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Study participants' demographic and injury characteristics 

Study participants' demographic and injury characteristics 

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Article
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The present study compared executive dysfunction among children with attention-deficit/hyperactivity disorder (ADHD) after traumatic brain injury (TBI), also called secondary ADHD (S-ADHD), pre-injury ADHD and children with TBI only (i.e., no ADHD). Youth aged 6-16 years admitted for TBI to five trauma centers were enrolled (n=177) and evaluated wi...

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... returning group was not significantly different from those who did not return for age, gender, GCS, SES, psychosocial adversity, or for pre-injury adaptive behavior. Unremitted S-ADHD was present in 17/141 (12%) study participants (see Table 1). The children with P-ADHD included 26/141 (18%) study participants, while the TBI-only group included 98/141 (70%) study participants. ...

Citations

... be kept alert [44]. Impaired attention is one of the most common complaints of TBI survivors [45][46][47]. Based on neuroimaging studies, some psychiatric symptoms have been shown to correspond to functional abnormalities in brain regions, such as selective attention being localized to the anterior cingulate cortex (ACC) [48]. ...
Article
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Neurological dysfunctions commonly occur after mild or moderate traumatic brain injury (TBI). Although most TBI patients recover from such a dysfunction in a short period of time, some present with persistent neurological deficits. Stress is a potential factor that is involved in recovery from neurological dysfunction after TBI. However, there has been limited research on the effects and mechanisms of stress on neurological dysfunctions due to TBI. In this review, we first investigate the effects of TBI and stress on neurological dysfunctions and different brain regions, such as the prefrontal cortex, hippocampus, amygdala, and hypothalamus. We then explore the neurobiological links and mechanisms between stress and TBI. Finally, we summarize the findings related to stress biomarkers and probe the possible diagnostic and therapeutic significance of stress combined with mild or moderate TBI.
... The study that did report an effect found that female sex increased the risk for attention problems (54). An equal number of studies found that socioeconomic status was a significant (27,49,52) or non-significant (36,40,45,48) risk factor for new ADHD or attention problems. Worse family functioning was sometime (42,45,48) but not always (27,32,46,49,54) shown to be associated with ADHD or more attention problems. ...
... The population study by Chang et al. (59) found that low birth weight but no other perinatal or birth factors increased the risk of developing ADHD after TBI. Studies that examined family psychiatric history (27,45,48,49) or baseline IQ (32,40,46) did not find associations with subsequent attention problems following TBI. Lower preinjury adaptive functioning was reported as a significant factor in 3 out of 4 studies that assessed it (27,31,49,63). ...
... Children with SADHD were reported to have reduced communication skills and socialization skills compared to children that did not develop SADHD as well as children with primary ADHD. However, ratings of daily living skills were not significantly different between groups (40). In line with this study, another study also found that SADHD was associated with reduced adaptive functioning as well as intellectual function relative to children who did not develop ADHD after injury (48). ...
Article
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Objective: To summarize existing knowledge about the characteristics of attention problems secondary to traumatic brain injuries (TBI) of all severities in children. Methods: Computerized databases PubMed and PsychINFO and gray literature sources were used to identify relevant studies. Search terms were selected to identify original research examining new ADHD diagnosis or attention problems after TBI in children. Studies were included if they investigated any severity of TBI, assessed attention or ADHD after brain injury, investigated children as a primary or sub-analysis, and controlled for or excluded participants with preinjury ADHD or attention problems. Results: Thirty-nine studies were included in the review. Studies examined the prevalence of and risk factors for new attention problems and ADHD following TBI in children as well as behavioral and neuropsychological factors associated with these attention problems. Studies report a wide range of prevalence rates of new ADHD diagnosis or attention problems after TBI. Evidence indicates that more severe injury, injury in early childhood, or preinjury adaptive functioning problems, increases the risk for new ADHD and attention problems after TBI and both sexes appear to be equally vulnerable. Further, literature suggests that cases of new ADHD often co-occurs with neuropsychiatric impairment in other domains. Identified gaps in our understanding of new attention problems and ADHD include if mild TBI, the most common type of injury, increases risk and what brain abnormalities are associated with the emergence of these problems. Conclusion: This scoping review describes existing studies of new attention problems and ADHD following TBI in children and highlights important risk factors and comorbidities. Important future research directions are identified that will inform the extent of this outcome across TBI severities, its neural basis and points of intervention to minimize its impact.
... Clinical studies have suggested that sustained attention in children is vulnerable to TBI-induced damages [46,47]. The continuous performance task (CPT) is one of the most widely used tasks to measure sustained attention and was shown to be a robust instrument to challenge the sustained attention in children with TBI [48]. ...
