The most common negative effect: attentional problems in driving

Some people still think that driving has little to do with your brain. In that case I urgently ask you to read driving with a normal brain. Convinced? No? Well, then please read the following examples given by family members and brain injured patients themselves. These stories tell you that brain injury, how mild or severe, can have a negative effect on your abilities to using a car. Fortunately, not always, but in special circumstances. And it would be wise to be prepared for these circumstances. Another blow to your head would not really be in your interests...

Attention is a multi-faceted brain function that entails concentration, dividing your attention between several activities at once, mental speed, and flexible correct reactions. Brain injury almost always has a negative effect on attention! But you won't notice it all the time, only in special circumstances. And just this fact is the most dangerous aspect of driving after a head or brain injury. Hopefully, I can make it a little bit less dangerous by giving you several examples (and tips) from real patients in their daily lives.

Holding your lane and drifting

One of the most important things when using a car is holding steady, I mean, keeping your track, staying in your lane. This task seems to require a sufficient spatial orientation and good vision at all angles. But most of all: you'll need a sufficient attentional system wherein your concentration and divided attention are adequate. The amount of attention you'll need in staying in your lane varies with your speed. The higher your speed, the less time you will have to correct your lane deviations. By the way, that is usually the reason why some elderly (with a lesser attentional system) are driving much slower than younger people.

Your attentional system can be distracted so that it must divide its attentional capacity between several tasks. Focusing on your right lane is just one thing. Talking to your passenger is another. Finding your radio and volume button is yet another. All these other tasks tap some attention from your attentional system, that certainly has a lesser capacity after your brain injury. When your (limited) attentional capacity is leaking towards other tasks like talking to someone on the hands free phone, less attention can be given towards your primary task, holding your lane. The result will inevitably be that you start drifting either to the left or right. Depending on how your speed this happens either quickly or more slowly. Nevertheless, due to lesser attention it can take more time to notice this gradual drift. Sometimes this can mean that you are heading towards oncoming traffic (that is drifting as well) and the next thing you'll know is a collision. Usually however, you'll notice the drift just in time (or your wife does) and correct it quickly. If you think this is fiction: it is not! This is the story told by family members, sitting in the passenger's seat of someone with a brain injury. What is the worst part of the story? The driver himself (mostly men) did nót notice his own mistake. It usually ends up in the situation that a wife will not step in the car again, not as as passenger at least.

A simple solution is to abort all unnecessary tasks while using your car. Do not talk to someone unless you have to. Do not answer your phone, not even when hands-free. Do not use the radio, neither for hearing music or listening to a talk show. And...reduce your speed a little when traffic becomes buys you more time to react normally. Forbid discussions in your car when you are steering, this distracts your attention too much.

When you don't believe all that's said above, please do yourself (and your family) a favor and take some lessons. But...take such a lesson and turn the radio on with quite a volume. Pick a talk show where much talking is going on. Instruct your instructor to just talk to you, about everything he can. Drive in areas where there is a lot of traffic and take a one-hour lesson at least. After that lesson, arrange that you will be picked up by someone to bring you home. Do not drive yourself! Evaluate with your instructor how your drifting was. Evaluate at home how you are feeling. And please be honest then with yourself.

Making corrections

Normally, everyone makes tiny corrections when using a car. Either by drifting errors or being too slow or too quick. Corrections are usually made by slightly turning your steering wheel or by touching your brakes or gas pedal a little. These corrections require constant attention. So, with a limited attentional system you can already guess what's happening when you get distracted by other tasks. Less attention is used for those corrections and the result is that you do not do a correction in time or at all. This can result in a collision. When you do make corrections in time, usually your passenger has already an uneasy feeling about your driving abilities (especially when it is an instructor).

You however, haven't got the faintest idea where they are talking about. All goes well, doesn't it? The only way you can see what is going on, is to see it with a camera behind your car. Then you can see how you are drifting, or how you are too close to the car in front of you and barely stop in time. 

Your decision making unit

One of the most incomprehensible things which is usually damaged after a brain injury, is a unit that I will call your decision making unit. Everyone has this unit and it functions sufficiently in most healthy human beings (and higher animals). However, after a brain injury, whether it be a brain injury due to a stroke, traumatic accident, an infection or a tumor, this unit is functioning less adequately. It is slower and less reliable. However, you do not feel it is functioning less efficiently.

And this dysfunctioning unit is the reason that you do not see all your mistakes as clearly as others (with a normal brain) see them. In traffic, you will probably be somewhat slower and your corrections will sometimes be too late or even absent. It will be hard for you to see that you are making these mistakes yourself. And that's pretty frustrating. It would be frustrating for everyone in such a condition!

