Dec. 29, 2022 -- Nadia Tawfik was 17 years old when she got her first car. Two months later, Tawfik was following behind her mother’s car when her mother continued driving straight and she made a fast decision to go a different way and make a left-hand turn. The light was green but there was no green arrow. Mid-turn, Tawfik got distracted by watching her mother driving off and didn’t see the car that was coming straight toward her.
She hit it head on.
“I wasn’t paying as much attention as I should have been,” Tawfik says four years after the accident.
Tawfik, who has ADD and is now a college senior studying nursing, is not alone in having difficulty paying attention while on the road. The risk of motor vehicle crashes is greater among teens ages 16 to 19 than among any other age group, according to the CDC. Driving accidents are also the leading cause of death among teens.
For teens with attention deficit hyperactivity disorder (ADHD), the crash risk is even higher. According to research published in JAMA Pediatrics, adolescents who have been diagnosed with ADHD are 36% more likely to get into a car accident than other teenage drivers. Some research has shown that having ADHD is also associated with a higher likelihood of multiple collisions.
Thankfully, Tawfik was not seriously injured in the car accident, but her car needed to be replaced. But the mishap left her shaken; she started to feel more afraid of driving.
About 8 months later, the teen came across an ad on social media for a study testing a computerized driving skills training program for teen drivers with ADHD. She happily signed on.
The purpose of the randomized, control trial was to determine if a computerized intervention could work to reduce long glances away from the roadway and lessen the driving risks for teens with ADHD, says Jeffrey Epstein, PhD, the lead author of the study, which was published this month in the New England Journal of Medicine.
The study showed that for adolescents with ADHD, the intervention significantly reduced the frequency of long glances away from the road as well as a measure of lane weaving compared to a control program. What's more, in the year after training, the rate of collisions and near collisions during real-world driving was significantly lower for those in the intervention group.
Those were the most surprising and significant findings to Epstein, who is also a pediatric psychologist and director for the Center for ADHD at Cincinnati Children’s Hospital, the primary site for the study.
“I had my doubts and I was very pleased when our results did generalize to real-world driving,” Epstein says.
Epstein says he decided to focus this study on the reduction of long glances (greater than 2 seconds) away from the roadway because an earlier ADHD research study, for which he was an author, found that teens with ADHD were not only having longer glances away from the roadway when they were distracted, but they were having more of those long glances.
“And so we determined that was a likely reason for teens with ADHD getting into accidents, and we said, 'OK, let’s try to address that. Let’s see if we can fix that.'”
For the study, a total of 152 teens drivers (ages 16 to 19) with ADHD were assigned to either the intervention or the control group. All the teens were licensed drivers and drove at least 3 hours per week. Each person received 5 weeks of training, once weekly.
Those in the intervention group were trained using a program called The Focused Concentration and Attention Learning (FOCAL) program, which targets decreasing long glances away from the roadway. Those in the control group were taught information generally taught in a typical drivers’ training program like rules of the road, but they did not learn anything about long glances and focusing their attention on the road.
The FOCAL program was developed by Donald Fisher, PhD, at the University of Massachusetts, who had been working on decreasing long glances away from the road in teens without ADHD. Epstein’s research team knew they needed to make the program more intensive to work with teens with ADHD, so they enhanced it to include multiple sessions. They also added a driving simulator piece where the teens had to go in the driving simulator after they completed this computerized FOCAL program and they were alerted with an alarm any time there was a glance that exceeded 2 seconds. The only way to make the alarm stop was to look at the roadway again. In effect, the training involved teaching the teens not to look away from the roadway for more than 2 seconds.
The multiple-time training lasted more than 7 hours, Epstein says.
"We kind of really made them learn the skill until it became rote.”
One of the key differences between the intervention and control group was that the intervention group received the auditory feedback when the teen looked away from the simulated roadway for more than 2 seconds, while those in control group did not get that auditory feedback training.
Participants in the intervention group were found to have an average of 16.5 long glances per drive at 1 month and 15.7 long glances per drive at 6 months as compared to 28 and 27 long glances respectively in the control group. A measure of lane weaving was also significantly reduced at 1 month and 6 months in the intervention group as compared to the control group.
“We got really large differences between the two groups and very, very statistically significant differences,” Epstein says.
Skill level didn’t change much between 1 and 6 months.
“They were remembering these skills that we taught them,” Epstein says.
Secondary trial outcomes were rates of long glances and collisions/near-collisions during 1-year of real-world driving.
In order to measure them, the research team placed cameras in the majority of the teens' cars. The cameras detected and recorded the moments leading up to driving episodes triggered by a high g-force on the vehicle, which occurred due to sudden changes in vehicle momentum such as a hard brake, hard swerve, or collision.
During real-world driving over the year after training, those who took part in the intervention had a 24% reduction in the rate of long glances per g-force event and a 40% reduction in the rate of collisions or near collision per g-force event as compared to controls.
Tawfik, who was in the intervention group, says the study was something she was genuinely interested in. Participating in it also made her better understand why some of these accidents happen.
“The simulation itself really stuck with me all these years,” she says. “It was helpful because it reminded me to be more aware of my surroundings and to not just pay attention directly on the road.”
"Training does work,” says John Ratey, MD, who is known for his books about ADHD, such as the “Driven to Distraction” series that was written with Edward Hallowell, MD.
“It’s like any learning, it helps if you go over and over and over,” Ratey says.
“I think the field of ADHD is moving toward skills-based learning. Like we need to teach teens with ADHD skills,” Epstein says.
There was at least one study limitation, however. While the researchers monitored real-world driving for 1 year after teens completed the training, they were not able to monitor teen’s medication use during that phase of the study. In other words, it wasn't clear if the teens were taking ADHD medication at the time of collisions or near-collisions. That said, the medication rates across the intervention and controls were very similar, Epstein notes.
Tawfik says she feels more comfortable on the road now. She’s learned to be self-aware and not “freak out” over driving. She has also internalized the message of don’t keep your eyes off the road for more than 2 seconds, a key takeaway for her from the study that she says she still applies to this day.
Sometimes her friends will try to show her something on their phones while she’s driving.
“I don’t look because I know that quick glance might turn into something horrific,” Tawfik says.
Parents and teens interested in learning more about the program can visit this website. Jeffrey Epstein, PhD, lead study author, said he hopes the intervention may someday be available using virtual reality or a smart phone application. (Anyone is welcome to do the training – currently five weeks -- onsite at Cincinnati Children’s Hospital starting in January 2023).