ohio, Children's Hospital of Philadelphia, and Diagnostic Driving, Inc., to identify underprepared driver license applicants through a virtual driving assessment system. The system, a computer-based virtual driving test, exposes drivers to common serious crash scenarios to identify critical skill deficits and is delivered in testing centers immediately before the on-road examination. A pilot study of license applicants who completed it showed that the virtual driving assessment system accurately predicted which drivers would fail the on-road examination and provided automated feedback that informed drivers on their skill deficits. At this time, the partnership's work is informing policy changes around integrating the virtual driving assessment system into licensing and driver training with the aim of reducing crashes in the first months of independent driving. The system can be developed to identify deficits in safety-critical skills that lead to crashes in new drivers and to address challenges that the coronavirus disease 2019 pandemic has introduced to driver testing and training.

The Free2B Multi-Media Bullying Prevention Experience: An Exemplar of Scientific Edutainment

OBJECTIVE

The objective of the current article is to highlight an example of a new paradigm, Scientific Edutainment. The manuscript describes how educational researchers and technologists worked together to develop a multi-media bullying prevention experience, called Free2B for middle school students paying particular attention to ensure that the programming was not only relevant to all students but also was appealing and responsive to the needs of urban youth. Bullying is the most common form of aggression experienced among school-aged youth, which impairs students' learning and social-emotional functioning and has financial costs to society. Given that the prevalence of bullying is highest in middle school, finding brief and feasible methods for motivating and sustaining change at this age is critically important, especially in the case of urban, under-resourced schools.

METHOD

In response to this challenge, multidisciplinary bullying prevention researchers collaborated with international technologists to develop the Free2B multi-media bullying prevention experience through an iterative Community-Based Participatory Research (CBPR) approach. In addition, the research team conducted a series of pilot studies to iteratively develop and initially evaluate the multi-media program, helping to ensure relevance specifically for urban middle school youth.

RESULTS

Results from the pilot studies indicated that the vast majority of middle school students found the Free2B multi-media bullying prevention experience to be enjoyable, relevant to their needs, and addressed important strategies to handle peer bullying and victimization. In addition, the brief prevention experience was associated with increases in problem-solving knowledge, prosocial attitudes about bullying, increased sympathy, and confidence in handling peer conflicts.

CONCLUSION

The current paper illustrates the use of a new paradigm, termed Scientific Edutainment, as a way to combine evidenced-based developmental science with the latest in entertainment technology to provide innovative, engaging, and technologically-sophisticated educational programming.

Working Memory Development and Motor Vehicle Crashes in Young Drivers

IMPORTANCE

Adolescent drivers have the highest rate of motor vehicle crashes, and among equally novice drivers, crash risk is inversely age graded. Working memory (WM), crucial to driving hazard awareness, is also age graded, with ongoing development into late adolescence. Variability in WM capacity and growth trajectory positions WM as a candidate crash risk factor for study, clinical screening, and possible preventative intervention.

OBJECTIVE

To test the association between crashes and differential WM development.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study used data from a longitudinal cohort of 118 community youth in Philadelphia, Pennsylvania. Working memory and other risk factors were measured annually from age 11 to 13 years (prelicensure, in 2005) to 14 to 16 years (in 2009), and again at 18 to 20 years (in 2013). In 2015, a follow-up survey of driving experience identified 84 participants who had started driving. Latent growth curve modeling was used to examine the association between variability in the baseline (intercept) and developmental trajectory (slope) of WM and the crash outcome.

MAIN OUTCOMES AND MEASURES

Self-reported crashes were the primary outcome. Variability in the relative growth of WM development along with traits and behaviors associated with risky driving were assessed.

RESULTS

Of 84 participants (39 [46%] male; mean [SD] age, 20.46 [1.09] years), 25 (29.8%) reported they had been involved in at least 1 crash. Controlling for other crash risk factors, the model indicated that variation in the linear slope of WM growth was inversely associated with reporting a crash (b = -6.41; SE = 2.64; P = .02). Crashes were also associated with reckless driving behavior (b = 0.40; SE = 0.18; P = .03). Variation in the intercept of WM was not associated with crashes (b = -0.245; SE = 0.67; P = .72).

CONCLUSIONS AND RELEVANCE

The results suggest that a relatively slower WM growth trajectory is associated with young driver crashes. Routine assessment of WM across adolescence may help to identify at-risk teen drivers and opportunities for providing adaptive interventions (eg, driving aids or training) that can address limitations in WM-related skills that are critical for safe driving.

Safety at the edge: a safety framework to identify edge conditions in the future transportation system with highly automated vehicles

Automated driving systems (ADS) have the potential for improving safety but also pose the risk of extending the transportation system beyond its edge conditions, beyond the operating conditions (operational design domain (ODD)) under which a given ADS or feature thereof is specifically designed to function. The ODD itself is a function of the known bounds and the unknown bounds of operation. The known bounds are those defined by vehicle designers; the unknown bounds arise based on a person operating the system outside the assumptions on which the vehicle was built. The process of identifying and mitigating risk of possible failures at the edge conditions is a cornerstone of systems safety engineering (SSE); however, SSE practitioners may not always account for the assumptions on which their risk mitigation resolutions are based. This is a particularly critical issue with the algorithms developed for highly automated vehicles (HAVs). The injury prevention community, engineers and designers must recognise that automation has introduced a fundamental shift in transportation safety and requires a new paradigm for transportation epidemiology and safety science that incorporates what edge conditions exist and how they may incite failure. Towards providing a foundational organising framework for the injury prevention community to engage with HAV development, we propose a blending of two classic safety models: the Swiss Cheese Model, which is focused on safety layers and redundancy, and the Haddon Matrix, which identifies actors and their responsibilities before, during and after an event.

