For Parents

Fitness to Drive & Other Factors with Teens or Special Population Young Adults: Perspectives from a Specialist in the Field

The first step in determining if driving is possible for an adolescent or young adult, one must look at minimum state requirements and medical fitness-to-drive and general potential-to-drive or readiness-to-drive factors.

From the medical perspective, fitness-to-drive is determined by the absence of any functional deficit or condition that significantly impairs an individual’s ability to fully control the vehicle while conforming to the rules of the road. For example, if the student did not meet the minimum vision requirements to drive or was having uncontrolled seizures, he/she would be unfit to drive.

Other medical fitness-to-drive impressions are made after examining the medical history and by doing a clinical assessment process which could include behind the wheel safe driving evaluation. Driving fitness might be impaired if the child has a startle response or progressive condition. Other reasons fitness-to-drive might be impaired for a teen could be related to significant attention or processing challenges. There are many factors that relate to fitness-to-drive and they are not always apparent prior to driving age.

To help screen fitness-to-drive with Teens, I created the Adolescent-Fitness-to-Drive-Safe (AFTDS) Screener for OT’s and caregivers.

Readiness-to-drive generally relates to a student’s level of safety/judgment and independence with life skills that should take precedence over driving such as self-care and home management tasks. Furthermore, due to the complexities of driving, if a student is struggling with a readiness level task, he or she will be more dangerous behind the wheel. General readiness-to-drive is usually pretty evident. However, readiness-to-drive-safe impressions are a bit more challenging. For example, there are plenty of teens I work with who are decent new drivers. They will pass the road test and they will still be at risk to drive safe. This is because all new drivers are inexperienced. Any young and novice driver when presented an entirely new tactical or strategic level stressor is bound to make a poor decision.

To help determine readiness to drive and to improve other safety/judgement and independence skills, I created the Readiness-to-Drive-Safe (RTDS) Screener for OT’s, caregivers and instructors.

Potential-to-drive impressions tend to relate to additional factors such as driving goals. For example, a person may have better potential-to-drive impressions if the family has decided to invest extra time and energy into a driver education plan and process. Potential-to-drive could also be influenced by driving decisions. For example, potential-to-drive safety could be impacted for a child with ADHD, Anxiety, or Seizure history who takes medication. The medication could, itself, enhance or reduce safe driving.

To improve potential to drive, my OT/DRS approach is to create an Individualized Driving Plan (IDP) with each student level of readiness/fitness and family system objectives in mind. If driving is not the best choice, an action plan is devised. Students will more independence in community mobility or access to gain social capital will have better well-being.

On a student and family’s journey towards a safe mobility and independence plan, it is recommended to work with an Occupational Therapist (OT). Using an Occupational Profile, the OT will look at what the concerns and goals are as well as what are supporting and limiting factors. The OT will perform an individualized assessment and create a plan of care with recommended treatment frequency, duration, approaches and objectives.

It’s important to note that while OT generalists or specialists can help with many life skills and assist with driving-related planning, only a trained and distinguished OT Driving Rehabilitation Specialist (DRS) should do driving-related assessment and intervention. Note that many DRS’s may have a goal of specialty certification and staying active as a CDRS. But this is not required by either the American Occupational Therapy Association or the Association for Driver Rehabilitation Specialists. To learn more about DRS/CDRS and find local providers, go to www.aded.net. Presently, there is somewhat of a shortage of OT/DRS’s or CDRS’s in the field while the OT profession feels over saturated at times.

Occupational Therapists have had extensive education and hold at least one college degree from a major university. Some OT’s may have a Bachelor’s of Science degree in Occupational Therapy and have extensive background in field experience, additional certifications and trainings such as many OT/DRS’s. Other OT’s may have a Master’s degree in OT, dual degrees, or Doctoral degree and more research experience than clinical field experience. Some may be registered at a national level. Others may not. Some may be members of AOTA, ADED, or other specialty groups. It’s important that you consider a variety of factors when making the choice about who you want to work with and how he/she is best suited for your child in need.

