A Driver Rehab Specialist Holds the Key to Getting People Behind the Wheel | Health + Fitness | Seven Days | Vermont's Independent Voice

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A Driver Rehab Specialist Holds the Key to Getting People Behind the Wheel


Published February 18, 2009 at 6:51 a.m.

For most drivers, getting from point A to point B is as simple as turning a key, putting the vehicle in gear and stepping on the gas. As long as the environs are familiar, driving tends to require minimal conscious thought. In fact, many motorists have experienced the phenomenon of driving on “autopilot,” or getting safely to a destination with little recollection of how they got there.

But that’s not the case for everyone. For drivers afflicted with Down syndrome, Asperger’s, autism or a traumatic brain injury, operating a motor vehicle in heavy traffic can be bewildering — even terrifying.

Miriam Monahan probably understands better than anyone the complex coordination of cognitive and motor skills needed to negotiate something as mundane as a four-way stop. She’s a certified driver rehabilitation specialist with Fletcher Allen Health Care, based at the Fanny Allen campus in Colchester. Her job is to evaluate people with physical and/or mental impairments, determine whether they’re capable of getting behind the wheel, and, if so, turn them into safe and competent drivers.

There is no other activity in daily life that challenges you “to search the environment, process what you see, make split-second decisions, and then physically react to it, at speeds of 55 miles per hour,” says Monahan, who’s also an occupational therapist and certified driving instructor. “I don’t care what you do in your kitchen, it’s never going to be that challenging . . . or the consequences so serious.”

It’s hard to say how many licensed Vermont drivers are motoring around with physical or mental impairments. The database for the Vermont Department of Motor Vehicles doesn’t distinguish among the various license conditions — corrective lenses, physical disabilities, prostheses and the like. By law, licensees are required to notify DMV of a “major medical event” that affects their driving ability. But many such cases go unreported, according to Monahan. Plus, DMV driver’s tests are more about how someone mechanically operates a vehicle, and less about their “executive functions,” or judgment and decision-making abilities.

Monahan is Fletcher Allen’s only driver-rehab specialist — one of only 500 or so nationwide. Not surprisingly, she’s booked five months out with patients who are typically referred either by a physician or family member. Some are new drivers, such as teenagers with cerebral palsy or spina bifida who are looking for a learner’s permit. Others are seasoned drivers recently paralyzed by an accident or stroke. Still others are elderly drivers urged by family members concerned about their loved ones’ recent memory lapses or bouts of disorientation.

Monahan also deals with physically handicapped drivers who require “adaptive” equipment such as steering wheel knobs and hand-operated gas and brake pedals. On a recent afternoon, she meets Mike at Ride-Away, an Essex Junction automotive shop that specializes in vehicles for people with disabilities. Ride-Away’s slogan, “We deliver freedom,” certainly rings true for the 62-year-old, who has been confined to a wheelchair since was in a car accident 35 years ago. Mike lives in a rural Vermont. His van means the difference between social isolation and seeing family and friends. “Unless you live in a city with public transit, you can’t get out and go anywhere,” he says.

Mike has been driving with his disability for more than a quarter-century, but recently purchased a new van outfitted with dozens of high-tech improvements. He has limited strength and range of motion in both arms and lacks the fine motor skills in his hands to operate normal vehicle controls. A motorized ramp allows him to drive his wheelchair into the vehicle and park himself directly under the steering wheel. Electronic buttons on the driver’s door enable him to shift gears. Another panel of buttons on his right allows Mike to operate the doors, windows, climate controls and other dashboard functions.

The van’s not perfect, though. One seatbelt needs to be modified because it hits Mike in an awkward spot, obstructing his range of motion. “Miriam is like the doctor and we’re like the pharmacist,” General Manager Briant Hamrell says of his company’s collaboration with the driver-rehab specialist. “She writes the prescription and we fill it,” he adds.

The modifications aren’t cheap, nor are they always covered by insurance. Individual elements can range from $85 for a steering knob to $185,000 for certain high-tech electronics. A new adaptive van can run $50,000 even before it’s been customized.

Working with a physically challenged driver like Mike is easy compared to teaching someone with a cognitive impairment, such as a traumatic brain injury, to operate an automobile. A slow braking reflex, for example, can have numerous origins, Monahan explains. The driver’s vision or depth perception may have changed, or they may have a “field cut,” or blind spot. There may be a physical limitation that makes it difficult to move a foot off the gas and onto the brake. Or, delayed braking may be a sign of something more serious, such as impaired judgment.

It’s easy to forget that driving involves a complex array of decisions in a rapidly changing environment. After a brain injury, Monahan explains, a person’s ability to filter out unnecessary information is often impaired, which affects the ability to prioritize information. A patient with a left-hemisphere stroke, for instance, typically makes impulsive decisions, such as changing lanes prematurely without checking first to see if the lane is clear.

The same can be true for drivers with Asperger’s. As Monahan explains, a young Asperger’s patient learning to drive tends to “take in all visual information equally.” They may not realize that the brake light on the car in front of them is far more important than the green light up ahead. Monahan has various methods for teaching these drivers how to tune out less important information and focus on what’s essential to being a safe and competent driver.

“These kids don’t learn to drive overnight, but they can learn to drive over time,” she says. “Once you give them a process, they get it.”

It’s also not unusual for Monahan to see older patients who’ve been getting lost or showing lapses of judgment on the road. “So many people say, ‘I’ll know when I need to stop driving,’” Monahan says. “The truth is, you may not know when you need to stop driving because your memory is already impaired.”

Monahan starts all of her cognitive cases off with a battery of tests in the office to determine what’s causing their difficulties. Next, she takes them driving and asks them to perform simple routines. But rather than giving them specific instructions, such as “Turn left here” or “Go right at the next traffic light,” she’ll ask them to drive to the post office, the bank and the hairdresser. Such tests help Monahan determine whether the driver’s judgment, decision-making abilities or memory skills are impaired, and how badly.

Depending on the problem, she may work with a patient for a few sessions or several years, but ultimately, Monahan uses gut instinct to decide if and when a driver is competent. “This isn’t very scientific,” Monahan admits, “but if I say to myself, ‘I could have slept through that last ride,’ then I know they’re good to go.” A recreational mountaineer and ice climber, she brings steady nerves to the passenger seat.

Of course, some patients are never “good to go.” Others, who have lost the privilege as a result of age-related impairments, take it very hard when Monahan recommends they surrender their car keys for good. Family members, on the other hand, often silently mouth the words “thank you” in appreciation.

The automobile holds a unique place in the American psyche. “It’s the first piece of independence we get as we go into adulthood and it’s the first piece of independence we lose when we get old,” Monahan points out. But her priority has to be the safety of her patients and other people on the road. While her recommendations are not binding — only a doctor can initiate a revocation process — they go a long way to keeping dangerous drivers off the roads.

As a people, we seem to have a collective blind spot about the quality of our own driving skills; bad driving is inevitably what the other guy is doing. Self-criticism is a rare quality in the American motorist, but it definitely saves lives. Monahan’s track record proves it. Over a decade of teaching differently abled people how to drive, she’s never been in an auto accident.

The original print version of this article was headlined "Road Scholar"