Examining the “Strategic” Level of Driving Behavior: Evidence and Implementation ADED 2019 Cassidy, Davis, Dickerson, & Touchinsky

Overview:

This session will first review Michon’s hierarchy of driving behaviors and why this theoretical

framework is essential for supporting evidence-based practice for driver rehabilitation and

occupational therapists who address the IADL of driving and community mobility. Using

current research and tools for evaluation, focus will be on Michon’s strategic level. Accordingly,

the evaluation and/or observation of executive functioning during carefully planned clinical tasks

and components of the on-road assessment will be the focus. Research evidence on the use of

wayfinding or navigation as a strategic task will underscore the strengths and challenges of

developing a comprehensive on road assessment. Select interventions will be discussed for their

use with a variety of diagnoses. Participants will have the opportunity to explore new

approaches for the on road assessment through an interactive activity with the goal of building

“strategic” evaluation components that will produce stronger evidence for decision making

and/or client recommendations.

Learning Objectives:

- Discuss Michon’s hierarchy of driving behaviors in order to use it as a framework for

decision making and determining recommendations.

- Determine appropriate approaches for the use of technology to support evaluation of a

client’s impaired strategic level of functioning.

- Learn examination strategies to assess on road assessments to ensure all levels of driving

behaviors are evaluated effectively.

- Explain how the Occupational Therapy Performance Analysis of Driving (OT-PAD) can be

used to design driving evaluations.

- Discuss the importance of evaluating the medically-at-risk clients at the strategic level.

Presentation Outline & Space for Notes:

Introduction: Identifying the importance of evaluating the medically-at-risk clients at the

strategic level. Value & Reason:

Examining the “Strategic” Level of Driving Behavior: Evidence and Implementation ADED 2019 Cassidy, Davis, Dickerson, & Touchinsky

Michon’s Hierarchy of Driving Behaviors

Operational

Tactical

Strategic

Research Evidence – Wayfinding or Navigation as Strategic Thinking

Examining the “Strategic” Level of Driving Behavior: Evidence and Implementation ADED 2019 Cassidy, Davis, Dickerson, & Touchinsky

Strategic Assessments & Interventions

OT PAD

Assessment of Motor &

Process Skills (AMPS

Executive Functioning

Performance Test (EFPT)

Brief Cognitive Assessment

Tool (BCAT)

Montreal Cognitive

Assessment (MoCA)

Allen Cognitive Level (ACL)/

Cognitive Performance Test

Trails Making Test A & B

Snellgrove Maze Test

Driving Simulator

Technology Interventions

Examining the “Strategic” Level of Driving Behavior: Evidence and Implementation ADED 2019 Cassidy, Davis, Dickerson, & Touchinsky

Application to Driving: Case Study Key Points & Notes

Case Study 1

Case Study 2

Case Study 3

Strategical Notes for Impacting Your Practice

Behind the Wheel: Driver Rehabilitation Intervention 347

Driving

Acuity

Visual field

Visual attention

Ocular–motor skills

ContinuedCopyright 2012 by the American Occupational Therapy Association.

348

Stereopsis or depth perception

Color perception

Visuo-cognition

Visual information processing speed

(cont.)

Driving

ContinuedCopyright 2012 by the American Occupational Therapy Association.

Behind the Wheel: Driver Rehabilitation Intervention

Attention

Memory

Information processing

(cont.)

Driving

ContinuedCopyright 2012 by the American Occupational Therapy Association.

350

Decision making or judgment

Executive function

Small body size

Flexibility, strength, endurance, sensation, and pain

(cont.)

Driving

Copyright 2012 by the American Occupational Therapy Association.

Behind the Wheel: Driver Rehabilitation Intervention 351

Coordination

Reaction time

Sources.

(cont.)

Driving

Note. Reprinted from "Behind the Wheel: Driver Rehabilitation Intervention," by A. Dickerson & D. Stressel, in Driving and Community Mobility: Occupational Therapy Strategies Across the Lifespan (pp. 347-351), by M. J. McGuire & E. Schold Davis (Eds.), 2012, Bethesda, MD: AOTA Press. Copyright 2012 by the American Occupational Therapy Association. Used with permission.

OT-PAD, page 1

Occupational Therapy - Performance Appraisal for Driving (OT-PAD)

Anne E. Dickerson, PhD, OTR/L, SCDCM, FAOTA, FGSA and Michel Bédard, PhD, FGSA

Purpose: Driving is a complex instrumental activity of daily living

(IADL). Consequently, using clinical reasoning based on evaluation

results, knowledge of the client, and observation of clients performing

other complex tasks, occupational therapists can make

recommendations about the activity of driving. The OTPAD1 has been

designed as a clinical tool to assist therapists in making the link

between their knowledge and the activity of driving as well and

considerations for supports or requirements for community mobility

options.

