1. Risk factors affecting Driving Behaviour during Adolescence John Brennan, Director Child & Adolescent Mental Health Service Sydney Children’s Hospital Associate Professor (UNSW Conjoint) SCH Grand Rounds June 10/2009

2. Fatality rates for 12-month period ending May 2009 NSW RTA Data Number of fatalities448 Rate per 100,000 population¹6.4 Rate per 10,000 vehicles²1 Rate per 100 million vehicle kilometres travelled³0.7

3. Casualty rates for 12-month period ending April 2009 Number of casualties*24,149 Rate per 100,000 population¹345 Rate per 10,000 vehicles²54 Rate per 100 million vehicle kilometres travelled³ 38

5. Number of fatalities for 12 months ending May 2009, sex of fatality

6. Distribution of fatalities for 12 months ending May 2009, by age and road user class

7. Number of fatalities for 12 months ending May 2009, age of fatality

8. Trends for fatalities and motor vehicle travel since 1978

9. NSW crash statistics show that young people are over-represented as drivers and motorcycle riders in fatal crashes. People under 26 comprise only 15% of driver licences but are involved in 36% of road fatalities

10. Young driver safety A 17-year-old driver with a P1 licence is about four times more likely to be involved in a fatal crash than a driver aged 26 or older. Within the over-representation of young people in crashes, males stand out as a concern. Males make up 79% of the drivers under 26 involved in fatal crashes.

11. Cases of Death USA 2005

12. PATTERNS OF RISK FOR ADOLESCENT DRIVERS In assessing risk, age matters In assessing risk, age matters 16-19yrs if data is aggregated, lose important information about age as a risk factor 16-19yrs if data is aggregated, lose important information about age as a risk factor Similar issues when considering older drivers 65+, 75+, 85+ Similar issues when considering older drivers 65+, 75+, 85+ Distance travelled allows comparison of crash risk, relative to exposure Distance travelled allows comparison of crash risk, relative to exposure License data – per person rates License data – per person rates Population data – overall risk for age group Population data – overall risk for age group (slides refer to US date aggregated across 50 states)

13. TEENAGE DRIVERS RISK FACTORS (AF WILLIAMS (2003) Teenage driving risks can be considered under 3 headings. Teenage driving risks can be considered under 3 headings. (a)Situations where risk is elevated for all drivers (a)Situations where risk is elevated for all drivers (b)Situations where risk is elevated for teenage drivers relative to older drivers (b)Situations where risk is elevated for teenage drivers relative to older drivers (c)situations where risk is unique to teenagers (c)situations where risk is unique to teenagers

14. Teenage drivers: patterns of risk (In The United States) Allan F. Williams* Journal of Safety Research 34 (2003) 5– 15 The following slides-indicate that younger and older drivers have the highest rates The following slides-indicate that younger and older drivers have the highest rates Younger > older crash rates Younger > older crash rates Males > females Males > females Women > males, per mile driven Women > males, per mile driven Fatal crash rates per distance travelled 16yr olds greatest Fatal crash rates per distance travelled 16yr olds greatest Older drivers greater fatality rate/mile – as they are more fragile Older drivers greater fatality rate/mile – as they are more fragile Note: mileage based rates exaggerates risks for younger and older drivers. They are driving shorter distances on more congested roads/younger drivers more night time exposure.

15. Teenage drivers: patterns of risk Allan F. Williams* Journal of Safety Research 34 (2003) 5– 15 Driver crash involvements per million miles travelled, 1995.

16. Teenage drivers: patterns of risk Allan F. Williams* Journal of Safety Research 34 (2003) 5– 15 Driver fatal crash involvements per million miles travelled, 1995.

17. Crashes / licence holder Teenage drivers: patterns of risk Allan F. Williams* Journal of Safety Research 34 (2003) 5– 15 Crashes / licence holder Youngest 16-19 (greatest for all crashes, greatest for fatal crashes) Youngest 16-19 (greatest for all crashes, greatest for fatal crashes) Young males slightly greater crash rate Young males slightly greater crash rate Per capita rates -youngest least likely to have a licence so 16yr olds lowest/capita -fatal crashes/16yr olds, and 20-24yr have highest per capita

18. Teenage drivers: patterns of risk Allan F. Williams* Journal of Safety Research 34 (2003) 5– 15 Driver fatal crash involvements per 100,000 licensed drivers, 2000.

19. Teenage drivers: patterns of risk Allan F. Williams* Journal of Safety Research 34 (2003) 5– 15 Driver crash involvements per 1,000 population, 2000.

20. Teenage drivers: patterns of risk Allan F. Williams* Journal of Safety Research 34 (2003) 5– 15 Driver fatal crash involvements per 100,000 population, 2000.