The Cellie Coping Kit for Children with Injury: Initial feasibility, acceptability, and outcomes

PURPOSE

Physical and psychological challenges can arise from paediatric injury, which can impact child health outcomes. Evidence-based resources to promote recovery are limited. The low cost, portable Cellie Coping Kit for Children with Injury provides evidence-based strategies to help children manage injury-related challenges. This study aimed to describe intervention feasibility and explore initial outcomes (learning, quality of life [QOL], and trauma symptoms).

METHODS

Three independent pilot studies were conducted. Child-parent dyads (n = 61) participated in the intervention; ~36% completed a 4-week follow-up assessment.

RESULTS

Results suggested that the intervention was feasible (e.g., 95% of parents would recommend the intervention; >85% reported that it was easy to use). Over 70% of participants reported learning new skills. No statistically significant differences were detected for children's QOL or trauma symptoms preintervention to postintervention.

CONCLUSION

Preliminary research suggests that the Cellie Coping Kit for Children with Injuries is a feasible, low-cost, preventive intervention, which may provide families with strategies to promote recovery from paediatric injury. Future research, including a randomized controlled trial, ought to further examine targeted long-term intervention outcomes.

Attitudes on technological, social, and behavioral economic strategies to reduce cellphone use among teens while driving

OBJECTIVE

The majority of U.S. teens admit to handheld cellphone use while driving, an increasingly common cause of crashes. Attitudes toward novel cellphone applications and settings that block use while driving are poorly understood, potentially limiting uptake. We examined teens' willingness to reduce cellphone use while driving and perceptions of potential strategies to limit this behavior.

METHODS

Teen drivers (n = 153) aged 16-17 who owned smartphones and admitted to texting while driving completed an online survey. Survey instruments measured willingness to give up cellphone use and perceptions of technological and behavioral economic strategies to reduce cellphone use while driving. We used chi-square tests to test the hypothesis that willingness to give up certain types of cellphone use while driving and the perceptions of strategies to reduce cellphone use while driving would differ by self-reported frequency of texting while driving in the past 30 days (low [1-5 days] vs. high [6 or more days]).

RESULTS

Most teens were willing or somewhat willing to give up reading texts (90%), sending texts (95%), and social media (99%) while driving. However, they were not willing to give up navigation (59%) and music applications (43%). Those who engaged in high-frequency texting while driving were more likely to say that they were not willing to give up navigation applications (73 vs. 44%, P <.001), music applications (54 vs. 32%, P <.001), and reading texts (15 vs. 4%, P =.029). Overall, the following strategies where rated as likely to be very effective for reducing texting while driving: gain-framed financial incentives (75%), loss-framed financial incentives (63%), group-based financial incentives (58%), insurance discounts (53%), automatic phone locking while driving (54%), e-mail notifications to parents (47%), automated responses to incoming texts (42%), peer concern (18%), and parental concern (15%). Those who engaged in high-frequency texting while driving were less likely to say that following strategies would be very effective: automated responses to incoming texts (33 vs. 53%, P =.016), peer concern (9 vs. 29%, P =.002), and parental concern (9 vs. 22%, P =.025). The strongest perceived benefit of cellphone blocking apps was decreasing distraction (86%). The predominant reason for not wanting to use this technology was not wanting parents to monitor their behavior (60%).

CONCLUSIONS

Promising strategies for increasing acceptance of cellphone blocking technology among teen drivers include automated screen locking and permitting hands-free navigation and music combined with behavioral economic incentives to sustain engagement.

Diagnostic Accuracy of Pediatric Teledermatology Using Parent-Submitted Photographs: A Randomized Clinical Trial

Importance

Advances in smartphone photography (both quality and image transmission) may improve access to care via direct parent-to-clinician telemedicine. However, the accuracy of diagnoses that are reliant on parent-provided photographs has not been formally compared with diagnoses made in person.

Objective

To assess whether smartphone photographs of pediatric skin conditions taken by parents are of sufficient quality to permit accurate diagnosis.

Design, Setting, and Participants

A prospective study was conducted among 40 patient-parent dyads at a pediatric dermatology clinic at the Children's Hospital of Philadelphia from March 1 to September 30, 2016, to assess concordance between diagnoses made by an independent pediatric dermatologist based on in-person examination and those based on parental photographs. Half of the patient-parent dyads were randomized for a secondary analysis to receive instructions on how best to take photographs with smartphones. Clinicians were blinded to whether parents had received photography instructions.

Exposures

Half of the patient-parent dyads received a simple, 3-step instruction sheet on how best to take photographs using a smartphone (intervention group); the other half did not (control group).

Main Outcomes and Measures

Concordance between photograph-based vs in-person diagnosis in the intervention vs control groups, as quantified using Cohen κ, a measure of interrater agreement that takes into account the possibility of agreement occurring by chance.

Results

Among the 40 patient-parent dyads (22 female children and 18 male children; mean [SD] age, 6.96 [5.23] years), overall concordance between photograph-based vs in-person diagnosis was 83% (95% CI, 71%-94%; κ = 0.81). Diagnostic concordance was 89% (95% CI, 75%-97%; κ = 0.88) in a subgroup of 37 participants with photographs considered of high enough quality to make a diagnosis. No statistically significant effect of photography instructions on concordance was detected (group that received instructions, 85%; group that did not receive instructions, 80%; P = .68). In cases of diagnostic disagreement, appropriate follow-up was suggested.

Conclusions and Relevance

Parent-operated smartphone photography can accurately be used as a method to provide pediatric dermatologic care.

