Presented by the
National Resource Center on ADHD
www.Help4ADHD.org (800) 233-4050
Daniel Cox, PhD
Director of the Virginia Driving Safety Laboratory
Professor of Psychiatric & Internal Medicine,
University of Virginia School of Medicine
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Daniel Cox, PhD
Director of the Virginia Driving Safety Laboratory
Professor of Psychiatric & Internal Medicine,
University of Virginia School of Medicine
Reducing the Risk of Driving Mishaps Among ADHD Drivers
Daniel J. Cox, PhD, ABPP
University of Virginia
Professor, Department of Psychiatry
Director, Virginia Driving Safety Laboratory
Bad News
0% 10% 20% 30% 40% 50% 60%
Fired from job
Incarcerated
Arrested
Serious car accident
Accident prone
Substance abuse
STD
Teen pregnancy
< high school
Repeat a grade
Subjects (%)
ADHD Normal
1. Barkley. Attention-deficit hyperactivity disorder. A handbook for diagnosis and treatment, 1998; 2. Barkley et al. JAACAP 1990; 3. Biederman et al. Arch Gen Psych 1996; 4. Weiss et al. JAACAP 1985; 5. Satterfield, Schell. JAACAP 1997; 6. Biederman et al. Am J Psych 1995.
Looking beyond the classroom Functional Impairment in Individuals with ADHD
Core symtp0oms of ADHD`
1.Inattention
2.Impulsivity
3.Hyperactivity
4.(Distractable)
Driving Safety
1. National Highway Traffic Safety Administration. Ann Emerg Med. 1997;29:546-547. 2. Barkley RA et al. Pediatrics.
1993;92:212-218. 3. Barkley RA et al. Pediatrics. 1996;98:1089-1095. 4. Cox DJ et al. J Nerv Ment Dis. 2000;188:230-
234. 5. Nada-Raja S et al. JAACAP. 1997;36:515-522.
ADHD and Driving: A Dangerous Mix
• Motor vehicle accidents are the leading cause of death
in adolescents, and ADHD is a major contributor.1
• Young drivers with ADHD are
– 2 to 4 times more likely to have traffic accidents.2-4
– 3 times as likely to have injuries.3
– 4 times as likely to be at fault.2
– 6 to 8 times more likely to have their license suspended.2,3
• This extends to females as well as males.5
Our Studies to Assess the Effect of ADHD and Interventions on Driving Safety
– STUDY 1: Simulated driving study of RITALIN® vs placebo1 among college students with and without ADHD
– STUDY 2: Simulated driving study of CONCERTA® vs RITALIN2
– STUDY 3: Simulated and on-road driving study of CONCERTA vs ADDERALL® XR vs Placebo4
– Study 4: On-road assessment of ADHD adolescents study of CONCERTA vs ADDERALL® XR vs Placebo4
– Study 5: On-road assessment of ADHD young adults on and off Daytrana
– Study 6: Simulator study- ADHD driving a manual vs automatic transmission
1Cox DJ Current Psychiatry Reports 13(5):345-50
Real World Driving Observations: DriveCam.com
• Inattention/distraction and Impulsive over correction
Good News
Virtual Reality Driving Simulator
• 165 degree visual field
• Updates every 60 msec
• Performance feedback
– Auditory
– Kinesthetic
– Visual
• Tracks 120 performance
variables
STUDY 1: RITALIN® vs Placebo Impaired Driving Score
ADHD improvement, P<0.05.
Cox DJ et al. J Nerv Ment Disord. 2000;188:230-234.
Imp
air
ed
Dri
vin
g S
co
re
Average driving
Lower score
denotes
better driving
performance.
-1.5
-1
-0.5
0
0.5
1
1.5
2
2.5
Placebo
ADHD Placebo
Control RITALIN
RITALIN
Control Placebo
ADHD RITALIN
Plasma Profiles Following Ritalin® tid
and CONCERTA® XL
Swanson J et al. Arch Gen Psychiatry 2003;60:204-211
0 2 4 6 8 10 12
20
16
12
8
4
0
Time (h)
IR MPH 10 mg tid (n=15)
CONCERTA® XL 36 mg qd (n=15)
Co
ncen
trati
on
(n
g/m
L)
P<0.01 (8:00 PM).