21. Teenage drivers: patterns of risk Allan F. Williams* Journal of Safety Research 34 (2003) 5– 15 Crashes per 10,000 drivers, by months of permit or licensure, Nova Scotia. Learner period – low risk as parents are supervising Permit period – Nova Scotia data; Clear increased risk immediately following Licensing

22. Teenage drivers: patterns of risk Allan F. Williams* Journal of Safety Research 34 (2003) 5– 15 All crashes per million miles, day versus night, by driver age, 1995. Night time driving risk – greatest risk especially in younger drivers.

23. Teenage drivers: patterns of risk Allan F. Williams* Journal of Safety Research 34 (2003) 5– 15 Fatal crashes per 100 million miles, day versus night, by driver age, 1995. Night time greater risk for fatal crashes drivers 16-20 even greater relative increase than in daytime

24. Teenage drivers: patterns of risk Allan F. Williams* Journal of Safety Research 34 (2003) 5– 15 Sixteen- to 17-year-old drivers in all crashes, hour by hour, 1995.

25. Teenage drivers: patterns of risk Allan F. Williams* Journal of Safety Research 34 (2003) 5– 15 Sixteen- to 17-year-old drivers in fatal crashes, hour by hour, 1995. Per trip students are 44 times more likely to be killed in a vehicle with a teen driver than whilst riding a school bus. in a vehicle with a teen driver than whilst riding a school bus. Time of day – fatal crashes two peaks; before and after school day for 16/17yr old drivers.

26. Teenage Drivers Alcohol Alcohol Low in teenage drivers compared to older drivers When young drivers do drink however, their relative increase in risk is greater than older drivers Alcohol related fatalities have fallen substantially due to changes in law.

27. Socio-cultural risk Factors Driving is a rite of passage and a developmental milestone for most adolescents Driving is a rite of passage and a developmental milestone for most adolescents Driving can be crucial for many young persons employment and education Driving can be crucial for many young persons employment and education Driving contributes to normal social development, self confidence and esteem with peers Driving contributes to normal social development, self confidence and esteem with peers Adolescents value driving as an opportunity for getting together with other adolescents without being supervised and scrutinized by adults Adolescents value driving as an opportunity for getting together with other adolescents without being supervised and scrutinized by adults Music, distracting talk, joking around together, are considered to be important pleasurable aspects of teenage driving experience but can encourage risk taking Music, distracting talk, joking around together, are considered to be important pleasurable aspects of teenage driving experience but can encourage risk taking

28. Crash Risks Unique to Adolescence Having passengers in the vehicle Having passengers in the vehicle -creates a social situation affecting driving behaviour -associated with increased risk It is a very high-risk situation for teenage drivers to have multiple passengers when they are also teenagers. More than 50% of all deaths in crashes of 16-17 year old drivers occur when passengers younger than 20 years old are present and there is no adult in the vehicle.

29. Teenage Passenger Crash fatality Rates: Many teens die as passengers in motor vehicles. -40% of deaths in 16-19 yr olds travelling in passenger vehicles were passengers. -for 16yr olds it is 50% of fatalities -often travelling with teenage drivers

30. Teenage drivers: patterns of risk Allan F. Williams* Journal of Safety Research 34 (2003) 5– 15 Deaths of passengers in passenger vehicles per 100,000 population, United States, 2000.

31. Crash Risks Unique to Adolescence Crash rates by driver age and number of passenger present per 10,000 trips. Crash rates by driver age and number of passenger present per 10,000 trips. With increasing numbers of passengers the risk for older driver falls With increasing numbers of passengers the risk for older driver falls For teenagers the rate increases exponentially with 1-3 plus passengers For teenagers the rate increases exponentially with 1-3 plus passengers The risk increases for male and female drivers with night time rates being higher The risk increases for male and female drivers with night time rates being higher The highest risk for male and female teenager drivers is with male passengers The highest risk for male and female teenager drivers is with male passengers The risk for teenage males falls with female passengers. The risk for teenage males falls with female passengers. The presence of one male passenger doubles the fatality rate; the presence of two male passengers doubles the fatality rate again ( for male and female teenage drivers) The presence of one male passenger doubles the fatality rate; the presence of two male passengers doubles the fatality rate again ( for male and female teenage drivers) Driving behaviour is affected, increased speed, increased risks Driving behaviour is affected, increased speed, increased risks But when carrying female passengers teenagers drive more safely But when carrying female passengers teenagers drive more safely

32. Teenage drivers: patterns of risk Allan F. Williams* Journal of Safety Research 34 (2003) 5– 15 Crash rates by driver age and passenger presence per 10,000 trips.

