Validity of the Cognitive Behavioral Drivers Inventory

in Predicting Driving Outcome

Louise Bouillon,
Barbara Mazer,
Isabelle Gelinas

OBJECTIVE. This study seeks to (a) compare Cognitive Behavioral Drivers Inventory (CBDI) scores for
clients who passed and failed a driving evaluation and for diagnostic groups (left cerebrovascular accident
[CVA], right CVA, traumatic brain injury [TBI], and cognitive decline); (b) determine sensitivity, specificity, and
positive and negative predictive values of the CBDI; (c) compare validity of the CBDI with other tools; and (d)
identify factors associated with outcome.

PARTICIPANTS. This historical cohort study included clients with neurological conditions who completed
a driving evaluation.

MEASURES. CBDI, Motor-Free Visual Perception Test (MVPT), Bells test, and driving results were extracted from the charts.

RESULTS. Mean CBDI (p < 0.0001) and MVPT (p < 0.0001) scores were significantly worse for those failing compared to passing the driving evaluation. Sensitivity of the CBDI was 62%, specificity was 81%, positive predictive values were 73%, and negative predictive values were 71%. Results varied according to diagnostic group.
CONCLUSIONS. The CBDI is not sufficiently predictive of outcome to replace a driving evaluation, and is
predictive only for clients with R-CVA and TBI. Evaluation of driving should vary according to diagnosis.
Bouillon, L., Mazer, B., & Gelinas, I. (2006). Validity of the Cognitive Behavioral Drivers Inventory in predicting driving outcome. American Journal of Occupational Therapy, 60, 420427.

Introduction

Louise Bouillon, BSc(OT), is Occupational Therapist,

Jewish Rehabilitation Hospital, 3205 Place Alton
Goldbloom, Chomedey, Laval, Quebec, Canada H7V1R2.
Barbara Mazer, PhD, is Research Associate, Centre de
Recherche Interdisciplinaire en Radaptation du Montral
(CRIR), Jewish Rehabilitation Hospital, 3205 Place Alton
Goldbloom, Laval, Quebec, Canada H7V1R2; and Assistant
Professor, McGill University School of Physical and
Occupational Therapy, Quebec, Canada;
barbara.mazer@mcgill.ca
Isabelle Gelinas, PhD, is Associate Professor, McGill
University School of Physical and Occupational Therapy,
Centre de Recherche Interdisciplinaire en Radaptation du
Montral (CRIR), Jewish Rehabilitation Hospital, Laval,
Quebec, Canada H7V1R2.

Driving a motor vehicle is an integral component of modern life and is particularly significant for the community reintegration of those with a newly diagnosed disability. Clients with neurological impairments, such as traumatic brain injury
(TBI) and cerebrovascular accident (CVA), may have residual cognitive and behavioral impairments that adversely affect the ability to drive safely (Galski, Ehle,
McDonald, & Mackevich, 2000; Haselkorn, Mueller, & Rivara, 1998). For these
clients who are facing great changes in lifestyle and self-esteem, the loss of the ability to drive can result in a reduced level of autonomy, diminished access to community activities, and limited opportunities for socialization (Lister, 1999), as well
as higher rates of depression (Marottoli et al., 1997).
The evaluation of driving ability requires an accurate analysis of the individuals cognitive, physical, and behavioral capacities (Korteling & Kaptein, 1996).
Driving is a complex task that requires the integrated use of high-level visual and
cognitive functioning (Ball, Owsley, Sloane, Roenker, & Bruni, 1993; Owsley &
Ball, 1993). Although it has been estimated that 90% of the informational input
to the driver is visual (Simms, 1985), the task also involves the interaction of sensory and motor skills and the constant use of judgment, abstract thinking, and
other cognitive perceptual abilities (Klavora, Heslegrave, & Young, 2000). Because
of the multifaceted nature of the driving task, even mild impairments after TBI or
CVA may have an impact on the ability to drive safely (Liddle & McKenna, 2003;
Sivak, Olson, Kewman, Won, & Henson, 1981). Frequently noted problems in
brain-damaged drivers include attention deficits, visual spatial impairments,
slowed reaction time, impulsivity, poor judgment, and impaired executive function