Average driving
Imp
air
ed
Dri
vin
g S
co
re
STUDY 2: CONCERTA® vs RITALIN® Impaired Driving Score
Cox DJ et al. J Am Acad Child Adolesc Psychiatry. 2004;43(3)269-275.
-3
-2
-1
0
1
2
3
4
5
6
2:00 PM 5:00 PM 8:00 PM 11:00 PM
Time
RITALIN tid
CONCERTA qd Equivalent performance
to male drivers 80+ yrs
Equivalent performance
to male drivers 55-59 yrs
STUDY 3: CONCERTA® vs ADDERALL® XR Impaired Driving Score
Imp
air
ed
Dri
vin
g S
co
re
5:00 PM 8:00 PM 11:00 PM
Placebo
CONCERTA
ADDERALL XR
-2
-1.5
-1
-0.5
0
0.5
1
1.5
2
Time Contrasts: Medication vs placebo P=0.01; CONCERTA vs placebo P=0.001;
ADDERALL XR vs placebo P=0.24; CONCERTA vs ADDERALL XR P=0.03. Cox DJ et al. Poster presented at APA 2005; manuscript in preparation.
Contrasts
Medication vs. placebo; P=.01
Concerta® vs. placebo; P=.001
Adderall® XR vs. placebo; P=.24
Concerta® vs. Adderall® XR ; P=.03
Equivalent performance
to male drivers 75-79 yrs
Equivalent performance
to male drivers 55-59 yrs
2.9
3
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
5:00 PM 8:00 PM 11:00 PM
Placebo
CONCERTA
Adderall XR
Subjective ratings (0-5) of driving ability post drive
-0.3
-0.2
-0.1
0
0.1
0.2
0.3
5:00 PM 8:00 PM 11:00 PM
Time
Plcebo
Adderall XR
CONCERTA qd
a
Average driving
Imp
air
ed
Neu
ro-C
og
nit
ive S
co
re
CONCERTA® vs Adderall® XR Impaired Neuro-Cognitive Score (Distractibility and Visual Memory)
®
®
Academy of Clinical Neuropsychology, 2006, Nov. (In Press)
Contrasts
OROS® MPH vs. Plcebo; P<.001
Adderall® XR vs. placebo; P=.042
-0.4
-0.1
0.2
0.5
0.8
Inattention Composite Score = Across Midline + Running Stop Signs + No signaling (p =.01)
Inatt
en
tio
n C
om
po
sit
e S
co
re
p=.008 p=.04
Placebo Adderall XR CONCERTA
STUDY 4: CONCERTA vs. Adderall XR On-Road Driving
Cox DJ, J. Child & Adolescent Psychopharmacology, 18(1), 1-10
Study 5: Routine ADHD driving off and on
long acting MPH (Daytrana)
• 20 young adult (18-25) drivers with ADHD who
routinely do not take medication
• Three months off and the on medication
• Two-camera DriveCam.com video system
Real World Benefits
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Female Male
Cox, et al, Archives of Pediatrics & Adolescent Medicine. 2008, 162 (8) 793-794
Driv
ing
Erro
rs
3 months on and off of Daytrana
0
1
2
3
4
5
6
7
8
No Medication Daytrana
Collisions
No Medication
Daytrana
Cox DJ, The Journal of Clinical Psychopharmacology . 32(2):225-30.
What to look for in a medication
Medications can be extremely helpful
1.Optimal dose
1.Greatest symptom relief: inattention & impulsivity
2. None to tolerable side effects
2.Driver recognizes benefits
3.Long acting
4.No rebound effects
-1.5
-1
-0.5
0
0.5
1
1.5
20:00 23:00
Manual Automatic
IDS
Study 6:
Non Pharmacological Interventions:
Automatic Vs. Manual transmission
Cox et al, J Atten Disord. 2006;10(2):212-216
What are non-Medication strategies?
Anything that enhances engagement and reduces distraction
1. Enhance engagement/attention to driving
1. Manual transmission
2. Back-up obstacle alert system
3. No cruise control
4.
2. Minimize distractions
1. Minimal passenger conversations
2. No teen passengers
3. No pets
4. Put cellphone in trunk/deactivate cell phone
5. ?
Ask A Question
Daniel Cox, PhD
Director of the Virginia Driving Safety Laboratory
Professor of Psychiatric & Internal Medicine,
University of Virginia School of Medicine
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