There are Driving Rehabilitation Specialists and CDRS’s that are not licensed Occupational Therapists. Their background may be as a certified OT assistant, driver education instructor, or other. My advice is to thoroughly vet any DRS to make sure he/she meets a level of education and specialization that satisfies your child’s medical or other safe driving need. See what scope of service he/she can legally and ethically provide. Also consider if the evaluating or treating provider qualified to medically code services for potential reimbursement from a payer source.

An additional tip is to ask around. Equipment vendors, physicians, payers, and therapist’s usually build relationships with providers. Be aware of bias and bizarre hints of competition that exist. Consider why you should be sitting on a long waitlist rather than going to an open provider in the same area. Maybe it’s because that person is the only one doing high tech evals and training. Contact various options yourself and make your own decision about who you want to work with and how long you want to wait for services.

One thing you want to be very cautious of as parents and instructors is beginning any sort of in car training without OT/DRS guidance. As a parent, the biggest risk is not having a training brake. Another factor is kids often get upset in the car with certain parents while driving. A problem more common with instructors is working at a level above their level of expertise. Is very concerning to know that some high-school graduate level instructors work with kids with disabilities. This is not okay. It’s also sad to see driver education schools making a ton of profit off of hopeful parents by making them buy a minimum number of lessons upfront without the child ever being evaluated by an OT/DRS to determine readiness or medical fitness to drive.

I am working very hard with my current DriversEd.com employer to pilot a remedial program for students here in Texas. There is a real problem with non-disclosure. Kids with autism spectrum, learning, attention, vision, processing or anxiety challenges are regulars. I see it and hear about it all the time. I’m glad when I work with them because it’s what I do best, but I know the way the current system is and how many problems there are. These problems exist at all the driver education schools.

Driving schools should have minimum safety measures in place. They should refer to medical driving rehab specialists before accepting certain students and have a support process in place if a student is struggling more than average. It may be that this student has an unidentified safety risk factor and would benefit most from an individualized Driving Plan (IDP) rather than the standard lesson approach without instructor guidance from an OT/DRS.

This is a problem that exists because, from the highest level, there are no disability standards in place regarding novice and teen driving education guidelines. I am actually working on this issue right now with a specialty ADED task force. We have provided numerous professional recommendations and are hopeful that our input will be added to the updated national standards.

Next, it is up to the state regulators. State agencies, such as TDLR, are allowed to pick and choose from the recommended national guidelines what and how they want to implement at the local level. Presently, in the state of Texas, OT/DRS’s face numerous issues with the current regulation language and interpretations regarding services for teens and young drivers with special needs. Other states have similar issues or not enough regulation. Myself and other OT/DRS colleagues across the country are working tirelessly to address and fix these concerns. For example, some driver schools are being licensed as a rehabilitation or special education facility without having a licensed rehab or certified teaching professional provide the services. This is quite misleading and dangerous.

We are also working to educate physicians and schools about the need to refer. For some reason, Doctor’s are often reluctant to initiate any driving restriction related conversations but there are clear medical advisory guidelines regarding driving limitations in each state. Doctors can refer to us for comprehensive driving evaluations in order to provide medical clearance to drive when there is a noted concern. Schools usually do not refer because they might have to legally pay for services they cannot provide due to IDEA law. However, school OT’s can be vital in assisting with not only driving readiness factors but also community independence planning. For these reasons, you should always bring up your driving questions to PCP’s and school therapists and expect the next step is referral to an OT/DRS.

Payer problems are the most difficult issue and we all face it. Getting insurance to cover driving rehab services is rare but possible. You may have to submit for reimbursement on your own with coding provided from the OT/DRS. In some cases, you can get vocational rehabilitation support by the state which might cover your intervention. OT/DRS services can be costly for some families so ask your provider about financial assistance. If you have to private pay, then my advice is pretty simple. When it comes to helping children be safe drivers, we must not look at the price as in dollar signs, but the total potential cost. How much would added prevention towards avoidable damages or accidents be worth?

