1 of 41

Case studies:� Implementation of novice driver training programs

Donald L. Fisher, Ph.D.

Principal Technical Advisor

Volpe National Transportation Systems Center

U.S. DOT

1

Johnathan Ehsani, Ph.D.

Associate Professor

Johns Hopkins

Bloomberg School of Public Health

2 of 41

I. Setting the stage

2

For many years, novice driver training programs had no effect either on known risky behaviors or, more importantly, on the crashes of the novice drivers being trained.
However, this has changed over the last twenty years or so.
Randomized control trials in simulators, field studies, and clinical trials have shown that novice driver training programs both can actually reduce the actual risk of novice drivers being involved in crashes.
The goal of this presentation is twofold:

First, we want to describe the reasons it has proven so difficult to get these training programs into the hands of any novice driver that wants access to such a training program and
Second, we want to describe several case studies of several ongoing efforts that are now being made to get around these problems.

We begin by the setting the stage, one with which most if not all of you are familiar, describing first the novice driver problem and second the programs that have reduced crashes among novice drivers.

3 of 41

I.A The novice driver problem

3

McCartt, Shabanova and Leaf (2003

5 X

4 of 41

I.B The novice driver training problem: Hazard anticipation

4

Training has been proposed as one way to reduce risk.
The recent efforts that have reduced crash risk have focused on hazard anticipation and attention maintenance.
First, lets consider hazard anticipation.
For purposes of our discussion about implementation, we need to define hazard anticipation, the results of evaluations of hazard anticipation training programs, and the actual content of the training programs that were evaluated, all in two minutes ☺.
This is an example of a latent environmental hazard, that is a potential hazard that is obscured by the environment but for which there is a clue.
The clue that a pedestrian may enter the roadway is given by both the sign in the middle of the road and the crosswalk pavement markings.
Note that the entry into the crosswalk on the right is obscured by the cars in the parking lane on the right.
A little child could emerge suddenly from behind the car parked closest to the crosswalk.
This is the area, the latent hazard, towards which a driver should glance.

5 of 41

RCTs: Evaluation of hazard anticipation training

5

18-year-old males: 32% reduction

Thomas et al. (2016)
Roberts et al. (2022)

It is one thing to have a training program.
It is another thing to have a training program which actually reduces crashes.
So, has the hazard anticipation training reduced crashes?
NHTSA analysis

Well, in 2016 NHTSA reported the results of an RCT of a hazard anticipation training program.
The effort was led by Dennis Thomas at Dunlap and Associates.
5,000 California 16-, 17-, and 18-year old teens were enrolled in the study.
Half were assigned to placebo training, half to the experimental training, RAPT or risk awareness and perception training.
That program decreased the crashes of 18-year-old males, the most risky group of drivers that were evaluated, by 32%.
The training effect was confined to males.

NHTSA re-analysis

Shannon Roberts at UMass Amherst reported a re-analysis of the 2016 NHTSA results using SES as a moderator variable.
In that re-analysis, training had an overall effect and it was not confined to just males

*****
Thomas, F., Rilea, S., Blomberg, R., Peck, R., & Korbelak, K. (2016). Evaluation of the safety benefits of the Risk Awareness and Perception Training program for novice drivers (DOT HS 812 235). Washington, DC: National Highway Traffic Safety Administration
Roberts, S., Zhang, F., Fisher, D., & Vaca, F. (2021). The effect of hazard awareness training on teen drivers of varying socioeconomic status. Traffic Injury Prevention

6 of 41

RAPT: The HA training program

6

7 of 41

I.C The novice driver training problem: Attention maintenance

7

Klauer et al. (2016)

Second, in addition to hazard anticipation, training programs have also been developed and evaluated for novice drivers which target attention maintenance.
For purposes of this presentation, we assume that attention maintenance refers to the spatio-temporal pattern of gazes.
Specifically, a driver will be assumed to maintain attention to the forward roadway if no glance away from the forward roadway is greater than two seconds.
This definition is adopted because Charlie Klauer and others showed that glances longer than two seconds away from the forward roadway increase the risk of a crash or near crash by a factor of three.
*****
Klauer, C., Dingus, T. A., Neale, V. L., Sudweeks, J. D., & Ramsey, D. J. (2006). The impact of driver inattention on near-crash/crash risk: An analysis using the 100-car naturalistic driving study data. National Highway Traffic Safety Administration. Washington, DC: Department of Transportation.

