1. Modifying Your Teaching Styles – In the Classroom and In the Car
Amanda Plourde, COTA/L, CDI, CDRS

2. How can a CDRS help
Help family, client, case manager, driver education instructor or physician decide if someone is appropriate to continue driving or be successful with learning how to drive.
If appropriate for training provides training
Refer to others to assist client with success
Vision specialist
Occupational Therapy/Speech Therapy
Transportation options
Offer family and client support

3. Mom and Dad are afraid to drive with the student/teenager
They have an IEP/504 plan
Visual problems
Difficulty with Mobility/Ambulation
Diagnosed Physical or Cognitive Disability
Client would like to learn how to drive but maybe family is unsure that it is an appropriate goal
Big red Flag did the student call to register or was it mom?
How do I know if someone is appropriate for drivers education vs. evaluation

4. Questions to ask Parents
IEP/504: Is the individual on an IEP/504 plan at school?
Independent with ADL’s: Is the individual able to dress themselves, do laundry, use the stove, cross the street independently, make a sandwich, manage money or checking account, do they know who to call if they get hurt or get into an accident? Are the able to perform household chores? Did they ever learn how to ride a bicycle?
Driving Experience/Gross Motor Activities: Does the individual have any driving experience? If so, how much and where? Do they ski, ride a bike, play sports, mow the lawn, shovel snow, rake leaves?
Endurance: Individuals should demonstrate reasonable all day endurance. This is particularly true for Individuals that may be learning to drive with adaptive equipment, such as Individuals with spinal cord injuries, Multiple Sclerosis, Muscular Dystrophy, leg amputation, or Cerebral Palsy.
Questions to ask Parents
IEP is federally Funded and the schools receives funds from government. If they don’t follow plan then they can be sued is a little less strict, less rights for the client/student

5. Questions to ask Parents
Physical and Medical Stability: Individuals should be medically stable and physical recovery should have plateaued. It is required that the patient be seizure free for at least the previous six months. If further re­covery is expected in extremities that might affect the need for, or type of adaptive equipment, evaluation should be delayed.
Cognition: Are there safety or judgement problems. Attention span should be at least 30 minutes Short-term memory problems should not be present or are they able to compensate for these deficits?
Perception: Learning disabilities and a personality disturbance or perceptual problems should not affect basic daily activities. Someone with a head injury or concussion may need to wait 6-12 weeks or until cleared by their physician before driving or returning to drive.
Questions to ask Parents

6. Questions to ask parents
Interpretation of road rules: The individual should be able to interpret traffic situations and predict changes.
Vision: When did you last see an eye doctor do you have any blurred or double vision? Individuals with a severe visual disturbance following any central nervous system trauma (concussion) should be cleared by a vision specialist or eye doctor prior to participating in an evaluation or return to driving. Some individual’s with a learning disability may have visual problems.
Psychological/Emotional: Individuals with a psychiatric history should be cleared (in writing) by their psy­chiatrist/psychologist. The patient must be stable and able to handle the stresses of driving.

7. Commonly Seen Diagnoses
Autism Spectrum Disorder/HFA (High Functioning Autism)
Cerebral Palsy
ADHD
PDD
Spina Bifida
Dwarfism
Non-Specified Learning Disability
Non-Verbal Learning Disability
Commonly Seen Diagnoses

8. Autism Spectrum Disorder
Autism is considered a spectrum condition and therefore the degree of severity varies. Individuals on the spectrum should consider a driving evaluation before learning to drive.
Autism Spectrum Disorder

9. Driving is a very social skill, it involves reading the actions of others and responding in an appropriate/timely manner, these are referred to as: Perspective Taking Skills

