Specialised driving lessons

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Specialised driving lessons

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Research question: 1. How many hours of specialised driving lessons is generally required for an individual with a disability to learn how to drive and attain their driver’s license? How does this vary between disability populations (e.g. ABI, Stroke, ID, ASD)?

2. What is the best practice approach for a driver rehabilitation program, are there any guidelines regarding the frequency of driving lessons and frequency of Driver Trained Occupational Therapist review/re-assessment?

3. What are the factors which determine successful attainment of licensing, especially for individuals with cognitive impairments?

Date: 01/12/2022 Requestor: Melody s22(1)(a)(ii) - irrelevant m Endorsed by: Katrin s22(1)(a)(ii) - irreleva Researcher: Aaron s22(1)(a)(ii) - irrelevant ma Cleared by: Stephanie s22(1)(a)(ii) - irrelevant mat

Review date:

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1. Contents

Specialised driving lessons ………………………………………………………………………………………….. 1

1. Contents ……………………………………………………………………………………………………….. 2

2. Summary ………………………………………………………………………………………………………. 2

3. Guidelines ……………………………………………………………………………………………………… 3

4. Evidence for on-road driving lessons …………………………………………………………………. 4

4.1 General ………………………………………………………………………………………………………. 4

4.2 Autism Spectrum Disorder …………………………………………………………………………….. 5

4.3 Traumatic brain injury …………………………………………………………………………………… 6

5. References ……………………………………………………………………………………………………. 6

6. Summary

This paper focussed on on-road driver training interventions for people with cognitive or emotional concerns which impact their driving. There is very little evidence evaluating on-road driving lessons despite this being one of the most widespread interventions used for driver training and rehabilitation. Lack of evidence for on-road driving lessons is a known issue for researchers and driver trained occupational therapists (DTOTs) and is frequently remarked on in the research literature.

Relevant studies have been conducted for drivers with Autism Spectrum Disorder (ASD) and traumatic brain injury (TBI). Surveys of driving instructors suggest learners with ASD may require 20-40 formal driving lessons. Evidence shows that while most people with TBI can return to driving, those who require additional training need on average seven 2hr formal driving lessons. Researchers have explored for other cohorts (stroke, mild cognitive impairment, psychosocial disability) but available studies were either exploratory (e.g., describing driver profiles) or examined other interventions (e.g., simulator training, driver education, physical rehabilitation etc.).

While there is consistent evidence that suggests people with disability take longer to get their license, any quantified results are based on very few studies and should be treated with caution.

No guidelines were found which offered recommendations for duration, frequency or number of driving lessons for people with cognitive or emotional concerns that might impact their driving. In response to lack of evidence, guidelines stress the need for individualised interventions which account for the learners’ specific needs.

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3. Guidelines

Database searches uncovered no published guidelines recommending an overall approach to frequency or duration of specialised driving lessons, reviews or reassessments for people with cognitive or emotional concerns that might impact their driving.

Assessing fitness to drive is a collaboration of AustRoads and the National Transport Commission and provides guidelines for determining when a driver with some medically relevant impairment meets licensing requirements (AustRoads & National Transport Commission, 2022). This includes required frequency of reassessment after a person has obtained their license. For example, reassessment may be more frequent if a driver has a progressive condition. However, Assessing fitness to drive does not provide recommendations around frequency of reassessment for drivers prior to obtaining their license. Nor does it provide guidelines around frequency or duration of lessons or rehabilitation strategy for drivers wanting to gain or regain their license. In fact, the guidelines state explicitly, “there is currently limited evidence to support the use of particular rehabilitation or retraining strategies” (AustRoads & National Transport Commission, 2022, p.23).

VicRoad’s Guidelines for Occupational Therapy Driver Assessors (VicRoads) does include some recommendations around driving lessons. VicRoads says, for instance, that driving instructors need to “use appropriate training methods to accommodate the driver’s past experience, current skill level and communication/impairment needs” (p.33). This might involve specifying number of lessons or recommending a duration of lessons. However, the guidelines do not specify how the DTOT’s should recommend frequency or duration of lessons.

Queensland’s Controlled Environment Driver Training Guidelines (Department of Transport and Main Roads, 2021) emphasises responding to individual learner circumstances and does not make recommendations around frequency or duration of lessons:

… consideration should be given to offering flexibility of approach and adapting learning principles to the needs of individuals, including those students with physical or mental health challenges. Driver trainers are not expected to conduct clinical assessments of special needs or challenges, but as educators there is a responsibility to be sensitive to these issues and to try to respond to them. Unfortunately, there is little research and evidence to prescribe specific driver training techniques for students with special needs; however, the key principle is to try to understand their circumstances and be as flexible in the conduct of training and communication methods as is reasonably practicable (2021, p.11).