33. Only one-third of people killed in fatal crashes involving teen drivers are the drivers themselves The analysis of U.S. crash data from 1998 to 2007 showed that crashes involving drivers aged 15 to 17 killed 28,138 people. Of those, 10,388 (36.9 percent) were the teen drivers. The other 17,750 (63.1 percent) included, 8,829 passengers of the teen drivers, 6,858 occupants of other vehicles, and 2,063 non-motorists.. A previous analysis of data from 1995 to 2004 found that crashes involving drivers aged 15 to 17 killed 30,917 people. Of those deaths, 36.2 percent were the teen drivers and 63.6 percent were others. The drop in deaths between this and the most recent analysis suggests that graduated licensing and other efforts to improve teen driver safety are having an effect. Only one-third of people killed in fatal crashes involving teen drivers are the drivers themselves The analysis of U.S. crash data from 1998 to 2007 showed that crashes involving drivers aged 15 to 17 killed 28,138 people. Of those, 10,388 (36.9 percent) were the teen drivers. The other 17,750 (63.1 percent) included, 8,829 passengers of the teen drivers, 6,858 occupants of other vehicles, and 2,063 non-motorists.. A previous analysis of data from 1995 to 2004 found that crashes involving drivers aged 15 to 17 killed 30,917 people. Of those deaths, 36.2 percent were the teen drivers and 63.6 percent were others. The drop in deaths between this and the most recent analysis suggests that graduated licensing and other efforts to improve teen driver safety are having an effect.

34. National Young-Driver Survey

37. Our data reveal a striking lack of awareness of how inexperience among adolescent drivers affects safety. Although 60% believed that inexperience heavily influences safety, only 15% reported exposure to inexperienced drivers in a sample that solely included passengers and young drivers, nearly all of whom would be considered inexperienced by experts. Inexperience is heavily mitigated during the learner period when a parent is present. A teen’s risk is at its lifetime highest level on the first day of independent driving. This risk continues to be disproportionately high for the first 6 months of independent driving and doe not reach adult levels until the age of 25 years. The steep decline that begins after the first month of driving demonstrates that inexperience contributes most heavily to crashes. Developmental factors, including cognitive immaturity, emotional liability, and risk taking, also affect crash rates. if these developmental factors were the primary forces contributing to crashes, a much slower decline in crash rates would be expected. National Young-Driver Survey

38. Driving Performance & Traffic Accidents (Barkley et al, 2004) Human factors are considered to be the most common cause of automobile accidents Human factors are considered to be the most common cause of automobile accidents Driving is a complex multidimensional behaviour that can be conceptualised on three hierarchical levels of competency Driving is a complex multidimensional behaviour that can be conceptualised on three hierarchical levels of competency 1. Strategic 2. Tactical 3. Operational Deficits in lower levels especially at the operational, can have a profound effect on higher levels of competency.

39. Operational Competency Comprises elementary mental functions Comprises elementary mental functions Attention and concentration Attention and concentration Reaction time Reaction time Visual scanning Visual scanning Spatial perception and orientation Spatial perception and orientation Visual motor integration Visual motor integration Speed of cognitive processing Speed of cognitive processing Motor co-ordination Motor co-ordination

40. Driving Performance & Traffic Accidents Inattention and distraction from within the vehicle (eg mobile phone, playing with radio/CD, iPod, talking to other passengers) is among the most common contributors to traffic accidents. Inattention and distraction from within the vehicle (eg mobile phone, playing with radio/CD, iPod, talking to other passengers) is among the most common contributors to traffic accidents.

41. TACTICAL COMPETENCY Skills and decision making to deal with different driving conditions Skills and decision making to deal with different driving conditions Eg- dense traffic - rain - intersections - traffic lights - changing speed limits - passing other vehicles - country roads - rough roads - navigating unfamiliar areas

42. STRATEGIC COMPETENCY Decisions about whether to drive and when Decisions about whether to drive and when eg- weather conditions eg- weather conditions - time of day and impact of fatigue - time needed to complete journey - route to take - rest stops - vehicle safety (ie. roadworthy)

43. Association of driving with the 3 hierarchical levels of competency — operational, tactical, and strategic. Russell A. Barkley, Daniel Cox Journal of Safety Research 38 (2007) 113–128

