Undiagnosed ADHD Among Unionized Drivers in Ghana: Public Health and Policy Implications

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1 Undiagnosed ADHD Among Unionized Drivers in Ghana: Public Health and Policy Implications Thad Ulzen MD Professor and Chair, Dept. of Psychiatry and Behavioral Medicine Associate Dean for Academic Affairs CCHS/UASOM Tuscaloosa, AL

2 US data According to the National Highway Traffic Safety Administration, car accidents are the leading cause of death in teenagers and adults, with motor vehicle crashes accounting for approximately 36 of all deaths for people aged 15 to 20. Additionally 45 of these fatalities occurred in speed-related crashes.

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5 Leading causes of death in Ghana World Ranking 1. Diarrheal diseases (175.69/100,000) 2 2. Stroke (125.45/100,000) Coronary Heart Disease (120.08/100,000) HIV/AIDS (91.00/100,000) Influenza & Pneumonia (72.88/100,000) Tuberculosis (60.37/100,000) Lung Disease (42.09/100,000) Malaria (31.84/100,000) Road Traffic Accidents (28.11/100,000) Kidney Disease (26.72/100,000) 38

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7 Comparative Mortality from RTAs.The Global average of deaths from RTAs is 18.0 deaths/100,000 US deaths from Motor vehicle accidents is 10.34/100,000 In Africa it is 27.8 deaths/100,000 In Ghana the deaths from RTAs is 22/100,000.

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9 WHO Road Safety Guidelines Road Safety Management Safer Roads and Mobility Safer Vehicles Safer road users Post-Crash Response

10 WHO Legislative Priorities for Road Safety manage speed, drink driving, motorcycle helmet use, seat-belts, child restraints.

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12 Motor Vehicle Accidents - Ghana Jan 2000 to Dec 2010 Road accident fatalities - 20,503 deaths Injuries - 63,384 injuries 2012 Road accident fatalities-2,249 Injuries - 14, Road accident fatalities-2,096 Injuries - 12,655 persons

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14 Measures ASRS Adult ADHD Self-Report Scale JDQ Jerome Driving Questionnaire (adapted) DBS Driving Behavior Survey (Self Report Form) Demographic data

15 Consensus of Core Symptoms of ADHD Pervasive sustained inattention, impulsivity and hyperactivity Emotional Lability

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20 Adults with ADHD were more likely than controls to have been involved in accidents, receive traffic citations for speeding, and have their licenses suspended or revoked (Barkley, Murphy, DuPaul, & Bush, 2002; Fried et al., 2006).

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22 Simulation studies comparing ADHD drivers to intoxicated controls Individuals with ADHD displayed driving impairment consistent with that observed in controls at the legal level of intoxication [ 0.08 blood alcohol concentration, BAC]. The ADHD group had more difficulty maintaining a constant speed in response to alcohol at 0.05 BAC relative to placebo. The individuals with ADHD rated themselves as significantly less intoxicated than did the controls in response to the higher dose. Further, those with ADHD rated themselves as more able to drive than did controls in all dose conditions. This is consistent with the positive illusory bias often observed in children with ADHD (Diener & Milich, 1997). In fact, these individuals did not just rate their ability to drive as comparable to controls, they actually rated themselves as more able to drive than did controls, which is clearly not the case. Moreover, those with ADHD also rated themselves as significantly less intoxicated in response to the high dose of alcohol. (Weafer et al., 2008).

23 ADHD and emotional regulation Individuals with attention deficit hyperactivity disorder (ADHD) reported more anger while driving and more aggression while using their vehicle than their non-adhd peers. Drivers with adult ADHD rate themselves as angrier, riskier, and unsafe and report experiencing more losses of concentration and vehicular control than did the college students with which they were compared, according to the results of the study supported in part by the Centers for Disease Control and Prevention (CDC) and the National Institute on Drug Abuse (NIDA).

24 Patient Name: Adult ADHD Self-Report Scale (ASRS) Today s Date: Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today s appointment. 1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? Never Rarely Sometimes Often Very Often 2. How often to you have difficult getting things in order when you have to do a task that requires organization? 3. How often do you have problems remembering appointments or obligations? 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? 6. How often do you feel overly active and compelled to do things, like you were driven by a motor? Part A

25 ADHD not ADHD Count within ADHD within group ADHD Count within ADHD within group Total Count within ADHD within group ADHD * group Crosstabulation group Control Experimen tal Total

26 ADHD Prevalence (ASRS) 17.6 P = Unionized Comparison

27 Results This is highly significant with the Chi-Square = 7.7, df = 1, p =.006

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29 General ADHD Sample Population Jerome Driving Questionnaire (GH) Version Mean SD Mean SD P Age License Obtained <.001 Driving Experience ns Route Driven per Day <.001 Route Driven per Week <.001 Parking Illegally Over-speeding <.001 Times at Fault for Accident <.001 Times Licensed Revoked Times Driving with Revoked/Suspended ns Times Paid Bribe to Keep License Stopped for Not Obeying Traffic Signs ns Ticketed Dangerous Driving Time Hit Pedestrian/Cyclist <.001 Times Stopped for DWI ns

30 88 Mean DBS Scale, Adj t = 3.58, df = 364, P < ADHD Non-ADHD

31 Driving Behavior Survey Professional Drivers Item ADHD Non- ADHD General Population ADHD Performing safety precautions before starting the car ns ns Non- ADHD Follow proper steps to move into traffic safely ns 8/92 37/63 Signal use before turning or lane changing ns 8/92 39/61 Follow proper steps to back up safely 9/91 2/98 0/100 41/59 Use side mirrors correctly when changing lanes ns 0/100 39/61 Abide by posted speed limit ns 0/100 60/40 Drive in correct lane on highway or two-lane road ns 0/100 43/57 Avoid driving on road shoulders/in breakdown lanes ns 8/92 43/56 Yield right of way to others 21/79 8/92 8/92 37/63 React quickly to break lights ahead ns 8/92 39/61

32 Driving Behavior Survey Professional Drivers General Population Item Response Not at all, Rarely, Sometimes v. Often, Very Often ADHD Non- ADHD ADHD Non- ADHD Keep appropriate distance from cars ahead 3/97 24/76 Brake smoothly for marked intersections ns 0/100 Keep two hands on steering wheel while driving ns 15/85 Drive at appropriate speed while in reverse gear 14/86 2/98 0/100 Notice/obey traffic signs ns 0/100 8/92 57/43 37/63 54/46 36/64 53/47 Follow posted route markers and do not get lost ns 8/92 49/51 Park at safe speed in designated space 14/86 1/99 0/100 Pay attention to road and traffic while driving 9/91 1/99 0/100 Volume of music kept at low levels 46/54 17/83 ns 38/62 38/62 Passengers riding wear their seat belts 83/17 52/48 100/0 77/23

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34 What we know about ADHD and driving Treatment with approved medications improves driving performance Increased stimulation by using manual transmission is better than automatic transmission for these drivers They are at greater risk for substance use They are more likely to have accidents when they have multiple passengers ADHD drivers are more distracted by secondary tasks phone, stereo etc.

35 Policy implications Should we routinely screen new driver s license applicants for ADHD? Should we approach this problem like epilepsy in relation to driving? Should we mandate treatment for those diagnosed with ADHD? Consider graduated licensing? Traffic school?

36 Thank you

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