Young drivers are disproportionately involved in motor vehicle crashes compared with other age groups. One potential contributing risk factor is the ongoing development of executive functions (EFs) with maturation of the frontal lobe through adolescence and into early adulthood. However, EF consists of distinct constructs, some of which have been studied more than others, and which have rarely been measured together in relation to objective driving performance on ecological and complex simulated driving tasks. This study recruited 16 to 24 year-old drivers ( N = 93) and measured their performance on an EF battery targeting key constructs (working memory, inhibitory control, and set-shifting), as well as speed of processing, and related it to performance on a validated virtual driving assessment (VDA) that exposes drivers to common crash-risk scenarios, while considering EF-related covariates. Univariate analysis identified independent variables associated with VDA performance, and multivariate regression models revealed that better set-shifting performance (i.e., cognitive flexibility/task-switching ability) was associated with a 43% decrease in the likelihood of unsafe driving. Higher sensation-seeking tendencies were also associated with a 17% lower likelihood of unsafe driving. There is limited prior work examining set-shifting in young drivers, however, these results suggest it may help in explaining safe driving performance in young drivers. Clarifying the underlying mechanisms of young driver crash-risk may lead to new opportunities for interventions that aim to reduce crashes.

Introduction: Sleep problems are common during adolescence. Additional impacts from congenital heart disease (CHD) may contribute to negative outcomes. Studies among adolescents with CHD have described a link between diagnosed sleep disorders, cognitive challenges, cardiovascular risk factors, and mental health problems. Less is known about the association between subjective sleep problems, cognitive function, and general health. Research Question: What are the associations between sleep problems (quality, disturbance, daytime sleepiness), cognitive function, and general health among adolescents with CHD? Methods: Adolescents with CHD (n = 87; age 13-19 years) were recruited via the Children’s Hospital of Philadelphia electronic health record system. General health, cognitive functioning, and sleep disturbances were assessed using Patient-Reported Outcomes Measurement Information System (PROMIS) pediatric short form measures. Sleep quality and daytime sleepiness were assessed using the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD). PROMIS and PSQI cut points were used to classify scores as within or above normal limits. Spearman’s rank correlation assessed bivariate correlations among key measures. Wilcoxon rank-sum test and the Kruskal-Wallis rank-sum test compared mean age across CHD severity, sex, and age groups. Chi-square and Fisher’s exact tests evaluated group differences in sex, CHD severity, and age based on PROMIS and PSQI cut points. Results: Nearly 39% of adolescents scored above the normal limit on PROMIS Global Health (24%); Cognition (37%) and Sleep Disturbance (39%). A majority also scored above normal on the PSQI (62%). Mean ESS-CHAD scores indicated average levels of daytime sleepiness (6.6 ± 4.0). Sleep disturbance was negatively correlated with cognition (r=-0.28) and global health (r=-0.47), and positively with ESS-CHAD (r=0.27) and PSQI (r=0.59) (p<0.05). No significant group differences were observed by CHD severity, age, or gender. Conclusion: Poor sleep was significantly associated with decreased cognition and general health among adolescents with CHD, with no significant differences across age, sex, and CHD severity. These findings highlight the prevalence of sleep problems, their association with cognitive function and overall health, and underscore the need for further investigation among adolescents with CHD.