For assistance with regard to any student in question, please reach out to me.

For OT’s

Pediatrics & Driving Rehabilitation: My Path, Where I’m Going, & Helpful Tips and Tools for Other OT’s

Professionals in the highly specialized field of Pediatric Occupational Therapy Driving Rehabilitation practice can tell you that certain medical conditions and other risk factors can make driving much more difficult and risky than what the average student faces. But how do you find us? That is a difficult question. We are a rare breed.

In the state of Texas, where more teens are sadly killed driving than in any other state, I am somehow the only pediatric OT specialist currently working on driving. Thank goodness there are other OT/DRS or CDRS’s serving kids here in Texas and across the country but, again, few of us come from a pediatric specialty background.

You should know I also happen to be a driving instructor for DriversEd.com. I highly advise any OT wanting to do this work get experience as a regular driving ed instructor. It will help you build important skills and give you a sense of what typical new drivers experience as the norm. Also, I think this is the way of the future. I know several DRS/CDRS OT’s working for driving schools across the country in some capacity and I am trying to do the same by proposing a remedial driving program and safety referral process for this school.

But let me get back on track. Even being a pediatric specialist, I didn’t face the complex area of driving rehabilitation as it pertains to pediatrics until some of my older OT clients approached driving age. Most kids in OT systems (school, hospital, or private) seem to sadly “age out” or get discharged prior to safe driving readiness or driving fitness discussions can even begin. It’s clearly a system problem that stems from other dysfunction in healthcare and education systems and unless you start your own clinic like I did, there isn’t much you can do about it.

Luckily, I was working at a pediatric therapy clinic that recognized this problem somewhat and was serving more teens than most other facilities in the area. But when it came to driving IADL assessment, support and training, there was nothing in existence other than a hospital-based adaptive driving program designed for adults. Perhaps, pediatric clinics avoid addressing any driving readiness because of additional liability factors.

It was only because I had prior experience in the specialized field of driving rehabilitation with adults that I had some idea about what struggles these students in question would face. The next logical step was to seek out additional professional education for creating a program, which I did. It was not easy to find training. And, even now, there are few OT educational opportunities related to kids and driving.

That is why I have continuously mentored several OT fieldwork students and provided in-services to our region’s school OT’s and parents. On my webpage, I have posted the Region XIII PowerPoint for anyone to access and download. I also recommend to OT programs to introduce this specialty field to students so they can consider it early on for a future career path.

As you can imagine, since most drivers are over 18, the focus of the driving rehab field is mostly with adults. Most education and service is related to physical disabilities, vision impairment, neurological issues, sensory loss, or degenerative conditions. You can find a lot of nice courses and can work to obtain badges from both AOTA and ADED related to driving rehab coursework completion.

Thankfully, field experts and pioneers like Dr. Miriam Monahan stepped up to the plate and worked with AOTA to develop additional coursework more relevant to pediatric OT’s. I highly suggest all of Miriam’s courses for any pediatric OT wanting to discuss driving with families of teens on his/her caseload. AOTA has wonderful coursework and materials from Susan Pierce, Elin Schold-Davis, Anne Dickerson and other OT driving specialists.

Today, Occupational Therapy “generalists” can find a few more options for driver rehabilitation training such as via the University of Florida and Adaptive Mobility Services. Haven personally taken the AMS route, and with Susie Touchinsky as one of my most actively involved and respected mentors, I highly recommend taking this route.

It’s an expansion of Susan Pierce’s work. It’s also more affordable, can be done at your own pace while working full-time, and requires a lot less travel. Upon completion, you will get a certificate with new credentials similar to what the other route gets you.

Presently, there is no OT “degree” of DRS. Through AOTA you can become specialty certified in this area. To learn more about DRS vs. CDRS distinctions, visit ADED. Becoming a member is suggested as it provides many useful benefits for new field practitioners. For example, there is a mentor program, specialty groups, and start-up tool kit.