44. Teenage drivers with ADHD Teenage drivers with ADHD A review of driving risks and impairments associated with ADHD Russell A. Barkley, Daniel Cox Journal of Safety Research 38 (2007) 113–128 Inattention/distractibility key factors increasing risk Inattention/distractibility key factors increasing risk Young drivers with ADHD-- key findings Young drivers with ADHD-- key findings 2-4 times more risk of traffic accidents 2-4 times more risk of traffic accidents 3 times more risk of injuries 3 times more risk of injuries 4 times more risk of being at fault 4 times more risk of being at fault 6-8 times more risk of license suspension 6-8 times more risk of license suspension Comorbid factors which add to risk Comorbid factors which add to risk Increased aggression Increased aggression Poor emotional regulation, anger Poor emotional regulation, anger Increased risk taking / limited insight Increased risk taking / limited insight If Conduct Disorder is also diagnosed If Conduct Disorder is also diagnosed

45. Anger, aggression, risky behavior, and crash-related outcomes in three groups of drivers. Deffenbacher, J. L., Lynch, R. S., Filetti, L. B., Dahlen, E. R., & Oetting, E. R. (2003). Behavioral Research and Therapy, 41(3), 333−349. Driving anger has been shown to be positively correlated with loss of concentration while driving, loss of vehicular control, near-collisions, and generally aggressive driving practices (Deffenbacher et al., 2000). High-anger drivers report, more aggressive and less constructive forms of expressing anger while driving, more aggressive and risky behaviour on the road, more frequent displays of anger and aggression when provoked during driving, and a greater number of crashes than do low-anger drivers (Deffenbacher et al., 2003).

46. The social re-orientation of adolescence: a neuroscience perspective on the process and its relation to psychopathology ERIC E. NELSON*, ELLEN LEIBENLUFT, ERIN B. MCCLURE AND DANIEL S. PINE Psychological Medicine, 2005, 35, 163–174. Observed alterations in adolescent social behaviour reflect genetically programmed developmental changes in the Cerebral Cortical Social Information Processing Network, (SIPN) This Network can be divided into 3 Subsystems 1. The Detection Node 2. The Affect Node 3. The Cognitive Regulation Node

47. A schematic depiction of the main regions contained within each of the three nodes of the Social Information Processing network (SIPN). Brain regions that make up the Detection node include the fusiform face area, the superior temporal sulcus and the anterior temporal cortex. involved in carrying out basic perceptual processes on social stimuli and are highlighted in green Developmental studies of brain processing in humans have generally found that brain systems in the detection node mature quite early in life.

48. Brain regions that make up the Affective node include the amygdala, hypothalamus, nucleus accumbens, and bed nucleus of the stria terminalis and are highlighted in red. The regions that make up the affective node are densely innervated by gonadal steroid receptors and undergo both functional and anatomical reorganization during puberty

49. Brain regions that make up the Cognitive-Regulation Node include the dorsomedial prefrontal cortex and the ventral prefrontal and Orbito- frontal cortex are depicted in blue. Detailed morphometric studies have shown that portions of the prefrontal cortex, including Orbito-frontal, ventrolateral, and medial prefrontal regions, do not reach maturity until early adulthood, typically in the late teens or early twenties (Sowell et al. 1999; Casey et al. 2000; Gogtay et al. 2004). This node is involved in inhibiting motivated response tendencies and understanding the psychological perspective of other individuals as in theory of-mind tasks.

50. Neurodevelopmental Trajectories of the Human CerebralCortex, Philip Shaw,1 Noor J. Kabani,3 Jason P. Lerch,4 Kristen Eckstrand,1 Rhoshel et al, The Journal of Neuroscience, April 2, 2008 28(14):3586 –3594 Developmental Trajectories of the Orbito-frontal Cortex

51. The social re-orientation of adolescence: a neuroscience perspective ERIC E. NELSON*, ELLEN LEIBENLUFT, ERIN B. MCCLURE AND DANIEL S. PINE Psychological Medicine, 2005, 35, 163–174. f 2004 While rapid and dramatic changes occur in the affective node of the SIPN at the onset of puberty, resulting in powerful emotional urges for sexual behaviour independence and the formation of new social bonds (Steinberg & Morris, 2001), the maturation of the cognitive node lags behind by several years (Beauregard et al. 2001; Casey et al. 2000; Ochsner et al. 2002; Schafer et al. 2002). Thus, in individuals who have powerful emotional responses to social stimuli the ability to regulate, contextualize, plan, or inhibit newly emergent and highly motivated behaviour in a context-appropriate manner is far from mature. This mismatch may lead to behavioural difficulties for some individuals.

