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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