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(Engum, Cron, Hulse, Pendergrass, & Lambert, 1988; van

Zomeren, Brouwer, & Minderhoud, 1987).
Clients with newly diagnosed disabilities are typically
referred to a Driving Evaluation Service for a functional
driving evaluation. In Canada, the occupational therapist is
responsible for conducting these types of evaluations and
providing a recommendation to the provincial licensing
bureau regarding fitness to drive (Korner-Bitensky, Sofer,
Kaizer, Gelinas, & Talbot, 1994). Currently, the driving
assessment is composed of a pre-driver evaluation that
includes the evaluation of individualized skills such as reaction time, visual perception, visual attention, and cognition, followed by an on-road functional driving evaluation.
A survey of North American driving programs (KornerBitensky, Sofer, Gelinas, & Mazer, 1998) indicated that the
most commonly used pre-driver screening tools include the
Motor-Free Visual Perception Test (MVPT) (Bouska &
Kwatny, 1982); Trail Making Test, Part A and Part B
(Reitan, 1986); and the Cognitive Behavioral Drivers
Inventory (CBDI) (Engum, Cron, et al., 1988).
Although studies indicate an association between scores
on the pre-driver paper-and-pencil tests with on-road driving evaluations, results have been inconsistent. Poor performance on the MVPT and Trail Making Test, Part B, was
associated with a large increase in the rate of failing the road
test (Mazer, Korner-Bitensky, & Sofer, 1998), whereas a follow-up study across six driving evaluation sites in Canada
and the United States concluded that the MVPT does not
have sufficient predictive validity to independently predict
on-road driving results (Korner-Bitensky et al., 2000). To
provide a more complete and objective evaluation, a perceptual and cognitive test battery was developed and found
to correctly classify participants in more than 80% of cases
(Nouri & Lincoln, 1992).
Computer-based testing has several potential advantages over the traditional paper-and-pencil tools. Time and
cost-effectiveness in a driving evaluation program may be
maximized with the use of computerized tools. Tests are
scored quickly and accurately, results are rapidly reported,
and immediate feedback is provided (Green, Green,
Harrison, & Kutner, 1994). A computerized neuropsychological test battery has been designed specifically to aid
rehabilitation professionals in assessing the cognitive and
behavioral skills integral to the safe operation of a motor
vehicle. The CBDI (Engum, Cron, et al., 1988; Engum,
Lambert, Womac, & Pendergrass, 1988) has been standardized, and norms and decision-making rules have been
developed (Engum, Lambert, & Scott, 1990; Engum,
Lambert, et al., 1988) for both clients with brain injury and
normal control clients (Engum & Lambert, 1990; Engum,
Lambert, & Scott, 1990; Lambert & Engum, 1990). These