8 of 41

RCTs: Attention maintenance

8

FOCAL+ teens

41% reduction in crashes/near crashes
23% reduction in long glances during hard braking events

Epstein et al. (2022)

Does the training work?
Well, in 2022, an analysis was reported in the New England Journal of Medicine of a training program designed to reduce long glances (lasting ≥2 seconds) away from the roadway in drivers 16 to 19 years of age with ADHD.
The research group was led by Jeff Epstein at Cincinnati Children’s Hospital.
154 participants were enrolled in the study.
Half were assigned to conventional driver’s education and half to experimental training, FOCAL+ which was an enhancement of FOCAL or FOcussed Concentration and Attention Learning.
The teens then drove their cars in a naturalistic driving study for a year after training.
The videos were analyzed to determine the spatio-temporal pattern of glances.
The FOCAL+ program decreased the crashes and near crashes of the ADHD drivers by almost 40%.
Importantly the FOCAL+ program also decreased the long glances of the teen drivers by 23%, indicating that the proposed mechanism for crashes, long glances, was indeed a likely explanation of the reduction in crashes.
*****
NHTSA analysis

In 2016, NHTSA reported the results of an RCT of a hazard anticipation training program.
5,000 California 16-, 17-, and 18-year old teens were enrolled in the study.
Half were assigned to placebo training, half to the experimental training, RAPT or the risk awareness and perception training.
Both groups received training at the time of licensure.
The California state DMV database was analyzed the year after training.
The program decreased the crashes of 18-year-old males, the most risky group of drivers that were evaluated, by 32%.
The training effect was confined to males.

NHTSA re-analysis

9 of 41

FOCAL+: The AM training program

9

Desktop Computer

Fixed-based Driving Simulator

FOCAL

FOCAL+

10 of 41

II. Barriers to implementation

10

11 of 41

II.A Federal

Federal
State
Expense
Accessibility

11

NHTSA (2017)

The first barrier to implementation is a constraint imposed on the federal government.
Their hands are tied.
In particular NHTSA, does not regulate state driver education programs.
NHTSA has made any number of robust efforts to provide states with both written guidance and professional help.
But that can go only so far when the states determine what is included in novice driver training programs
*****
NHTSA

Here you see the cover of the novice teen driver education and training administrative standards.
The standards were developed and substantiated from research findings, when available, and were based on the collective knowledge of subject matter experts (SMEs) in the field.
The standards were further reviewed and approved by the Association of National Stakeholders in Traffic Safety Education (ANSTSE), the professional body recognized by the National Highway Traffic Safety Administration (NHTSA) to maintain the Standards.
https://www.nhtsa.gov/book/countermeasures-that-work/young-drivers/countermeasures/unproven-further-evaluation/pre-licensure#:~:text=While%20some%20of%20the%20research,recommendations%20for%20improving%20the%20program.
While some of the research shows that under some conditions the benefits of pre-licensure driver education might be inconclusive, NHTSA has identified potential safety benefits and through support from the driver education community and the Association of National Stakeholders in Traffic Safety Education (ANSTSE), developed the Novice Teen Driver Education and Training Administrative Standards (NTDETAS) to enhance driver education delivery in the States. In addition to an overall revision of the 2009 NTDETAS, the new version includes updates to the instructor training and instruction delivery standards (NHTSA, 2017). NHTSA offers a State Assessment Program to assist States in meeting the standards. At the request of a State, NHTSA will send a team of peers with expertise in different areas of the NTDETAS to review current State practices and make recommendations for improving the program.

NTDETAS 2017 edition

NHTSA, "Novice Teen Driver Education and Training Administrative Standards (NTDETAS) 2017 Revision," National Highway Traffic Safety Administration, Washington, DC, 2017.

12 of 41

II.B State

Federal
State
Expense
Accessibility

12

Education

Licensing

Chaudry et al. (2011)

The second barrier both to the implementation of effective driver training curricula and the inclusion of appropriate items on the driver’s license are the states.
First, consider driver education curricula.

The state curricula are generally not developed by researchers but, instead, are similar to curricula that are proposed by organizations of driving instructors such as ADTSEA (American Driver and Traffic Safety Education Association) (Chaudry et al.).
These organizations will not necessarily be aware of the latest developments in research.
In order to have an effect on state curricula, researchers need to step out of their comfort zone and approach either state employees or driving instructor organization leaders.
None of this activity would necessarily be funded.
And it would need to be distributed across all 50 states in order to have a national effect.

Second, consider driver licensing

The states are also each individually responsible for driver licensing.
Driver licensing is important because the items that are included on the license are the ones which are targeted in training.
If the license does not include items that measure behaviors with known relations to crashes, then it almost goes without saying that the novice driver training will not target those behaviors.

