1. TEEN DRIVING: WHAT WORKS….WHAT DOESN’T Injury Free Coalition for Kids/SECSI

3. Alabama has a GDL law 1. Yes 2. No 3. Don’t know

4. Alabama’s GDL law addresses which of the following: 1. Number of passengers 2. Time of driving 3. Both 4. neither

5. I discuss safe driving with my teen patients….. 1. Always 2. sometimes 3. never 4. I don’t see teens in my practice

6. Teen driving: (1/3 rd ) 34% are passenger

7. Why are teens at risk  Novice, night, passenger  Brain centers “under construction”(areas of impulse control, prioritization, and strategy

8. The number of teens who died in 2007 could fill up 10 sophomore homeroom classes, ranking Alabama as one of the deadliest states nationwide for young drivers. – Anniston Star

9. The 10 deadliest hotspots among the nation's 50 largest metro areas :  Tampa-St. Petersburg-Clearwater, FL Orlando-Kissimmee, FL Jacksonville, FL Nashville-Davidson--Murfreesboro, TN ******Birmingham-Hoover, AL***** Phoenix-Mesa-Scottsdale, AZ Kansas City, MO-KS Atlanta-Sandy Springs-Marietta, GA Charlotte-Gastonia-Concord, NC-SC  AllState Foundation Teen Driving “Hotspots

10. Alabama Teen (16-19 year old) MVC crashes  From 2000-2011 there were  783 deaths  46413 reported injuries

12. Alabama Teens: risky business?  When asked about driving behaviors in the past 30 days:  41% report texting  11% report drinking after driving When asked about passenger situations:  67% reported being passenger when driver texting  27% reported being passenger when driver drinking Overall 58% reported no seatbelt 13% have driven after drug use 60% routinely drive over the speed limit

13. Specific Data  80% had discussed safe driving with a parent  25% had signed a driver contract  63% had taken a driver education class  16% with a physician

14. So… how can we help?  Driver’s education  Parents  GDL laws  Pediatricians

16. Drivers education in Alabama: current state  Convenience sample study: 2011  PED and Adolescent Health Center  17 questions re: knowledge of Alabama graduated driver’s license laws  83 Surveys with overall score of 27%

17. Results:  There was no statistical correlation to show that attending driver’s education improved your knowledge of the states new GDL law (t=-.43 p=0.67).  mean score of 26% vs 28% on the evaluation

18. Parents:  93% of parents feel they can teach their children to drive  60% or less are aware of current GDL law in their state

19. >50% of parents talked on cell phone, >33% read texts and 20% sent text while driving

20. Parent effect:  Review of literature is clear:  risky driving, traffic violations and crashes are lower among teens whose parents apply restrictions  Parents intend to impose substantial limits on trip conditions but not on risk conditions  Large number of rules, with talking or warning as the primary consequence

22. Four new and interesting studies:  Karaca-Mandic P, Ridgeway G. Behavioral impact of graduated driver licensing on teenage driving risk and exposure. J Hlth Econ. 2010; 29: 48- 61.  Maston SV, Foss RD, Marshall SW. Graduated driver licensing and fatal crashes involving 16- to 19-year-old drivers. JAMA 2011; 306 (10):1098- 1103.  Rogers SC, Bentley GC, Campbell B. et al. Impact of Connecticut’s gdl system on teenage mvc rates. J Trauma 2011 Nov;71(5 Suppl 2): S527-30.  Jacobsohn L, Garcia-Espana JF, Durbin DR, Erkoboni D, Winston F. Adult- supervised practice driving for adolescent learners: The current state and directions for interventions. J Safety Res 2012 Feb; 43(1):21-8.

23. Karaca-Mandic P, Ridgeway G. Behavioral impact of graduated driver licensing on teenage driving risk and exposure. J Hlth Econ. 2010; 29: 48-61.  Do GDL laws improve driving behavior or simply reduce teen drivers on the roads?  Do GDL laws result in better teen drivers later in life?  Comment: The article has an excellent literature review for studies evaluating GDL and crash outcomes (pgs 49-50). This study has a very complex methodology and statistical analysis, it takes time for a thorough review and understanding.

24. Results: J Hlth Econ. 2010; 29: 48-61.  GDL policies have reduced the number of 15-17 yo crashes by limiting the amount of teen driving (not improving teen driver behavior).  GDL reduces relative teen driving prevalence by 5% in day and 15% in night.  Stricter policies have been more effective (night time and passenger restrictions).  GDL policies do not make teens better drivers in later years.