10. Skills required for driving
Executive function – These issues can lead to difficulty managing a roadside emergency, a routine police stop, a detour, or a significant change in weather.
They have difficulty planning, organizing, and sequencing the steps to solve a problem.
They have difficulty with flexibility of thought.
Social skills – Driver’s don’t tend to follow the rules all of the time. Therefore drivers need to rely on their ability to anticipate actions of other drivers. Individuals with AS/HFA often have difficulty anticipating actions of other drivers.
Individuals with AS/HFA have difficulty interpreting verbal and nonverbal information.
Individuals with AS/HFA tend to be extremely literal.
Skills required for driving

11. When it comes to sitting in the driver's seat for the first time, a young person with ASD faces all the same issues a typically developing adolescent does, as well as additional difficulties posed by ASD. There are definitely some aspects of driving that he or she may need special help to master
Often what I find is that these clients do not have the gross motor experiences that other need drivers have and or they or their family never thought that driving would be an option therefore they haven’t even tried it.

12. Studies show that one of the biggest strengths for many with ASD is attention to detail. What is more of a challenge is grasping the "gist" of a situation in a timely manner to safely move yourself through space. Whether you are walking, driving or riding a bike.
But with this attention to detail they get upset with other driver’s who do not follow these rules, which can distract them from their own driving.

13. Autism Characteristics
Often require more practice with driving instructor hours
Emphasize that not everyone follows the rules and to let it go
Learn to anticipate potential hazards
Don’t expect eye contact
Don’t expect to get through a full lesson
Parents may be reluctant to help
Anxiety/ADHD
Don’t want to drive in the first place
Coordination
Did the learn to ride a bike, play sports?
Do they play a lot of video games

14. In addition to our many science research grants, Autism Speaks is extremely proud to fund important new or expanding programs for individuals with autism.
In 2010 a $25,000 grant was awarded to the Beth Israel Deaconess Medical Center  in Boston, MA. Entitled  "DriveAdvise", the project entailed the development of a toolkit and an educational video to facilitate decisions about whether an individual with ASD might consider driving in the future.
However this program does not provide behind- the-wheel training and it is for all ages.
DriveAdvise

15. The researchers found that, on average, adults with autism earn their drivers' licenses at later ages, drive less frequently and put more restrictions on their driving. These self-imposed limits include not driving on highways or at night. Adult drivers with autism also reported more traffic violations, on average, than did a comparison group of drivers without autism.
The report, by investigators at Drexel University, appears in the Journal of Autism and Developmental Disorders.
Better Drivers?

16. Warning Signs www.NortheastRehab.com
Information processing – These difficulties can cause the individual to have impaired reactions to changes in the driving environment. This becomes more challenging as the individual advances into more complex traffic.
Individuals with AS/HFA tend to take in too much information.
They consider all information to be of equal importance and therefore have difficulty prioritizing the information that they see.
Individuals with AS/HFA can have difficulty shifting attention quickly around the driving environment.
Motor skills – This can make it initially difficult to learn to operate the steering, acceleration, and braking to effectively control the vehicle through turns, hills, and curves. As the individual advances in driving, it can impact the ability to carry out the visual and physical steps to make a lane change.
Individuals with AS/HFA have eye–hand coordination difficulties.
Warning Signs

17. Clinical Assessment www.NortheastRehab.com Vision Cognition Perception
Traffic Rule Knowledge
Reaction Speeds
Neuro Motor Abilities
Clinical Assessment
Vision-State vision requirements, ability to shift and divide attention to monitor speedometer, check traffic and use rearview mirrors.
Perception ability to recognize, remember and interpret traffic information, interpret and traffic information. Insight in their own deficits
Cognition – determine if they will be able to make appropriate decision and respond appropriately to hazards.

