When Road Rage Is a Nervous System Cue: What ADHD, Sensory Processing, and the IADL of Driving Have to Do with Each Other

I want to open with something that happened to me recently, because I think the gap between what it looked like from the outside and what was actually happening underneath it is exactly the kind of gap that occupational therapy is built to close.

I had “road rage” on my commute in to work. Not the super dramatic kind. No confrontations, no dangerous maneuvers. Just that particular quality of disproportionate fury that rises when someone cuts you off and your nervous system decides, without consulting you, that this is the moment it has been waiting for.

I am a neurodivergent occupational therapist. I work with neurodivergent clients on nervous system regulation every day. I am aware of the irony.

But here is what I want to offer, both as a clinician and as someone with lived ADHD experience: that moment of road rage was not a failure of self-awareness or self-regulation. It was helpful information, an actual useful, useable cue about my current nervous system state, and once I understood what it was communicating, then I could do something about it.

Analyzing my morning using “Spoon Theory” or “Window of Tolerance” or “Energy/Emotion Bucket” whatever other analogy helps you understand a lot of stuff building up before it becomes too much

Looking back, before I had even gotten in the car, I had already placed significant demand on my regulatory system.

My routine was disrupted in several compounding ways: I was going into the office on a Friday, which I rarely do. I was leading campus tours, a role outside my usual responsibilities, which had been generating some low-grade anxiety since the night before. I had just returned from two days off for Jewish holidays, which meant my nervous system was managing schedule re-entry on top of everything else. And I was genuinely looking forward to a fun event with my students later that day, which, for those familiar with the social battery mathematics of neurodivergence, meant I was already running calculations on the cost before I had spent a single unit of energy.

By the time I turned the key, my nervous system was, by my own estimate, at approximately a seven out of ten. Traffic wasn’t really the cause of the dysregulation, just the match that ignited what had already been building.

Understanding Driving as an IADL

Per the Occupational Therapy Practice Framework (OTPF), driving is classified as an Instrumental Activity of Daily Living, a complex, context-dependent activity that supports independent community participation. It is one of the IADLs we (meaning occupational therapists and other mental health professionals) most commonly take for granted in our assessments of high-functioning neurodivergent adults, in part because performance is visible and measurable in blunt terms: they are driving, they are arriving, the IADL is being executed.

What that framing misses is the cost.

Competent driving requires the simultaneous integration of sustained attention, working memory, executive function, sensory processing, emotional regulation, and real-time motor and cognitive decision-making. The driving environment itself is a dynamic sensory field of variable auditory input, shifting visual stimuli, vestibular feedback from acceleration and braking, proprioceptive input from the steering wheel and seat, and the continuous, unpredictable behavior of other drivers.

For individuals with ADHD, sensory processing differences, or both, this demand profile is not neutral background noise. It is an active load placed on systems that may already be operating near capacity before the drive begins.

What the evidence says about ADHD and driving

The research on ADHD and driving is more nuanced than public discourse typically reflects. The dominant narrative focuses on inattention, and while attention deficits do contribute to adverse driving outcomes, emerging evidence suggests that emotional dysregulation plays a significant and underappreciated role in driving risk in ADHD populations, potentially more so than inattention alone (Reimer et al., 2005; Barkley et al., 2002).

Simulation studies comparing drivers with and without ADHD have found that ADHD groups show greater speed variability, more frequent near-miss events, and a higher rate of driving violations. Critically, research has found that outcomes such as driving anger and unsafe behavior correlate more strongly with emotional dysregulation and impulsivity than with inattention measures, with these effects most pronounced via the hyperactive-impulsive symptom dimension (Reimer et al., 2005). Adults with ADHD in simulator studies also demonstrate a pattern of expressing frustration and anger verbally toward other road users, and causing near-misses more frequently than controls, consistent with impairment in emotional and behavioral self-regulation rather than simply in attentional capacity (Barkley et al., 2002; Murphy et al., 2007).

Epidemiologically, the numbers are significant. The crash hazard among newly licensed drivers with ADHD is approximately 36% higher than their neurotypical peers (Curry et al., 2017). In a longitudinal cohort study using data from the Multimodal Treatment Study of ADHD (MTA), adults with persistent ADHD symptoms showed crash involvement rates 1.81 times higher than adults with no ADHD history, with the key moderating variable being symptom persistence into adulthood, not diagnosis history alone (Roy et al., 2020).

Between 34% and 70% of adults with ADHD experience meaningful difficulty with emotional dysregulation (Shaw et al., 2014). The neurobiological basis for this range is well-established: ADHD disrupts functional connectivity within a striato-amygdalo-medial prefrontal cortical network, which are the systems responsible for appraising emotional stimuli and modulating the intensity and duration of emotional responses (Shaw et al., 2014). When that regulatory circuitry is compromised, the response to a frustrating driving event does not simply feel more intense. It fires faster AND takes longer to resolve.

The sensory processing layer

For clients who present with sensory processing differences alongside ADHD, as is a common profile, the driving environment introduces an additional layer of demand that standard driving assessments rarely capture.

Auditory sensitivity can make traffic noise, horn use, and sudden sounds disproportionately activating. Visual sensitivity affects tolerance for glare, oncoming headlights, and the dense visual field of highway driving. Vestibular differences can also make the proprioceptive experience of driving, particularly in stop-and-go traffic or on winding roads, more fatiguing or disorienting than it would be for a neurotypical driver. Interoceptive awareness, often disrupted in neurodivergent individuals, can also impair the ability to recognize early signs of dysregulation before they escalate.