The person factors that are most likely to affect driving include:

Physical/sensory, Cognitive, Emotional regulation, and Insight.

Questions are separated into three sections, based on Michon’s three

levels of Driving Behaviors2.

1 Dickerson, A.E. & Bédard, M. (2014). Decision tool for clients with medical issues: A Framework for identifying driving risk and potential to return to driving. Occupational Therapy in Health Care, 28, 194-202. 2 Michon JA. (1985). A critical view of driver behavior models: What do we know,

what should we do? L Evans & RC Schwing (Eds.) Human behavior and traffic

When related to driving, these are defined as: Strategic level: Decision-making process, affecting all levels of driving

Determining trip goals and mode of transport (e.g., bike, drive,

walk).

Navigating how to get there as well as being able to modify or

change “plans” both in anticipation of trip and while on the road.

Tactical level: Decisions/maneuvers made during driving maneuvers

Slowing down due to weather

Knowing if it safe to make a left turn

Deciding whether to pass a slower vehicle.

Operational level: Human-machine interaction used to control the vehicle

Steering, pushing brake pedal, using turn signal.

Having the physical skills to carry out the tactical maneuvers.

Possessing the overlearned skills developed through driving

experience

safety, (pp.485–520). New York: Plenum Press.

OT-PAD, page 2

Examples of IADL applications for each of the three levels. Client Notes: Strategic: Does the client have the cognitive ability to make decisions at the strategic level?

Does the client know whether he or she has the information to make an appropriate decision? Does

the client initiate seeking additional or clarifying information?

If the client were to make a meal, would he or she be able to plan it correctly (as with similar

competence to prior to his or her medical condition)?

Can the client recognize, organize, reorder from pharmacy, and remember to take medication

accurately and safely?

Can the client plan a meeting with a friend or family member or make an appointment and

appropriately follow through without instructions from others?

Is the client able to calm down and perform tasks after being surprised, flustered, or annoyed by any

incidents or other people?

Does the client plan how to manage his or her physical mobility within the immediate environment

without significant assistance (i.e., how to plan to get his or her wheelchair in and out of a vehicle as

well as in and out of the home)?.

Tactical: Does the client have the performance skills to perform actions at this level?

Does the client immediately slow down when there is a wet floor or pavement?

Does the client acknowledge others passing by in the hallway or on the sidewalk to say hello in

recognition?

Does the client adjust or accommodate immediately and appropriately when problems occur, such as

being disconnected on a phone call, when coffee is spilled, a pet jumps up and down, a family

member doesn’t show up, a household item breaks, or food burns on the stove?

Is the client able to multitask (i.e., one task being automatic), like walk and talk, read and drink, wash

dishes and talk on the phone, tell a story and exercise, give instructions and make coffee?

Operational: Does the client have the performance skills to perform actions at this level?

Does the client perform normal daily tasks efficiently and automatically without cues (e.g., brushing

teeth, eating, dressing)?

Does the client have difficulty manipulating tools like cutlery?

Does the client bump into doorways or walls?

If the client loses balance, is his or her recovery effective?

How is the client’s reaction to environmental changes?

How fast does the client recognize change in the environment? For example:

o Does the client immediately see when someone enters the room?

o Does the client recognize sounds and the sources of the sound?

The OT-PAD facilitates the link between daily tasks and driving. Using clinical reasoning based on evaluation results, knowledge of the

client, and clinical observations, indicate the degree of impairment for each person factor under each level of driving behavior.

OT-PAD, page 3

Levels Descriptors of how to consider each factor under each level:

physical/sensory, cognitive, emotional regulation, and insight.

Degree of Impairment

None Mild Moderate Severe

Strategic:

Does the

client have

the cognitive

ability to

make

decisions?

Physical/sensory – Aware of physical limitations and is able to plan for

successful compensation (e.g., if in a wheelchair, demonstrates ability to

plan time and/or assistance for transfer).

Cognitive – Demonstrates ability to plan in advance using appropriate

decisions to meet the goals of the task; self-regulates with insight into

decisions; organizes steps to complete task.

Emotional regulation – Can plan with appreciation of the emotional

state (e.g., Does not drive if experiencing excessive, anxiety, depression,

or anger).

