This article was downloaded by: [Linköping University Library] On: 23 September 2014, At: 03:26 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Neuropsychological Rehabilitation: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/pnrh20
Driving problems and adaptive driving behaviour after brain injury: A qualitative assessment a
Anna Lundqvist & Jerker Rönnberg
a
a
Linköping University, Sweden Published online: 22 Sep 2010.
To cite this article: Anna Lundqvist & Jerker Rönnberg (2001) Driving problems and adaptive driving behaviour after brain injury: A qualitative assessment, Neuropsychological Rehabilitation: An International Journal, 11:2, 171-185, DOI: 10.1080/09602010042000240 To link to this article: http://dx.doi.org/10.1080/09602010042000240
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication
Downloaded by [Linköping University Library] at 03:26 23 September 2014
are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
NEUROPSYCHOLOGICAL REHABILITATION, 2001, 11 (2), 171–185
Driving problems and adaptive driving behaviour after brain injury: A qualitative assessment Downloaded by [Linköping University Library] at 03:26 23 September 2014
Anna Lundqvist and Jerker Rönnberg Linköping University, Sweden
One professional driving expert was interviewed after each of 22 on-road driving occasions with brain-injured patients. Driving problems were found in five prescribed qualitative dimensions: speed, manoeuvring, position, attention, and traffic behaviour. In addition, three non-prescribed qualitative dimensions were found: orientation, decision-making , and confidence. Also, adaptive aspects important for safe driving despite brain injury were identified: anticipatory attention, slowing down speed, interest and motivation for safe driving, and driving experience. The results are discussed in terms of a hierarchical model of driving performance. In addition, driving problems and adaptive aspects are discussed in relation to attention and information processing. Anticipatory attention is considered a working memory-based attention system, which is essential for driving quality. Practical implications are outlined, for example, educational practice for driving evaluators and adaptive driving behaviour for patients facilitating driving practice as a part of the rehabilitation programme.
Driving is a complex behaviour dependent on several factors, such as, attention, perceptual and cognitive processing, experience, and attitudes to driving. It requires automatised motor performance, flexibility, and fast judgements to cope with complex traffic situations. Consequently, attention and cognitive processing speed are of major importance for driving. Such functions are often affected by brain injury (Brooks, 1984; Stuss et al., 1985; Van Zomeren, Brouwer, & Deelman, 1984). The brain-damaged patient may have difficulty processing many simultaneous inputs, and slow information processing may be
Correspondenc e should be sent to Anna Lundqvist, Department of Rehabilitation Medicine, Faculty of Health Sciences, Linköping University, S-58185, Sweden. Phone: +46 13 221570. Fax: +46 13 221564. Email:
[email protected] . We would like to thank the Swedish National Road Administration for financial support, Johan Alinder, Lars Owe Dahlgren, and P.O. Nilsson for help in performing the study. Ó 2001 Psychology Press Ltd http://www.tandf.co.uk/journals/pp/09602011.html DOI:10.1080/09602010042000240
Downloaded by [Linköping University Library] at 03:26 23 September 2014
172
LUNDQVIST &RÖNNBERG
a problem in driving but there are also compensatory possibilities based on over-learned cognitive and perceptual–motor skills (Brouwer & Ponds, 1994; Brouwer, Van Zomeren, & Van Wolffelaar, 1990). Driving after brain injury is a question that demands careful consideration. How to decide whether the patient has regained sufficient cognitive ability to drive is often discussed during rehabilitation. The assessment of cognitive ability relevant for driving has been a major research concern. A variety of procedures have been used to identify which patients will be able to drive after brain injury. These studies offer a possibility of considering different types of factors important in evaluating and predicting driving performance. Neuropsychologica l assessment, simulator driving, closed road driving and on-road driving have been used. Neuropsychological examination is often used to quantify cognitive capacity. Several studies have found significant relationships between neuropsychological test performance and driving performance (Engum et al., 1989; Engum, Lambert, & Scott, 1990; Galski, Bruno, & Ehle, 1992; Gouvier et al., 1989; Korteling & Kaptein, 1996; Lambert & Engum, 1992). However, the predictive validity of neuropsychological tests has also been somewhat conflicting (Brouwer & Withaar, 1997; Van Zomeren, Brouwer, & Minderhoud, 1987). Nevertheless, tests assessing perceptual and cognitive speed seem to have some predictive value (Withaar, 2000), and the neuropsychological examination can be a useful screening method, but cognitive functioning alone is insufficient for predicting various aspects of driving performance. There is no standardised method of evaluating driving performance for patients suffering from brain injury, because driving demands a variety of skills in order to cope with situations of different complexity. Driving evaluators usually prefer the patient to take an on-road driving test before making conclusive recommendations and decisions (Korner-Bitensky, Sofer, Gelina, & Mazer, 1998). Thus, a driving test should be part of the assessment procedure (Brooke, Questad, Patterson, & Valois, 1992). Michon (1979, 1985) presented a model of driving with three levels of decision-making. At the strategic level decisions concern planning of safe driving with regard to time and route. At the tactical level the driver is expected to make correct judgements of traffic situations and to have anticipatory risk avoidance behaviour (Van Wolffelaar, Brouwer, & Van Zomeren, 1990; Van Zomeren, Brouwer, Rothengatter, & Snoek, 1988) requiring cognitive control, flexibility, and awareness of current traffic demands. At the operational level decisions concern immediate reactions, depending mainly on perceptual speed and automatic driving skill. We have used a quantitative, multi-factorial approach in two former studies to estimate the consequences of attention and cognitive impairments on driving performance (Lundqvist et al., 1997; Lundqvist, Gerdle, & Rönnberg, 2000). The evaluations required neuropsychological tests to identify relevant