52. The American Academy of Pediatrics advises pediatricians to: * Ask 16-year-olds if they are applying for a driver's permit soon. * Discuss driving risks and ask probing questions about driving behaviour. * Ask specific questions about medication use, use of alcohol, night- time driving, seatbelt use, and use of a cell phone while driving. * Encourage parents to place driving restrictions on their teenagers, such as making sure the novice driver is accompanied by an adult. * Ask parents to consider a written contract with their children, establishing the rules of engagement and penalties for failure to follow them. * Remind teens and parents that many state laws restrict cell phone use and night-time driving for novice drivers. The American Academy of Pediatrics advises pediatricians to: * Ask 16-year-olds if they are applying for a driver's permit soon. * Discuss driving risks and ask probing questions about driving behaviour. * Ask specific questions about medication use, use of alcohol, night- time driving, seatbelt use, and use of a cell phone while driving. * Encourage parents to place driving restrictions on their teenagers, such as making sure the novice driver is accompanied by an adult. * Ask parents to consider a written contract with their children, establishing the rules of engagement and penalties for failure to follow them. * Remind teens and parents that many state laws restrict cell phone use and night-time driving for novice drivers. ADHD especially if associated with ODD and poor anger management places adolescents at particularly high risk. ADHD especially if associated with ODD and poor anger management places adolescents at particularly high risk.

53. P1 drivers must: P1 drivers must: Have P plates (red P on white background) displayed conspicuously at the front and rear exterior of the car when driving. The letter P on the plate must not be hidden. If towing a trailer, a P plate must be on the back of the trailer. Have P plates (red P on white background) displayed conspicuously at the front and rear exterior of the car when driving. The letter P on the plate must not be hidden. If towing a trailer, a P plate must be on the back of the trailer. Not exceed zero blood alcohol concentration (this means you cannot drink before driving). It is also illegal to drive under the influence of drugs. Not exceed zero blood alcohol concentration (this means you cannot drink before driving). It is also illegal to drive under the influence of drugs. Observe a maximum speed limit of 90 km/h. Observe a maximum speed limit of 90 km/h. Observe towing restrictions (you are only allowed to tow light trailers of up to 250 kilograms unloaded weight). Observe towing restrictions (you are only allowed to tow light trailers of up to 250 kilograms unloaded weight). Not accumulate more than three demerit points. Not accumulate more than three demerit points. Be restricted to driving an automatic or clutchless manual transmission vehicle, if the test was not passed in a manual vehicle. Be restricted to driving an automatic or clutchless manual transmission vehicle, if the test was not passed in a manual vehicle. Not supervise a learner driver. Not supervise a learner driver. Not upgrade the licence to a higher class. Not upgrade the licence to a higher class. If aged under 25, you may only carry one passenger under the age of 21 between 11pm and 5am. If aged under 25, you may only carry one passenger under the age of 21 between 11pm and 5am. Only carry the number of passengers that can be properly seated in seats and restrained by approved seat belts or child restraints. Only carry the number of passengers that can be properly seated in seats and restrained by approved seat belts or child restraints. Only drive vehicles that have a seat belt fitted to the driver's position and you must wear the seat belt. Only drive vehicles that have a seat belt fitted to the driver's position and you must wear the seat belt. Not use any functions of a mobile phone including hands-free devices. Not use any functions of a mobile phone including hands-free devices. Not drive certain prohibited vehicles. Not drive certain prohibited vehicles. Failure to comply with any of the above requirements is an offence and carries heavy penalties, including loss of licence. P1 licence holders will also have their licence suspended for at least three months for any speeding offence. Failure to comply with any of the above requirements is an offence and carries heavy penalties, including loss of licence. P1 licence holders will also have their licence suspended for at least three months for any speeding offence.

59. Gogtay, N., Giedd, J. N., Lusk, L., Hayashi, K. M., Greenstein, D., Vaituzis, A. C., Nugent, T. F., Herman, D. H., Clasen, L. S., Toga, A. W., Rapopport, J. L. & Thompson, P. M. (2004). Dynamic mapping of human cortical development during childhood through early adulthood. Proceedings of the National Academy of Sciences USA 101, 8174–8179.