The UK’s National standard for driver and rider training (National standard, 2020) outlines what a driver instructor should know when training learner drivers. It describes a client-centred approach which responds to individual needs and takes into account to prior knowledge and experience of the learner. It does not provide guidance on frequency or duration of lessons.

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4. Evidence for on-road driving lessons

There is a notable lack of evidence regarding the efficacy of on-road driving lessons for people with disabilities. A 2014 systematic review of occupational therapy assisted driver rehabilitation notes:

while it is our experience that the most common intervention approach used in clinical practice is a series of lessons with a driving instructor, we were unable to identify any studies that evaluated this intervention approach. This kind of intervention has received very limited description in the literature which may be due to the heterogeneous nature of the training provided. (Unsworth & Baker, 2014, p.112)

While there is some efficacy data published since 2014, the lack of evidence of on-road driving lessons for people with disabilities is noted in almost all studies referenced in this paper (AustRoads & National Transport Commission, 2022; Berndt et al, 2022; Vindin et al, 2021; Department of Transport and Main Roads, 2021; Dun et al, 2020; Sangrar et al, 2019; Wilson et al, 2018; Lindsay & Stoica, 2018; Unsworth et al, 2015; George et al, 2014). For example, as recently as 2021, Australian researchers in Perth and Sydney could claim to have completed the first experimental on-road driving training intervention study for people with ASD (Vindin et al, 2021, p.3708).

4.1 General

In a recent interview-based study of Australian DTOTs looking at self-reported clinical reasoning regarding recommendations for interventions, Berndt et al note that:

Participants asserted that peer-reviewed scientific research evidence for particular driver rehabilitation interventions was sparse, so they often deferred to clinical judgment and experience to guide practice. In the absence of specific driver rehabilitation intervention research evidence, general evidence was transferred across to a driver rehabilitation context, applied and then evaluated (Berndt et al, 2022, p.442).

Unfortunately, the authors do not elaborate on what this general evidence consists of. Participants reported factors related to on-road driving lessons as crucial to their decision making. For example, participants noted that in order to determine whether a skill was acquired, they needed to observe the skill being implemented across multiple lessons, rather than just once during an assessment. Responses also imply that a DTOT will create a hypothesis about the learner’s driving ability and then test the hypothesis over multiple lessons.

Breault et al (2019) found young learners with disabilities took longer on average to learn to drive compared to young people without disabilities but did not provide details about average duration or frequency of lessons.

In their review, Sangrar et al (2019) found interventions including in-vehicle training could reduce driver errors and improve control of vehicle for older drivers. However, as the

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interventions generally included multiple components (e.g., simulator training and group education) it is unclear how much of the effect could be attributed to on-road lessons. Also, the on-road component of training in these studies was generally limited to one or 2 sessions. Similar findings for older drivers were reported by Castalucci et al (2020). Beanland and Huemer (2021) raise the same concern regarding one- or 2-day driver training programs for all post-license drivers.

4.2 Autism Spectrum Disorder

A 2019 systematic review reported on 3 papers recommending strategies to assist people with ASD to drive. Strategies included shorter lessons, repetitions of lessons and regular, frequent and consistent lessons (Lindsay, 2019). The necessity for repeating lessons could be a reason people with ASD often take longer to learn to drive (Tyler, 2013).

The use of frequent repetition of lessons was supported in two publications reporting on an interview-based study of driving instructors (Myers et al, 2019; Myers et al, 2021). These studies always noted other specific strategies around duration and frequency of on-road driving lessons. One driving instructor suggested a typical pattern was 24hrs formal instruction from a driving instructor/OT plus another 200 hours of driving practice with parents/carers. Others described requiring 3 to 4 times more hours of on-road practice for people with ASD compared to those without. The authors suggested lessons can continue for 2-3 years. Instructors often recommended a course of driving lessons, followed by months or years of on- road practice with informal supports. During this time students were instructed to work on foundational pre-driving skills (e.g., learning to ride a bike or catch public transport independently) after which they may return for another course of driving lessons.

Participants in the Myers et al study predicted that around 30% of their students eventually got their license (Myers et al, 2019; Myers et al, 2021). This is consistent with evidence that 1 in 3 young people with ASD acquire their driver’s license (Curry et al, 2018).