Objective To provide data on characterizing returning to drive after concussion in adolescents. Design Prospective cohort study. Setting A large integrated pediatric health system. Participants Concussed adolescents ≤28 days of injury, ages 16.5–18 years with a driver's license. Interventions (or Assessment of Risk Factors) Adolescents completed a self-report survey of demographic information and pre-injury and current concussion symptoms (Post-concussion Symptom Inventory (PCSI, total score pre- and post-injury)). Adolescents also downloaded an application for daily self-report symptom monitoring (Recovering Concussion Update on Progression of Symptoms (ReCoUPS)). Outcome Measures Length of time to return to drive post-injury measured via self-report survey or ReCoUPS. Main Results Forty-three concussed adolescents (65% female, 76% White), age 17.2 [95% CI 17.02–17.38] years, licensure length of 10.3 [7.88–12.63] months, 13.95 [11.45–16.46] days post-injury and current PCSI score=28.68 [20.53–36.84] (pre-injury PCSI=12.4 [7.61–17.32]). At enrollment, 76.7% (n=33) had already gone back to driving, within 5.9 [3.95–7.86] days post-injury. Of this back to driving cohort, PCSI score=22.2 [13.07–31.33] (pre-injury PCSI=12.16 [6.45–17.87]. Of the 23.3% (n=10) that had not yet gone back to driving at enrollment, daily reports from ReCoUPS and bi-weekly check-ins indicated six participants returned to driving within 15.1 days [95% CI 3.66–26.67] post-injury. PCSI score on day of returning to drive was 26.6 [95% CI 7.43, 45.76] (pre-injury PCSI=8.20 [0, 18.19]). Conclusions Overall, most concussed adolescents returned to driving within a week after injury, even while still experiencing substantial symptoms. Results will help provide evidence for clinicians as they guide families in their returning to drive experiences.

Objective Apply functional near-infrared spectroscopy (fNIRS) to evaluate how concussed and uninjured adolescents manage cognitive demands of simulated driving. Design Matched case-control. Setting Fixed-based, open-cockpit, high-fidelity driving simulator. Participants completed a validated simulated driving assessment with four cellphone distraction events (texting, phone call, map navigation, music) while wearing fNIRS. Participants 17 concussed (25±8.3 days since injury) and 17 age, sex, and length of licensure matched uninjured adolescent drivers between 16.5 and 18 years (Age:17.6±0.6 years, Sex:30 female (15 in each group), 8.2±6.8 months licensed). Independent Variables Injury status (concussed v. uninjured) and distraction events. Outcome Measures Driving kinematic metrics: standard deviation of lane position, speed variability, lateral acceleration, yaw, braking deceleration; mean prefrontal cortical activity (PFCA) via fNIRS; neural efficiency (NE) calculated to determine relationship of PFCA to driving performance for each distraction event and injury status. Main Results There were no significant differences by injury status in kinematic metrics, regardless of distraction type. Concussed adolescents displayed significantly lower mean PFCA during phone calls while turning left (Concussed:0.64(0.38,0.92)uM; Uninjured:1.16(0.85,1.47) uM) and during a sudden stop (Concussed:-0.003(-0.22,0.21)uM; Uninjured: 0.64(0.32,0.96)uM). Concussed adolescents displayed significantly lower NE during three driving events: texting while driving straight (Concussed: 0.90(0.53,1.27); Uninjured: 0.52(0.38,1.0)); map navigation while turning left (Concussed: 0.06(-0.19,0.32); Uninjured: -0.51(-0.77,-0.25)); phone call during a sudden stop (Concussed: 0.56(0.32,0.79); Uninjured: -0.33(-0.68,0.02)). Conclusions Concussed adolescents were significantly less efficient at complex driving scenarios, even at approximately 3 weeks since injury. fNIRS may be a promising objective method to help determine cognitive readiness to return to driving.

Magnetoencephalography (MEG) is particularly well-suited to the study of human motor cortex oscillatory rhythms and motor control. However, the motor tasks studied to date are largely overly simplistic. This study describes a new approach: a novel event-based simulated drive made operational via MEG compatible driving simulator hardware, paired with differential beamformer methods to characterize the neural correlates of realistic, complex motor activity. We scanned 23 healthy individuals aged 16-23 years (mean age = 19.5, SD = 2.5; 18 males and 5 females, all right-handed) who completed a custom-built repeated trials driving scenario. MEG data were recorded with a 275-channel CTF, and a volumetric magnetic resonance imaging scan was used for MEG source localization. To validate this paradigm, we hypothesized that pedal-use would elicit expected modulation of primary motor responses beta-event-related desynchronization (B-ERD) and movement-related gamma synchrony (MRGS). To confirm the added utility of this paradigm, we hypothesized that the driving task could also probe frontal cognitive control responses (specifically, frontal midline theta [FMT]). Three of 23 participants were removed due to excess head motion (>1.5 cm/trial), confirming feasibility. Nonparametric group analysis revealed significant regions of pedal-use related B-ERD activity (at left precentral foot area, as well as bilateral superior parietal lobe: p < .01 corrected), MRGS (at medial precentral gyrus: p < .01 corrected), and FMT band activity sustained around planned braking (at bilateral superior frontal gyrus: p < .01 corrected). This paradigm overcomes the limits of previous efforts by allowing for characterization of the neural correlates of realistic, complex motor activity in terms of brain regions, frequency bands and their dynamic temporal interplay.