60. Dzirasa also urges pediatricians to learn about their state's driving laws and discuss them with both teens and parents. Maryland has a graduated driver's licensing law that eases novice drivers into driving in three stages: learner's permit, provisional license and driver's license. Research shows that graduated licensing reduces both the number of accidents and the number of severe injuries, Dzirasa says. For example, one study showed that graduated licensing led to 35 percent fewer crashes that require hospitalizations among 16-year- olds. Other studies have shown that the crash rate among 16- year-olds dropped by 26 percent to 41 percent in the first year after the adoption of a graduated licensing law. High-risk behaviors or conditions among teen drivers include lack of experience; nonuse of seatbelts; alcohol and other drug use; common pediatric conditions, such as ADHD, that increase accident risk; use of cell phones and audio equipment that distract drivers; nighttime driving; and the "it can't happen to me" thinking that's typical of teenagers and youth. In 2001 alone, 3,600 teens died in car accidents and 337,000 were injured, according to the National Highway Traffic Safety Administration. Dzirasa also urges pediatricians to learn about their state's driving laws and discuss them with both teens and parents. Maryland has a graduated driver's licensing law that eases novice drivers into driving in three stages: learner's permit, provisional license and driver's license. Research shows that graduated licensing reduces both the number of accidents and the number of severe injuries, Dzirasa says. For example, one study showed that graduated licensing led to 35 percent fewer crashes that require hospitalizations among 16-year- olds. Other studies have shown that the crash rate among 16- year-olds dropped by 26 percent to 41 percent in the first year after the adoption of a graduated licensing law. High-risk behaviors or conditions among teen drivers include lack of experience; nonuse of seatbelts; alcohol and other drug use; common pediatric conditions, such as ADHD, that increase accident risk; use of cell phones and audio equipment that distract drivers; nighttime driving; and the "it can't happen to me" thinking that's typical of teenagers and youth. In 2001 alone, 3,600 teens died in car accidents and 337,000 were injured, according to the National Highway Traffic Safety Administration.

61. A review of driving risks and impairments associated with attention-deficit/hyperactivity disorder and the effects of stimulant medication on driving performance Russell A. Barkley Daniel Cox. Journal of Safety Research 38 (2007) 113–128 Committee on Injury, Violence, and Poison Prevention and Committee on Adolescence Pediatrics 2006;118;2570-2581

62. Young driver safety Crashes and passengers Young drivers have a greater risk of involvement in a fatal crash if they have two or more passengers. Of the 89 young drivers involved in fatal crashes from 2001 to 2003, 36 per cent were driving with two or more passengers. This contrasts with 15 per cent for drivers aged 26 and over.

63. Young driver safety Time of crash The involvement of young drivers in late night and early morning fatal crashes is significantly higher than that of older drivers as outlined in figure 3. Of the 96 P plate drivers aged under 26 who were involved in fatal crashes from 2001 to 2003, 33% crashed between 10pm and 5am.This compared with 14% of drivers aged 26 years and over. Young drivers with a P licence are six times more likely to be involved in a fatal crash between 10pm and 5am than other drivers.** The over-involvement of young drivers is highest on Friday and Saturday nights. However, young drivers are also over-represented on other nights of the week.

64. National Young-Driver Survey: Teen Perspective and Experience With Factors That Affect Driving Safety Pediatrics 2008;121;e1391-e1403 Kenneth R. Ginsburg, Flaura K. Winston, Teresa M. Senserrick, Felipe García-España, Sara Kinsman, D. Alex Quistberg, James G. Ross and Michael R Elliott.

66. Factors related to seat belt use among fatally injured teenage drivers Anne T. McCartt, and Veronika Shabanova Northrup McCarttNorthrupMcCarttNorthrup Seat belt use was examined for teenage (16–19 years) drivers who were fatally injured in traffic crashes occurring in the United States during the years 1995–2000. Seat belt use was examined for teenage (16–19 years) drivers who were fatally injured in traffic crashes occurring in the United States during the years 1995–2000. Results: During 1995–2000, mean belt use was 36% among fatally injured teenage drivers Results: During 1995–2000, mean belt use was 36% among fatally injured teenage drivers and 23% among fatally injured teenage passengers. and 23% among fatally injured teenage passengers. Lower belt use among fatally injured teenage drivers was associated with Lower belt use among fatally injured teenage drivers was associated with increasing age; increasing age; Male drivers; Male drivers; Drivers of SUVs, vans, or pickup trucks rather than cars; older vehicles; Drivers of SUVs, vans, or pickup trucks rather than cars; older vehicles; crashes occurring late at night; crashes occurring late at night; crashes occurring on rural roadways; single vehicle crashes; crashes occurring on rural roadways; single vehicle crashes; and drivers with BACs of 0.10 or higher. and drivers with BACs of 0.10 or higher. Teenage driver belt use declined as the number of teenage passengers increased, Teenage driver belt use declined as the number of teenage passengers increased, but increased in the presence of at least one passenger 30 years or older. but increased in the presence of at least one passenger 30 years or older.