findings have been summarized and published in a comprehensive manual (Engum, Lambert, & Bracy, 1990). The
CBDI was intended to provide clinicians with a tool that
evaluates complex visual and cognitive skills related to drivingthat is, one that discriminates efficiently between persons with neurological impairments who recovered sufficiently to operate a motor vehicle and persons whose
residual disabilities render them unfit to drive (Antrim &
Engum, 1989). It has high internal reliability (Cronbachs
alpha of 0.95) and test scores are highly related to on-road
driving performance (Engum, Cron, et al., 1988; Engum,
Lambert, & Scott, 1990). Engum and colleagues (Engum,
Cron, et al., 1988) demonstrated that 95.5% of participants with brain injury who passed the CBDI were found
capable of operating a motor vehicle safely, whereas all participants who failed the CBDI were assessed as unfit to
drive. In 1990, Engum and colleagues (Engum, Lambert,
& Scott, 1990) performed validity studies using a double
blind analysis, whereby both the psychologist performing
the CBDI and the driving instructor conducting the onroad test rated driving ability (pass or fail). Validity studies
were conducted by comparing normal control participants
with 215 clients with neurological conditions. There was a
significant correlation between CBDI outcome (pass, fail)
and the psychologists judgment based on CBDI performance (pass, fail) (Engum, Lambert, & Bracy, 1990).
Driving evaluation programs serve a wide range of
clientele, with the most common medical conditions being
TBI, CVA, and age-related changes in functioning (KornerBitensky et al., 1998). Whereas driving evaluation programs typically use the same battery of tests and procedures
to evaluate all clients, it is unclear whether this process is
equally effective for all diagnostic groups. Studies have
detected differences in driving abilities and in the rate of
success on the driving evaluation according to the clients
condition (Fisk, Owsley, & Pulley, 1997; Quigley &
DeLisa, 1983; van Zomeren et al., 1987).
The administration of perceptual and cognitive tests is
costly and time consuming, and their value to the driving
evaluation process is not well understood. Although predriver screening tools may never be adequately predictive
to eliminate the need for a road test, the information they
provide is crucial to focusing the driving evaluation and
determining safety and potential on the road. In addition,
the usefulness of the CBDI for clients with various conditions and how it compares to other typically used measures
is not known. The overall purpose of this study was to
examine the usefulness of the CBDI as an evaluation of
driving ability in clients with a variety of neurological conditions. Specifically, this study was designed to: (a) compare the mean CBDI scores for those who passed and

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421

failed the on-road driving evaluation in clients with neurological conditions and in the most commonly seen diagnostic groups (left CVA, right CVA, TBI, and cognitive
decline), (b) determine the sensitivity, specificity, and positive and negative predictive values of the CBDI for the
group as a whole and for the diagnostic groups, (c) compare
the validity of the CBDI with other commonly used predriver screening tools, and (d) identify the demographic
and clinical factors associated with on-road driving outcome for clients with neurological conditions.

Methods
Study Design
This is a historical cohort study. The medical charts of all
eligible participants were reviewed and the results from the
CBDI, MVPT, Bells test, and the on-road driving evaluation were extracted. Demographic information, including
gender, date of birth, language, condition, date of diagnosis, and level of verbal expression and comprehension were
also recorded.
Participants
All clients with a diagnosis of a neurological condition who
completed testing at our Driving Evaluation Service as part
of their regular clinical intervention between January 2000
and March 2003 were included in the study. Commonly,
referrals to the service are made if one or more treating clinicians are concerned about the motor, perceptual, or cognitive functioning of their client. Although the majority of
referrals are for individuals receiving inpatient or outpatient
rehabilitation services at our center, referrals may be
received from other rehabilitation centers, acute care hospitals, and private physicians. Clients with medical conditions
that legally precluded them from driving (e.g., visual
homonymous hemianopsia, a primary visual impairment
inadequately improved by corrective lenses, class IV cardiac
status, uncontrolled seizures) were not eligible. In addition,
those participants who received their road test more than 75
days after the screening evaluation were excluded.
Measures
The evaluation procedure consisted of two components: a
pre-driver screening session and an on-road driving evaluation. The pre-driver session included the perceptual and
cognitive testing and took approximately 1.5 hr to complete. The test order was consistent, with the MVPT
administered first, followed by the Bells test, the CBDI subtests, and last, the CBDI computerized tests. Approximately 1 week later, clients received the on-road test, which typ-