But, there is a solution. If you are ready to accept more feedback then, and only then, you can train yourself to become better in driving, even with your handicap. What I would do is taking special lessons in which you confront yourself with difficult traffic conditions, using a good instructor. He (or she) can show you how to compensate for your lesser abilities. Using this active, confronting strategy, you will succeed in driving more safely and confidently.

Seeing things clearly?

A brain damage can lessen your ability to see all things around you. Especially after a stroke on the right side of the brain, patients can miss things on their left side (either due to a visual field defect or a more serious attention disorder called hemi-neglect. For more information about visual impairments after brain injury go to Problems in vision. Seeing things clearly is not so obvious after a brain injury. Because seeing has a pretty strong relationship with attention, usually after brain damage, you will tend to miss things either completely or partly. In both cases, the risks of getting involved in a car accident are quite high. Especially when you know that usually with a neglect (special attention deficit), your decision making unit is not functioning very well either. So you tend to make wrong decisions much earlier than others.

Examples of not seeing clearly normally amount to not seeing other traffic coming from the left (or right), not seeing correctly the direction signs so you have to take more time to read them. Also your drifting is much more serious, because you tend to drive over the midline of your lane far to the left into oncoming traffic. Or you will drive too closely to parked cars to the right, or worse, passed cyclists or scooters. Getting lost more easily or taking a wrong turn is also mentioned a lot by patients and their family. Especially, when it is raining or when it is dark. In both cases your sight is seriously hindered.

Visual problems after brain injury have far more serious negative effects for using a car then memory problems, as you can understand. It takes much more effort and time to compensate for them, and your driving will be limited in time and space. However, it is possible to drive with such serious disabilities but you have to learn it. Again, my advice would be to take lessons with a good instructor and confront yourself with difficult traffic conditions. Soon it will become clear whether you can indeed compensate for your defects, or you must find other ways for transportation. In either case, you have taken the initiative and built your confidence a little bit. Hazard Perception driving is a form of lesson which trains you in preplanning dangerous situations in traffic. It would be very wise for patients with brain injury to be trained in Hazard Perception driving. The link below shows you just an example of a hazard that will not likely be seen by someone with a left visual neglect or a left hemianopia. Especially not when attention has to be directed at the oncoming traffic on the right as well.
Go to Hazard Perception Example on YouTube 

A last word of advice

Of course, reading this all is not funny, especially when you have to struggle with the consequences of your brain injury. However, in my experience, it is true that patients with brain injury do recover to some extent within one year after their injury. Especially, the ones who will not stop fighting for what they are worth. Especially, the ones who are eager to hear the truth, who are ready to hear sincere feedback about their functioning.

Together with good coaching you can take your life into your hands again and make the best of it. With driving, I urgently advise you to take lessons with a good instructor, about 3 to 4 months after your brain injury. Don't be afraid of the reality and confront yourself with it. The instructor can show you ways to compensate for your deficits and this takes time and energy to learn. You can decide whether you want to take that time and energy or not. And remember, using a car is not the most important part here. It is your goal to be mobile! And mobility is not only reached by using a car, there are always other alternatives. Stay open for new challenges and you will be fine! When you want more (positive) information about safe driving and hemianopia I have found a very nice article about this subject. The authors state that there are indeed patients with hemianopia who cán be safe drivers. However, they also state that driving is much more than just normal vision. Just as I have explained it here in somewhat lesser scientific words. I give you the link to this interesting article:Driving and Hemianopia: are we asking the right questions? 

I also found a nice recent article about driving after a stroke in which researchers bundled 30 studies on this subject. Their main conclusions corroborate what I have said above. Firstly, only 54% of the 1728 stroke patients passed an on-road driving test. So 46% did not! Secondly, training has to be on driving tasks directly, either on the road or in a driving simulator to increase the passing rate. Thirdly, some neuropsychological tests can predict pretty good the passing of an on-road test. These tests emphasize the main factors I have already outlined above: attention, vision and mental speed are important in driving. My objection to this study has to do with the recommendation to use doctors to administer tests. Unfortunately, they are not specialized in tests and do not have the real expertise to interpret the test results. Such interpretation should therefore be done very carefully or done by neuropsychologist. But overall I am glad this study that examined 30 studies about driving after stroke has been done. In the following link you can download the article, with my comments. As a very nice bonus more explanation is given about a stroke and most importantly: How to prevent a stroke!Link to Article about Driving after a stroke - in Neurology, feb 2011 

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