Downloaded by [Linköping University Library] at 03:26 23 September 2014
DRIVING AFTER BRAIN INJURY
173
functions and impairments. On-road driving was the external criterion of driving performance and was evaluated by a driving expert. By means of the test battery used, we could quantitatively predict driving skill from impairments in neuropsychological functions. Neuropsychologica l tests assess driving skill mainly at the operational level but also, to some extent, at the tactical level of control. On-road driving taps additional aspects of driving behaviour (Brooke et al., 1992) in the interaction between operational and tactical aspects of driving (Withaar & Van Wolffelaar, 1996). Some of these aspects of driving behaviour are possible to measure with quantitative variables, but they do not elucidate the processes or the qualitative content that constitute these variables. Consequently, there is some information, which is difficult or impossible to explain from a purely quantitative perspective. Therefore, it is interesting to make a complementary qualitative analysis to the quantitative measurements. The qualitative approach can contribute to interpretations of the unique content of driving behaviour and capture specific phenomena of the topic. For example, if the driver suddenly overtakes without care, is it due to poor attention, insufficient judgement of the situation, or lack of consideration for other road users? Is poor speed adjustment approaching junctions an indication of unawareness of speed rules, or poor attention? The qualitative approach allows us to explore and describe what happens in the driving situation and can potentially point out other aspects of driving behaviour than can be captured by traditional tests. The first aim of the current study is to describe how driving problems are manifested in a group of brain-injured drivers. We assume that there are operational and tactical aspects of driving associated with decreased driving performance which are not possible to assess with neuropsychological tests or quantitative on-road evaluation. A second aim is to describe aspects that appear important to maintain safe driving despite brain injury. Therefore, we suggest that comprehensive interviews with a driving inspector will discern and describe further aspects regarding driving problems and adaptive aspects after brain injury.
METHOD The study is a series of repeated interviews with one informant from 22 driving occasions requesting information on significant driving characteristics. The sample of driving occasions was selected from a heterogeneous group of 22 brain-injured patients according to age (M = 51.5 years, SD = 11.9), 16 men and 6 women. All drivers suffered from a brain injury. Criteria for medically verified brain lesion were neurological symptoms for more than 24 hours, visible damage or cerebral oedema observed during surgery, or brain lesion
Downloaded by [Linköping University Library] at 03:26 23 September 2014
174
LUNDQVIST &RÖNNBERG
verified by computerised tomography (CT) or magnetic resonance imaging (MRI). Diagnoses were three tumours, five traumatic brain injuries, nine infarctions, and five cerebral haemorrhages. At the time of the study the patients were treated at the Rehabilitation Department of the University Hospital of Linköping, Sweden and were assessed on average 23 months after injury (SD = 17.5). Based on previous research (Lundqvist et al., 1997, 2000) and for clinical practice we have already adapted a minimal test battery. The Trail Making Test B (TMTB) and three computerised tests (Levander, 1988) containing a Complex Reaction Time test (a reaction speed test also requiring reaction inhibition), a K test (a focused attention test), and a Simultaneous Capacity test (a divided attention test). In addition, a Listening Span test, measuring working memory (Baddeley, 1990; Daneman & Carpenter, 1980) was used. Neuropsychological test results are presented in Table 1. On the TMTB, K test, and Simultaneous Capacity test the patients performed within ±1 SD compared to normal data, while the results were significantly below normal on the Complex Reaction Time test and the Listening Span test. From the test results a reasonable generalisation is that the patients suffer from moderate lesions, especially affecting controlled reaction speed and working memory. In addition, the patients performed significantly lower on the minimal test battery compared to a control group (N = 59) within the same age range (M = 56.4, SD = 15.2), used in former studies (Table 1). All patients had a valid driving licence and were driving their own car in the driving test. They had driving experience of 30.7 years (SD = 11.8). On average they had driven 3.490 km (SD = 2.710) after brain injury. Ten patients had resumed driving on public roads after brain injury, while two had not. In addition, six patients had practised privately, driving between 1000 and 5000 km, while four had driven less then 500 km since the brain injury. Nine patients failed the driving test. Among these, one had not yet resumed driving and six
TABLE 1 Neuropsychological test data for patients and controls Patients N = 22 Tests Trail Making Test B (sec) Complex Reaction Time (T-score) K test, (T-score) Simultaneous Capacity Test, (T-score) Listening Span test (0–54)
Controls N = 49
t-test
x
SD
x
SD
t
113.5 29.3 48.1 45.5 23
86.8 16.1 9.0 8.4 5.1
82.9 52 52 52 28
43.4 6.3 7.1 10.4 6.5
2.10* 9.30** 2.47** 2.58** 3.10**
* p £ .5, ** p < .01, df = 79, T-score: mean = 50; SD = 10. T-tests for independent samples, two-tailed.
