By Wendy Stav, PhD, OTR/L, CDRS, and Michelle Kaelbel, OTR/L
Teenagers yearn for their sixteenth birthdays—dreaming of the independence that a driver’s license brings. In addition to a long-awaited independence, attaining a driver’s license represents an important social developmental milestone. Driving is an activity of daily living (ADL) listed under community mobility in the Practice Framework1 and should be recognized as such. Driving is a meaningful occupation that provides autonomy2 and mobility,3 fulfills life roles,4 and provides the ability to explore leisure pursuits5 and engage in occupations.6
The transportation afforded by driving allows individuals to travel to and from work, manage household duties, transport children, and explore outside arenas of recreation and travel. As individuals age, the need and desire to be independently mobile in the community do not change. Older adults continue to use driving to maintain connections in the community for access to friends and relatives, attend social events, obtain medical care, and shop.
A number of agencies, including the American Medical Association (AMA), Transportation Research Board (TRB), American Society on Aging (ASA), and American Occupational Therapy Association (AOTA), have expressed concern about the lack of attention to driving among rehabilitation professionals. Their concerns are valid considering there are only 298 certified driving rehabilitation specialists (CDRS) in the United States7 to address the community mobility needs of an aging society. AOTA has developed a driving network to educate and support occupational therapy practitioners working in the area of driving; provide a means to share information and ideas; and to increase the visibility of the occupational therapy profession as service providers who are capable and interested in responding to growing societal needs associated with driving.8 The Driving/Driver Rehabilitation network, which requires AOTA membership, includes a listserv where therapists can collaborate and share information. This is a positive effort in the right direction, but practitioners who do not specialize in driving are not taking advantage of these resources.
MENTAL HEALTH AND PHYSICAL DISABILITY
Therapists who work in mental health may initially feel immune to driving issues among their clients because there is no obvious physical disability. However, there are multiple mental health influences on driving performance. According to the Canadian Medical Association, psychiatric disorders significantly affect the ability to operate a motor vehicle safely.9 Interfering psychiatric factors may include “suicidal thoughts, extreme agitation, impulsive or violent actions, delusions or hallucinations.”9 In addition, psychotropic mediations can alter attention, judgment, and psychomotor performance.10 Because of these issues, occupational therapists working in mental health should consider the driving safety of clients living in the community as well as those being discharged into the community.
Rehabilitation hospitals have been the source of driving programs since occupational therapists began working with clients with physical disabilities in the 1950s. The specialty practice area grew as new techniques and technologies became available for patients with physical limitations. Driver rehabilitation specialists have worked with patients who have spinal cord injuries, cerebrovascular accidents, and traumatic brain injuries for years. But these are not the only patients who can benefit from attention to driving. There are driving implications for patients with arthritis, joint replacements, cardiac conditions, neuromuscular disorders, diabetes, amputations, and low vision. The ADL of driving is often surpassed by the more obvious ones such as bathing, dressing, and toileting.
GERONTOLOGY
The diminishing physical, sensory, and cognitive performance components due to the natural effects of aging hinder the ability to drive safely. Older adults often experience changes in vision related to color discrimination, acuity, peripheral field, and contrast sensitivity, which limit visual access and proper interpretation of the driving environment. Cognitively, older adults may present with impaired attention and processing speed causing increased risk of crashes. Changes in strength, response speed, and range of motion limit the ability to operate vehicle controls. When smaller adults drive large vehicles, ergonomic concerns also exist, such as accessibility to foot pedals, visibility, seat belt positioning, and pathway of airbag. The vehicle features that may enhance safety, such as seat belts, air bags, dual side view mirrors, tilt steering wheels, six-way power adjustable seats, and adjustable shoulder anchors on seat belts, were not in existence when older adults learned to drive. Most older adults leave all the equipment in the original factory-installed position, which likely does not meet the positioning needs of the individual. Additionally, older adults are more susceptible to injuries and fatalities when involved in a crash because they are less able to sustain the energy forces of a crash than their younger counterparts.
Adaptive driving equipment allows those with disabilities the opportunity to operate a motor vehicle independently. There is both high and low technology adaptive equipment to allow physically impaired drivers to operate a motor vehicle, and driving simulators for training and research are available. The future also holds autonomous vehicles run by computers that will allow passive community mobility, which opens the door for collaboration with other disciplines such as engineering.
ON THE JOB
Occupational therapists who are involved in work programs concentrate their efforts on improving the performance of clients to return to work. These efforts may be futile if clients are not able to transport themselves back to the workplace. The occupational therapist looks at all aspects of a client’s job including getting to and from work and on-the-job driving duties. In addition to addressing injury-related issues, driving is a concern for occupational medicine settings where employees required to drive as part of their job duties undergo driver screenings to determine safety prior to operating company-owned vehicles.
Therapists should be aware of medical reporting requirements for impaired driving laws that exist in their state of practice.11 The AOTA Code of Ethics creates an obligation for administrative occupational therapists to be aware of the laws related to health care practitioners and driving as well as to disseminate that knowledge. It is the role of the manager to create departmental policies consistent with those laws and provide the administrative support necessary for observance of those policies.11 According to the National Highway Traffic Safety Administration, AMA, ASA, and TRB, there is a growing need for occupational therapist involvement in driving issues and it is imperative that occupational therapists receive the educational foundation necessary to address driving as a critical occupation in clients’ lives. Driving topics can be addressed in a number of different areas of occupational therapy curricula as outlined in the Standards for an Accredited Educational Program for the Occupational Therapist12including: basic tenets of occupational therapy; screening and evaluation; intervention plan, formulation, and implementation; context of delivery service; management of occupational therapy services; and professional ethics, values, and responsibilities.
HOME, COMMUNITY, AND SCHOOL SETTINGS
Home health care clients live in the community and need access to community resources. The fact that patients need to be “home bound” in order to receive this level of care does not ensure that these patients stay home. Their automobiles and keys are accessible and they may attempt to drive regardless of having been instructed not to. Community health clients who are currently driving present with the most obvious driving issues. The nature of the patient’s need for community health care may or may not be the source of the driving risk, therefore it is important to look thoroughly for factors that might influence driving performance. For example, a therapist working with battered women may address social- emotional issues and overlook possible vision changes as a result of abuse that may interfere with safe driving.
Students with learning disabilities, attention deficit disorder, cerebral palsy, spina bifida, mild developmental delay, or other disabilities may not be successful in a traditional driver education class. These classes are typically taught by teachers/instructors who have been certified by the state. Unfortunately, these teachers are not trained to recognize or work with students who have different learning or adaptation needs. This is a tremendous opportunity for occupational therapists in the school system to serve as consultants.
Driving is not just for physical disabilities anymore. It now reaches all aspects of rehabilitation practice and will continue to grow as the population ages and growing numbers of Baby Boomers present with health and age-related issues that affect driving performance and safety. The broad application of driving to multiple practice areas offers a number of opportunities and an equal number of questions. Those working in management should foster program development, administrative support of therapists working in the area, and exploration of markets not currently being served.
References
Wendy Stav, PhD, OTR/L, CDRS, is an assistant professor, Occupational Therapy Program of the Health Sciences Department in the College of Science at Cleveland State University, Cleveland. She also serves as the American Occupational Therapy Association liaison to the American Medical Association in the development of a guide to best practices for physicians related to older drivers. Michelle Kaelbel, OTR/L, is an occupational therapist at Pediatric Therapy Associates in Plantation, Fla.