Trial Registration

clinicaltrials.gov Identifier: NCT03246945.

Executive Function Capacities, Negative Driving Behavior and Crashes in Young Drivers

Motor vehicle crashes remain a leading cause of injury and death in adolescents, with teen drivers three times more likely to be in a fatal crash when compared to adults. One potential contributing risk factor is the ongoing development of executive functioning with maturation of the frontal lobe through adolescence and into early adulthood. Atypical development resulting in poor or impaired executive functioning (as in Attention-Deficit/Hyperactivity Disorder) has been associated with risky driving and crash outcomes. However, executive function broadly encompasses a number of capacities and domains (e.g., working memory, inhibition, set-shifting). In this review, we examine the role of various executive function sub-processes in adolescent driver behavior and crash rates. We summarize the state of methods for measuring executive control and driving outcomes and highlight the great heterogeneity in tools with seemingly contradictory findings. Lastly, we offer some suggestions for improved methods and practical ways to compensate for the effects of poor executive function (such as in-vehicle assisted driving devices). Given the key role that executive function plays in safe driving, this review points to an urgent need for systematic research to inform development of more effective training and interventions for safe driving among adolescents.

Motor Vehicle Crash Risk Among Adolescents and Young Adults With Attention-Deficit/Hyperactivity Disorder

IMPORTANCE

Attention-deficit/hyperactivity disorder (ADHD) often persists into adolescence, when motor vehicle crash risk peaks. We know little about when adolescents with ADHD get licensed and, once they do, the extent to which they have increased crash risk compared with adolescents without ADHD.

OBJECTIVES

To examine the association between ADHD and both driver licensing and crash involvement and whether it varies by sex, licensing age, and/or being prescribed ADHD medication at licensure.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted at 6 primary care practices of the Children's Hospital of Philadelphia, a large pediatric health care network in southeastern Pennsylvania and southern New Jersey. Using electronic health records, we defined a cohort of 2479 adolescents and young adults with ADHD and 15 865 without ADHD who were (1) born from 1987 to 1997; (2) residents of New Jersey and patients at 1 of 6 New Jersey primary care practices at age 12 years or older; and (3) age-eligible to obtain a driver's license from 2004 through 2014. Electronic health records data were then linked with New Jersey's statewide driver licensing and crash databases for 2004 through 2014.

MAIN OUTCOMES AND MEASURES

Acquisition of a driver's license and first involvement as a driver in a police-reported crash. Survival analysis was used to estimate adjusted hazard ratios for licensing and crash outcomes through age 25 years.

RESULTS

The median age of individuals at the end of the study was 22.2 years (interquartile range, 19.7-24.8). Compared with individuals without ADHD, the licensing probability of individuals with ADHD 6 months after eligibility was 35% lower (for males: adjusted hazard ratio, 0.65; 95% CI, 0.61-0.70; females: adjusted hazard ratio, 0.64; 95% CI, 0.58-0.70). Among individuals with a driver's license, 764 of 1785 with ADHD (42.8%) and 4715 of 13 221 without ADHD (35.7%) crashed during the study period. The adjusted risk for first crash among licensed drivers with ADHD was 1.36 times higher than for those without ADHD (95% CI, 1.25-1.48) and did not vary by sex, licensing age, or over time. Only 129 individuals with ADHD (12.1%) were prescribed medication in the 30 days before licensure.

CONCLUSIONS AND RELEVANCE

Adolescents with ADHD get licensed less often and at an older age. Once licensed, this cohort has a greater risk of crashing. Additional research is needed to understand the specific mechanisms by which ADHD influences crash risk.

Wearable health device dermatitis: a case of acrylate-related contact allergy

The popularity of mobile wearable health devices has skyrocketed. Some of these devices are worn on the wrist and have been associated with the development of allergic contact dermatitis. Although nickel has been the suspected culprit in cases reported by the media for consumers, we present a rare report of a patient who developed a localized contact dermatitis that was linked to acrylate allergy on epicutaneous patch testing. We surmise that the source of this acrylate might derive from leaching of this compound from the rechargeable battery housing given its correspondence to where the rash arose.

Road safety perspectives among employees of a multinational corporation in urban India: local context for global injury prevention

In rapidly developing economies, like urban India, where road traffic injury rates are among the world's highest, the corporate workplace offers a non-traditional venue for road safety interventions. In partnership with a major multinational corporation (MNC) with a large Indian workforce, this study aimed to elicit local employee perspectives on road safety to inform a global corporate health platform. The safety attitudes and behaviours of 75 employees were collected through self-report survey and focus groups in the MNC offices in Bangalore and Pune. Analysis of these data uncovered incongruity between employee knowledge of safety strategies and their enacted safety behaviours and identified local preference for interventions and policy-level actions. The methods modelled by this study offer a straightforward approach for eliciting employee perspective for local road safety interventions that fit within a global strategy to improve employee health. Study findings suggest that MNCs can employ a range of strategies to improve the road traffic safety of their employees in settings like urban India including: implementing corporate traffic safety policy, making local infrastructure changes to improve road and traffic conditions, advocating for road safety with government partners and providing employees with education and access to safety equipment and safe transportation options.

Application of a Framework to Implement Trauma-Informed Care Throughout a Pediatric Health Care Network

INTRODUCTION

To evaluate the initial application of a recently published three-step framework for implementing trauma-informed care (TIC) in a pediatric health care network by applying Framework for Spread.