In 2018-2019, an Australian team of researchers completed a scoping review and RCT to examine interventions for young learner drivers with autism (Wilson et al, 2018; Vindin et al, 2021). The scoping review supports the suggestion raised in other studies (Myers et al, 2021; Myers et al, 2019; Lindsay, 2019; Tyler, 2013) that young drivers with ASD may require more lessons of shorter duration compared to those without ASD. In a survey of 388 respondents, Shepard et al (2022) found drivers with ASD typically required 20-40 professional driving lessons compared to people without who required on average 0-20 lessons, and driver with ASD typically got their license later. This is consistent with the only other quantified recommendation of an average of 24 lessons (Myers et al, 2019).

Wilson et al’s (2018) scoping review found interventions reporting simulator or computer-based training but found no studies examining on-road driving lesson interventions. To address this gap, the research team designed an RCT to assess the efficacy of an on-road driving program for 72 young people with ASD (Vindin et al, 2021). In this study, both the intervention and control group were given 10 driving lessons with driving instructors who were not DTOTs. The

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intervention group lessons were delivered by instructors trained in an ASD specific driving program. The control group lessons were delivered by instructors with no additional training. The researchers found large effect sizes for both groups but found no statistically significant difference between groups. It is noteworthy that both groups showed significant benefit after a course of on-road driving lessons with mainstream professional driving instructors. However, the authors note there is a possibility of self-selection bias resulting in a group of driving instructors with interest or experience in training young people with ASD.

4.3 Traumatic brain injury

Duration of driver training after traumatic brain injury depends on the severity of the injury (Schultheis & Whipple, 2014). Estimates for return to driving after TBI range from 42% to 98%. In their sample of 48 people with traumatic brain injury, Stolwyck et al (2019) found 31 were fit to drive following an assessment from an occupational therapist, while 9 of the 17 who failed the assessment were recommended take one or more driving lessons before being reassessed. All those who underwent driving lessons were re-assessed and cleared to return to driving. However, the report does not make clear how many lessons were required for the cohort of participants who failed the initial test.

Ross et al (2018) found in an Australian sample of 340 people with traumatic brain injury, 72% passed the initial post-injury driver assessment and of the 28% who failed the initial assessment, 98% passed after an average of 7 driving lessons (14 specialist driving instructor hours) and 2.5 on-road assessments (9.8 OT hours and 3.8 specialist driving instructor hours). Only 7 out of the 340 were not able to return to driving.

5. References

AustRoads & National Transport Commission. (2022). Assessing fitness to drive for commercial and private vehicle drivers. Australian Government. https://austroads.com.au/publications/assessing-fitness-to-drive/ap-g56

Beanland, V and Huemmer, I. (2021) The effectiveness of advanced driver training. Waka Kotahi NZ Transport Agency research report 677. https://nzta.govt.nz/assets/resources/research/reports/677/677-the-effectiveness-of- advanced-driver-training.pdf

Berndt, A., Hutchinson, C., Tepper, D., & George, S. (2022). Professional reasoning of occupational therapy driver rehabilitation interventions. Australian Occupational Therapy Journal, 69(4), 436–446. https://doi.org/10.1111/1440-1630.12804

Breault, C., Giroux, L., Gauvreau, A., Belanger, S., Lamontagne, M.-E., & Morales, E. (2019). Acceptability of the process of obtaining a driver’s license by young people with and without disabilities. Journal of Accessibility and Design for All, 9(1), 90–117. https://doi.org/10.17411/jacces.v9i1.198

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Castellucci, H. I., Bravo, G., Arezes, P. M., & Lavallière, M. (2020). Are interventions effective at improving driving in older drivers?: A systematic review. BMC Geriatrics, 20(1), 125. https://doi.org/10.1186/s12877-020-01512-z

Curry, A. E., Yerys, B. E., Huang, P., & Metzger, K. B. (2018). Longitudinal study of driver licensing rates among adolescents and young adults with autism spectrum disorder. Autism: The International Journal of Research and Practice, 22(4), 479–488. https://doi.org/10.1177/1362361317699586

Department of Transport and Main Roads. (2021). Controlled environment driver training guidelines. Queensland Government. https://www.tmr.qld.gov.au/- /media/busind/accreditations/driverandridertrainers/Controlled-Environment-Driver- Training-Guidelines.pdf?la=en

Di Stefano, M & Ross, P. (2018). VicRoads Guidelines for Occupational Therapy Driver Assessors (3rd edition). Roads Corporation Victoria, Melbourne.

