Driving

Driving and Brain Injury

Closeup of steering console and front instruments of a car More so than many other daily activities (e.g., showering, eating, chores), driving draws upon a large number of cognitive abilities. Safe driving requires a number of skills, including:

Alertness
Attention
Multi-tasking
Adequate processing speed
Visual-spatial skills (e.g., for judging distances)
Intact motor abilities (e.g., dexterity to operate the steering wheel, brake/gas pedals, and turn signal and windshield wiper controls)
Memory (e.g., for navigating)
Complex skills (e.g., planning, problem solving)
Emotional Regulation

Even mild brain injuries can interfere with skills required to effectively operate a motor vehicle. Because of this, questions regarding when/if a person should resume driving are often raised by persons with a brain injury, as well as their providers and family members, particularly in the early period following the injury. It is estimated that between 40 and 80% of persons with cognitive difficulties following TBI return to driving while those who must cease driving face an increased risk of depression, poor social integration, and difficulty engaging in activities outside the home.

More information about Driving and Brain Injury

Symptoms/Conditions Potentially Impacting Driving Ability

In addition to the direct cognitive effects of brain injury (e.g., difficulty concentrating), there are many symptoms/conditions that can accompany a brain injury, which can diminish cognitive functioning and increase the risk of a motor vehicle collision. These include:

Fluctuations in level of alertness/consciousness
Headaches or other pain
Fatigue, drowsiness, changes in sleep patterns
Dizziness, balance problems
Clumsiness, Coordination difficulties
Changes in vision (e.g., double vision)
Disorientation
Slowed responses
Sensitivity to light or noise
Irritability, impulsivity (may contribute to road rage, risky driving behaviors)
Diminished insight, lack of awareness of limitations
Seizures (Missouri law requires that persons be seizure-free for six months before driving)

Caution is needed when considering whether a person is ready to resume driving following a brain injury. In addition to other consequences of car accident (e.g., orthopedic injuries), individuals with a history of brain injury risk a cumulative effect, complicating recovery and increasing the risk for persisting problems, if another brain injury is incurred.

Promoting Recovery and Return to Driving

Perhaps the most important thing to ensure safety in returning to driving after a brain injury is to allow adequate time to pass for his/her recovery. During this recovery period, steps can be taken to promote optimal progress. Basic activities to promote well-being also apply for individuals recovering from a brain injury:

Allowing sufficient time for rest
Avoiding over-stimulation
Eating well
Abstaining from substance use/abuse
Returning gradually to normal activities

In addition to these fundamentals, participation in inpatient and/or outpatient rehabilitation therapies (e.g., speech, occupational, physical therapies), which can be ordered by a physician, may be helpful in maximizing recovery of abilities.

Assessment of Driving Skills

Neuropsychological evaluation may be recommended to assess the person's cognitive functioning (e.g., attention, processing speed, visual-spatial skills). Based on this evaluation, it may be suggested that:

The individual complete an Over-the-Road Driving Evaluation,
The decision regarding driving be postponed to allow for additional recovery time,
Driving may be contraindicated (e.g., if cognitive/physical limitations are severe and unlikely to improve sufficiently for this particular activity with additional recovery time).

Over-the-Road Driving evaluations are often performed by individuals with specific expertise. For example, the Association for Driver Rehabilitation Specialists certifies driver rehabilitation specialists, who conduct these evaluations.

Over-the-Road Driving evaluations can be expensive and are often not covered by health insurance companies. Therefore, it is often helpful to complete a neuropsychological evaluation first to determine the likelihood that an applied assessment of driving abilities would be passed.

In addition to a standard evaluation of cognitive and physical abilities, there are several additional factors that may be taken into account on a case-by-case basis when recommendations regarding a return to driving after brain injury are made. They include:

What was the person's driving record prior to the brain injury (e.g., was there evidence of particular skill in driving, as might the case for someone whose job involved driving)?
Are there any novel post-injury considerations?

Will the person be required to learn to drive a different car following the injury?
Will the person be driving in unfamiliar locations (e.g., following a move)?

If the person's brain injury was caused by a motor vehicle collision, is he/she experiencing anxiety or posttraumatic stress symptoms associated with returning to driving?
Does the person have cognitive strengths to draw upon to compensate for observed cognitive weaknesses?
Is the person aware of his/her limitations? Is he/she willing to follow through with restrictions if prescribed?

Collateral report (e.g., by a family member/friend/significant other) may be especially important in providing a "real world" account of the individual's functioning, which can highlight problems or strengths that may not be evident in a brief clinical evaluation.

Possible Recommendations about Resumption of Driving

Many individuals will be able to return to driving following sufficient time for recovery from their injuries. For these individuals, emotional support and practical assistance (e.g., help in identifying temporary alternative transportation options) during the recovery period can ease distress that is often associated with restrictions on driving.

For some individuals, a return to driving may be approved, although limitations on driving activities may be recommended with guidance from their health care provider and/or Department of Revenue Motor Vehicle Division. For example, persons may be required to utilize the following guidelines:

Restrict driving to daylight hours
Restrict driving to familiar locations
Ensure that someone is riding with them
Limit driving to non-highway driving

Importantly, multiple technologies are available to assist drivers with disabilities (e.g., to accommodate wheelchairs, amputations, motor limitations). Simply having a disability is NOT a reason for an individual's driving privileges to be restricted.

Finally, if it is determined that a person should not return to driving, it is important that family member(s), friend(s), community brain injury resource(s), or health care provider(s) assist in identifying alternative methods of transportation. Social support and integrated multidisciplinary health care (e.g., open communication with physicians across specialties, participation in counseling to problem solve and discuss frustration with limitations) can be especially important during such transitions.

Missouri Law: Reporting Impaired Drivers

While physician/medical provider reporting is not required in Missouri, state law provides a list of individuals who can make reports about unsafe drivers, including:

Physicians
Law enforcement personnel
Social workers
Therapists
Immediate family members

Action will be taken if the Department of Revenue Motor Vehicle Division receives information suggesting that a driver is unsafe from ANY source. This may include:

Further investigation;
Require the person to take a written, vision, or physical exam; and/or
License restriction or revocation.

Importantly, anonymity is available, wherein the identity of the reporter would only be available upon court order. Sources are immune from civil liability when a report is made in good faith. Forms for making a report are available on the Missouri Department of Revenue website.