METHODS

In steps 1 and 2 of the framework, we established commitment from the health care network leadership and initial interest in TIC among clinical providers (step 1), set evidence-based training goals and created the associated TIC training content (step 2). In step 3, 440 health care professionals (from 27 health care teams) participated in single-session, 1-hour training that covered the psychological impact of injury- and illness-related trauma, identification of traumatic stress symptoms, and how to respond to children exposed to potentially traumatic events. A concomitant quality improvement project allowed us to assess potential changes in training participants' favorable attitudes toward the integration of TIC and confidence in delivering TIC.

RESULTS

Compared with pretraining, participants demonstrated increases in attitude toward TIC, t(293) = 5.8, P < .001, Cohen's d = 0.32, and confidence in delivering TIC, t(293) = 20.9, P < .001, Cohen's d = 1.09.

DISCUSSION

Trainings were effective in achieving proximal goals targeting attitudes and confidence, thereby demonstrating the feasibility and clinical relevance of TIC training when implemented according to the three-step framework. Future research should examine methods of training to reach wide audiences to promote systematic change and evaluate changes in patient outcomes associated with providers' implementation of TIC.

Parental influence on driver licensure in adolescence: A randomized controlled trial

OBJECTIVE

Newly licensed adolescent drivers have skill deficits that increase risk for motor vehicle crashes. Development of programs targeted to prelicensed adolescents has been hindered by concerns about encouraging overconfidence and early licensure. The study had 2 primary objectives: (a) determine whether an Internet-based intervention designed to improve parent-supervised practice (TeenDrivingPlan [TDP]) influenced adolescents' time to licensure and parents' perceptions of adolescents' driving skill, expertise, and safety and (b) evaluate the association of these perceptions and practice diversity (number of different environments where practiced occurred) with time to licensure.

METHOD

A randomized controlled trial was used to compare TDP with a control condition. Participants (N = 295 parent-adolescent dyads) completed periodic surveys over 24 weeks and were subsequently followed for up to a year to determine adolescents' licensure status.

RESULTS

TDP did not influence time to licensure and did not affect parents' perceptions of skill, expertise, and safety. Practice diversity was associated with faster licensure. A more favorable perception of adolescents' skill in comparison to peers was associated with faster licensure.

CONCLUSIONS

Targeting parents' beliefs about adolescents' safety in relation to other road users may not be conducive to altering licensing trajectories, whereas sensitizing parents to their adolescents' emerging skills might be more effective in promoting safe entry into licensure. (PsycINFO Database Record

The role of appraisals and coping in predicting posttraumatic stress following pediatric injury

OBJECTIVE

Given the millions of children who experience potentially traumatic injuries each year and the need to maximize emotional and physical health outcomes following pediatric injury, the current study examined the individual and collective contributions of the malleable variables of appraisals and coping in predicting posttraumatic stress symptoms (PTSS) in children following injury.

METHOD

This study combined data from 3 prospective investigations of recovery from pediatric injury (N = 688) in which children ages 8-17 years were recruited shortly after an injury (within 4 weeks). At baseline (T1), children completed measures of their threat appraisals of the injury event and PTSS. Six to twelve weeks later (T2), children completed a measure of coping and PTSS. Finally, PTSS was assessed again 6 months post-injury (T3).

RESULTS

Structural equation modeling analyses provide evidence that appraisals and coping contribute to PTSS. Furthermore, results suggest that escape coping mediates the relationship between threat appraisals and PTSS.

CONCLUSIONS

Early interventions designed to prevent or reduce PTSS after pediatric injury may be more successful if they primarily target modifying escape coping behaviors. To best inform clinical practice, future research should examine factors influencing the development of children's appraisals and coping behaviors in the context of potentially traumatic events. (PsycINFO Database Record

Pilot Randomized Controlled Trial of a Novel Web-Based Intervention to Prevent Posttraumatic Stress in Children Following Medical Events

OBJECTIVE

To assess feasibility and estimate effect size of a self-directed online intervention designed to prevent persistent posttraumatic stress after acute trauma.

METHODS

Children aged 8-12 years with a recent acute medical event were randomized to the intervention (N = 36) or a 12-week wait list (N = 36). Posttraumatic stress, health-related quality of life, appraisals, and coping were assessed at baseline, 6, 12, and 18 weeks.

RESULTS

Most children used the intervention; half completed it. Medium between-group effect sizes were observed for change in posttraumatic stress severity from baseline to 6 weeks (d = -.68) or 12 weeks (d = -.55). Exploratory analyses suggest greatest impact for at-risk children, and a small effect for intervention initiated after 12 weeks. Analysis of covariance did not indicate statistically significant group differences in 12-week outcomes.

CONCLUSIONS

This pilot randomized controlled trial provides preliminary evidence that a self-directed online preventive intervention is feasible to deliver, and could have an effect in preventing persistent posttraumatic stress.

Implementing a Trauma-Informed Approach in Pediatric Health Care Networks

Pediatric health care networks serve millions of children each year. Pediatric illness and injury are among the most common potentially emotionally traumatic experiences for children and their families. In addition, millions of children who present for medical care (including well visits) have been exposed to prior traumatic events, such as violence or natural disasters. Given the daily challenges of working in pediatric health care networks, medical professionals and support staff can experience trauma symptoms related to their work. The application of a trauma-informed approach to medical care has the potential to mitigate these negative consequences. Trauma-informed care minimizes the potential for medical care to become traumatic or trigger trauma reactions, addresses distress, provides emotional support for the entire family, encourages positive coping, and provides anticipatory guidance regarding the recovery process. When used in conjunction with family-centered practices, trauma-informed approaches enhance the quality of care for patients and their families and the well-being of medical professionals and support staff. Barriers to routine integration of trauma-informed approaches into pediatric medicine include a lack of available training and unclear best-practice guidelines. This article highlights the importance of implementing a trauma-informed approach and offers a framework for training pediatric health care networks in trauma-informed care practices.

