ADHD and Safety

ADHD AND Safety
–Leslie E. Packer, PhD

This article was first published in 1998 on www.tourettesyndrome.net and has been updated occasionally over the years. It was last updated in 2011.

WAIT! IS MY INSURANCE PAID UP?

(1998) A few months ago — as I got ready to jump in the car and pick up my son to transport him to an emergency room to find out why he had reportedly lost his hearing after getting hit in the head with a ball in gym — my daughter asked me, “Mom, how many times have you had to take Justin to the emergency room?” Well, that was not exactly the time to discuss it, but as I drove to my son’s school, I tried to think back…..

There was the time when he fell off the school bus getting off, but hey, he was only 6, and any kid can fall, right? His school picture taken the next day showed this gorgeous kid with a beautiful Mickey Mouse sweater and a fat lip…..

Then there was the time when he was playing with a neighbor’s child and amazingly ran head on into a tree that had only been there for about 50 years….

And the time that he stood up on the school bus because he thought that they had arrived, only to fall backwards when the bus started moving again, requiring stitches to the back of his head….

And the time he stepped on a fish hook in his summer camp cabin, and had to get the hook removed in the E.R….

And the time a kid in his gym bumped or pushed him, and he fell down, breaking his wrist….

And now this — his failure to duck when a large round object was coming at his head in gym, where one might reasonably expect people to be aware of airborne balls during sports….

As a former medic, I tend to stay pretty calm in emergencies. After all, I’d handled plenty of car crashes at the race tracks. And I was the one all the neighbors came to when their children fell or got hurt. But was I under-reacting to my son’s safety needs now? Was his school? This would be his 5th emergency room visit compared to 0 for his younger sister. Now I know boys are supposed to be active, but was my son just a klutz, was this a gender thing, or are kids with ADHD more likely to have accidents, and if so, why?

IS ADHD LINKED TO INCREASED RISK OF ACCIDENT OR INJURY?

While it might seem almost intuitively obvious that children who are inattentive or impulsive are more likely to get into accidents, is it their inattention, their impulsivity, or both that contributes to the risk — and does the research even confirm that people with ADHD are at greater risk? It is now 13 years since I first wrote this article and posed those questions, and it now seems clear that ADHD does constitute a significant risk factor, but it’s not the whole story.

Gayton et al. (1986) rated 189 patients at a child psychiatric clinic on a scale which included measures of hyperactivity and accident proneness. They reported that hyperactivity was correlated with reports of being “accident prone,” and that the relationship applied to girls as well as to boys. Farmer and Peterson (1995) expanded on earlier research by looking at specific processes that might account for the increased risk. In their study, two groups of 7-11-year-old boys (14 ADHD and 16 controls) were asked to watch a videotape which simulated play activities. The children were asked to identify risky behaviors and then answer questions about risky scenes. Both the ADHD and control groups were able to identify the hazards, but the children with ADHD underestimated or anticipated less severe consequences following risky behavior than the non-ADHD controls. The ADHD children also generated fewer active methods for preventing injury than did the controls. Their data suggest, then, that the ADHD child’s reduced expectation of personal risk or injury and their reduced ability to generate preventive strategies may contribute to increased risk of accident and injury. Their hypothesese received some confirmation in a virtual reality study conducted years later by Clancy, Rucklidge, & Owen (2006). Those investigators observed that ADHD teens had problems walking and crossing the street: the teens with ADHD walked slower, underused an available gap in oncoming traffic, and showed greater variability in road-crossing behavior than non-ADHD controls. They were also involved in twice as many collisions as the non-ADHD controls. Other studies also reported a significantly elevated risk of pedestrian accidents for those with ADHD, as described below.