DRIVING AFTER BRAIN INJURY
175
were subsequently suspended from driving. Driving experience in terms of years of driving and mileage before or after brain injury, was however not related to driving performance outcome (p > .05), neither was type of diagnosis (p > .05).
Downloaded by [Linköping University Library] at 03:26 23 September 2014
PROCEDURE The procedure was to explore and describe driving performance with openended interviews of driving occasions. The interviews lasted about one hour and started with a wide, open question about the present driving occasion. The interviewer was a senior clinical neuropsychologist . We found that after 22 interviews saturation was attained that is, additional questions were not expected to produce more information (Kvale, 1996). The interviews were unstructured and the recorded interviews were transcribed verbatim and consecutively systematised and analysed. The informant was a professional, certified driving inspector employed at the Swedish National Road Administration. We sought to obtain reliable information by interviewing an expert on driving characteristics. Having one informant made the descriptions consistent. In former studies we have evaluated inter-rater reliability between two driving inspectors (r = .96, p < .01). The inspector has been a driving instructor in a motor vehicle driving agency for 18 years. For 6 years he has evaluated whether or not people reported to the police show deviant driving behaviour. He has also evaluated re-licencing after medical illness, for instance, motor dysfunction, traumatic brain injury, stroke and age-related changes in function. The driving inspector was informed about the aim of the study. He made detailed descriptions of driving performance based on a rational, logical discourse. The standardised driving route of 25 km involved a variety of driving situations regarding action and locality. The driving inspector had an informal conversation with the driver during driving. The Swedish National Road Association uses an evaluation covering five evaluation areas: speed, manoeuvring, lateral position, attention, and traffic behaviour. These areas are established standards, which are comprehensive for the public. Moreover, they are based on professional consensus and experience (VVFS, 1996:168; VVFS, 1998:53). The driving inspector followed the prescribed evaluation areas, which he was used to. To be considered as deviant behaviour, failure had to recur during driving, except for serious mistakes, for instance driving through a red light. Qualitative methods aim at identifying and categorising phenomena of the research topic. From empirical data, dimensions are generated by discovering, describing and interpreting these phenomena (Dahlgren & Fallsberg, 1991). Corroboration of research results is connected to the concepts of reliability and validity. The qualitative approach refers to discovering new and different
Downloaded by [Linköping University Library] at 03:26 23 September 2014
176
LUNDQVIST &RÖNNBERG
data when repeating a research question. Consequently, consistency is not subjected to replication but to internal logic and to the consistency between the parts and the whole of the study. Validity refers to issues of verification and correctness. Qualitative dimensions are supposed to capture the uniqueness of the phenomenon, still maintaining distinctions between different aspects of the phenomenon, and satisfying the requirements of inter-subjective agreement (Larsson, 1993). Since the prescribed evaluation areas were based on professional consensus the first step in analysing data was to use the interview content to elucidate the prescribed evaluation areas and to make them more clear. Therefore, the data were broken down into discrete parts with a similar content, which formed a specific descriptive dimension and with differences between dimensions. In this way the prescribed descriptive dimensions were defined (Table 2). Data were the broken down in the same way and systematised according to the first aim, that is, to describe driving problems in the brain-injured group. In addition, interview data were analysed according to the second aim, that is, to find aspects important for safe driving despite brain injury. To establish inter-subject agreement, two additional independent evaluators checked the correspondence between data and the descriptive dimensions. In addition, respondent validation was used. Data analyses were brought back to the driving inspector who judged the plausibility of the data analysis related to the descriptive dimensions. He confirmed the overall qualitative impressions related to the proposed dimensions described in the text. TABLE 2 Prescribed dimensions of driving behaviour Speed Speed adjusted according to the driver’s ability, traffic situation and environment. Follow traffic pace and comply with speed limits. Manoeuvring Handle the car correctly. Ability to steer, change gear, brake in a flexible and smooth way so as not to interfere with concentration on other demands of driving. Position Correct position of the vehicle in traffic lane, driving direction, and gap to vehicle ahead. Distinct and stable position before and at junctions, roundabouts, and residential areas. Attention Flexible and sufficient attention to traffic signs, at junctions, roundabouts, and in residential areas. Select and interpret relevant information. Attend to stationary as well as to moving objects. Anticipate whether a situation may develop into a problem. Traffic behaviour Know traffic rules and regulations, and apply them correctly. Plan the driving. Approach and behave appropriately towards other road users. Avoid risks. Be aware of and adjust to the current traffic situation. Provide oneself with sufficient time. Start acting in time.