ically lasted 2 hr for those with TBI and 1 hr for all other
diagnostic groups. The tests were administered as part of
the routine clinical driving assessment. All measures were
directed by experienced occupational therapists who followed the standard administration procedures for each evaluation. The same occupational therapist administered both
the pre-driver and on-road components. The following
measures were included in the study:
Cognitive Behavioral Drivers Inventory. The CBDI
(Engum, Cron, et al., 1988; Engum & Lambert, 1990) was
designed to assess the cognitive and behavioral skills
required for driving. It includes four components of Bracys
Computer Assisted Cognitive Rehabilitation (Bracy, 1985)
that are completed on the computer: visual reaction differential response, visual reaction differential response
reversed, visual discrimination differential response II, and
visual scanning III. Also included in the scoring are results
from the Wechsler Adult Intelligence ScaleRevised
Picture Completion and Digit Symbol subtests; Trail
Making Test, Part A and Part B; brake reaction test; and an
examination of visual fields (Keystone Perimeter Field of
Vision, Keystone View, 2200 Dickerson Road, Reno,
Nevada 89503). It takes approximately 1 hr to complete.
The software calculates standard scores with a mean of 50
and a standard deviation of 10. The total score generated is
called the General Drivers Index (GDI28) and consists of
the average of the 27 standard scores and the scatter variance. The GDI28 provides the best single estimate of driving ability by classifying clients as passing (47 or less), borderline (48 to 51), or failing (52 or greater), with higher
scores reflecting greater levels of dysfunction.
Motor-Free Visual Perception Test. The MVPT (Bouska
& Kwatny, 1982) is a standardized paper-and-pencil test of
visual-perceptual skills in five areas: spatial relations, visual
discrimination, figureground discrimination, visual closure, and visual memory. A maximum score of 36 indicates
no errors. The time required to complete each item is noted
and the average time per item is calculated. Total test time
is approximately 20 min. Normative data is available for
adults aged 18 to 80 years.
Bells Test. The Bells test (Gauthier, Dehaut, & Joanette,
1989) is a complex paper-and-pencil test of selective attention and visual scanning. The test sheet contains 35 bells
embedded within 264 distracters. Participants are asked to
circle each bell that they see. The score is the total number
of bells circled and the time it took to complete the task.
The test takes about 10 min to complete.
On-road driving evaluation. The on-road driving evaluation is based on the standard test procedure used by the
provincial licensing board in Quebec, Canada. The on-road
driving evaluation is conducted by the same occupational

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therapist who administers the perceptual tests. An experienced driving school instructor, who is unaware of the
results of the perceptual testing, directs the evaluation. For
those with physical impairments, the vehicle is equipped
with adaptations such as a spinner knob and a left accelerator. Clients are oriented to the driving school car and to
any adaptations needed to compensate for physical deficits.
The driving instructor provides specific instructions to the
client while directing him or her on a standard route. The
occupational therapist sits in the rear seat and rates driving
performance. The 17-km [10.5-mile] course begins on
quiet streets and then proceeds to busy boulevards and
highways. All driving evaluations are conducted during
daylight hours and take approximately 50 min to complete. An assessment form is completed by the occupational therapist, documenting the clients strengths and weaknesses. Subscales include the use of controls, maneuvering,
specific driving skillssuch as visual exploration and
response to traffic signalsand general driving skills,
including decision-making, planning, and tolerance. Once
the evaluation is completed, the occupational therapist
reviews the clients driving behaviors, knowledge, application of driving regulations, and ability to maneuver the
vehicle safely and determine whether the client has passed,
has failed, or requires driving lessons. Interrater reliability
for the overall categorization of pass and fail on the onroad evaluation was assessed by two occupational therapists
on five clients and agreement between them was found to
be 100%.
Potential confounding variables. Demographic and clinical information were recorded, including gender, age, language spoken for the evaluation, presence of comprehension and expression difficulties, diagnosis, time since
diagnosis, and time between the pre-driver testing and onroad testing.

Tables were created in which on-road driving outcome

and CBDI score were dichotomized into pass or fail.
Sensitivity, specificity, and positive and negative predictive
values were calculated for the entire group and for each of
the four diagnostic groups. Initially, the cutoff value suggested by the CBDI test was used, with borderline and fail
ratings collapsed together. For the purposes of this analysis,
participants with scores >47 were classified as failures and
47 as a pass.
To identify the best cutoff score on the CBDI for our
sample, Receiver Operating Curves (ROCs) were generated
and different cutoff values were analyzed. ROCs determine
the accuracy of a screening test (CBDI) according to how
well the test separates the groups into those who pass and
fail the road test. Because it is most important to identify
persons who will fail an on-road driving evaluation to prevent needless and dangerous on-road testing, priority was
given to obtaining a high sensitivity.
Logistic regression analyses were performed to determine the combination of tests (CBDI, MVPT score and
time, Bells test) that best predicts pass and fail on the driving evaluation. Univariate analyses were first performed and
all possible combinations of the tests were examined.
Diagnostic testing was conducted to determine whether
collinearity was present. Demographic (age, gender) and
clinical (comprehension, expression, and time since diagnosis) characteristics were added one at a time to the best
model of tests to determine any potential confounding or
interaction. To examine the impact of different conditions
on the results, all analyses were repeated for those with left
CVA, right CVA, TBI, and cognitive decline separately. All
data analyses were performed using the SAS statistical software, Version 8.1.