Use of mobile apps: a patient-centered approach

OBJECTIVES

This study explored what smartphone health applications (apps) are used by patients, how they learn about health apps, and how information about health apps is shared.

METHODS

Patients seeking care in an academic ED were surveyed about the following regarding their health apps: use, knowledge, sharing, and desired app features. Demographics and health information were characterized by summary statistics.

RESULTS

Of 300 participants, 212 (71%) owned smartphones, 201 (95%) had apps, and 94 (44%) had health apps. The most frequently downloaded health apps categories were exercise 46 (49%), brain teasers 30 (32%), and diet 23 (24%). The frequency of use of apps varied as six (6%) of health apps were downloaded but never used, 37 (39%) apps were used only a few times, and 40 (43%) health apps were used once per month. Only five apps (2%) were suggested to participants by health care providers, and many participants used health apps intermittently (55% of apps ≤ once a month). Participants indicated sharing information from 64 (59%) health apps, mostly within social networks (27 apps, 29%) and less often with health care providers (16 apps, 17%).

CONCLUSIONS

While mobile health has experienced tremendous growth over the past few years, use of health apps among our sample was low. The most commonly used apps were those that had broad functionality, while the most frequently used health apps encompassed the topics of exercise, diet, and brain teasers. While participants most often shared information about health apps within their social networks, information was less frequently shared with providers, and physician recommendation played a small role in influencing patient use of health apps.

A new method for assessing content validity in model-based creation and iteration of eHealth interventions

Background

The advent of eHealth interventions to address psychological concerns and health behaviors has created new opportunities, including the ability to optimize the effectiveness of intervention activities and then deliver these activities consistently to a large number of individuals in need. Given that eHealth interventions grounded in a well-delineated theoretical model for change are more likely to be effective and that eHealth interventions can be costly to develop, assuring the match of final intervention content and activities to the underlying model is a key step. We propose to apply the concept of “content validity” as a crucial checkpoint to evaluate the extent to which proposed intervention activities in an eHealth intervention program are valid (eg, relevant and likely to be effective) for the specific mechanism of change that each is intended to target and the intended target population for the intervention.

Objective

The aims of this paper are to define content validity as it applies to model-based eHealth intervention development, to present a feasible method for assessing content validity in this context, and to describe the implementation of this new method during the development of a Web-based intervention for children.

Methods

We designed a practical 5-step method for assessing content validity in eHealth interventions that includes defining key intervention targets, delineating intervention activity-target pairings, identifying experts and using a survey tool to gather expert ratings of the relevance of each activity to its intended target, its likely effectiveness in achieving the intended target, and its appropriateness with a specific intended audience, and then using quantitative and qualitative results to identify intervention activities that may need modification. We applied this method during our development of the Coping Coach Web-based intervention for school-age children.

Results

In the evaluation of Coping Coach content validity, 15 experts from five countries rated each of 15 intervention activity-target pairings. Based on quantitative indices, content validity was excellent for relevance and good for likely effectiveness and age-appropriateness. Two intervention activities had item-level indicators that suggested the need for further review and potential revision by the development team.

Conclusions

This project demonstrated that assessment of content validity can be straightforward and feasible to implement and that results of this assessment provide useful information for ongoing development and iterations of new eHealth interventions, complementing other sources of information (eg, user feedback, effectiveness evaluations). This approach can be utilized at one or more points during the development process to guide ongoing optimization of eHealth interventions.

Systematic, theoretically-grounded development and feasibility testing of an innovative, preventive web-based game for children exposed to acute trauma

BACKGROUND

Millions of children are affected by acute medical events annually, creating need for resources to promote recovery. While web-based interventions promise wide reach and low cost for users, development can be time- and cost-intensive. A systematic approach to intervention development can help to minimize costs and increase likelihood of effectiveness. Using a systematic approach, our team integrated evidence on the etiology of traumatic stress, an explicit program theory, and a user-centered design process to intervention development.

OBJECTIVE

To describe evidence and the program theory model applied to the Coping Coach intervention and present pilot data evaluating intervention feasibility and acceptability.

METHOD

Informed by empirical evidence on traumatic stress prevention, an overarching program theory model was articulated to delineate pathways from a) specific intervention content to b) program targets and proximal outcomes to c) key longer-term health outcomes. Systematic user-testing with children ages 8-12 (N = 42) exposed to an acute medical event and their parents was conducted throughout intervention development.

RESULTS

Functionality challenges in early prototypes necessitated revisions. Child engagement was positive throughout revisions to the Coping Coach intervention. Final pilot-testing demonstrated promising feasibility and high user-engagement and satisfaction.

CONCLUSION

Applying a systematic approach to the development of Coping Coach led to the creation of a functional intervention that is accepted by children and parents. Development of new e-health interventions may benefit from a similar approach. Future research should evaluate the efficacy of Coping Coach in achieving targeted outcomes of reduced trauma symptoms and improved health-related quality of life.

Simulated Driving Assessment (SDA) for teen drivers: results from a validation study

BACKGROUND

Driver error and inadequate skill are common critical reasons for novice teen driver crashes, yet few validated, standardised assessments of teen driving skills exist. The purpose of this study is to evaluate the construct and criterion validity of a newly developed Simulated Driving Assessment (SDA) for novice teen drivers.