67. Passenger effects on teenage driving and opportunities for reducing the risks of such travel llan F. Williamsa,,, Susan A. Fergusonb and Anne T. McCarttc bFerguson International LLC, 1328 Lancia Drive, McLean, VA 22102, USA 2007 Williamsa FergusonbMcCarttc Williamsa FergusonbMcCarttc Despite passenger restrictions in the majority of US states, Despite passenger restrictions in the majority of US states, 42% of 16- and 17-year-old drivers in fatal crashes in 2005 were transporting teenagers with no adults in the vehicle; 42% of 16- and 17-year-old drivers in fatal crashes in 2005 were transporting teenagers with no adults in the vehicle; 61% of teenage passenger deaths (1,222 in 2005) occurred in vehicles driven by other teenagers. 61% of teenage passenger deaths (1,222 in 2005) occurred in vehicles driven by other teenagers. Wider application of passenger restrictions is indicated. Wider application of passenger restrictions is indicated. Ways to make passenger restrictions more effective are needed, and other techniques for reducing this major problem need development and testing. Ways to make passenger restrictions more effective are needed, and other techniques for reducing this major problem need development and testing.

68. Association of driving with the 3 hierarchical levels of competency — operational, tactical, and strategic. Russell A. Barkley, Daniel Cox Journal of Safety Research 38 (2007) 113–128

69. The effect of teenage passengers on the fatal crash risk of teenage drivers Preusser, DF | Ferguson, SA | Williams, AF Accident Analysis & Prevention [Accid. Anal. Prev.]. Vol. 30, no. 2, pp. 217-222. Mar 1998. Fatal crash-involved drivers of passenger vehicles were identified in the Fatality Analysis Reporting System for the period 1990 through 1995. Each driver was categorized as being alone in the vehicle at the time of the crash or with one or more passengers. Drivers at fault or responsible for crash occurrence were defined as all drivers involved in a single-vehicle crash, or drivers in multiple-vehicle crashes who were coded in the Fatality Analysis Reporting System as committing one or more driver errors. The results indicated that passenger presence was associated with proportionately more at-fault fatal crashes for drivers aged 24 and younger, were a neutral factor for drivers aged 25-29, and were associated with fewer at-fault involvements for drivers aged 30 and older. Relative risk of fatal crash involvement was particularly high for teenage drivers traveling, day or night, with two or more teenage passengers. Fatal crash-involved drivers of passenger vehicles were identified in the Fatality Analysis Reporting System for the period 1990 through 1995. Each driver was categorized as being alone in the vehicle at the time of the crash or with one or more passengers. Drivers at fault or responsible for crash occurrence were defined as all drivers involved in a single-vehicle crash, or drivers in multiple-vehicle crashes who were coded in the Fatality Analysis Reporting System as committing one or more driver errors. The results indicated that passenger presence was associated with proportionately more at-fault fatal crashes for drivers aged 24 and younger, were a neutral factor for drivers aged 25-29, and were associated with fewer at-fault involvements for drivers aged 30 and older. Relative risk of fatal crash involvement was particularly high for teenage drivers traveling, day or night, with two or more teenage passengers. Additional research is needed to determine how the added risk associated with teenage passengers riding with teenage drivers can be reduced or eliminated. Additional research is needed to determine how the added risk associated with teenage passengers riding with teenage drivers can be reduced or eliminated.

70. Passenger effects on teenage driving and opportunities for reducing the risks of such travel llan F. Williamsa,,, Susan A. Fergusonb and Anne T. McCarttc bFerguson International LLC, 1328 Lancia Drive, McLean, VA 22102, USA 2007 Williamsa FergusonbMcCarttc Williamsa FergusonbMcCarttc Passenger presence increases crash risk for teenage drivers, especially when the passengers are other teenagers and especially when they are male. Passenger presence increases crash risk for teenage drivers, especially when the passengers are other teenagers and especially when they are male. Teenagers are more susceptible to peer influences than adults. Teenagers are more susceptible to peer influences than adults. The combination of passenger-induced distraction and driving inexperience can disrupt driving behavior, The combination of passenger-induced distraction and driving inexperience can disrupt driving behavior, teenage driver risk taking increases in vehicles with multiple teenagers. teenage driver risk taking increases in vehicles with multiple teenagers. Possible ways to reduce the resulting crash problem include altering the in-vehicle behavior of teenagers or influencing their selection of travel partners. Possible ways to reduce the resulting crash problem include altering the in-vehicle behavior of teenagers or influencing their selection of travel partners. Legal restrictions on passengers with teenage drivers have been found effective in reducing the crash problem. Parental monitoring of teenage driving behavior, Legal restrictions on passengers with teenage drivers have been found effective in reducing the crash problem. Parental monitoring of teenage driving behavior, programs aimed at teenagers themselves, could be other options programs aimed at teenagers themselves, could be other options but their efficacy is unproven. but their efficacy is unproven. It currently is unknown why female passengers have a different effect than males or if that might offer clues about future interventions. It currently is unknown why female passengers have a different effect than males or if that might offer clues about future interventions. Conclusions Conclusions Despite passenger restrictions in the majority of states, Despite passenger restrictions in the majority of states, 42% of 16- and 17-year-old drivers in fatal crashes in 2005 were transporting teenagers with no adults in the vehicle; 42% of 16- and 17-year-old drivers in fatal crashes in 2005 were transporting teenagers with no adults in the vehicle; 61% of teenage passenger deaths (1,222 in 2005) occurred in vehicles driven by other teenagers. 61% of teenage passenger deaths (1,222 in 2005) occurred in vehicles driven by other teenagers. Wider application of passenger restrictions is indicated. Wider application of passenger restrictions is indicated. Ways to make passenger restrictions more effective are needed, and other techniques for reducing this major problem need development and testing. Ways to make passenger restrictions more effective are needed, and other techniques for reducing this major problem need development and testing.