Data Analysis

The study included 172 participants: 28 with left CVA, 20

with right CVA, 58 with TBI, 23 with cognitive decline
(Alzheimers disease, early dementia, undiagnosed cognitive
deficits), 25 with other cerebral vascular disease (bilateral
CVA, cerebellar CVA, subarachnoid hemorrhage,
aneurysm), 7 with multiple sclerosis, and 11 with other
neurological disorders such as Parkinsons disease, meningitis, Charcot-Marie-Tooth disease, tumors, and GuillainBarre syndrome. Clients were tested on the road an average
of 1.8 weeks (SD = 1.9) after the pre-driver assessment. The
demographic and clinical characteristics of the study participants are presented in Table 1.
Road test outcomes show that 93 (54.1%) participants
passed their driving evaluation, 59 (34.3%) failed, and 20
(11.6%) were recommended lessons and a reevaluation

Individuals were classified according to their on-road evaluation outcome, either pass, fail, or recommended lessons.
Those who were recommended lessons were grouped with
the fail group, because they were, at the time of testing,
deemed not sufficiently skilled to obtain a driving license.
Descriptive statistics were used to document the general characteristics of the participants. T-tests were used to
compare the mean test scores on the CBDI, MVPT, and
Bells tests for those who passed and those who failed the onroad driving evaluation for the group as a whole, as well as
for four homogeneous diagnostic groups (left CVA, right
CVA, TBI, and cognitive decline). There were insufficient
numbers to examine other less common diagnostic groups
independently.

Results

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423

Table 1. Demographic and Clinical Characteristics of Study

Participants (N = 172)
Data

Characteristics
Gender n (%)
Male
Female
Age [years] mean (SD)
Language of evaluation n (%)
French
English
Other
Comprehension level n (%)
Normal
Impaired
Expression level n (%)
Normal
Impaired
Diagnosis n (%)
Left CVA
Right CVA
Other CVA
TBI
Cognitive decline
Multiple sclerosis
Other conditions
Time from screen to on-road [weeks] mean (SD)
Time since diagnosis [months] n (%)
02.9
3.05.9
6.08.9
9.011.9
12.017.9
18.0

135
37
58.9

(78.5)
(21.5)
(17.9)

140
24
8

(81.4)
(14.0)
(4.6)

141
31

(82.0)
(18.0)

140
32

(81.4)
(18.6)

28
20
25
58
23
7
11
1.83

(16.3)
(11.6)
(14.5)
(33.7)
(13.4)
(4.1)
(6.4)
(1.94)

23
55
34
17
17
26

(13.4)
(32.0)
(19.8)
(9.9)
(9.9)
(15.1)

Note. CVA = cerebrovascular accident; TBI = traumatic brain injury.

Results for participants in different diagnostic groups indicate the rate of failure (fail and lessons) as 46.4% for left
CVA, 55.0% for right CVA, 27.6% for TBI, and 82.6% for
those with cognitive decline.