Insight – Has accurate awareness of the skills and abilities he or she

possess to meet the demands of the task (e.g., to clean the windows,

skills/ abilities to use a ladder safety? Can make modified decisions based

on driving experience and/or training.)

Tactical: Does the

client have

performance

skills to

perform

actions at this

level?

Physical/sensory – Is aware of his or her physical limitation and adjusts

as required (e.g., if floors are wet, walks more slowly).

Cognitive – Can evaluate a complex, dynamic context and adjust or

accommodate through appropriate actions.

Emotional regulation – Can recognize and manage emotions that arise

in challenging situations.

Insight – Can accurately gauge the risk and skills/abilities needed to meet

the demands of a task requiring immediate decisions.

Operational: Does the

client have

performance

skills to

perform

actions at this

level?

Physical/sensory – Meets the minimum requirements (e.g., vision) or is

able to compensate for limitation (e.g., with training, will be able to use

hand controls to compensate a lower extremity amputation)

Cognitive – Awareness and flexibility to use the appropriate actions to

achieve desired results.

Emotional regulation – Emotional state does not negatively affect

performance of automatic tasks.

Insight –Not applicable.

Research Summary 2019 ADED – Summarized by Dr. Anne Dickerson

1

Annotated Bibliography of Studies with Navigational or Wayfinding Implications.

Aksan, N., Anderson, S. W., Dawson, J., Uc, E., & Rizzo, M. (2015). Cognitive functioning differentially

predicts different dimensions of older drivers’ on-road safety. Accident Analysis and Prevention, 75, 236-

244. doi:10.1016/j.aap.2014.12.007

Examined specific cognitive domains from a driving database of older adults. The on-road included

navigational performance, safety errors with navigation and safety errors without navigation. Those with

conditions (AD, DP) performed worse than healthy (but not differently between the two) with different

domains of functioning predicted distinct facets of driver safety. Processing speed predicted safety issues,

but not navigation. Memory and set-shifting predicted performance in navigation, but not safety.

Implications: Need different types of cognitive assessments when determining fitness to drive, not

just age, diagnosis and visual/sensory. Navigational performance is an important element to add,

especially for those with graduated restrictions.

Eby, D. W., Silverstein, N. M., Molnar, L. J., LeBlanc, D., & Adler, G. (2012). Driving behaviors in early stage

dementia: A study using in-vehicle technology. Accident; Analysis and Prevention, 49, 330-337.

doi:10.1016/j.aap.2011.11.021 [doi]

Study used in-vehicle technology to describe driving behaviors that may be common in individuals with

early stage dementia and compared to behaviors of healthy drivers. Drivers with early dementia had

significantly restricted driving space relative to the comparison group but drove as safely as the comparison

group. Getting lost was not common, but when it did occur, it was the early dementia group. Implications:

Individuals with early/mild dementia are likely to be fit to drive for a time. Navigational errors may

be a clue to knowing when it is time to stop.

Anstey, K. J., Horswill, M. S., Wood, J. M., & Hatherly, C. (2012). The role of cognitive and visual abilities as

predictors in the multifactorial model of driving safety. Accident Analysis and Prevention, 45, 766-774.

doi:10.1016/j.aap.2011.10.006

Model called Capacity to Drive Safely operationalized using three validated screening measures for older

drivers: Useful Field of View (UFOV), a Hazard Perception Test (HPT), and a Hazard Change Detection

Task (HCDT). Cognition has the greatest impact with processing speed and executive measures working

form a single factor. Poorer performance with increased age, associated with higher order cognition with

manipulation and storage of visuo-spatial information and processing speed. Limitation: no on road.

Implication: Support that processing speed, executive functioning and higher-level cognition is most

important for driving risk.

Vardaki, S., Dickerson, A.E., Beratis, I., Yannis, G. & Papageorgiou, S.G. (2019). Driving difficulties as

reported by older drivers with mild cognitive impairment and without neurological impairment, Traffic

Injury Prevention, DOI: 10.1080/15389588.2019.1626986. These study explored the factors that

determine driving difficulties from the viewpoints from older drivers with mild cognitive impairment as

well as age-matched controls without cognitive impairment. Although both groups showed difficulties

with switching from automatic to decision making, the difficulties were different. The study suggested that

older adults understand the probable impairments in various driving skills. Implications: Similarities

and differences of healthy older adults and those with MCI will have implications when designing in-

vehicle technologies and developing programs to educate or train older adults in how to use the

technology in their vehicles.