*****
Driver education curricula

NHTSA, "Traffic Tech. Technology Transfer Series. Driver Education Practices in Selected States. (Number 404)," 2011.
N. Chaudry, L. Bayer, K. Ledingham and T. Casanova, "Driver Education Practices in Selected States," National Highway Traffic Safety Administration, Washington, DC, 2011

Chicken and egg problem

So, we are caught in a chicken and egg phenomenon:
The State curricula don’t provide drivers training on the most recent behaviors linked to crashes;
As consequence, the license exams don’t include questions on those behaviors;
In turn, the training programs are not incentivized to teach the behaviors that are closely linked to reductions in crashes.
And even if researchers could find someone in a state licensing agency willing to consider a new set of questions, the effort would need to be replicated across all states and the funds available for researchers to reach out are minimal if non-existent for one state, let alone 50 states.

13 of 41

II.B State

Federal
State
Expense
Accessibility

13

Riley et al. (2023)

JE

14 of 41

II.C Expense

Federal
State
Expense
Accessibility

14

Brookline Driving School, 2024; Dong et al., 2023)

The third barrier to implementation is the expense of the standard 30-hour classroom, 6 hour behind the wheel novice driver training program.
We randomly chose one driver education course in Massachusetts to estimate the expense of a 30-6 course.
The total cost was $950, perhaps not a surprise to most of you.
Cost is a likely barrier to novice drivers getting the education that they need.
For example, in one study, researchers from the Children's Hospital of Philadelphia (CHOP) at the University of Pennsylvania found that teenagers living in lower-income areas of the Columbus, Ohio metro area were up to four times less likely to complete driver training and obtain their driver's license before age 18 (Dong et al, 2023).
*****
Brookline driving school website

Brookline Driving School, "Brooline Driving School," [Online]. Available: https://www.brooklinedriving.com/prices.htm. [Accessed 27 December 2024].
This includes:

2 hours parent class
30 hours classroom instructions
12 hours behind-the-wheel lessons
6 hours driving observation instructions
Driver's Education Certificate

Dong, X., Wu, J., Jensen, S., Walshe, E., Winston, F., & Ryerson, M. (2023). Financial status and travel time to driving schools as barriers to obtaining a young driver license in a state with comprehensive young driver licensing policy. Accident Analysis and Prevention, 191, 107198.

15 of 41

II.D Barriers to implementation

Federal
State
Expense
Accessibility

15

Driver Training Deserts

Ryerson et al., 2022

16 of 41

II.D A way forward

16

17 of 41

IV.E Implementation models

Safety model

Medical model

Administrative model

17

18 of 41

III. Safety model: Novice driver training organizations

18

50 States

State of Washington

19 of 41

III.A Safety model: National distribution - AAA

19

20 of 41

Results

20

50% Increase

21 of 41

Enabling conditions: Accessibility

21

22 of 41

Enabling conditions: Engagement and Effectiveness

22

23 of 41

Enabling conditions: Open Source

23

24 of 41

Enabling conditions: Shared IP

24

25 of 41

AAA classroom training

25

Of course, the four enabling conditions I just described don’t guarantee that the training program, even if effective, will be used as it is by any driving school.
But, as luck would have it, because the AAA Foundation for Traffic Safety funded the development and evaluation of the ACCEL training program, Bill van Tassel who managed the AAA’s national driver training program learned of it.
He came to me and asked whether the AAA could use ACCEL.
I said of course.
*****
Bill wanted to upgrade the version we had to make it more appealing.
Again I said of course.
So, Bill and I spent days around my dining room table in Boston making sure that the changes that were made to the upgrade did not somehow dilute the effect.
The end result is that portions of the ACCEL program were incorporated into their in person driving school training, a program that is delivered across most states.
This was the first time ever that any training proven to reduce crashes was actually incorporated into the training delivered by driving schools.
*****
AAA Driving School

https://northeast.aaa.com/driving-school.html?gclid=Cj0KCQiA4L67BhDUARIsADWrl7HWFqR_UF4sGlzl3v6EjLQMGJKQDrmT8_Ycgz0e_TuXXgy895WqirUaAuWKEALw_wcB&cmpid=int_pd_googl_dsx-eg&ef_id=Cj0KCQiA4L67BhDUARIsADWrl7HWFqR_UF4sGlzl3v6EjLQMGJKQDrmT8_Ycgz0e_TuXXgy895WqirUaAuWKEALw_wcB:G:s&s_kwcid=AL!13316!3!715491169411!e!!g!!aaa%20drivers%20ed%20courses!20305780022!157428757384&gad_source=1