For the group as a whole, the mean test scores on the

CBDI and MVPT (score and processing time) were significantly worse for those who failed as compared to those who
passed the on-road evaluation (see Table 2). When comparing scores for the specific diagnostic groups, the test scores
that discriminated between those who passed and failed differed according to diagnosis (see Table 2).
The sensitivity of the CBDI in detecting failure, using
the suggested CBDI cutoff of >47, was 62%, indicating
that the CBDI accurately classified only 49 of the 79 clients
who failed the driving test. Specificity was 81%; the CBDI
correctly identified 75 of 93 clients who passed the on-road
evaluation. Positive and negative predictive values of the
CBDI were 73% and 71%, respectively. Because the primary clinical concern is to accurately detect those who are
unsafe drivers, when selecting a cutoff, priority was given to
accurately detect failures. Results of ROCs analysis indicated that the value yielding the best combination of sensitivity and specificity for the group was 45. With the CBDI
cutoff of >45, the sensitivity was 86.1% and specificity was
55.9% (see Table 3). The results also indicate that this is the
best cutoff value for each of the specific diagnostic groups,
except for the TBI group, where a lower cutoff (43) would
better detect failures (see Table 3).
Results of univariate logistic regression analyses indicate that the CBDI score (GDI28; = 0.33, p = < 0.0001),
MVPT score ( = 0.23, p < 0.0001) and MVPT time ( =
0.27, p < 0.0005) were significant predictors of on-road
outcome. In multivariate analyses, once the CBDI was
included, no other test scores provided significant additional information, and the addition of demographic and clini-

Table 2. Comparison of Scores for Those Who Passed and Failed the Road Test [mean (SD )]
Diagnosis
All Participants (N = 172)
Pass (n = 93)
Fail (n = 79)
p value
Left CVA (n = 28)
Pass (n = 15)
Fail (n = 13)
p value
Right CVA (n = 20)
Pass (n = 9)
Fail (n = 11)
p value
TBI (n = 58)
Pass (n = 42)
Fail (n = 16)
p value
Cognitive Decline (n = 23)
Pass (n = 4)
Fail (n = 19)
p value

CBDI (GDI28)

MVPT Score

MVPT Time

Bells Test

44.97 (3.22)
50.75 (7.54)
< 0.0001

32.92 (3.12)
29.89 (4.24)
< 0.0001

4.63 (2.30)
6.11 (2.45)
0.0002

32.96 (2.16)
32.28 (2.40)
0.06

47.60 (3.74)
51.23 (9.51)
0.22

30.79 (5.13)
28.85 (3.50)
0.27

5.42 (2.28)
6.36 (2.35)
0.32

33.21 (1.97)
32.54 (2.15)
0.40

45.00 (2.35)
49.55 (3.39)
0.003

32.89 (3.33)
30.18 (4.47)
0.15

5.36 (2.24)
6.74 (2.76)
0.28

33.00 (1.50)
32.46 (2.42)
0.56

43.57 (3.07)
46.00 (3.10)
0.01

33.84 (2.03)
33.79 (2.33)
0.94

4.00 (2.43)
4.83 (1.91)
0.26

33.36 (1.83)
32.93 (1.90)
0.46

46.75 (3.77)
53.58 (7.19)
0.08

31.75 (1.26)
27.53 (3.67)
0.04

5.75 (2.09)
6.80 (1.77)
0.31

32.00 (1.15)
31.05 (3.29)
0.58

Note. The ns provided are for those who passed and failed the CBDI test. Some missing data occurred for the other evaluations. CBDI = Cognitive Behavioral
Drivers Inventory (Engum, Cron, et al., 1988); GDI28 = General Drivers Index; MVPT = Motor-Free Visual Perception Test (Bouska & Kwatney, 1982); Bells Test =
Bells Test (Gauthier, Dehaut, & Joanette, 1989); CVA = cerebrovascular accident; TBI = traumatic brain injury.

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Table 3. Sensitivity, Specificity, and Predictive Values According