DRIVING AFTER BRAIN INJURY
177
Downloaded by [Linköping University Library] at 03:26 23 September 2014
RESULTS The first purpose of the study was to describe in what dimensions driving problems occur. From the interviews with the driving inspector, shortcomings in the prescribed dimensions were disclosed. In Table 3 examples of driving problems within the prescribed dimension speed, manoeuvring, position, attention, and traffic behaviour are presented. In addition, during the analysis we found that not all data could be sorted into and covered by the prescribed dimensions. Therefore, from the examples of driving problems we organised the remaining data and generated three non-prescribed dimensions, orientation, decision-making , and confidence (Table 4). The second aim of the study was to describe aspects appearing important to maintain safe driving despite the brain injury. From the interview data anticipatory attention and slowing down speed appeared to be essential aspects. From conversations with the driver, the driving inspector concluded that a genuine premorbid interest in driving and a motivation to drive safely appeared to be supporting aspects of safe driving. In addition, experience of driving was a relevant aspect according to the interview data (Table 5).
Table 3 Manifestations of driving problems under prescribed dimensions Speed Impaired speed control with respect to current traffic situation and environment, for instance, bad road conditions, oncoming traffic, narrow, and bending country road. Violation of speed limits, not giving way to traffic coming from the right. Late adjustment of speed leading to hard braking at traffic lights. Manoeuvring Unsteady clutch and accelerator pressure. Position Impaired perception of the vehicle size. Diffuse or incorrect position according to side of road and to other road users, for instance, too close to vehicle ahead. Diffuse position in roundabouts, on narrow streets. Unsteady position on country road and highway, continuously moving between centre line and side of road. Attention Impaired attention to pedestrians, in residential areas, at roundabouts, when changing traffic lanes, and when overtaking. Changing lanes at a roundabout without being aware of a vehicle at the side. Having attentional routines but still impaired attention. Impaired attention to traffic signs and directions, for instance, driving through a red light, entering a highway in opposite direction, not realising that a vehicle is moving in the opposite direction. Traffic behaviour Inconsistent structure of driving behaviour and impaired consideration for other road users. Failing to apply traffic rules, e.g., failing to give way to traffic coming from the right, exceeding speed limits, driving through red traffic lights. Lack of caution with respect to position at roundabouts .
178
LUNDQVIST &RÖNNBERG TABLE 4 Manifestations of driving problems under non-prescribed dimensions
Downloaded by [Linköping University Library] at 03:26 23 September 2014
Orientation Impaired ability to orient oneself in complex traffic situations despite clear instructions and traffic signs, e.g., turning left on country road, at roundabouts, intersections and junctions where there is little other traffic. Remaining at an intersection despite there being no traffic, requiring help to continue to drive. Asking about obvious matters, e.g., which traffic lane to use, in which direction to drive despite instructions and traffic signs. Decision making Difficulty in making decisions and finding solutions in unambiguous but complex traffic situations. Indecisive about whether or not to overtake, or to stop at a stop sign. Inability to use the traffic information to make decisions, requiring other road users to solve traffic situations. Confidence in driving situation Inexperienced traffic behaviour despite long driving experience. Impaired position on the road despite many years of driving indicating insecurity, similar to a beginner. Insecurity and indecision when driving, for instance, when crossing a main road.
TABLE 5 Aspects appearing important to maintain safe driving despite brain injury Anticipatory attention Early attention, planning in advance. Endeavouring to allow time for planning. When getting into problems solving them with early interventions. Slow down driving speed Slow driving. Slowing down implying careful driving, leaving gap to vehicle ahead, having control of the car and the situation. Slowing down when talking. Interest in driving/motivation for safe driving Interest in learning from traffic situations to improve driving performance. Motivation to do a safe driving test. Concentrating on the driving task. Driving experience Relaxed, careful driving behaviour. Driving which is also pleasant for the passenger .
The interview data also consistently emphasised inconsistent lane position and impaired attention among drivers who failed the driving task, while drivers who passed the driving test mainly showed early attention and concentration.
DISCUSSION The aim of the current study was to describe how driving problems were manifested in a group of brain-injured drivers, and to describe adaptive aspects of driving despite the brain injury. The discussion is divided into two parts: driving problems, and continuing to drive after brain injury.