26 of 41

AAA online course training

26

27 of 41

Implementation results and lessons

Results

National implementation of HA and AM training in the classroom
National implementation of HA and AM training online
In process development of VR training

Lessons

Enabling components

Accessible software and platform
Engagement and effectiveness
Open source code
IP sharing

Good luck
Committed partners

27

28 of 41

III.B ACCEL dissemination barriers in WA

28

JE

Legacy systems are difficult to change

Institutional inertia- reluctance to change status quo

29 of 41

Enabling conditions

29

Public and private sector engagement

Personal relationships

JE

30 of 41

ACCEL development and evaluation - Washington

30

Phase 1 Research and Analysis (Projected Close Q2 2025)

John Hopkins Study – Pilot Concludes Q1 2025

Q2 2025 DOL receives recommendations from John Hopkins Study

Phase 2 Design and Development (Projected Close Q2 2026)

Phase 3 Statewide Implementation of the New Skills Test (Projected Close Q3 2028)

Phase 4 Tracking and Monitoring of Progress and Success (Projected Close Q3 2033

JE

31 of 41

IV. Medical model: Healthcare needs of teens

31

ADHD

Pediatricians

32 of 41

FOCAL+ dissemination barriers

32

33 of 41

Enabling conditions: VR FOCAL+ training

33

34 of 41

VR FOCAL+ driving environment

34

35 of 41

Demand for FOCAL+

35

Teens with ADHD

Parents of teens with ADHD

Driving school owners

Occupational therapists

Driving rehabilitation specialists

36 of 41

Costs

36

Step 1: Evaluation. In general, private insurance, Medicare, and Medicaid do not cover driving evaluations.

Step 2: Training. To include driving therapy as part of a Medicaid treatment plan, a doctor must clearly demonstrate the medical necessity of this therapy for the patient's specific condition, linking it to a diagnosed medical issue that significantly impacts their ability to function independently, and document this connection thoroughly in the patient's medical record; this often requires a comprehensive driving evaluation conducted by a qualified professional, outlining the specific driving deficits and how they relate to the patient's overall health and treatment goals

But the existence of the above demand does not address the cost of training or its accessibility.
CCH is taking multiple routes to addressing costs and accessibility.
Perhaps the most promising is a two-step route: the first step is evaluation and the second step is actual training or treatment.
The two step route would require the coordination of an ADHD mental health treatment provider and an ADHD novice driver training organization.
In the first step, a doctor would recommend that a teen with AHDH ready for driving be evaluated.

The cost of an evaluation would be incurred by the training organization.

In the second step, assuming that the ADHD teen is evaluated as unsafe, the doctor would then prescribe driver training as necessary in order to function independently.

The cost of the driver training would then potentially be covered by Medicaid or a health insurance plan.

There are other approaches to reducing the cost which are being considered, but the above seems most likely at present.
****
Step 1

https://www.google.com/search?q=does+medicaid+reimburse+teens+for+driving+evaluations&sca_esv=ac943ea8c69708b9&rlz=1C1GCEU_enUS1119US1119&sxsrf=ADLYWILoKGmWURJxAqegSq4nyADWpEfylg%3A1736097077897&ei=Nb16Z6W7NsjFp84Pup6WiAo&ved=0ahUKEwjlqf7Mid-KAxXI4skDHTqPBaEQ4dUDCBA&uact=5&oq=does+medicaid+reimburse+teens+for+driving+evaluations&gs_lp=Egxnd3Mtd2l6LXNlcnAiNWRvZXMgbWVkaWNhaWQgcmVpbWJ1cnNlIHRlZW5zIGZvciBkcml2aW5nIGV2YWx1YXRpb25zSOMxUOsEWLMvcAd4AZABAJgBygGgAYYXqgEGMC4xNi4xuAEDyAEA-AEBmAIBoAIEwgIKEAAYsAMY1gQYR5gDAIgGAZAGCJIHATGgB5kc&sclient=gws-wiz-serp
https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52759&ver=6&stateRegion=s56&contractorNumber=all&articleStatus=all&sortBy=title&bc=5#:~:text=Article%20Guidance&text=In%20order%20for%20a%20service,to%20any%20billed%20line%20item.