Wazana (1997) reviewed 11 general child injury studies and 6 child pedestrian injury studies to determine if there really is a pattern of accident proneness that is specific to any disorder or behavioral factors. When design limitations and other factors are considered, it appeared that: (1) aggression or aggressive behavior is a consistent risk factor for general injuries but not for pedestrian injuries, (2) hyperactivity is inconsistently associated with all types of injuries, and (3) both a general measure of behavior problems and a measure of unsafe behavior were found to be significantly related to pedestrian injuries. The role of aggressive behavior or conduct problems received subsequent confirmation a study by Bruce, Kirkland, and Waschbusch (2007). They compared children with ADHD, ADHD plus conduct problems, children with conduct problems but no ADHD, and non-disorder controls on unintentional injury events resulting in either a physician office visit, emergency room visit, or hospitalization. Children with ADHD were found to be at increased risk for all three types of outcomes when compared to non-disorder controls, but it was the children with conduct problems (without ADHD) who were at greatest risk for the most serious injuries. Subsequent research by Schewebel and his colleagues, however, suggests that by age 10 or 11, ADHD is more of a factor than conduct issues (Schewebel et al., 2011).

It is important to note that in Wazana’s data, while child risk factors contributed significantly to pedestrian injuries, their overall effect or contribution was small compared to environmental and social risk factors. Indeed, other investigators have noted that risk of injury is correlated with social class differences and parental education in terms of addressing home stressors (such as parental behaviors that contribute to increased risk), developing safety rules and strategies for their children, and supervising the children. Rivara (1995, 1998) notes that the most important risk factors for injury are gender, age, socioeconomic status, developmental status, behavior problems, substance abuse by parent and adolescent, and parents’ perceptions of injury risk. Rather than looking to tag or label the child as “accident prone,” Rivara’s approach emphasizes the need for parents and society to alter our behavior to keep all children safe by considering whether there is a match (or mismatch) between a child’s skill and their development age so that anticipatory guidance can be provided.

Rivara’s hypotheses about parental perceptions of risk and parent supervision received some support in a study by Schwebel et al. (2006). Those investigators observed mothers and children in a “hazard room” that contained items that would appear to be dangerous. Maternal ignoring of children’s dangerous behavior in the hazard room was the strongest correlate of children’s injury history, although children’s behavior and their behavior in the hazard room also correlated with the children’s injury history.

Parenting makes a significant difference. Some parents, however, may need direct training with reinforcement on how to properly supervise their children. It may be that they underestimate risks as much as their children do if they also have ADHD, or it may be that they have other issues or challenges that are interfering with their ability to accurately perceive risk and proactively prevent injury to their children.

Even when parents are appropriately diligent in supervision, they are not present at school and in many other settings. There is a compelling need for school personnel, bus drivers, camp personnel, and other adults who are responsible for children to become more aware of the safety risks for students with ADHD and to provide added adult supervision. All too often, however, such added adult supervision is not provided. Children may be out of range of playground monitors at school, school bus drivers may never be told about a student’s diagnosis or needs, parents may not inform summer camps or extracurricular coaches about a child’s diagnoses or needs, and so children may have accidents that we may have been able to avoid.

WOULD TREATMENT MAKE A DIFFERENCE?

By now you may be suitably alarmed and wondering if treating ADHD would make any difference. Marcus, Wan, et al. (2008) looked at that question somewhat indirectly by analyzing pharmacy and service claims data from 2000-2003 California Medicaid for youth aged 6 to 17 years who were prescribed stimulant medication for ADHD. Their study did not find support for any relationship between using prescribed stimulants and injury risk or rate, but without any direct evidence as to whether the youth were actually taking their medication, it is difficult to draw any firm conclusions from their data. Studies and reviews published in the last few years [cf, Jerome et al. (2006); Barkley and Cox (2007)], however, all conclude that there is evidence that the use of stimulant medications may improve driving safety.