18. Cognition Orientation, Day, Time, Place Memory Attention
Insight, Judgment and Safety Awareness
Problem Solving and Logical Reasoning
Cognition

19. Vision Far visual acuity Near visual acuity Peripheral vision
Depth perception
Color perception
Lateral phoria
Vertical phoria
fusion
Vision

20. Snellen Chart

21. Areas of Vision that is Assessed
Pupillary Response
Ocular Motor Function
Contrast Sensitivity
Diplopia
Eye Dominance
Areas of Vision that is Assessed

22. Traffic Knowledge Right left discrimination Lane position
Right of way knowledge
General traffic rule knowledge verbal or written quiz
Traffic Knowledge

23. Is the new driver able to attend to what is most important?

24. Motor Abilities Mobility assistive device
Upper and Lower Extremity Function
ROM, Strength, Sensation, Coordination, Tone
Trunk and Neck
Balance and Endurance
Reaction Speed
Upper Body for Hand Controls or Steering
Lower Body for using OEM pedals/Left Accelerator
Motor Abilities

25. Behind the Wheel Skills
Environments
Parking Lot
Residential
Rural
Light city traffic
Moderate city traffic
Highway
Complex environment
Parking (forward or reverse)
Behind the Wheel Skills

26. Behind the Wheel Orientation to car Pre drive setup Driver Positioning
Parking Skills
Lane Positioning
Attention
Right & Left Turns
Application Right of Way Knowledge
Speed Control
Scanning
Application Traffic Sign Knowledge
Able to learn & apply new info
Safety Awareness

27. Skills required for driving
Executive functioning – These issues can lead to difficulty managing a roadside emergency, a routine police stop, a detour, or a significant change in weather.
They have difficulty planning, organizing, and sequencing the steps to solve a problem.
They have difficulty with flexibility of thought.
Social skills – Driver’s don’t tend to follow the rules all of the time. Therefore drivers need to rely on their ability to anticipate actions of other drivers. Individuals with AS/HFA often have difficulty anticipating actions of other drivers.
Individuals with AS/HFA have difficulty interpreting verbal and nonverbal information.
Individuals with AS/HFA tend to be extremely literal.
Skills required for driving

28. Once a License is Obtained
Recommend in writing that they limit their driving for 6-12 months
Avoid distractions
Practice new routes before going out on own
Recommend the parent continue driving with them until they are comfortable with them going out on their own
Often these licensed drivers are only route driver’s meaning to work-home only
These clients tend to be just route drivers
Good Employees
Once a License is Obtained

29. Pleasant 25 year old male with a diagnosis of Mental Retardation who was referred for a driving evaluation by Dr.. XXX lives with his father and mother in Litchfield, NH. He graduated from Campbell High school in Litchfield, NH in He works approximately 24 hours per week at Sam’s Club in Hudson, collecting carts. He reports performing pre-driving activities such as bike riding, baseball, basketball and operating a lawn tractor. He and his father report that his visual deficits have limited his ability to perform tasks proficiently. He has driven with his father and has had 6-8 private driving lessons, but has had continued difficulty operating a motor vehicle smoothly and at higher speeds. XXX was seen on 1/5/16 for a pre-clinical and behind-the-wheel driving assessment through Northeast Rehabilitation Hospital.
Case study

30. Case Study Corrected Visual Acuity Binocular 20/22 Right 20/28 Left
20/100
Case Study
Vertical Balance
Impaired
Lateral Balance
Fusion
Intact
Usable Vision Right Eye
Usable Vision Left Eye
Usable Vision Both Eyes
Stereopsis (depth perception)
Color Perception
Peripheral Vision
Tracking
Saccades
Convergence

31. He meets the NH visual acuity requirements of 20/30 minocular vision; however he has significant visual deficits including; impaired vertical balance, impaired lateral balance, impaired left eye acuity, impaired stereopsis, impaired tracking, impaired saccades and impaired convergence.
Case Study

32. Based on the clinical assessment, areas of concern which may adversely impact on driving performance included: XXX has significant deficits in vision that may impact his on-road assessment. Decreased vertical balance, impaired lateral balance, impaired L eye acuity, impaired stereopsis, impaired tracking, impaired saccades and impaired convergence may impact his ability to look adequately down the road and scan as needed. Impaired perceptual deficits including figure ground, visual organization, visual memory and visual closure may impact his ability to manage a vehicle in intersections, lane changes/merging and precise maneuvers such as parking.
Case Study

