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Experts Advise Treating Kids With ADHD
Just Like Other Kids in Most Situations. Evidence Shows
That Following This Advice When Teens Learn to Drive Can Be A
Dangerous Mistake.
by Matt McMillen, Washington Post, December 10, 2002
For more articles visit
www.bridges4kids.org.
Driven to Distraction
When Brian Cox got his driver's license at 16, his parents
wouldn't allow him to have passengers in the car until he had
clocked 5,000 safe miles behind the wheel.
Kevin Snyder's parents made him drive with them for 21
consecutive days without the slightest infraction before they
allowed him to apply for his license. Any time he looked away
from the road to change a radio station, for example, his
parents pushed him back to Day One. It took him two years to
graduate from learner's permit to full license.
Both teens' parents had worries beyond those that most parents
have when their children start to drive: Brian and Kevin have
attention-deficit hyperactivity disorder (ADHD).
Studies indicate that young people with the disorder, who often
find it difficult to concentrate and are more prone than others
to impulsive behavior, have abnormally high rates of traffic
violations, accidents and instances of driving without a
license. One study, funded by the National Institute of Child
Health and Human Development and published in July, reported
that of 105 people with ADHD who were studied, about 20 percent
had had their license suspended or revoked -- the same number
who had received 12 or more traffic citations or had caused more
than $6,000 in damage in their first crash. Those figures are
two to four times the norm for young adults. In addition, about
25 percent of them had been involved in three or more crashes --
a rate seven times higher than normal.
For those familiar with the disorder -- an estimated 3 to 7
percent of school-age children have it, with perhaps half of
them continuing to be affected into adulthood -- those
statistics likely are not terribly surprising. Larry B. Silver,
a clinical professor of psychiatry at Georgetown University
Medical Center who specializes in treating ADHD, puts it
plainly: "Those who are distractible may be paying attention to
things other than driving."
This suggests that many parents of teens with ADHD should pay
particularly close attention to their child's driving.
"We did a lot of road riding with Brian," says his father,
Daniel Cox. "We were vigilant about his inattention. [Still,]
the first time I took [Brian] out, he pressed the accelerator
instead of the brake at a stop sign. On the highway, [I caught
him with] his whole head down when changing the radio station."
Those early mistakes were hardly unexpected. Cox had started to
prepare Brian for driving long before he got his learner's
permit.
"We knew it was coming," Cox says. "We talked about it, we set
up steps."
Marlene Snyder, Kevin Snyder's mother, has a similar story: "We
started talking to Kevin in second grade about consequences
[involved in driving]." She also talked with him about his ADHD.
She wanted to be certain that he understood it and its
implications for driving -- and to prepare him for the
possibility that he might not start to drive when his friends
did. For many children with ADHD, says John Pleasant, a
Washington-based clinical social worker, the disorder brings
with it "a sense of shame and embarrassment . . . of feeling
different and angry. . . . For kids old enough to drive, there
has been a long-term wrestling with that."
Snyder agrees. "Kids don't want to be different from other
kids," she acknowledges sympathetically. For her, though, it's a
safety issue. "It's a horrible experience, going to a teenager's
funeral," says Snyder, who believes ADHD was a factor in several
accidents that have left acquaintances dead or seriously
injured.
It falls to parents to help their child to understand and accept
the disorder -- "not like it," says Pleasant, "accept it" -- and
to take charge of it.
Cox took a novel approach to doing that with his son: He not
only talked with Brian about the disorder and safe driving; he
also encouraged him to study the subject. When Brian was 14, he
built a rudimentary driving simulator and entered it in a
statewide science fair in Virginia. He won a first-place award.
If the attention that Daniel Cox and Marlene Snyder paid to
driving and ADHD seems unusual, it may be because they are
drawing on professional experience. Snyder, an education
consultant specializing in ADHD-related issues, has written a
book called "ADHD and Driving: A Guide for Parents of Teens with
ADHD." Cox, a professor of psychiatric medicine and the director
of the Behavioral Medicine Center at the University of Virginia,
has researched the relationship between driving and such
diseases and disorders as alcoholism, Alzheimer's and diabetes.
Now, his focus is on driving and ADHD. Both of his sons -- Brian
and younger brother Cory -- have the disorder.
"Seeing them grow up got me focused on that," he says.
For both Cox and Snyder, one rule was paramount for their teens
once they started to drive: Take your medicine or you can't take
the car. Recent drug studies, some conducted by Cox, are giving
new strength to that advice.
First Line of Treatment
Stimulant medications such as Ritalin are the most frequent
first line of treatment for ADHD. They have been prescribed for
more than 50 years and are overwhelmingly regarded as safe for
adults and children aged 6 and older who have properly diagnosed
ADHD.
"Ritalin is a specific drug for a specific disorder," says Cox,
whose own research on Ritalin, conducted in 2000, showed
evidence that Ritalin improved the driving of college students
with ADHD. Comparing seven students with ADHD to six without,
his study found that "there was no difference between ADHD and
non-ADHD subjects while on Ritalin."
More recently, Cox compared the driving behavior of young adults
on Ritalin to those taking a newer drug, Concerta. Both are
methylphenidate-based stimulants; however, Concerta is a
long-acting drug that requires a single daily dose, while
Ritalin must be taken two to three times a day. The results of
that second study, which was funded by McNeil Consumer and
Specialty Pharmaceuticals, the maker of Concerta, suggest that
those taking the longer-acting stimulant will drive consistently
more safely during a given day than those on shorter-acting
drugs.
