1. The Enhanced Focused Concentration and Attention Learning (FOCAL+) training program, compared to the FOCAL control program, reduced the number of long stares and lane position deviations in adolescent drivers with attention deficit disorder with hyperactivity (ADHD).
2. Under real-world driving conditions monitored for one year, FOCAL+ program participants had lower rates of long stares and crash or near-crash events.
Level of evidence assessment: 1 (Excellent)
Summary of the study: Teens with ADHD have difficulty maintaining their visual attention on the road and have twice as many collisions as teens without ADHD. In the laboratory, these effects are characterized by long gazes (≥ 2 seconds) from the roadway and position deviations in the lane. The FOCAL program is a one-session, computer-based program that trains neurotypical drivers to reduce long looks away from the roadway. This randomized controlled trial compares the effectiveness of FOCAL control and FOCAL+ intervention programs for adolescent drivers with ADHD. Participants were first trained over five sessions and then followed for a year. During simulated driving assessments at both one and six months after training, adolescents in the intervention group had significantly fewer long gazes away from the roadway and lane position deviations compared to the control group. Within a year of training, adolescents in the intervention group had significantly lower incidences of long stares, near misses, and crashes during sudden changes in vehicle momentum compared to the control group. As a limitation, the study could not assess the effect of ADHD medications on crashes or near crashes. The study was also unable to assess whether the intervention program would be effective without pre-driver training, such as tuition and supervised driving.
Click to read the study in the NEJM
In depth [retrospective cohort]: This randomized controlled trial compared the effectiveness of FOCAL control and FOCAL+ intervention driver training programs in 16-19 year old drivers with ADHD. Participants were randomized 1:1 to receive FOCAL (n=76) or FOCAL+ (n=76) and followed for one year. The primary outcomes were the number of long looks (≥ 2 seconds) away from the roadway and lane deviations in map search tasks during simulated trips of 15 minutes at one and six months. Secondary outcomes were rates of long looks away from the roadway and crash events during sudden changes in vehicle momentum (g-force event) over the real-world driving year. The mean number of long gazes was significantly lower in the intervention group compared to the control group at one month (16.5 and 28.0, respectively; incidence rate ratio, 0.64; confidence interval at 95% [CI], 0.52 to 0.76; p<0.001) and six months (15.7 and 27.0, respectively; incidence rate ratio 0.64; 95% CI, 0.52 to 0.76; p<0.001). The standard deviation (SD) of track position was also significantly lower in the intervention group compared to the control group at six months (adjusted mean difference, -0.22 SD; 95% CI -0.31 to -0.13; p<0.001). Over the year of real-world driving, participants in the intervention group had fewer long stares during g-force events than those in the control group (hazard ratio, 0.76; 95% CI, 0.61 to 0.92). Near misses and motor vehicle collisions occurred during fewer g-force events in the intervention group compared to the control group (relative risk, 0.60; 95% CI, 0.41 to 0.89). These results suggest that a modified FOCAL+ training program may be effective in improving attention and reducing crash rates in adolescent drivers with ADHD.
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