72. Hyperactive children as young adults: Driving behavior, safe driving abilities, and adverse driving outcomes. Fischer, M., Barkley, R. A., Smallish, L., & Fletcher, K. (2007). Accident Analysis and Prevention, 39, 94−105. A multimethod, multilevel, multisource battery of driving measures was collected during young adulthood (mean age, 20 years) on a large sample of clinically referred hyperactive children (n=147) and community control children (n=71) who were followed for more than 13 years A greater percentage of children in the hyperactive group than in the control group reported receiving a ticket for reckless driving, driving without a license, having hit- and-run crashes, or having their licenses suspended or revoked a greater proportion of the hyperactive group compared with the control group had received traffic citations, and the mean number of citations per individual was greater in young adults with a history of hyperactivity/ADHD behind-the-wheel road tests revealed a significantly greater number of errors in driving resulting from impulsiveness in the hyperactive group than in the control group.

73. Hyperactive children as young adults: Driving behavior, safe driving abilities, and adverse driving outcomes. Fischer, M., Barkley, R. A., Smallish, L., & Fletcher, K. (2007). Accident Analysis and Prevention, 39, 94−105. performance on simulated driving tests demonstrated slower and more variable reaction times, more frequent errors of impulsiveness (e.g., false alarms, poor rule following), greater steering variability, and a greater number of scrapes and crashes of the simulated vehicle against road boundaries in the hyperactive group than in the control group. The road test and simulator results began to reveal a possible basis for elevated driving risks in formerly hyperactive/ADHD children — Impairment in Level I Operational (elementary cognitive) abilities that are necessary for the safe operation of the vehicle. Noteworthy in this study was that it did not find a greater frequency of crashes or a greater proportion having such crashes in the hyperactive than in the control group. The hyperactive/ADHD participants dramatically underreported their current symptoms relative to the reports given by their parents for those same symptoms (Barkley, 2002a). This problem of underreporting may also have affected the validity of their self-reported driving behavior or their history of adverse driving outcomes.

74. Driving outcomes of young people with attentional difficulties in adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 39(5), 627−634. (Woodward, Fergusson, & Horwood, 2000). Attention deficits were assessed in a large sample of 13-year-old children from New Zealand (the Christchurch longitudinal project; N=1265), driving outcomes were evaluated during a follow-up study, when the children were 21 years of age Data collection included reports of teacher and parent-rated measures of attentional difficulties; incidents of risky driving behavior, including drinking and driving, traffic violations, and involvement in automobile accidents; and measures of potentially confounding factors, including individual, socio- familial, and driving-related factors. Thirteen-year-old children with high levels of attention deficit were at greater risk as adolescents for traffic offenses and vehicular crashes. After various confounding factors were controlled, the associations between attention deficits and increased risk of injury during an accident, driving without a license, and traffic violations were still present.

75. Inattentive and hyperactive behaviors and driving offenses in adolescence. Nada-Raja, S., Langley, J. D., McGee, R., Williams, S. M., Begg, D. J., & Reeder, A. I. (1997). Journal of the American Academy of Child and Adolescent Psychiatry, 36(4), 515−522. In a comparable study that was also conducted in New Zealand (the Dunedin Multidisciplinary Health and Development Study), Symptoms of ADHD and other comorbid disorders were assessed at age 15, and their influence on driving offenses was evaluated when the adolescents were between 15 and 18 years of age Attention deficits were associated with increased risks for crashes involving injury, driving without a license, and traffic violations. Associations persisted after conduct problems, driving experience, and sex of subjects were controlled. Notably, Conduct Disorders were associated with driving risks beyond those associated with the symptoms of ADHD. In addition, ADHD in female subjects was significantly associated with driving offenses and more traffic crashes compared with females with other disorders (CD and anxiety/depressive disorder) or no disorder (P=0.05).