Statement of Purpose Adolescents frequently experience neurocognitive deficits post-concussion, potentially affecting driving performance. Measurement of cognitive workload and deficits can be obtained using functional near-infrared spectroscopy (fNIRS), a portable, non-invasive imaging technology that measures prefrontal cortical (PFC) activity. The goal of this exploratory study was to quantify differences in cognitive workload, as measured by fNIRS, among concussed and uninjured adolescent drivers during distracted driving events in a driving simulator. Methods/Approach Licensed concussed and uninjured adolescents completed three experimental drives from a validated simulated driving assessment in a high-fidelity driving simulator. Each experimental drive contained four cell phone distraction events: sending a scripted text message, navigating to a location in a GPS app, finding a playlist in a music app, and engaging in a phone call. Participants wore a continuous wave fNIRS device positioned over the forehead to record PFC activity. Linear mixed-effects models were used to examine the fixed effects of distraction type, injury status, and optode (four distinct spatial regions of the prefrontal cortex) and random effect of subject on cognitive workload. Results Nine concussed adolescents (8 female, days since injury (mean±sd): 19.78±6.52), and nine uninjured controls matched by age, sex, and length of licensure, completed the experimental drives. There were significant effects of distraction, optode, injury status, and the interaction between distraction and injury status on PFC. Concussed adolescents displayed a significantly different mean PFC activation pattern in comparison to uninjured controls during the phone call and GPS distraction events. Conclusion Concussed and uninjured adolescents display differing PFC activation patterns during distracted driving events in a driving simulator. Future work will compare prefrontal cortical activation to simulator-measured behavioral data, such as speed variability and standard deviation of lane position, during distraction events. Significance These findings support further study of how adolescents manage driving tasks post-concussion.

Driving evaluations aim to ensure adequate skills; however, feedback beyond pass/fail is needed for improvement. Therefore, the goal of this study was to inform driving feedback report design to ensure ease of use and understandability while motivating improvements. Participants ages 18–25 years (n = 521) were recruited from CloudResearch Prime Panels to rate one of nine report design conditions with various combinations of five key features: performance summary presence, action plan (AP) length, AP order, AP grading system, and peer comparison presence; they then completed questionnaires. Participants were more motivated to improve when a summary was present (p = 0.02); they rated reports easier to use if they had a long AP (p = 0.01), a short AP paired with a summary (p = 0.007), or an AP with a number grade (p = 0.016); and they rated reports easier to understand if they had a short AP (p = 0.002) or an AP ordered by worst-to-best performance (p = 0.05). These results suggest that feedback reports designed with a performance summary and short, targeted action plan starting with the biggest area for improvement are likely to motivate action to improve driving skills while being easy to use and understand. Future research should evaluate the effect of such a redesigned report on driving outcomes among young drivers.