When it comes to assessment, the above mentioned training routes will teach you the most. But you should know there aren’t many choices for standardized driving tests for students outside of what you already use in pediatric OT. The positive here is it leaves room for us as OT professionals to make clinical reasoning about driving potential. Thankfully, this is part of best-practice guidelines already.

Common pediatric standardized measures can be used in clinical assessment of motor, perceptual and sensory functions. To some degree, this is helpful because clients can probably get this part of a clinical assessment covered by insurance.

For some areas of testing, OT/DRS’s have to generalize findings to adult measures with current tools available such as Trails A & B. And, if qualified to do vision testing (which requires additional training), this would be the same for anyone with regard to meeting state requirements. Note that you can also have vision testing done by another professional.

The primary concern I have identified with regard to pediatric assessment related to driving are the following:

First, the typical test measures used in driving screenings have standardized findings based on older adults. As a field, it’s pretty evident we need to gather information related to young and new driver performance on these tests if we are to be using them. I think it is important for us to work together as a field for better tracking and compiling of information when using tools that were designed for adults with our younger populations.

Second, there are useful tools in existence for pediatric OT’s to utilize such as the OT-DRIVE framework model, OT-PAD (performance appraisal) and Fitness-to-Drive-Screening measure (FTDS) but nothing very thorough and specific to teens. I’d like to change that.

I have reached out in many people in many ways and will continue to do so to get some tool development projects like these going. The outcome of that outreach hasn’t been super productive. The unfortunate reality is that everyone is quite busy with other work, research and development. And I think we all know how long grant-funded research projects at major hospitals and universities can take. Hopefully, something will come. But it may take years.

For now, I’ve decided to grab the wheel and create some new screeners for my own program use. I’d be glad to share them with fellow colleagues who would like to help me with some very simple field research. It’s going to be a work in progress of course, but here is what I have created and why.

To help assess “readiness to drive” I have made a tool useful for both OT practitioners and caregivers. It is called the Readiness-To-Drive-Safe (RTDS) Screener. I have created this because there isn’t currently an informal assessment like it which is specifically applicable to potential young drivers. I believe it can be used with a variety of teens with or without added risk from a medical condition and for a variety of purposes.

I can tell you that as a regular driving education instructor, most “normal” students are not fully prepared for what safe driving preparedness takes. Those of you who are parents of new drivers also know this. It will be important for anyone using this tool to assess the individual strengths/weaknesses of any student interested in driving as a future goal. If driving is not recommended as the safest choice, the tool can still be used to measure progress in a variety of skills helpful for safer and more independent living and community access.

For “driving fitness” for students at risk who have already obtained a permit or license, I have created a separate safety/risk identification tool. It is called the Adolescent-Fitness-To-Drive-Safe (AFTDS) Screener. My intention with this tool is to help caregivers, and instructors working under guidance of an OT/DRS better identify safety concerns and know how best to approach or modify driver training. It is it will be used in conjunction with the RTDS and additional safe driving risk tracking measures such as a driving lesson note taking template for instructors.

My goal is to help make informal screening tools like these (or something bigger and better through grant-funding and support) easily accessible and low cost (if not free) to everyone while supporting needed research in the fields of occupational therapy driving rehabilitation and driver education. Please contact me for project planning if you would like to collaborate with or help support similar efforts with assistance in research or funding.

At this time, select content of the RTDS and AFTDS screeners are free and accessible through safedrivingrehab.com/resources. If you are an OT/DRS or CDRS please contact me for access to additional components of these screening tools. Let’s discuss intended usage and how we can share data for field research.

I have some exciting new projects underway and would be glad to help collaborate with any efforts related to improving the safety of young and new drivers while expanding awareness of our field.

If you are a pediatric OT generalist or interested in this field, feel free to reach out to me for more information on how to get started.