George, S., Crotty, M., Gelinas, I., & Devos, H. (2014). Rehabilitation for improving automobile driving after stroke. Cochrane Database of Systematic Reviews, 2, CD008357. https://doi.org/10.1002/14651858.CD008357.pub2

Myers, R. K., Bonsu, J. M., Carey, M. E., Yerys, B. E., Mollen, C. J., & Curry, A. E. (2019). Teaching autistic adolescents and young adults to drive: Perspectives of specialized driving instructors. Autism in Adulthood Knowledge Practice and Policy, 1(3), 202–209. https://doi.org/10.1089/aut.2018.0054

Myers, R. K., Carey, M. E., Bonsu, J. M., Yerys, B. E., Mollen, C. J., & Curry, A. E. (2021). Behind the wheel: Specialized driving instructors’ experiences and strategies for teaching autistic adolescents to drive. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 75(3), 7503180110p1. https://doi.org/10.5014/ajot.2021.043406

National standard for driver and rider training. (2020). Driver and Vehicle Standards Agency. https://www.gov.uk/government/publications/national-standard-for-driver-and-rider- training/national-standard-for-driver-and-rider-training#unit-2—design-learning- programmes

Lindsay, S. (2017). Systematic review of factors affecting driving and motor vehicle transportation among people with autism spectrum disorder. Disability and Rehabilitation, 39(9), 837–846. https://doi.org/10.3109/09638288.2016.1161849

Lindsay, S., & Stoica, A. (2017). A systematic review of factors affecting driving and public transportation among youth and young adults with acquired brain injury. Brain Injury, 31(10), 1257–1269. https://doi.org/10.1080/02699052.2017.1321140

Ross, P. E., Di Stefano, M., Charlton, J., Spitz, G., & Ponsford, J. L. (2018). Interventions for resuming driving after traumatic brain injury. Disability and Rehabilitation, 40(7), 757– 764. https://doi.org/10.1080/09638288.2016.1274341

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Sangrar, R., Mun, J., Cammarata, M., Griffith, L. E., Letts, L., & Vrkljan, B. (2019). Older driver training programs: A systematic review of evidence aimed at improving behind-the- wheel performance. Journal of Safety Research, 71, 295–313. https://doi.org/10.1016/j.jsr.2019.09.022

Sheppard, E., van Loon, E. & Ropar, D. (2022). Dimensions of Self-Reported Driving Difficulty in Autistic and Non-Autistic Adults and their Relationship with Autistic Traits. Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-021-05420-y

Schultheis, M. T., & Whipple, E. (2014). Driving after traumatic brain injury: evaluation and rehabilitation interventions. Current Physical Medicine and Rehabilitation Reports, 2(3), 176–183. https://doi.org/10.1007/s40141-014-0055-0

Stolwyk, R. J., Charlton, J. L., Ross, P. E., Bédard, M., Marshall, S., Gagnon, S., Gooden, J. R., & Ponsford, J. L. (2019). Characterizing on-road driving performance in individuals with traumatic brain injury who pass or fail an on-road driving assessment. Disability and Rehabilitation, 41(11), 1313–1320. https://doi.org/10.1080/09638288.2018.1424955

Tyler S. (2013). Asperger’s syndrome: the implications for driver training methods and road safety. Journal of the Australasian College of Road Safety, 24, 55–62.

Unsworth, C. A., & Baker, A. (2014). Driver rehabilitation: a systematic review of the types and effectiveness of interventions used by occupational therapists to improve on-road fitness-to-drive. Accident; Analysis and Prevention, 71, 106–114. https://doi.org/10.1016/j.aap.2014.04.017

Unsworth, C., Harries, P., & Davies, M. (2015). Using Social Judgment Theory method to examine how experienced occupational therapy driver assessors use information to make fitness-to-drive recommendations. The British Journal of Occupational Therapy, 78(2), 109–120. https://doi.org/10.1177/0308022614562396

Vindin, P., Cordier, R., Wilson, N. J., & Lee, H. (2021). A driver training program intervention for student drivers with autism spectrum disorder: A multi-site randomised controlled trial. Journal of Autism and Developmental Disorders, 51(10), 3707–3721. https://doi.org/10.1007/s10803-020-04825-5

Wilson, N. J., Lee, H. C., Vaz, S., Vindin, P., & Cordier, R. (2018). Scoping review of the driving behaviour of and driver training programs for people on the autism spectrum. Behavioural Neurology, 2018, 6842306. https://doi.org/10.1155/2018/6842306

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