Are we doing enough to prevent the perfect storm?: novice drivers, ADHD, and distracted driving.

Motor vehicle crashes, the leading cause of teendeaths in the United States, pose amajor public health threat for teen drivers, their passengers, and others on the road.1 Yet only one implemented interventionhasproveneffective in reducing fatal teen crashes—3-stage graduated driver licensing (GDL) systems.2 Recognizing that the first 6 months of solo driving pose thehighest crash risk, GDL restricts newdrivers to lower risk driving situations, progressively allowing increased exposure to higher risk situations with experience. Substantial and sustained reductions in teendeathshavebeen realizedby the states that have instituted GDL, but GDL alone is not sufficient toaddress theepidemicof teencrashes. Someteendrivers possess characteristics (eg, attention-deficit/hyperactivity disorder [ADHD]) and/or perform risky driving behaviors (eg, texting while driving) that could put them at heightened risk for the perfect storm, a serious crash. There is an urgent health need to build on the foundation of GDL with additional effective interventions to reduce teen driver crashes. Agrowing scientific foundation for teencrashes is informingdevelopmentof new interventions focusedonnovice teen drivers,3-7 but teens with heightened risk might require tailored approaches.Morework is needed to understandhow to reduce risk (eg, impaired and distracted driving and driving inexperience) and promote protective factors (eg, parent involvement and invehicle monitoring) for a specific teen at a developmental stage (cognitive, social, and emotional) with individual characteristics (eg, medical, psychological, social, andenvironmental factors).8Borrowingfrom the InstituteofMedicine’s framework forpreventivehealthservices to addressmajorhealthproblems,9 interventions should be placed within a tiered clinical and public health prevention strategy to reduce teen driver risk (universal-, selective-, and indicated-level interventions) thatmatches the level of intervention to the risk level of the target population, and matches effective interventions to specific risks and problem behaviors. Graduated driver licensing is a universal-level intervention (ie, targeting all novice teen drivers, regardless of individual risk), but some teensmayneedmore. Just as teens vary in risk for behavioral healthproblems, teens vary in their risk for unsafe driving behaviors and crashes. In this month’s JAMA Pediatrics, Narad et al10 add to the scientific foundation for an important but understudied area: the combined effects of a known driving risk factor—driving while distractedby cell phone conversations and textmessaging—with a known individual difference risk factor— ADHD—on novice teen driver performance. Recognizing potential study risks with placing teens in on-road hazardous situations, this study was conducted in a low-fidelity, simulateddriving environment and should inspire futurework examining the clinical relevance of their simulator findings regarding real-world driving and crash risk, the etiology of risk, and thedevelopment and evaluation of interventions tomitigate risks. To inform this future research agenda, this editorial summarizes current knowledge and researchondistraction and ADHD among novice teen drivers, provides an introduction to driving researchmethods, and poses a vision for a comprehensive clinical andpublic health approach to reducecrashesassociatedwithdistractionandADHDamongnovice teen drivers. Distracteddrivinghasbecomenearlysynonymouswiththe use of cell phones while driving, but, in fact, distraction from cell phone use represents a fraction of the distractions resulting in teendriver crashes.11 Amultitudeof factors in andout of thevehiclecausedistraction,which theNationalHighwayTraffic Safety Administration12 defines as “a form of driving inattentionthatoccurswhendriversdivert theirattentionawayfrom thedriving task to focusonanotheractivity instead.”12(p13) Such diverted attention can result from visual, auditory, cognitive, ormanual distraction (tasks that involve the driver looking at, speaking/listening to, or thinking about something other than the driving task or where the driver’s fingers aremanipulating adevice). Basedon this commondefinition, adriver readingor responding to a text message might be highly distracted visually, manually, and cognitively and is at risk for crashes. Further complicating this, most drivers underestimate their level of distraction and do not recognize the personal relevance of distractionontheirdrivingperformance.13Therefore, interventions to reduce distracted driving need to address a broad array of activities, as well as the driver’s intentions and motivations to engage in themwhile driving. Jerome et al14 demonstrated ADHD as an important risk factor for negative driving outcomes but did not exclusively focus on teens. The compounded effects of ADHD on immaturity anddriving inexperience in teens likely result in higher ADHD-related crash risk in teens, but a recent systematic review by Classen andMonahan15 points to the low level of evidencesupportingcurrent interventions to improvedrivingperformance for teen drivers with ADHD. Advances are needed in evidence-based, rigorously evaluated assessments of risk and targeted interventions for teenswithADHD that take into account factors such as the subtypes of ADHD, comorbid diRelated article page 933 and JAMAPediatrics Patient Page page 984 Opinion