Step 2. This is an AI generated response. I have not double checked.

https://www.google.com/search?q=how+can+a+doctor+include+driving+therapy+as+part+of+a+medicaid+treatment+plan&rlz=1C1GCEU_enUS1119US1119&oq=how+can+a+doctor+include+driving+therapy+as+part+of+a+medicaid+treatment+plan&gs_lcrp=EgZjaHJvbWUyBggAEEUYOTIHCAEQIRiPAjIHCAIQIRiPAtIBCTE2ODA0ajFqNKgCALACAQ&sourceid=chrome&ie=UTF-8

37 of 41

IV.B. ACCEL dissemination barriers

37

Acquiring ACCEL

Accessibility

Cost: $1,100 (AAA)

38 of 41

Enabling conditions

38

Pediatricians

Available on website

Can be trained on a smartphone

No charge

39 of 41

ACCEL smartphone driving environment

39

40 of 41

V. Administrative model

40

Finally, we want to speak very briefly about the administrative model of implementation.
Here it is the licensing exam that serves as the change agent.
It requires someone committed at a state DMV as well as the research funds to develop the additional skills test.
We described how the additional skills development was tied to the training program when discussing the state of Washington
But other states, assuming that performance on the hazard anticipation license questions is predictive of crashes, may now be willing to pay for the development of such questions out of their own budget.
They have plenty of other countries to which they can turn for examples of hazard anticipation questions on a driver’s license exam.

The states are also each individually responsible for driver licensing.
Driver licensing is important because the items that are included on the license are the ones which are targeted in training.
If the license does not include items that measure behaviors with known relations to crashes, then it almost goes without saying that the novice driver training will not target those behaviors.

41 of 41

Conclusion

41

Model		Safety			Medical		Administrative
Organization	x	AAA driving school	WA driving school	x	CHOP NIH R01	CCH NIH RO1	WA DMV
Teens		All	All		All	ADHD	All
Distribution		National	State		CHOP	Driving School	State
Initiation		Client	Client		Pediatrician	Health care provider
Platform		Any Device	Desktop		Any Device	Desktop/VR
Access content		Anywhere, Anytime	Driving school		Anywhere, Anytime	Driving School
Training Location		Anywhere	Driving School		Anywhere	Driving School
Cost of training		$1,000	$1,000		Free	Insurance?	N/A
Reduces Crashes		Yes	Yes		Yes	Yes

Perhaps the most salient take-away from this presentation is that we as researchers do not need to let the perfect be the enemy of the good.
Ideally, one would like novice driver education to be available to all teens across the country, accessible anytime and anywhere, and free.
No one of the models we described meets all of these requirements, nor potentially can it.
But we believe they are a large step forward.
*****
There are countermeasures that can be taken that affect only slices of the overall population of teen drivers.
And some of these countermeasures may require decades to implement.
However, it is useful to think about how long it took to implement Graduated Driver Licensing programs in all 50 states.
Scholars estimate that it took some 40 years at a minimum, from the first discussion of graduated driver licensing laws in the 1970s to the final implementation of a GDL program in all 50 states in 2013
*****
The first discussion of graduated driver licensing (GDL) laws in North America began in the 1970s by Professor Patricia Waller of the University of North Carolina. The first GDL program in the United States was implemented in Florida in 1996. By 2012, all 50 states and the District of Columbia had adopted some form of GDL

https://www.google.com/search?q=when+were+graduated+driver+licensing+laws+first+discussed&rlz=1C1GCEU_enUS1119US1119&oq=when+were+graduated+driver+licensing+laws+first+discussed&gs_lcrp=EgZjaHJvbWUyCQgAEEUYORigATIHCAEQIRigATIHCAIQIRigATIHCAMQIRigATIHCAQQIRiPAtIBCjE0Njk0ajBqMTWoAgiwAgE&sourceid=chrome&ie=UTF-8

GDL was adopted first in 1996 by Florida, and states have gradually implemented and refined components. Thirty-one states implemented GDL prior to 2000 and 19 more between 2000–2006. As of 2013, various versions of GDL have now been adopted by all 50 states, and these continue to evolve.

https://www.google.com/search?q=how+long+did+it+take+graduated+driver+licensing+programs+to+be+implemented&rlz=1C1GCEU_enUS1119US1119&oq=how+long+did+it+take+graduated+driver+licensing+programs+to+be+implemented&gs_lcrp=EgZjaHJvbWUyBggAEEUYOTIHCAEQIRiPAjIHCAIQIRiPAjIHCAMQIRiPAtIBCjE2ODIyajFqMTWoAgiwAgE&sourceid=chrome&ie=UTF-8