Statement of Purpose Motor vehicle crashes are a leading cause of adolescent death and disability. Risky driving behaviors are associated with adolescent motor vehicle crashes. We report on initial data for risky driving behaviors in adolescent drivers using a smartphone application. Methods/Approach Prospective data was collected using Way to Drive, a novel research smartphone application developed by TrueMotion-Cambridge Mobile Telematics and managed by University of Pennsylvania. Adolescent licensed Pennsylvania drivers aged 16–18 years downloaded Way to Drive. For this analysis, we used the first six weeks of data to describe trip-level variations in metrics passively collected by the app: trip duration and length, nighttime driving (11pm-5am), hard braking events, speeding, and handheld phone use while driving. Results The 18 adolescent drivers were mean age of 17.4 years (50% male; 89% white), with a mean licensure length of 9.6 months. They recorded 1370 unique trips, totaling 8,247 miles and 344.8 hours. Adolescents drove a mean of 76.1 trips at 6.0 miles/trip and 15.1 minutes/trip. There was little nighttime driving (1.6% of trips). Hard braking occurred in 35.7% of trips. Speeding occurred in 41.5% of trips (mean duration of 1.3 minutes speeding). Handheld phone use was detected in 24.6% of trips (mean duration of 2.3 minutes). Handheld phone use while driving >25mph occurred in 18.8% of trips (mean duration of 2.1 minutes), and handheld phone use while speeding occurred in 4.5% of trips (mean duration of 1.1 minutes). Nighttime handheld phone was detected in <0.2% of trips. Conclusions Way to Drive gives insight into normally difficult to measure teen driving behaviors. Variations in risky driving behaviors in this sample highlight key intervention opportunities for motor vehicle crash prevention. Significance This tool can provide a novel, scalable approach for remotely conducting epidemiologic data collection and testing real-time behavioral interventions.

Statement of Purpose Novice driver crash rates are highest early in licensure and due to driver errors (95%). To help ensure adequate safe driving skills before licensure, Children’s Hospital of Philadelphia (CHOP) incorporated a self-guided, validated virtual driving assessment with personalized feedback, as part of usual adolescent care. Early implementation results are presented here. Methods/Approach Initial implementation was in five practices: 4 in PA (urban, rural, suburban); 1 in NJ (suburban). Clinical champions (MD/DO, NP, RN) oversaw on-site implementation with project manager. Staff were trained by vendor on-site on how to use the system. Teenagers over age 15 at their annual well visit were offered the assessment either before or after the visit based on practice preference. Practice managers viewed weekly reports to optimize delivery. Project manager, practice managers and clinical champions reviewed monthly progress reports during champion meetings to share best practices and overcome technical and workflow issues. Results In the first 5 months, 444 assessments were conducted. There were fluctuations in the volume of VDAs by practice and by month (Fig 1). Issues currently being addressed: correctable technical failures, timing of relevance to families (at learner/before license exam); timing of assessment in visit (before/after/self-scheduling); and automated reminders and scheduling (rather than providers). Conclusion Despite launching during a pandemic, early experience suggests successful implementation of the driving skills assessment in primary care. Future studies will determine best practice for the delivery of the assessment within busy clinical workflows and evaluate the impact of the personalized assessment feedback on driving performance and crash outcomes. Significance Primary care could be a new and effective way to reach teens before their highest risk of crashing – providing valuable personalized feedback about their safety critical driving skills.

: Metacognition and Impulsivity Play a Role

Objective: The current study investigated relationships between metacognitive ability, impulsive tendencies (i.e. acting without thinking and sensation seeking), and reported and objective simulated risky driving in a sample of young adult drivers (n= 65) aged 18 to 24 years (Mage= 21.2 years; 52.3% female) from a larger analysis of executive functions and driving. Metacognitive ability was measured via the self-report Behavior Rating Inventory of Executive Function (BRIEF) Metacognition Index (MI), Acting without Thinking (AWT) was measured via items from the Eysenck Junior Impulsivity Scale, and Sensation Seeking (SS) was measured via the Brief Sensation Seeking Scale-4 (BSSS-4). A modified Driving Behavior Questionnaire (mDBQ) was used to assess risky driving behaviors. In addition, the Virtual Driving Test (VDT) measured ecologically valid driving performance.

Objective Identify factors that impact parents’ decisions about allowing an unaccompanied child to ride in an autonomous vehicle (AV). Background AVs are being tested in several U.S. cities and on highways in multiple states. Meanwhile, suburban parents are using ridesharing services to shuttle children from school to extracurricular activities. Parents may soon be able to hire AVs to transport children. Method Nineteen parents of 8- to 16-year-old children, and some of their children, rode in a driving simulator in autonomous mode, then were interviewed. Parents also participated in focus groups. Topics included minimum age for solo child passengers, types of trips unaccompanied children might take, and vehicle features needed to support child passengers. Results Parents would require two-way audio communication and prefer video feeds of vehicle interiors, seatbelt checks, automatic locking, secure passenger identification, and remote access to vehicle information. Parents cited convenience as the greatest benefit and fear that AVs could not protect passengers during unplanned trip interruptions as their greatest concern. Conclusion Manufacturers have an opportunity to design family-friendly AVs from the outset, rather than retrofit them to be safe for child passengers. More research, especially usability studies where families interact with technology prototypes, is needed to understand how AV design impacts child passengers. Application Potential applications of this research include not only designing vehicles that can be used to safely transport children, seniors who no longer drive, and individuals with disabilities but also developing regulations, policies, and societal infrastructure to support safe child transport via AVs.