DRIVING AFTER BRAIN INJURY
179
Downloaded by [Linköping University Library] at 03:26 23 September 2014
Driving problems One interesting issue is how driving problems are related to the hierarchical three-level model of driving behaviour (Michon, 1979, 1985). Problems of operational as well as tactical driving behaviour are described in the study. At the strategic level a realistic awareness of the driver’s own cognitive state and social responsibility is important. However, this study has not focused on the strategic level of control. Impaired speed, manoeuvring, and position concern elementary driving skills corresponding to the operative level of control. In complex traffic situations the driver is sometimes required to act promptly, and sometimes to inhibit action, for instance, when a traffic light is changing. Consequently, control of driving speed is even more important when the driver has a slow reaction time and slow information processing. Manoeuvring is, to a great extent, automated and some drivers were driving a car with an automatic gearbox, which facilitated manoeuvring and may explain the few examples of problems in this dimension. Inconsistent position appeared mainly among failing drivers. At the operational control level perceptual and motor speed is important. The patients demonstrated a reduced performance on a complex reaction speed test compared to controls (Table 1). Thus, the results demonstrated that the patients have problems in speed and precision of operational driving. This is in accordance with Brouwer and Withaar’s findings (1997). At the tactical control level driving problems were shown in impaired attention. “Looking but not perceiving, using excessive and unjustified attention routines without paying attention to relevant events” was one description of impaired attention. Early attention not only to evident but also to potential dangers is required to anticipate and avoid dangerous traffic situations. Insufficient anticipatory attention of position and speed of other road users may cause incorrect judgements and insufficient safety margins. “He knows that he must observe cyclists, pedestrians and cars, but he does not observe potential dangers which are not present at the moment, but just possible risks”. Anticipatory behavioural deficits are a problem for many patients suffering from brain injury (Van Zomeren et al., 1987). Impaired traffic behaviour comprised violation against other road users. Failing to be explicit in showing one’s intention while driving were violations against unwritten rules of traffic behaviour. Thus, the distinction between traffic behaviour and other dimensions has to do with giving insufficient information to other road users or violations against traffic rules. For instance, wrong position in a roundabout was evaluated as impaired traffic behaviour if the driver deluded other road users. Impaired orientation occurred in complex traffic situations requiring processing a sequence of two or more parts of information. Processing seemed to be occupied by the first part of the sequence, and suddenly the driver did not have enough information to complete the task.
Downloaded by [Linköping University Library] at 03:26 23 September 2014
180
LUNDQVIST &RÖNNBERG
Consequently, he or she had to ask about where to go. Impaired confidence included irregular, stuttering and awkward driving behaviour. “He moved backwards at the stop sign giving me an unsafe feeling . . . You feel it in the whole driving, the whole moving pattern”. Impaired decision-making was impulsive driving behaviour, “She saw the car but had problems in deciding what to do in that situation”. At the tactical level correct interpretation of traffic situations and flexible traffic behaviour require shifting between focused and divided attention, sorting out relevant information for processing. And, on the focused and divided attention tests, the patients also demonstrated inferior capacities compared to controls (Table 1). Generally, it is claimed that slowness in information processing is the crucial deficit after brain injury. It is therefore important to analyse the overall information processing ability into some of its constituent functions relevant for driving. Processing is assumed to start with encoding of traffic information into a spatial coding system. Then, a short-term memory temporarily holds information while it is relevant for the processing. Additional information is successively encoded into short-term memory storage. New traffic events and previous experience from long-term memory continuously interact when information is retrieved, updated and modified. All information components are integrated in working memory during processing. What represents speed of processing is the ability quickly to allocate the limited resources of working memory to encoding, storage, and retrieval operations. A controlling attentional system, or central executive, is assumed to supervise and co-ordinate the interaction between the different information processing components. To a great extent traffic information processing is automated. However, the controlling supervisory system is required when automatic control systems are insufficient, for example, in new situations encountering unfamiliar information where no automatic system is developed, and in cognitively demanding situations. Besides pointing to reaction speed and focused and divided attention as responsible for driving problems, the interview data uncovered the importance of anticipatory attention. It is here considered a working memory-based attention system, which influences driving quality, for instance, driving speed, safety margins, and driving confidence. We suggest that encoding, temporary storage and retrieval from long-term memory are inherent in anticipatory attention. It is the on-line function of information processing which is mediated by long-term memory experience and directed by the supervisory control system. This is probably what is expressed in the interviews as “reading” the traffic. Thus, an impairment of working memory capacity causes deficits in the process that integrates information into a comprehensive driving context. The patients also had a reduced quantitative performance on the Listening Span test measuring working memory (Table 1). In our two former studies the
Downloaded by [Linköping University Library] at 03:26 23 September 2014
DRIVING AFTER BRAIN INJURY
181
Listening Span test was the most sensitive test to differentiate between braininjured patients and control subjects and it also predicted driving performance (Lundqvist et al., 1997, 2000). In addition, what seemed to impair the orientation ability was described as a reduced capacity to hold a sequence of information, probably due to reduced working memory capacity. In addition, decision making is preceded by information processing, which is dependent on working memory including the supervisory control system. Consequently, if drivers manage to keep their anticipatory attention going they may reduce the mental effort inherent in the driving task, facilitating decision making and increasing driving confidence.