to CBDI Cutoff Values
CBDI Score

Sensitivity

Specificity

PV+

PV

All Participants
49
48
47
46
45
44
43

0.42
0.51
0.62
0.73
0.86
0.91
0.95

0.91
0.89
0.81
0.68
0.56
0.45
0.39

0.80
0.80
0.73
0.66
0.62
0.59
0.57

0.65
0.68
0.71
0.75
0.83
0.86
0.90

Left CVA
49
48
47
46
45

0.31
0.39
0.46
0.69
1.00

0.67
0.60
0.53
0.53
0.53

0.44
0.45
0.46
0.56
0.57

0.53
0.53
0.53
0.67
1.00

Right CVA
49
48
47
46
45
44

0.46
0.55
0.73
0.73
0.91
1.00

1.00
0.89
0.89
0.67
0.56
0.56

1.00
0.86
0.89
0.73
0.71
0.73

0.60
0.62
0.73
0.67
0.83
1.00

TBI
48
47
46
45
44
43
42

0.06
0.25
0.44
0.50
0.63
0.81
0.94

0.95
0.86
0.81
0.71
0.64
0.62
0.45

0.33
0.40
0.47
0.40
0.40
0.45
0.39

0.73
0.75
0.79
0.79
0.82
0.90
0.95

Cognitive Decline
51
50
49
48
47
46
45

0.58
0.58
0.63
0.79
0.79
0.90
0.95

1.00
0.75
0.75
0.75
0.50
0.50
0.25

1.00
0.92
0.92
0.94
0.88
0.89
0.86

0.33
0.27
0.30
0.43
0.33
0.50
0.50

nostic groups are presented in Table 4. Results for those

with left CVA indicate that no one evaluation or combination of evaluations was significantly associated with on-road
outcome. Only time since diagnosis was significant, with
those tested longer after CVA having an increased chance of
passing the on-road test. CBDI scores alone significantly
predicted driving outcome for those with right CVA and for
participants with TBI. None of the evaluations or factors
included in this study was significantly associated with driving outcome for the group with cognitive decline.

Discussion
Individually, the CBDI score, MVPT score, and MVPT
time were significant predictors of on-road outcome for the
group of clients with neurological conditions seen in our
driving evaluation program. In multivariate analyses, the
CBDI was found to be the most predictive tool, with the
MVPT and Bells tests offering no additional information
over that provided by the CBDI. Using the cutoff value
specified by the creators of the CBDI tool did not provide
the best results for our sample. After evaluating all possible
cutoff values, it was determined that the sensitivity of the
test to detect failure improved when using a lower cutoff
value of >45.
This study set out to examine the evaluation procedures for clients with various neurological conditions.
Given the different impairments associated with different
conditions, clinicians have often believed that certain tests
are more or less useful for some clients. The study findings
provide a guide for clinicians to identify the most accurate
and efficient screening procedure for clients with various
conditions. Although the findings indicate that different
approaches may be required to accurately address the specific needs of each diagnostic group, several of the groups in
this study were quite small and cannot provide definitive
recommendations. The CBDI is a significant predictor of
driving outcome in those with right CVA and TBI. In
clients with left CVA and those with cognitive decline, none
of the tests that were included in this study accurately predicted on-road outcome. This finding can be explained by

Note. CBDI = Cognitive Behavioral Drivers Inventory (Engum, Cron, et al.,

1988); PV = predictive values; CVA = cerebrovascular accident.

cal factors revealed that none of the factors significantly

contributed to the model. The ( coefficient of 0.33 represents an odds ratio of 0.72, denoting that for every increase
in the CBDI score of 1 point, the likelihood of passing the
on-road test is reduced by .72. The best logistic regression
models for the group as a whole and for each of the diagTable 4. Logistic Regression: Pass/Fail on the On-Road Driving Evaluation
Variable
Whole Group
CBDI
Left CVA
Time since diagnosis
Right CVA
CBDI
TBI
CBDI

Standard Error

0.33

0.06

31.28

0.48

0.20

0.61
0.24

Odds Ratio

Confidence Interval

< 0.0001

0.72

0.640.81

5.89

0.02

0.62

0.420.91

0.28

4.93

0.03

0.54

0.320.93

0.10

5.63

0.02

0.79

0.640.96

Note. CBDI = Cognitive Behavioral Drivers Inventory (Engum, Cron, et al., 1988); CVA = cerebrovascular accident.