25. Conclusion J Hlth Econ. 2010; 29: 48-61  The Public Health Perspective  More restrictive GDL policies for 15-17 year old drivers reduce teen crashes and fatalities.  Stronger GDL policies defer unrestricted driving thus reducing teens’ exposure to high risk driving situations.  GDL policies could emphasize stronger measures to improve teen driving skill. (increase the supervised driving period or as a personal note – integrate skill based checklists in the mentored driving period).

26. Maston SV, Foss RD, Marshall SW. Graduated driver licensing and fatal crashes involving 10- to 19-year-old drivers. JAMA 2011; 306 (10):1098-1103. Objective: To estimate the association of GDL programs with involvement in fatal crashes among 16- to 19-year-old drivers. Outcomes: Fatal crash rates for each age group - 16, 17, 18, 19 year old drivers. Compared strong restriction states/quarters (night driving restriction (before 1 am and 1 passenger) to weaker restriction states/quarters.

27. Results: JAMA 2011; 306 (10):1098-1103.  Fatal crash incidence among teen drivers increased with age. (note: un-adjusted for vmt, vmt adjusted rates for 16 and 17 yrs are 150% and 90% higher than 18 and 19 yrs).  After adjustment for confounders: stronger GDL programs were associated with lower incidence of fatal crashes in 16 year old drivers. (RR=0.74, 95%CI (0.65, 0.84)).  RR’s for 17 and 19 year olds and combined ages 16-19, were not statistically different from the null.  Stronger GDL programs were associated with higher fatal crash incidence for 18 year old drivers (RR=1.12, 95%CI (1.01, 1.23)).

28. Authors Comments and Conclusions  GDL programs are designed to improve learning among novice drivers and to protect them from their inexperience. (Not a program to control excessive behaviors involved in fatal crashes).  GDL programs in the U.S. were associated with substantial reductions in fatal crashes of drivers to whom the protective elements most apply – 16 year olds.  GDL programs are associated with somewhat higher fatal crash incidence among 18 year old drivers, who are not directly subject to GDL restrictions.  Questions: 1. Should GDL age restrictions be increased to 18 year old drivers? 2. What factors account for the increase among 18 year old drivers?

29. Rogers SC, Bentley GC, Campbell B. et al. Impact of Connecticut’s GDL system on teenage mvc rates. J Trauma 2011 Nov;71(5 Suppl 2): S527-30.  Description – a ten year look at age stratified mvc rates pre and post GDL intervention.  GDL included restrictions on age, passengers, late night driving (11p thru 5a).  MVC rate decreased 40% for 16 yo’s and 30% for 17 yo’s.  MVC rates decreased 16% for 18 yo’s and 7% for 19 yo’s.  During late night driving restriction period, MVC rates decreased 54% in 16 yo’s and 49% for 17 yo’s.  MVC rate with passengers decreased by 65% in 16yo’s and 53% for 17yo’s.

30. Jacobsohn L, Garcia-Espana JF, Durbin DR, Erkoboni D, Winston F. Adult-supervised practice driving for adolescent learners. J Safety Res 2012 Feb; 43(1):21-8.  Description – a national survey of 945 parents  Purpose – to determine correlates to the amount of parent supervised practice hours of novice teen drivers.  Results:  61% parents reported practicing 50 or more hours.  Correlates to 50+hrs : 2 parent involvement ; state law mandate of 50 or more hours.  Use of a professional driving instructor was not a correlate to parent teen practice hours.

31. RISK TO TEEN DRIVERS: INEXPERIENCE Novice driver crash risk MonthsMiles Note: 1 st 6 months or 1000 miles of driving Source: Mayhew, 2002; McCartt et al, 2001

32. WHAT CAN PARENTS DO? SET LIMITS to reduce the risk of a fatal crash for drivers 16-19 years of age. For at least 6 months or 1,000 miles of driving time to reduce crash risk. Use skill based training plans +

33. HELP SET THE RULES Always wear seatbelts ! Put away cell phone ! Six months or 1,000 miles Passenger Rule No nighttime driving (until stage 4 training) Safe driving behaviors: no alcohol, cell phone, or speeding Complete skills based training plans

34. Practice Skills  Stage 1: Beginner (low speed, low traffic)  basics, turning, braking, accelerating  Stage 2: Intermediate (low speed, low traffic)  scanning for hazards, passing, maintaining speeds,  following distances, 4 way stops, light change pause  Stage 3: Advanced ( speed and traffic)  merging, passing, changing lanes, emergency lane  Stage 4: Advanced (challenging conditions)  night time, weather, passengers