METHODS

The SDA's 35 min simulated drive incorporates 22 variations of the most common teen driver crash configurations. Driving performance was compared for 21 inexperienced teens (age 16-17 years, provisional license ≤90 days) and 17 experienced adults (age 25-50 years, license ≥5 years, drove ≥100 miles per week, no collisions or moving violations ≤3 years). SDA driving performance (Error Score) was based on driving safety measures derived from simulator and eye-tracking data. Negative driving outcomes included simulated collisions or run-off-the-road incidents. A professional driving evaluator/instructor (DEI Score) reviewed videos of SDA performance.

RESULTS

The SDA demonstrated construct validity: (1) teens had a higher Error Score than adults (30 vs. 13, p=0.02); (2) For each additional error committed, the RR of a participant's propensity for a simulated negative driving outcome increased by 8% (95% CI 1.05 to 1.10, p<0.01). The SDA-demonstrated criterion validity: Error Score was correlated with DEI Score (r=-0.66, p<0.001).

CONCLUSIONS

This study supports the concept of validated simulated driving tests like the SDA to assess novice driver skill in complex and hazardous driving scenarios. The SDA, as a standard protocol to evaluate teen driver performance, has the potential to facilitate screening and assessment of teen driving readiness and could be used to guide targeted skill training.

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.

EMERGENCY BRAKING IN ADULTS VERSUS NOVICE TEEN DRIVERS: RESPONSE TO SIMULATED SUDDEN DRIVING EVENTS

Motor vehicle crashes remain the leading cause of death in teens in the United States. Newly licensed drivers are the group most at risk for crashes. Their driving skills are very new, still very often untested, so that their ability to properly react in an emergency situation remains a research question. Since it is impossible to expose human subjects to critical life threatening driving scenarios, researchers have been increasingly using driving simulators to assess driving skills. This paper summarizes the results of a driving scenario in a study comparing the driving performance of novice teen drivers (n=21) 16-17 year olds with 90 days of provisional licensure with that of experienced adult drivers (n=17) 25-50 year olds with at least 5 years of PA licensure, at least 100 miles driven per week and no self-reported collisions in the previous 3 years. As part of a 30 to 35 simulated drive that encompassed the most common scenarios that result in serious crashes, participants were exposed to a sudden car event. As the participant drove on a suburban road, a car surged from a driveway hidden by a fence on the right side of the road. To avoid the crash, participants must hard brake, exhibiting dynamic control over both attentional and motor resources. The results showed strong differences between the experienced adult and novice teen drivers in the brake pressure applied. When placed in the same situation, the novice teens decelerated on average 50% less than the experienced adults (p<0.01).

TeenDrivingPlan effectiveness: the effect of quantity and diversity of supervised practice on teens' driving performance

PURPOSE

The large contribution of inexperience to the high crash rate of newly licensed teens suggests that they enter licensure with insufficient skills. In a prior analysis, we found moderate support for a direct effect of a web-based intervention, the TeenDrivingPlan (TDP), on teens' driving performance. The purpose of the present study was to identify the mechanisms by which TDP may be effective and to extend our understanding of how teens learn to drive.

METHODS

A randomized controlled trial conducted with teen permit holders and parent supervisors (N = 151 dyads) was used to determine if the effect of TDP on driver performance operated through five hypothesized mediators: (1) parent-perceived social support; (2) teen-perceived social support; (3) parent engagement; (4) practice quantity; and (5) practice diversity. Certified driving evaluators, blinded to teens' treatment allocation, assessed teens' driving performance 24 weeks after enrollment. Mediator variables were assessed on self-report surveys administered periodically over the study period.

RESULTS

Exposure to TDP increased teen-perceived social support, parent engagement, and practice diversity. Both greater practice quantity and diversity were associated with better driving performance, but only practice diversity mediated the relationship between TDP and driver performance.

CONCLUSIONS

Practice diversity is feasible to change and increases teens' likelihood of completing a rigorous on-road driving assessment just before licensure. Future research should continue to identify mechanisms that diversify practice driving, explore complementary ways to help families optimize the time they spend on practice driving, and evaluate the long-term effectiveness of TDP.

Comparison of teen and adult driver crash scenarios in a nationally representative sample of serious crashes

Motor vehicle crashes are the leading cause of death and acquired disability during the first four decades of life. While teen drivers have the highest crash risk, few studies examine the similarities and differences in teen and adult driver crashes. We aimed to: (1) identify and compare the most frequent crash scenarios-integrated information on a vehicle's movement prior to crash, immediate pre-crash event, and crash configuration-for teen and adult drivers involved in serious crashes, and (2) for the most frequent scenarios, explore whether the distribution of driver critical errors differed for teens and adult drivers. We analyzed data from the National Motor Vehicle Crash Causation Survey, a nationally representative study of serious crashes conducted by the U.S. National Highway Traffic Safety Administration from 2005 to 2007. Our sample included 642 16- to 19-year-old and 1167 35- to 54-year-old crash-involved drivers (weighted n=296,482 and 439,356, respectively) who made a critical error that led to their crash's critical pre-crash event (i.e., event that made the crash inevitable). We estimated prevalence ratios (PR) and 95% confidence intervals (CI) to compare the relative frequency of crash scenarios and driver critical errors. The top five crash scenarios among teen drivers, accounting for 37.3% of their crashes, included: (1) going straight, other vehicle stopped, rear end; (2) stopped in traffic lane, turning left at intersection, turn into path of other vehicle; (3) negotiating curve, off right edge of road, right roadside departure; (4) going straight, off right edge of road, right roadside departure; and (5) stopped in lane, turning left at intersection, turn across path of other vehicle. The top five crash scenarios among adult drivers, accounting for 33.9% of their crashes, included the same scenarios as the teen drivers with the exception of scenario (3) and the addition of going straight, crossing over an intersection, and continuing on a straight path. For two scenarios ((1) and (3) above), teens were more likely than adults to make a critical decision error (e.g., traveling too fast for conditions). Our findings indicate that among those who make a driver critical error in a serious crash, there are few differences in the scenarios or critical driver errors for teen and adult drivers.