When your sensory system is already heightened by prior demands in the day, such as a noisy environment, an unexpected schedule change, or a social interaction that required sustained masking, the sensory load of driving stacks onto an already-taxed system. The car does not create the dysregulation. It inherits it.

What this means for OT assessment and intervention

For occupational therapists working with neurodivergent adults, driving warrants more attention than it typically receives outside of formal driving rehabilitation contexts. A few clinical considerations:

Assess the baseline, not just the behavior. When a client reports road rage, aggressive driving, or significant fatigue after driving, the relevant clinical question is not only what is happening in the car, but what their regulatory state was before they got in. The IADL performance is downstream of the nervous system state.

Ask about sensory load across the day. Driving does not occur in isolation. A client who manages morning traffic competently on a low-demand day may struggle significantly on a day with sensory or schedule disruption. Sensory processing assessment provides a framework for understanding this variability and communicating it to the client in terms that reduce shame and support self-awareness.

Pre-drive regulation is an intervention target. Diaphragmatic breathing, brief grounding routines, and intentional transition time before driving are evidence-informed strategies that activate parasympathetic tone and engage prefrontal regulatory capacity before the drive begins. For clients with ADHD, building these into a pre-drive routine — rather than relying on in-the-moment regulation, which is where ADHD most significantly impairs performance — may reduce both emotional reactivity and driving risk.

The car environment is modifiable. Sensory modifications to the driving environment — auditory (curated playlists, noise-reducing features), visual (polarized lenses for glare sensitivity), and proprioceptive (seat supports, steering wheel texture) — are legitimate occupational therapy interventions. We routinely modify environments for sensory needs in every other context. The car is not an exception.

Cognitive reappraisal is trainable. For clients with ADHD, the default interpretive frame in frustrating driving situations tends toward personalization and urgency. Practicing the reappraisal of traffic delays, other drivers' behavior, and sensory discomfort as neutral rather than threatening is a skill that can be developed, and OT is well-positioned to support that development within a broader regulation framework.

A note on lived experience in clinical practice

I share my own experience here deliberately, not to center myself, but because I think the field benefits from clinicians who can articulate what these experiences feel like from the inside — not just what they look like in the literature.

Road rage, for me, is not primarily a driving problem. It is a signal that my nervous system has been asked to absorb more than it had capacity for. Understanding that does not eliminate the dysregulation. But it changes what I do with it. I know to pause before I act, to name what is happening, to extend myself the same framework I would offer a client.

That is what sensory-informed, neurodivergent-affirming occupational therapy looks like in practice. It is not about eliminating hard days. It is about building the self-knowledge and the strategy set to navigate them without compounding the cost.

If this is relevant to you or your clients

Whether you are a neurodivergent person who recognizes this pattern in yourself, or a clinician looking to better support clients for whom driving is a significant source of difficulty, a sensory-informed OT evaluation is a grounded starting point.

A comprehensive sensory processing assessment identifies how an individual's nervous system takes in and responds to sensory input across modalities, where regulatory capacity tends to break down, and what strategies and environmental modifications are most likely to be effective for their specific profile.

If you found this post useful, I share content at this intersection of lived neurodivergent experience and occupational therapy practice regularly. You can follow along on Instagram and TikTok for more.

This post is written from the dual perspective of a neurodivergent individual and a licensed occupational therapist. It is intended for educational purposes and does not constitute clinical advice or an OT-patient relationship.

References

Barkley, R. A., Murphy, K. R., Dupaul, G. I., & Bush, T. (2002). Driving in young adults with attention deficit hyperactivity disorder: Knowledge, performance, adverse outcomes, and the role of executive functioning. Journal of the International Neuropsychological Society, 8(5), 655–672. https://doi.org/10.1017/S1355617702801345

Curry, A. E., Metzger, K. B., Pfeiffer, M. R., Elliott, M. R., Winston, F. K., & Power, T. J. (2017). Motor vehicle crash risk among adolescents and young adults with attention-deficit/hyperactivity disorder. JAMA Pediatrics, 171(8), 756–763. https://doi.org/10.1001/jamapediatrics.2017.0910

Murphy, K. R. (2002). Psychological counseling of adults with ADHD. In S. Goldstein & A. T. Ellison (Eds.), Clinicians' guide to adult ADHD: Assessment and intervention (pp. 133–145). Academic Press.

Reimer, B., D'Ambrosio, L. A., Gilbert, J., Coughlin, J. F., Biederman, J., Surman, C., Fried, R., & Aleardi, M. (2005). Behavioral differences in drivers with attention deficit hyperactivity disorder: The driving behavior questionnaire. Accident Analysis & Prevention, 37(6), 996–1004. https://doi.org/10.1016/j.aap.2005.05.005

Roy, A., Garner, A. A., Epstein, J. N., Hoza, B., Nichols, J. Q., Molina, B. S. G., Swanson, J. M., Arnold, L. E., & Hechtman, L. (2020). Effects of childhood and adult persistent attention-deficit/hyperactivity disorder on risk of motor vehicle crashes: Results from the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 59(8), 906–922. https://doi.org/10.1016/j.jaac.2019.08.007

Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion dysregulation in attention deficit hyperactivity disorder. American Journal of Psychiatry, 171(3), 276–293. https://doi.org/10.1176/appi.ajp.2013.13070966