33. Decreased cognition including decreased memory, impaired divided attention, impaired abstract thinking and limited problem solving may impact his ability to handle more complex driving environments such as highway and city driving. He has had no formal driver education and his awareness of rules of the road is limited. His left/right discrimination is impaired and may affect his ability to follow directions and determine right of ways at intersections.
Case Study

34. XXX should be assessed by a Dr. Kevin M. Chauvette O. D
XXX should be assessed by a Dr. Kevin M. Chauvette O.D. Neuro-Ophthalmology at Merrimack Vision Care (603) or Developmental Ophthalmologist Dr. Amy Pruszenski Concord Location (603) or Portsmouth (603) ) to address his vision, eye teaming abilities and to explore any strategies that may be helpful to him. Improving his vision will not only be beneficial for driving, but for work and life skills.
Initiate 10 hours of skilled driver training with a driver rehabilitation specialist after he has evaluated and treated by a Developmental or Neuro ophthalmologist. Driver training should help determine if XXX is appropriate to continue with one on one driver training and tutoring with a driver rehabilitation specialist. It is anticipated that XXX may potentially need an additional hours of driver training if he is found to be appropriate to continue to pursue driving.
XXX should participate in Driver readiness activities (see the attached sheet) with his parents as he prepares for driver training.

35. Behavioral Optometrist
Catherine A. Kennedy, O.D., FCOVD Behavioral Optometrist,  Board Certified in Vision Therapy, Burlington, MA   ,    
Behavioral Optometrist

36. XXX is pleasant 26 year old male with a diagnosis of Mental Retardation and visual deficits. No other significant medical history was reported. XXX lives with his father and step-mother in Litchfield, NH. He graduated from Campbell High school in Litchfield, NH in He works 40 per week at Sam’s Club in Hudson, doing multiple tasks. He reports performing pre-driving activities such as bike riding, softball, basketball, and operating a lawn tractor. He competes in the Special Olympics. He and his father report that he has driven with his father and has had 6-8 private driving lessons, but has had continued difficulty operating a motor vehicle smoothly and at higher speeds.
Case Study 9/18/2018

37. Case Study 1 ½ years later After vision therapy
Corrected Visual Acuity
09/18/2018
1/5/2017
Binocular
20/20-1
20/22
Right
20/30
20/28
Left
20/50
20/100
Case Study 1 ½ years later After vision therapy
Vertical Balance
Impaired
Lateral Balance
Fusion
Intact
Usable Vision Right Eye
Usable Vision Left Eye
Usable Vision Both Eyes
Stereopsis (depth perception)
Color Perception
Peripheral Vision
Tracking
Saccades
Convergence

38. Decreased vertical balance, impaired lateral balance, impaired L eye acuity, impaired stereopsis, impaired tracking, impaired saccades and impaired convergence may impact his ability to look adequately down the road and scan as needed. Impaired perceptual deficits including figure ground, visual organization, visual memory and visual closure may impact his ability to manage a vehicle in intersections, lane changes/merging and precise maneuvers such as parking.
Problem Areas

39. Initiate 10 hours of skilled driver training with a certified driver rehabilitation specialist to assist with determining if XXX is appropriate to continue with one on one driver training and tutoring with a driver rehabilitation specialist and if driving is an appropriate goal.
IF successful with the initial 10 hours of training it is anticipated that XXX may potentially need an additional hours of skilled driver training. The amount of skilled driver training will rely on how much outside support/family involvement and effort XXX puts toward this goal.
XXX should participate in Driver readiness activities (see the attached sheet) with his parents as he prepares for driver training. XXX should study the NH manual and attempt the knowledge test at the DMV. Prior to initiate training and or concurrent with driver training.
His vision training was beneficial and his visual scanning and attention has improved. He is very motivated and has a supportive family. Has FUNDING