Driving errors of learner teens: frequency, nature and their association with practice

BACKGROUND

Despite demonstrating basic vehicle operations skills sufficient to pass a state licensing test, novice teen drivers demonstrate several deficits in tactical driving skills during the first several months of independent driving. Improving our knowledge of the types of errors made by teen permit holders early in the learning process would assist in the development of novel approaches to driver training and resources for parent supervision.

METHODS

The purpose of the current analysis was to describe driving performance errors made by teens during the permit period, and to determine if there were differences in the frequency and type of errors made by teens: (1) in comparison to licensed, safe, and experienced adult drivers; (2) by teen and parent-supervisor characteristics; and (3) by teen-reported quantity of practice driving. Data for this analysis were combined from two studies: (1) the control group of teens in a randomized clinical trial evaluating an intervention to improve parent-supervised practice driving (n=89 parent-teen dyads) and (2) a sample of 37 adult drivers (mean age 44.2 years), recruited and screened as an experienced and competent reference standard in a validation study of an on-road driving assessment for teens (tODA). Three measures of performance: drive termination (i.e., the assessment was discontinued for safety reasons), safety-relevant critical errors, and vehicle operation errors were evaluated at the approximate mid-point (12 weeks) and end (24 weeks) of the learner phase. Differences in driver performance were compared using the Wilcoxon rank sum test for continuous variables and Pearson's Chi-square test for categorical variables.

RESULTS

10.4% of teens had their early assessment terminated for safety reasons and 15.4% had their late assessment terminated, compared to no adults. These teens reported substantially fewer behind the wheel practice hours compared with teens that did not have their assessments terminated: tODAearly (9.0 vs. 20.0, p<0.001) and tODAlate (19.0 vs. 58.3, p<0.001). With respect to critical driving errors, 55% of teens committed a total of 85 critical errors (range of 1-5 errors per driver) on the early tODA; by comparison, only one adult committed a critical error (p<0.001). On the late tODA, 54% of teens committed 67 critical errors (range of 1-8 errors per driver) compared with only one adult (p<0.001). No differences in teen or parent gender, parent/teen relationship type or parent prior experience teaching a teen to drive were observed between teens who committed a critical error on either route and teens that committed no critical errors. A borderline association between median teen-reported practice quantity and critical error commission was observed for the late tODA. The overall median proportion of vehicle operation errors for teens was higher than that of adults on both assessments, though median error proportions were less than 10% for both teens and adults.

CONCLUSION

In comparison to a group of experienced adult drivers, a substantially higher proportion of learner teens committed safety-relevant critical driving errors at both time points of assessment. These findings, as well as the associations between practice quantity and the driving performance outcomes studied suggest that further research is needed to better understand how teens might effectively learn skills necessary for safe independent driving while they are still under supervised conditions.

Effect of the teen driving plan on the driving performance of teenagers before licensure: a randomized clinical trial

IMPORTANCE

Many studies have failed to show an effect of parent-supervised practice driving on the driving performance of teenagers; nevertheless, most Graduated Driver Licensing programs have provisions that require supervised practice.

OBJECTIVE

To determine whether a web-based intervention, the Teen Driving Plan (TDP), can improve the driving performance of teenagers before licensure as measured by the Teen On-road Driving Assessment (tODA).

DESIGN, SETTING, AND PARTICIPANTS

Randomized, single-blind, clinical trial among 217 dyads (1 parent: 1 teenaged learner's-permit holder) to test TDP effectiveness on increasing the quantity and diversity of supervised practice and improving the teenagers' prelicensed driving performance. The study was conducted from December 2011 through January 2013 in Southeastern Pennsylvania.

INTERVENTIONS

Dyads were randomized (3:2) to receive the TDP or the Pennsylvania driver's manual (control group). The TDP is a psychoeducational intervention designed to increase the quantity and diversity of parent-supervised practice. Materials are grouped by the following driving environments: empty parking lots, suburban residential streets, intermediate (1- or 2-lane) roads, highways, rural roads with curves and elevation changes, and commercial districts.

MAIN OUTCOMES AND MEASURES

The main outcomes were self-reported practice driving across 6 environments and 2 conditions and driving performance as measured by the teenagers' completion of the standardized and validated tODA 24 weeks after enrollment. Certified professional driving evaluators blinded to randomization status terminated the tODA if they determined that the teenager could not safely complete it. We examined mean differences in the quantity of supervised practice, differences in the overall proportion of teenagers in each group that had assessments terminated for unsafe driving, and the point of termination during the assessment.

RESULTS

The TDP dyads reported more practice in 5 of the 6 environments and at night and in bad weather compared with the control dyads. Overall, 5 of 86 TDP teenagers (6%) had the tODA terminated compared with 10 of 65 control teenagers (15%) (risk difference [TDP - control], -9% [95% CI, -21% to 2%]; P = .06). The hazard ratio for exposure to TDP was 0.35 (95% CI, 0.12-1.03; P = .05, log-rank test).

CONCLUSIONS AND RELEVANCE

Preliminary evidence suggests that the TDP improves supervised practice and the driving performance of prelicensed teenaged drivers. Future studies can explore how to revise the TDP to enhance the treatment effect and how best to disseminate the TDP without compromising implementation fidelity.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01498575.