Continuing to drive after brain injury Many brain-injured patients resume driving. For instance, Priddy, Johnson, and Lam (1990) argued that brain-injured patients could adapt their driving behaviour to current impairments. The second aim of our study concerned such adaptive aspects of driving. Anticipatory attention was demonstrated as a relevant adaptive ability. Early attention provides early information that allows time and space to act, in order to avoid surprises in the traffic environment, all of this leading to a smooth driving behaviour. “If you give yourself time you can make choices.” Certainly, slowing down driving speed has the same effect of giving time for alternative action. “He slows down his speed so that he has complete control of the car before entering roundabouts, junctions, and at stop signs.” Consequently, there are two alternative behaviour adaptations if the driving demands overload the driver. One is to put more mental effort, that is, attention and concentration, into the driving task, the other is to slow down. Thus, for patients unable to increase attention there remains the alternative to slow down. Interest in driving and motivation to drive safely are important aspects for safe driving. In this context it reflects a premorbid interest and motivation for driving safely which was both revealed by the driving style and through the informal conversation between the driver and the traffic inspector. According to the interview data, interest in driving and motivation to drive safely influence driving style. The safety-oriented driver is aware of and monitors his or her driving behaviour, which may lead to improvement of driving performance by capitalising on previous mistakes and incidents. However, Lajunen and Summala (1997) showed that motivation to drive safely is also related to individual characteristics like low sensation-seeking, control of behaviour and the driver’s assessment of him/herself as a driver. For an overview of assessing skill and safety-motive dimensions in drivers’ selfassessment, see Lajunen and Summala (1995, 1997). Also, it is well known that self-awareness about residual neuropsychological deficits is important for implementing adaptive strategies after brain injury (Ben-Yishay & Prigatano,
Downloaded by [Linköping University Library] at 03:26 23 September 2014
182
LUNDQVIST &RÖNNBERG
1990; Prigatano, 1991) and thus, supposedly has an impact on motivation to drive safely. According to motivational models of driving (Evans, 1991; Fuller, 1984; Näätänen & Summala, 1976; Summala, 1985; Wilde, 1982), motivation is an important determinant of driving behaviour at all control levels, and a prerequisite for adjusting behaviour (Katz et al., 1990; Priddy et al., 1990). Given cognitive impairments, motivation to drive safely can influence the driver to make strategic decisions, for instance, to avoid driving in darkness. At the tactical level, motivation can consciously influence consideration for other road users. At the operational level, motivation to drive safely can make the driver reduce driving speed and increase following gap distance. Experience in driving probably improves driving performance. “To get such driving competence, more than learning to drive is required.” According to the interview data, acquiring experience depends on how the individual can profit from earlier traffic situations. If the driver memorises and learns from a situation experienced on a former occasion (Brouwer & Withaar, 1997) he can learn to anticipate different courses of traffic events and figure out risks in advance, that is, he can be tactical. According to the driving inspector the driver can “read” the traffic. In this study driving experience in terms of quantitative measurements was not significantly related to whether the driver passed or failed the driving task, reflecting that driving is not only to transport oneself but also an issue of driving quality.
Limitations of the study The results are derived from a set of interviews about various driving situations, in a certain patient group during rehabilitation. At this stage we cannot make any safe general conclusions about driving problems or adaptive driving patterns to any other brain-injured or normal groups. The study does not claim to have shown that the drivers actually compensate for impaired driving ability. Instead, we have been less ambitious, discussing adaptation rather than compensation (Dixon & Bäckman, 1995; Rönnberg, 1995). Another limitation of the study might be that only one driving inspector was interviewed which may reduce the reliability of the results. However, driving inspectors have an experience of about 500 supervised driving occasions which increases validity and reliability, and a high inter-rater reliability of driving evaluation was shown in former studies.
Theoretical and practical conclusions Among several cognitive demands for driving performance, attention stands out as the crucial function (Withaar, 2000). Theoretical implications of the present study are that the results stress the importance of anticipatory attention. The concept of anticipatory attention suggests that working memory plays a
Downloaded by [Linköping University Library] at 03:26 23 September 2014
DRIVING AFTER BRAIN INJURY
183
prominent role in real driving. It constitutes two sides of the same coin: On the one hand, impaired anticipatory attention comes out strongly when identifying driving problems, while on the other hand, early attention capacity is a salient adaptive resource. More concretely, impaired attention was the main qualitative characteristic for drivers who failed the driving test, while anticipatory attention strategies were characteristic of successful drivers passing the test. Practical implications of the study are that the results may contribute to more information about prescribed dimensions as well as for evaluating new qualities of on-road driving, for example, orientation and decision-making. Although not specifically geared towards qualitative detail of particular neuropsychological deficits in the present population, the study generates, for example, suggestions for development of dynamic tests of anticipatory attention that may be operationalised and quantitatively evaluated. In addition, the study can generate increased competence for professional driving inspectors in educational practice. This includes assessing additional dimensions and would improve guidance in what to observe, and how to interpret driving problems of patients suffering from brain injury. Another practical implication for rehabilitation is that, when there is any doubt about a patient’s driving performance, on-road evaluation must be a relevant part of the comprehensive driving performance assessment. The intervention should focus on the importance of adaptive aspects. To inform patients about the importance of anticipatory attention and adequate driving speed, and to give possibilities to train such adaptive behaviours will serve as important interventions for patients suffering from brain injury.