WHEN THE CHILD HAS ADHD + OTHER CONDITIONS

The preceding discussion only considered the potential relationship between ADHD and accidents. What if the child also has Tourette’s Syndrome, or Obsessive-Compulsive Disorder, or Bipolar Disorder? Are these children at even more risk if they feel they “have to” touch something in response to an obsessive worry? What about the Bipolar child who is manicky and impulsive? Will she be more likely to engage in behaviors that can lead to injury? What about the depressed child who is angry?

In my experience, children with ADHD plus comorbid conditions do seem to be at more risk for accidents and/or injury than the child who has ADHD without any comorbid conditions.

In the absence of research on this population, it is impossible to know whether the children are underestimating the risk or danger to themselves (as is the case with ADHD children) or if they estimate it properly but still can’t stop themselves.

Whenever possible, planning for the student with ADHD or ADHD+ should incorporate reducing the environmental triggers or risks. And added adult supervision should be incorporated for those settings that are reasonably likely to increase safety risks — such as gym, the playground, and field trips.

But even with vigilance, there may be times when your student or child will do something that you didn’t anticipate. If you’re lucky, you and the child will escape with just a “near miss” story. But when things calm down, talk with the child and help them figure out how they will manage that kind of situation if it occurs again.

Safety first. Yes, I know it may sound odd to have The Mother of the Child With Five ER Visits tell you this, but so far (and knock wood!), my son has never had an accident when he’s been with me or under my supervision. Indeed, it was that last accident that made me realize how much we may need to educate educators so that they don’t assume and don’t take things for granted on the premise that the child “should know” by that age….

THE 2/3  RULE

A number of years ago, psychologist Russell Barkley described a 2/3 rule. If you calculate 2/3 of your child’s chronological age, that is their maturational level and social level. So if a child is 15, the 2/3 rule suggests that they will have the maturity of a 10 year-old.

So if your teenager is 17 and wants the car keys, ask yourself this: would you give a 12 year old the car keys?

THE ADHD STUDENT AND DRIVING

Early studies by Barkley (1993, 1996) found that while knowledge of driving was not affected by ADHD, teens and young adults with ADHD were more likely to have had automobile accidents, to have had more crashes than their non-ADHD peers, to be at fault for more crashes than control subjects, and to have had more physical injuries associated with the accidents. They are also more likely to have received traffic citations and more of them than control subjects (particularly for speeding). In a simulated driving task, young adults with ADHD had more crashes, scrapes, and erratic steering than their non-ADHD peers. As with younger children with ADHD, young adults who had comorbid conduct issues were at highest risk for problems. Subsequent research by Barkley as well as other investigators has supported the relationship between ADHD and driving problems.

Of especial note, Barkley and his colleagues (2002) compared 105 young adults with ADHD (age 17-28) to 64 community control adults on five domains of driving ability and a battery of executive function tasks. As expected, the ADHD subjects reported more driving problems (e.g., speeding tickets), license suspensions, and crashes. On cognitive measures, the ADHD group was less attentive than the controls, but there was no significant relationship between scores and driving skills in a simulated driving task or either measure and actual driving records. Other research, however, led Barkley (2004) to conclude that ADHD interferes with safe driving by its impact on attention and deficits in resisting distraction, deficits in response inhibition, slower and more variable reaction time, and deficits in self-monitoring or self-awareness that lead teens and adults with ADHD to overestimate their skills.

NOW WHAT?

Safety first. Many high schools or secondary schools offer drivers’ education training programs to students. I have never seen a school district factor in ADHD to the training protocols or even inform their driving instructor that a particular student has ADHD and may require additional training and experience as part of the program. In general, driver’s education programs seem to be a “one size fits all” approach. The teenager who has completed the course — and the worried parents — may have a false sense of security because the course was taken and completed. To complicate matters, many high school students’ medications wear off in the afternoon, but the student may want to drive at night or on weekends when they may not be taking medication.

Educators who are aware of the safety risks might wish to share some of this information with parents and encourage them to arrange for additional supervised training or restriction to daytime driving until the teen gets more experience under their (seat)belt.

Safety first!

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