Engagement with the TeenDrivingPlan and diversity of teens' supervised practice driving: lessons for internet-based learner driver interventions

OBJECTIVE

Inexperienced, less-skilled driving characterises many newly licensed drivers and contributes to high crash rates. A randomised trial of TeenDrivingPlan (TDP), a new learner driver phase internet-based intervention, demonstrated effectiveness in improving safety relevant, on-road driving behaviour, primarily through greater driving practice diversity. To inform future learner driver interventions, this analysis examined TDP use and its association with practice diversity.

DESIGN

Posthoc analysis of data from teen/parent dyads (n=107), enrolled early in learner phase and assigned to treatment arm in randomised trial.

METHODS

Inserted software beacons captured TDP use data. Electronic surveys completed by parents and teens assessed diversity of practice driving and TDP usability ratings at 24 weeks (end of study period).

RESULTS

Most families (84%) used TDP early in the learner period; however, the number of TDP sessions in the first week was three times higher among dyads who achieved greater practice diversity than those with less. By week five many families still engaged with TDP, but differences in TDP use could not be detected between families with high versus low practice diversity. Usability was not a major issue for this sample based on largely positive user ratings.

CONCLUSIONS

An engaging internet-based intervention, such as TDP, can support families in achieving high practice diversity. Future learner driver interventions should provide important information early in the learner period when engagement is greatest, encourage continued learning as part of logging practice drives, and incorporate monitoring software for further personalisation to meet family needs.

TRIAL REGISTRATION

NCT01498575.

Adolescence, attention allocation, and driving safety

Motor vehicle crashes are the leading source of morbidity and mortality in adolescents in the United States and the developed world. Inadequate allocation of attention to the driving task and to driving hazards are important sources of adolescent crashes. We review major explanations for these attention failures with particular focus on the roles that brain immaturity and lack of driving experience play in causing attention problems. The review suggests that the potential for overcoming inexperience and immaturity with training to improve attention to both the driving task and hazards is substantial. Nevertheless, there are large individual differences in both attentional abilities and risky driving tendencies that pose challenges to novice driver policies. Research that can provide evidence-based direction for such policies is urgently needed.

Understanding recovery in children following traffic-related injuries: exploring acute traumatic stress reactions, child coping, and coping assistance

Millions of children incur potentially traumatic physical injuries every year. Most children recover well from their injury but many go on to develop persistent traumatic stress reactions. This study aimed to describe children's coping and coping assistance (i.e., the ways in which parents and peers help children cope) strategies and to explore the association between coping and acute stress reactions following an injury. Children (N = 243) rated their acute traumatic stress reactions within one month of injury and reported on coping and coping assistance six months later. Parents completed a measure of coping assistance at the six-month assessment. Children used an average of five to six coping strategies (out of 10), with wishful thinking, social support, and distraction endorsed most frequently. Child coping was associated with parent and peer coping assistance strategies. Significant acute stress reactions were related to subsequent child use of coping strategies (distraction, social withdrawal, problem-solving, blaming others) and to child report of parent use of distraction (as a coping assistance strategy). Findings suggest that children's acute stress reactions may influence their selection of coping and coping assistance strategies. To best inform interventions, research is needed to examine change in coping behaviors and coping assistance over time, including potential bidirectional relationships between trauma reactions and coping.

Residual cognitive disability after completion of inpatient rehabilitation among injured children

OBJECTIVE

To determine the prevalence and nature of residual cognitive disability after inpatient rehabilitation for children aged 7-18 years with traumatic injuries.

STUDY DESIGN

This retrospective cohort study included children aged 7-18 years in the Uniform Data System for Medical Rehabilitation who underwent inpatient rehabilitation for traumatic injuries in 523 facilities from 2002-2011. Traumatic injuries were identified by standardized Medicare Inpatient Rehabilitation Facility-Patient Assessment Instrument codes. Cognitive outcomes were measured by the Functional Independence Measure instrument. A validated, categorical staging system derived from responses to the items in the cognitive domain of the functional independence measure was used and consisted of clinically relevant levels of cognitive achievement from stage 1 (total cognitive disability) to stage 7 (completely independent cognitive function).

RESULTS

There were 13,798 injured children who completed inpatient rehabilitation during the 10-year period. On admission to inpatient rehabilitation, patients with traumatic brain injury (TBI) had more cognitive disability (median stage 2) than those with spinal cord injury or other injuries (median stage 5). Cognitive functioning improved for all patients, but children with TBI still tended to have significant residual cognitive disability (median stage on discharge, 4).

CONCLUSIONS

Injured children gained cognitive functionality throughout inpatient rehabilitation. Those with TBI had more severe cognitive disability on admission and more residual disability on discharge. This is important not only for patient and family expectation setting but also for resource and service planning, as discharge from inpatient rehabilitation is a critical milestone for reintegration into society for children with serious injury.

Anticipated increases in medically attended injuries by children and young adults with the Affordable Care Act: the growing role of primary care in the pediatric trauma system

OBJECTIVES

To guide implementation of the Affordable Care Act 2010 by estimating anticipated increases in medically attended injuries and site of care by the young who are currently uninsured.

METHODS

The 2008 National Health Interview Survey was used to estimate injury episodes and care site for uninsured and insured youth ≤26 years old. Increases in medically attended injuries were estimated by assuming that rates and care site for the currently uninsured would match those of the currently insured once the uninsured receive coverage.

RESULTS

In 2008, approximately 11 938 800 episodes of medically attended injuries occurred for youth ≤26 years. An anticipated 6.1% increase in medically attended injuries (737 081; 95% confidence interval = 564 000-879 000), the majority of which would be seen in the outpatient setting, could occur once all uninsured youth become insured.

CONCLUSIONS

Injury prevention strategies and additional injury care training for primary care physicians may help ensure appropriate triage and optimal outcomes while containing costs.