As Cox pointed out in the first study, "A major limitation with
Ritalin is its short half-life. If a driver takes the medication
twice a day, at breakfast and lunch, there would be no
medication in the bloodstream at one of the high accident times,
the 5 to 6 p.m. rush hour." There is also a significant lag
period between doses, during which symptoms can return in force.
Drivers on Concerta, Cox found, did not have this problem: "One
of the unanticipated events was the consistency of the [Concerta]
subjects over time," he says. "Their driving behavior at 11 p.m.
was the same as at 2 p.m."
Both studies conducted by Cox were small, a limitation that he
acknowledges. Still, they are significant -- not only for what
they suggest but also for the fact that they are being done at
all. Until 10 years ago, the relationship between ADHD and
driving risks had gone largely unnoticed.
Studying the Problem
In the early 1990s, on a visit to a rehabilitation center in
Milwaukee, Russell Barkley walked past a lab in which the
driving skills of elderly people were being measured. Using
baby-toy steering wheels connected to a computer, researchers
gathered data on critical abilities such as reaction time and
problem-solving. Barkley had recently read a Canadian study
suggesting a rate of traffic violations and accidents among ADHD
drivers that was four times the norm. That study piqued his
curiosity. Those flimsy steering wheels gave him an idea.
"I looked around at the lab," Barkley recalls, "and said someone
should do this for ADHD."
Not everyone agreed. On his return to the University of
Massachusetts, he found little interest among his colleagues in
psychiatry and psychology. To him, though, the idea was new and
exciting: "No one had done this."
Now at the Medical University of South Carolina in Charleston,
Barkley was until recently the director of psychology and a
professor of psychiatry and neuropsychology at the University of
Massachusetts; he also founded the university's clinics for
children and adults with ADHD.
Barkley began his driving research by attempting to confirm the
Canadian findings in a study he conducted in Milwaukee. Surveys
submitted by parents of teens with ADHD, as well as by parents
of teens who did not have the disorder, revealed a tremendous
number of accidents and traffic violations among the former
group. During the three- to five-year period covered by the
surveys, nearly a quarter of the 44 teens with ADHD had had
their licenses suspended or revoked, and the ADHD drivers were
involved in 54 crashes. In a control group of 37, only 16 cashes
were reported a crash during the same period.
"We replicated the Canadian study," Barkley says of his
research, the results of which were published in 1993, "but we
also saw that it was worse than we had imagined. Their knowledge
of the rules of the road was normal -- they just didn't know how
to apply them.
"At that point we realized it was a scary problem."
According to Barkley, that first study was crudely done. He
wanted to use sophisticated driving simulators and he wanted to
evaluate driving behavior on the road. So he hired driving
instructors to ride with both ADHD teens and a control group of
other young drivers. The teens with the disorder became easily
frustrated, and their emotions were closer to the surface as
they drove, the study found. The data, as it accumulated, began
to paint a frightening picture.
"Our driving instructors found that [ADHD teens] wouldn't wait
at stop lights, they cut people off, they drove on the shoulder
and ran lights." Two of the instructors quit the study -- they
didn't feel safe.
Barkley recalls: "If it had not been a study, they said they
would have sought revocation of the [ADHD teens'] driver's
licenses."
Barkley now realizes he shouldn't have been shocked by what his
studies revealed: "In hindsight, it doesn't surprise me, but no
one was interested then" in the impact of ADHD on driving
performance, he says. "At the time nobody cared, nobody looked,
nobody knew."
Parents in Control
Now, as a result of studies like those conducted by Barkley and
Daniel Cox, that has begun to change, at least among
researchers. And Marlene Snyder hopes to bring the research
findings to parents, along with her guidelines for reducing
risks on the road. In the 20 steps she offers in her book, the
stress repeatedly falls on parental involvement. That
involvement, she emphasizes, has to begin before the teen starts
to drive:
"Parents have to talk really early. The best time to think about
responsibilities is before your teen gets behind the wheel."
More than just talk, though, parents must model safe driving
behavior -- using the side view mirror and signaling before
changing lanes, coming to a complete stop at stop signs,
observing speed limits. School-based driver's education
programs, she writes, "should be treated as an excellent
supplement to your own driver education efforts."
"Kids with ADHD are often behind [other kids] in age
maturation," she points out. "Parents have to honestly observe
their kids -- do I feel safe [when I am riding with them]?"
And if they don't? "They have no business allowing them to
drive."
Of course, the same could be said of the parents of any teen. As
Daniel Cox stresses, "There are all sorts of conditions out
there that affect driving: sleep apnea, diabetes requiring
insulin. . . . What I want to point out is ADHD is not unique in
making driving dangerous."
Brian Cox, 19, and Kevin Snyder, 25, have been driving for a few
years. With supportive parents and the right medication ("No
medication, my son doesn't drive," says Daniel Cox, who notes
that Brian keeps some Ritalin in his car in case his dosing
routine is interrupted), each has learned to drive safely.
Cox laughs when asked about his 14-year-old, Cory, but his
trepidation is plain. Cory really wants to drive.
"He gets to get in and start Brian's '66 Mustang every night,"
Cox says.
But father and son have already started talking about the day,
and the conditions, when Cory will start driving. He'll be
prepared.•
Matt McMillen last wrote for Health about adults with ADHD and
his own experience with the disorder.
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