40. Decreased cognition including decreased memory, impaired divided attention, impaired abstract thinking and limited problem solving may impact his ability to handle more complex driving environments such as highway and city driving. He has had no formal driver education and his awareness of rules of the road is limited. His left/right discrimination is impaired and may affect his ability to follow directions and determine right of ways at intersections.
Case Study

41. Clinical Outcomes 1/2017 9/2018 Functional Limits MVPT 24/40 32/30
34/40
HOOPER
20/30
24/30
MOCA
15/30
23/30
26/30
Trails A
72 seconds
50 seconds
90 seconds
Trails B
138 seconds
180 seconds
SOMC
28/28
Memory
Impaired
Slightly Impaired
Hearing
Intact
Problem Solving
Rules of Road
Right/Left
Map
Right of Way
Sign Interpretation
Clinical Outcomes

42. His clinical outcomes improved, WHY?
Case Study

43. BREAK

44. Classroom Accommodations
Have student sit next to teacher
Increase space between desks
Foot Rests and seat cushions
Stand near the student when talking
Place student away from doors and windows
Classroom Accommodations

45. Classroom Accommodations
Organization
Use an assignment notebook
Provide student with extra books
Provide written outline of curriculum
Color code materials ie: driving times each day have a color
Classroom Accommodations

46. Classroom Accommodations
Test Taking
Provide fewer questions and problems
Give Frequent short quizzes
Give extra time offer a quiet space to take test
Allow student to answer questions out loud or use fill in the blank
Classroom Accommodations

47. Classroom Accommodations
Classwork
Allow to use computer
Give credit for work even if late
Break long assignments into smaller chunks
Don’t‘ worry about neatness
Classroom Accommodations

48. Classroom Accommodations
In-Class Learning
Give directions out loud and in writing
Use pictures and graphics
Have another student take notes
Give the student the outline so they don’t have to take notes
Classroom Accommodations

49. Classroom Accommodations
Behavior
Praise for good ignore the bad
Talk through problems one on one
Monitor Frustration Check in with student
Come up with a behavior plan
Classroom Accommodations

50. Classroom Accommodations
Classroom setup
Small group/large group
Modify testing
Allow an aide or parent to assist in classroom
Community mobility specialist
Vision or OT intervention
Vehicle Modification
Frequent Breaks
Verbal tests vs. Written test
Hands on activities
Classroom Accommodations

51. How will these clinical findings affect learning?

52. Are you going to let them move around?

53. What are some ways to modify teaching in the classroom
Beach Ball activity
Set up a car situation to demonstrate distracted driving
Texting and walking activity/AAA Reaction Timer
Traction, take off shoes run down the hallway
Hallway demonstrate right of way, walking on the correct side of the highway
What are some ways to modify teaching in the classroom

54. In-Car Accommodations
Behavior
Praise for good ignore the bad
Talk through problems one on one
Monitor Frustration Check in with student
Come up with a behavior plan
In-Car Accommodations

55. In-Car Accommodations
Pictures and Diagrams
Switch Seats
Use Match Box Cars
In-Car Accommodations

56. In-Car Accommodations
Pull over Look up intersections before progressing through
Use GPS
Video tape session
In-Car Accommodations

57. In-Car Accommodations
Discuss what is going to be taught
Before you put the car in motion
Start all lessons in the same location
Pull over to discuss lesson
Point left/right vs. just saying it
In-Car Accommodations

58. In Car Activities Go out into the car, Show parking techniques
Mapping activity/Matchbox cars
Driver readiness activities
Jar of Jiggles
In Car Activities

59. Adaptive Equipment www.NortheastRehab.com
Left side MPD hand control (push/pull or push/right angel)
Adaptive Equipment

60. Adaptive Equipment Left side Sure Grip Hand Controls
Left Foot Accelerator
Spinner Knob
Adaptive Equipment

61. Van Transport Recommendations

62. Bioptics Keplarian Telescope Galilean Telescope Larger Smaller Heavier
Lighter
Smaller field of view
Less expensive
Poorer image quality
Rarely used above 3X power
Brighter image due to only 4 lens surfaces
Keplarian Telescope
Larger
Heavier
Larger field of view
More expensive
Good quality image
Smaller ring scotoma
Spectacle mounted up to 10X power
Less bright image due to 10 lens surfaces
Bioptics