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the fact that the CBDI does not specifically evaluate all
important deficits that affect driving in these clients.
Lesions in the right hemisphere likely result in deficits in
visual-spatial skills that are crucial for driving, such as visual scanning of the environment, use of space, awareness of
traffic conditions, planning, and shifting attention to deal
with complex situations.
Left hemisphere lesions often produce deficits in verbal
and visual-spatial sequencing abilities, which are not evaluated in depth by the CBDI. However, performance on
CBDI tasks may be slightly slower but not inaccurate, particularly in the weeks immediately after sustaining a CVA.
Elderly persons experience declines in the sensory system, perceptual skills, and cognitive functioning. For those
who have been identified with cognitive decline or suspected early dementia, performance on a computer may be an
inaccurate method of evaluation. Many elderly persons are
unfamiliar with the computer and the additional anxiety
associated with performing in this new situation may
impair performance on the CBDI tasks.
In addition, the impact of impairments associated with
central nervous system damagesuch as excessive risk-taking behavior, poor judgment, confusion, emotional instability, and reduced frustration toleranceis known to affect
on-road driving outcome, but may be inadequately
addressed by the CBDI tasks.
In fact, the CBDI assesses only a portion of the skills
necessary for driving. Driving is described by Michons
model (Michon, 1985) as a hierarchical structured task
involving three levels of cognitive control: operational, tactical, and strategic. According to this model, the CBDI
evaluates mostly skills at the lowest level, the operational
level. This level is concerned with immediate vehicle control tasks such as accelerating, braking, and steering. It relies
largely on automatic action patterns as well as reaction time,
attention span, information processing speed, and visualspatial ability. The other two levels, the tactical and strategic levels, however, are assessed by the on-road evaluation
but not necessarily on the CBDI. The tactical level is concerned with maneuvers and the negotiation of common
driving situations such as curves, intersections, and entering
the traffic stream, which involve executive functions. The
strategic level involves general trip planning, such as selecting a mode of transportation or evaluating the risks.
Although the same occupational therapist administered
the pre-driver and on-road tests as part of his or her clinical
practice, this should have had little impact on the study
results. Because this study was conducted retrospectively,
the evaluators were not aware of the purpose of the study at
the time they were conducting the evaluations and would

have had no reason to be biased toward scoring the evaluations similarly.

Possible factors that may have reduced the association
found between the CBDI scores and on-road performance
are limitations related to the administration of the CBDI.
Administering the CBDI requires additional skills, over and
above those addressed by the evaluation. Those with fine
motor coordination difficulties, hemiplegia, or other motor
impairments are at a disadvantage for those tasks requiring
rapid reaction time and accuracy. For those tests that are not
able to be administered, the CBDI gives a default score of
50 (borderline range), providing a wrong estimation of
actual performance. Participants with aphasia who have difficulty following written or verbal instructions also may not
be accurately assessed by the CBDI.
In addition, the CBDI was measured against the standard on-road test currently used in our clinical setting.
Although the route and procedures are standardized,
changes in road conditions, weather, and the presence of
hazardous events cannot be controlled. The on-road outcome is determined subjectively by the evaluator based on
the findings from the evaluation. The lack of a reliable and
validated on-road test may have contributed to a reduced
association between CBDI outcome and the on-road result.

Conclusion
Although the CBDI scores are, on average, worse in those
who fail the on-road test, they are not sufficiently predictive
of driving outcome to allow for the elimination of the onroad test. A universal approach to driver evaluation may not
provide the most accurate and clinically relevant information. The study findings suggest that different pre-driver
tests are needed to give a precise indication of driving abilities and impairments for clients with different conditions.
To provide an efficient and effective method of driver evaluation, specific testing for different diagnostic groups
appears to be necessary. These results are an initial step in
attempting to determine the best approach for each of our
clients.

Acknowledgments
Thank you to Gevorg Chilingaryan, MSc, for conducting
the statistical analyses and to Chantal Simard, PhD, for
reviewing the manuscript. We are grateful to the Jewish
Rehabilitation Hospital Foundation for their financial assistance. This article was presented at the 6th National
Workshop for Driver Rehabilitation Specialists, Edmonton,
Alberta, Canada, on May 28, 2004.

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July/August 2006, Volume 60, Number 4

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