35. Table 1. Most Critical Teen Driver Caused Crash Factors (2008-2011) Odds Injury Value Significant Ratio MaxGain OverSpeedLimit TRUE 4.91 1205 OverCorrecting/OverSteering TRUE 3.00 171 DistractedbyUseofOtherElectronicDevice TRUE 2.95 49 NegotiatingaCurve TRUE 2.70 516 AggressiveOperation TRUE 1.98 72 DistractedbyUseofElectronicCommunDevice TRUE 1.89 55 RanOffRoadRight TRUE 1.87 224 FailedtoYieldRight‐of‐WayfromStopSign TRUE 1.87 295 DistractedbyPassenger TRUE 1.86 48 Fatigued/Asleep TRUE 1.85 102 VehicleLeftinRoad TRUE 1.80 81 SingleVehicleCrash(alltypes) TRUE 1.71 1236 AvoidObjectinRoad TRUE 1.66 67 RanOffRoadLeft TRUE 1.61 86 DrivingtooFastforConditions TRUE 1.61 299 FailedtoYieldRight‐of‐WayfromTrafficSignal TRUE 1.53 64 FailedtoYieldRight‐of‐WayMakingLeftorU‐Turn TRUE 1.48 134 adapted from: http://www.safehomealabama.gov/InfoTraining/YoungDriverIssues.aspx authors: J Norris and D Brown

36. Alabama Teen Driver Deaths (Years 2000 - 2011) (r sub s = -0.87, p<0.001)

37. Data Needs  Seat belt use among Alabama teen drivers.  Prevalence of cell phone and hand held device use among Alabama teen drivers.  Prevalence of risk behaviors among Alabama teen drivers.  Prevalence of night and day driving (teen driver VMT).  Parents’ knowledge of the Alabama GDL.  Crash scenarios over-represented among Alabama teen drivers (fatal versus nonfatal events).  Enforcement levels of current Alabama GDL law.

38. Pediatricians- How are we doing? 150/1301 (11.5%) of participants had spoken to their pediatrician about driving. Within that group that had spoken to their pediatrician they were less likely to text while driving (OR 0.55, 95% CI (0.38- 0.78), p<0.01), less likely to be a passenger in a car with someone who had been drinking alcohol (OR 0.68, 95% CI (0.47-0.99), p <0.03).

39. AAP Guidelines (cont’d)  Encourage parents to restrict driving  Spend time in car with teen  Written contract  Remind teens and parents of state laws

40. In the past I’ve recommended driving contracts to my families …. 1. Often 2. Rarely 3. Never 4. Was not familiar with driving contracts til today

41. Implications for Pediatricians: Anticipatory Guidance  Start discussing safe passenger behavior by age 11 years  Help parents set limits  Start discussing driving rules by age 13

42. Alabama GDL (Cliff notes)  15 year olds get “temporary” – have to be accompanied by adult  16 yo can get restrictive :  Passengers  Cell phones  curfew

43. Two take home messages:  Our states’ teens are at exceptionally high risk for death or injury when driving or as passengers  Parents are the key influence on teens and we can help parents set rules, teach skills and keep our teens safe

44. I knew the components of the GDL law BEFORE today’s lecture 1. Yes 2. No

45. Alabama’s GDL limits the number of passengers a teen can transport 1. Yes 2. No 3. Don’t Know

46. Alabama GDL sets a curfew for teen drivers with a restricted license 1. Yes 2. No 3. Don’t Know

47. How many Adolescents do you see in your practice in a year? 1. <10 2. 10-30 3. 30-50 4. 50-70 5. >70

49. Alabama GDL  Stage 1 learners permit  15 or older  Written exam and accompanied by guardian or licensed driver over 21  Minimum 30 hrs supervised driving or complete drivers ed  Must have 6 month holding period for this stage

50. Restricted license  Stage 2  16 or over and guardians permission  Road skills exam  No more than one passenger in vehicle other than parents, or drivers over 21  No handheld communications devices  No driving between midnight and 6 am unless….. With adult Going to work, school or religious event Medical, fire, legal emergency Hunting/fishing activities

51. Unrestricted license  Must be 17 or older  (must have had a stage 2 license for at least 6 months if 17 yo)

52. New texting bill  Bans driving while manually using a cellphone or other wireless device to communicate by text message or email  Does not apply to calls for emergency services  If parked on side of road  GPS systems  Fine: $25 first office, $50 for second and $75 third  Each conviction carries 2 points on driving record  (suspended license for 12 pt in 2 yrs)