64. The number of older drivers is growing rapidly and they are driving longer distances
Driver cessation is inevitable for many and can be associated with negative outcomes
Many older drivers successfully self-regulate their driving
The crash rate for older drivers is in part related to physical and/or mental changes associated with aging and/or disease
Older Driver Factors

65. Contrary to public belief, the majority of older drivers are good drivers
As we age we change our driving habits to adjust to our capabilities
Driving less or only during the day
Avoid driving in poor weather conditions
Less likely to drink and drive
Less likely to speed
Talk on the phone or text
Who is the older driver

66. In Car Accommodations Inattentional Blindness
Sometimes, we are not able to perceive an object, a person or an event that is in our field of view. That happens when we are focused on one object in our perceptual field, and something else that we didn't expect appears in front of us. This is called in attentional blindness and various psychologists have recently started bringing it into correlation with distracted driving.
blindness
In Car Accommodations

67. Aging Increases Inattentional Blindness
When engaged in an attention-demanding task, (such as driving) people are surprisingly vulnerable to inattentional blindness—the failure to notice an unexpected event.
Gorilla,
WHODUNIT?
Aging Increases Inattentional Blindness

68. Possible Effects Age has on Driving
Medication side effects
Difficulty getting in and out of the car
Community mobility deficits
Difficulty managing assistive devices
Difficulty seeing in reverse
Difficulty checking right and left at intersection
Difficulty checking blind spots
Difficulty seeing over dashboard/steering wheel
Difficulty using seatbelt
Difficulty turning the steering wheel
Difficulty using the secondary controls
Difficulty reaching the gas and brake
Difficulty using the parking brake
Difficulty shifting gears
Possible Effects Age has on Driving

69. Ways to Increase Senior Driver Safety
Driver education and training
Understanding safety features in car
Limit environments
Limit length/time of day driving
Travel planning
Adaptive equipment
Positioning
Proper vehicle
Physical conditioning
Rest periods
Medication adjustment
Increase public awareness
Re-examination for license
Ways to Increase Senior Driver Safety

70. Staying Active Exercise Part time job Puzzles Bowling Volunteering
Playing cards
Scrabble
Suduko
Golfing
Skiing
Biking
Hiking
Baby sitting grandchildren
Staying Active

71. Possible Effects of Giving up a License
Isolation
Depression
Dependence on family and friends
May need to change living environment
Loss of social network
Inability to continue normal daily pattern
Life expectancy after discontinuation of driving
Males 7 years
Females 10 years
Possible Effects of Giving up a License

72. Options for Funding Private Pay Service
School system
Vocational Rehabilitation
Private pay
Grant money
Workers Compensation
Family Members
Church Groups VA
Go Fund Me
Options for Funding Private Pay Service

73. Resources INSTRUCTIONAL VIDEO FROM CHOP
Independent life skills check list:
Asperger’s Association of New England | T: | F: Main Street, Suite 101, Watertown, MA
American Driver and Traffic Safety Education Associations Novice Driver Education Curriculum Standards Classroom and In-Car, March 2015,
Autism Speaks, Autism and Driving: Study Opens Research into Unmet Needs of Adults.
(12) RULES OF THE ROAD: DRIVING AND ASD, Teresa Foden IAN Assistant Editor,
AOTA, American Occupational Therapy Association
ADED, Association for Driver Rehabilitation Specialists
INSTRUCTIONAL VIDEO FROM CHOP
Resources

74. To Schedule Call: 603-890-7664 Fax: 603-898-8368
Amanda Plourde, COTA/L, CDI, CDRS
To Schedule Call: Fax:
Northeast Rehabilitation Hospital Network
70 Butler Street
Salem, NH 03079
(603)