REFERENCES Baddeley A.D., (1990). Human memory: Theory and practice. Hove, UK: Lawrence Erlbaum Associates Ltd. Ben-Yishay, Y., & Prigatano, G.P. (1990). Cognitive remediation. In E. Griffith, M. Rosenthal, M.R. Bond, & J.D. Miller (Eds.), Rehabilitatio n of the adult and child with traumatic brain injury (pp. 393–409). Philadelphia, PA: F.W. Davis. Brooke, M.M., Questad, K.A., Patterson, D.R., & Valois, T.A. (1992). Driving evaluatio n after traumatic brain injury. American Journal of Physical Medicine and Rehabilitatio n, 71, 177–182. Brooks, N. (1984). Cognitive deficits after head injury. In N. Brooks (Ed.), Closed head injury: Psychological , social, and family consequence s (pp. 44–73). Oxford: Oxford University Press. Brouwer, W.H., & Ponds, R.W.H.M. (1994). Driving competence in older persons. Disability and Rehabilitation, 16, 149–161. Brouwer, W.H., & Withaar, K.F. (1997). Fitness to drive after traumatic brain injury. Neuropsychological Rehabilitatio n, 7, 177–193. Brouwer, W.H., Van Zomeren, A.H., & Van Wolffelaar , P.C. (1990). Traffic behaviour after severe traumatic brain injury. In B.G. Deelman, R.J. Saan, & A.H. Van Zomeren (Eds.), Traumatic brain injury, clinical, social and rehabilitationa l aspects (pp. 89–100). Lisse: Swets and Zeitlinger.
Downloaded by [Linköping University Library] at 03:26 23 September 2014
184
LUNDQVIST &RÖNNBERG
Dahlgren, L.O., & Fallsberg, M. (1991). Phenomenograph y as a qualitativ e approach in social pharmacy research . Journal of Social and Administrative Pharmacy, 8, 150–156. Daneman, M., & Carpenter, P.A. (1980). Individua l difference s in working memory and reading. Journal of Verbal Learning and Verbal Behavior, 19, 450–466. Dixon, R., & Bäckman, L. (1995). Compensating for psychologica l deficits and declines. Hillsdale, NJ: Lawrence Erlbaum Associates Inc. Engum, S.G., Lambert, E.W., & Scott, K. (1990). Criterion-relate d validity of the Cognitive Behavioral Driver’s Inventory: Brain-injure d patients versus normal controls. Cognitive Rehabilitation, 8, 20–26. Engum, S.G., Lambert, E.W., Scott, K., Pendergrass , T., & Womac, J. (1989). Criterion-relate d validity of the Cognitive Behavioral Driver’s Index. Cognitive Rehabilitatio n, 7, 22–31. Evans, L. (1991). Traffic safety and the driver. New York: Van Nostrand Reinhold. Fuller, R.A. (1984). Conceptualisation s of driver behavior as threat avoidance . Ergonomics, 27, 1139–1155. Galski, T., Bruno, R.L., & Ehle, H.T. (1992). Driving after cerebral damage: A model with implications for evaluation. American Journal of Occupational Therapy, 46, 324–332. Gouvier, W.D., Maxfield, M.W., Schweitzer J.R., Horton, C.R. Shipp, M., Neilson, K., & Hale, P.N. (1989). Psychometric predictio n of driving performance among disabled . Archives of Physical Medicine and Rehabilitatio n, 70, 745–750. Katz, R.T., Golden, R.S., Butter, J., Tepper, D., Rothke, S., Holmes, J., & Sahgal, V. (1990). Driving safety after brain damage: Follow-up of twenty-two patients with matched controls. Archives of Psychical Medicine and Rehabilitatio n, 71, 133–137. Korner-Bitensky , N.A., Sofer, S., Gelina, I., & Mazer, B.L. (1998). Evaluating driving potential in persons with stroke: A survey of occupationa l therapy practices . American Journal of Occupational Therapy, 52, 916–919. Korteling, J.E., & Kaptein, N.A. (1996). Neuropsychologica l driving fitness tests for braindamaged subjects. Archives of Physical Medicine and Rehabilitatio n, 77, 138–145. Kvale, S. (1996). Interviews. An introductio n to qualitativ e research interviewin g. London: Sage. Lajunen, T., & Summala, H. (1995). Driving experience , personalit y and skill and safety-motiv e dimensions in drivers’ self-assessments . Personality and Individual Differences, 19, 307–318. Lajunen, T., & Summala, H. (1997). Effects of driving experience , personality , driver’s skill and safety orientation on speed regulation and accidents . In T. Rothengatte r and E.C. Vaya (Eds.), Traffic and transport psycholog y. Amsterdam, New York, Oxford, Tokyo: Pergamon. Lambert, E.W., & Engum, E.S. (1992). Construct validity of the cognitive behaviora l drivers inventory: Age, diagnosis and driving