Motor vehicle crashes (MVC) are the leading cause of injury and death among adolescents and young adults (National Center for Statistics and Analysis, 2019). Driving while distracted, such as using a cell phone, increases the likelihood of a MVC (National Center for Statistics and Analysis, 2019). People who physically interact with a cell phone while driving (e.g., engaging in a phone conversation, typing out a text message) can adequately sample the surrounding environment, but they are unable to direct and maintain sufficient visual attention to potentially hazardous events (Balk, Moore, Spearman, Steele, & Duckowski, 2006). As a result, engaging in a phone conversation or typing out a text message leads to poor driving performance (Caird, Johnston, Willness, Asbridge, & Steel, 2014; Caird, Simmons, Wiley, Johnston, & Horrey, 2018). But how do cell phones affect eye behavior and driving performance when the driver is not physically interacting with the phone, such as while it is ringing? In an ecologically valid driving simulation, young drivers proceeded through an intersection with and without the presence of a visible ringing cell phone. The median number of glances taken away from the forward roadway in the presence of a ringing cell phone was greater than in the absence of a ringing cell phone. Participants also took longer to drive through the intersection in the presence of a ringing cell phone. We further examined participants’ longest glance away from the forward roadway (LGOR), the moderating role of executive function capacity on LGOR, and speed variables. Altogether, our results suggest that even in the absence of physical interaction, cell phones can encourage visual inattention away from the forward roadway which can lead to poor driving performance.

Increasingly, vehicles are equipped with assistive devices and advanced warning systems to mitigate driver errors, which account for 94% of motor vehicle crashes. However, these technologies require humans to appropriately respond or take over the vehicle. If we want to design effective aids, we need to better understand the neural mechanisms underlying driver error and test how the brain responds to countermeasures. For this, we need sensitive measures of brain activity during driving. This paper present a new paradigm for driver assessment, using magnetoencephalographic (MEG) recording of whole cortex neural oscillatory activity while participants undergo an ecologicallyrelevant simulated driving experience of graded complexity. A pilot experiment set out to demonstrate that expected and motor cortex responses to basic drivingrelated movements (without salient cues) could be recorded, without significant artifact. Following this, a preliminary study of adults (n=5) explored if additional cognitive neural responses to increasing driving task demands can be identified. This paradigm was successfully piloted and preliminary results reveal localized brain regions of expected motor cortex activity, as well as power increases in the frontal lobe. This paradigm can be used to identify not only the neural mechanisms underlying driver errors, but also measure the impact of assistive and alert/warning technologies on these mechanisms in both typical and impaired populations of drivers.

Motor vehicle crashes remain a leading cause of injury and death in adolescents, with teen drivers three times more likely to be in a fatal crash when compared to adults. One potential contributing risk factor is the ongoing development of executive functioning with maturation of the frontal lobe through adolescence and into early adulthood. Atypical development resulting in poor or impaired executive functioning (as in Attention-Deficit/Hyperactivity Disorder) has been associated with risky driving and crash outcomes. However, executive function broadly encompasses a number of capacities and domains (e.g., working memory, inhibition, set-shifting). In this review, we examine the role of various executive function sub-processes in adolescent driver behavior and crash rates. We summarize the state of methods for measuring executive control and driving outcomes and highlight the great heterogeneity in tools with seemingly contradictory findings. Lastly, we offer some suggestions for improved methods and practical ways to compensate for the effects of poor executive function (such as in-vehicle assisted driving devices). Given the key role that executive function plays in safe driving, this review points to an urgent need for systematic research to inform development of more effective training and interventions for safe driving among adolescents.