ability. Cognitive Rehabilitation, May/June, 32–45. Larsson, S. (1993). On quality in qualitative studies. Nordisk pedagogik, 13, 194–211. Levander S (1988). An automated psychologica l test battery. IBM-PC version (APT-PC). Research Reports from the Department of Psychiatry & Behavioral Medicine, University of Trondheim, 11, No 65. University of Trondheim, Norway. Lundqvist, A., Alinder, J., Alm, H., Gerdle, B., Levander, S., & Rönnberg, J. (1997). Neuropsychologica l aspects of driving after brain lesion: Simulator study and on-road driving. Applied Neuropsycholog y, 4, 220–230. Lundqvist, A., Gerdle, B., & Rönnberg, J. (2000). Neuropsychologica l aspects of driving after stroke—in the simulator and on the road. Applied Cognitive Psychology, 14, 135–148. Michon, J.A. (1979). Dealing with danger. Summary report of a workshop in the Traffic Research Center, State University, Groningen, The Netherlands . Michon, J.A. (1985). A critical view of driver behavior models. What do we know, what should we do? In L. Evans & R. Schwing (Eds.), Human behavior and traffic safety (pp.485–520). New York: Plenum Press. Näätänen, R., & Summala, H. (1976). Road user behavior and traffic accident s. New York: North Holland.
Downloaded by [Linköping University Library] at 03:26 23 September 2014
DRIVING AFTER BRAIN INJURY
185
Priddy, D.A., Johnson, P., & Lam, C.S. (1990). Driving after severe head injury. Brain Injury, 4, 267–272. Prigatano, G.P. (1991). Disturbance s of self-awarenes s of deficit after traumatic brain injury. In G.P. Prigatano & D.L. Schachter (Eds.), Awareness of deficit after brain injury: Theoretical and clinical implication s (pp. 111–126). New York: Oxford University Press. Rönnberg, J. (1995). Perceptual compensation in the blind and deaf: Myth and reality. In R. Dixon & L. Bäckman (Eds.), Compensating for psychologica l deficits (pp. 251–274). Hillsdale, NJ: Lawrence Erlbaum Associates Inc. Stuss, D.T., Ely, P., Hugenholtz , H., Richard, M.T., LaRochelle, S., Poirier, C.A., & Bell, I. (1985). Subtle neuropsychologica l deficits in patients with good recovery after closed head injury. Neurosurgery, 17, 41– 47. Summala, H. (1985). Modelling driver behavior: A pessimistic prediction? In L. Evans, & R.C. Schwing (Eds.), Human behavior and traffic safety. New York: Plenum Press Summala, H. (1986). The deterministi c man in a stochastic world: Risk management on the road. In B. Brehmer, H. Jungerman, P. Lourens, & G. Sevon (Eds.), New direction s in research on decision making. North-Holland: Elsevier Science. Van Wolffelaar, P.C., Brouwer, W.H., & Van Zomeren, A.H. (1990). Driving ability 5–10 years after severe head injury. In T. Benjamin (Ed.), Driving behavior in a social context (pp. 564–574). Caen: Paradigme. Van Zomeren, A.H., Brouwer, W.H., & Deelman, B.G. (1984). Attentional deficits: The riddles of selectivity , speed and alertness . In N. Brooks (Ed.), Closed head injury: Psychological , social and family consequence s (pp. 74–107). New York: Oxford University Press. Van Zomeren, A.H., Brouwer, W.H., & Minderhoud , J.M. (1987). Aquired brain damage and driving: A review. Archives of Physical Medicine and Rehabilitatio n, 68, 697–705. Van Zomeren, A.H., Brouwer, W.H, Rothengatter, J.A., & Snoek, J. (1988). Fitness to drive a car after recovery from severe head injury. Archives of Physical Medicine and Rehabilitation, 69, 90–96. VVFS (1996) 168. Vägverkets författningssamling. The Swedish National Road Association VVFS (1998) 53. Vägverkets författningssamling. The Swedish National Road Association Wilde, G.J.S. (1982). The theory of risk homeostasis : Implication s for safety, and health risk analysis. Risk Analysis, 2, 209–225. Withaar, F.K. (2000). Divided attention and driving: The effects of aging and brain injury. Copy Service Leeuwarden. Withaar, F.K., & Wolffelaar, P.C. (1996). A simulated test-ride to assess the driving ability of cognitivel y impaired persons. In K. Brookhuis, D. De Waard, & C. Weikert (Eds.), Simulators and Traffic Psychology (pp. 57–75). Groningen: Centre for Environmental and Traffic Psychology. Manuscript received May 2000 Revised manuscript received December 2000