Article
Full-text available
Traumatic brain injury (TBI) is highly prevalent in children. Attention deficits are among the most common and persistent post-TBI cognitive and behavioral sequalae that can contribute to adverse outcomes. This study investigated the topological properties of the functional brain network for sustained attention processing and their dynamics in 42 children with severe post-TBI attention deficits (TBI-A) and 47 matched healthy controls. Functional MRI data during a block-designed sustained attention task was collected for each subject, with each full task block further divided into the pre-, early, late-, and post-stimulation stages. The task-related functional brain network was constructed using the graph theoretic technique. Then, the sliding-window-based method was utilized to assess the dynamics of the topological properties in each stimulation stage. Relative to the controls, the TBI-A group had significantly reduced nodal efficiency and/or degree of left postcentral, inferior parietal, inferior temporal, and fusiform gyri and their decreased stability during the early and late-stimulation stages. The left postcentral inferior parietal network anomalies were found to be significantly associated with elevated inattentive symptoms in children with TBI-A. These results suggest that abnormal functional network characteristics and their dynamics associated with the left parietal lobe may significantly link to the onset of the severe post-TBI attention deficits in children.
... Clinical studies have suggested that sustained attention in children is vulnerable to the TBIinduced damages [42,43]. Continuous performance task (CPT) is one of the most widely used task to measure sustained attention and was shown to be a robust instrument to challenge the sustained attention in children with TBI [44]. ...
Preprint
Full-text available
Traumatic brain injury (TBI) is highly prevalent in children. Attention deficits are among the most common and persistent post-TBI cognitive and behavioral sequalae that can contribute to adverse outcomes. This study investigated the topological properties of the functional brain network for sustained attention processing and their dynamics in 42 children with severe post-TBI attention deficits (TBI-A) and 47 matched healthy controls. Functional MRI (fMRI) data during a block-designed sustained attention task was collected for each subject, with each full task block further divided into the pre-, early-, late-, and post-stimulation stages. The task-related functional brain network was constructed using the graph theoretic technique. Then the sliding-window-based method was utilized to assess the dynamics of the topological properties in each stimulation stage. The results showed that relative to the matched controls, children with TBI-A had significantly reduced nodal efficiency and/or degree of left postcentral, inferior parietal, inferior temporal, and fusiform gyri and their decreased stability during the early- and late-stimulation stages. The left postcentral inferior parietal network anomalies were found to be significantly associated with elevated inattentive symptoms in children with TBI-A. These results suggest that abnormal functional network characteristics and their dynamics associated with left parietal lobe may significantly link to the onset of the severe post-TBI attention deficits in children.
... Up to 60% of children sustaining an msTBI may develop novel psychiatric disorders [Brown et al. 1981;Max et al. 2012], which are heterogeneous and additional comorbidity is typical. These novel psychiatric disorders have demonstrable lesion correlates and show distinct neuropsychological profiles [Max et al. 2015] including when compared to developmental or pre-injury disorders [Ornstein et al. 2014]. Heterogeneity in novel psychiatric disorders combined with relatively small sample sizes complicate efforts to understand their neurobiological substrates. ...
Article
Full-text available
Traumatic brain injury (TBI) is a major cause of death and disability in children in both developed and developing nations. Children and adolescents suffer from TBI at a higher rate than the general population, and specific developmental issues require a unique context since findings from adult research do not necessarily directly translate to children. Findings in pediatric cohorts tend to lag behind those in adult samples. This may be due, in part, both to the smaller number of investigators engaged in research with this population and may also be related to changes in safety laws and clinical practice that have altered length of hospital stays, treatment, and access to this population. The ENIGMA (Enhancing NeuroImaging Genetics through Meta-Analysis) Pediatric Moderate/Severe TBI (msTBI) group aims to advance research in this area through global collaborative meta-analysis of neuroimaging data. In this paper, we discuss important challenges in pediatric TBI research and opportunities that we believe the ENIGMA Pediatric msTBI group can provide to address them. With the paucity of research studies examining neuroimaging biomarkers in pediatric patients with TBI and the challenges of recruiting large numbers of participants, collaborating to improve statistical power and to address technical challenges like lesions will significantly advance the field. We conclude with recommendations for future research in this field of study.
... 3,5,27 Difficulties in attention are reflected in the high rate of acquired, or secondary ADHD following TBI, 28 and place children at elevated risk for compromised attention and executive functions including planning and working memory. 29 Hot SR problems may be manifested by increased emotional dysregulation, risky decision making, and increased risk for externalizing behaviors such as oppositional and conduct disorders. 5,6,30 Although greater severity of TBI has generally been linked to more significant problems in cool and hot SR, 5,31 there are inconsistencies. ...
... 5,6,30 Although greater severity of TBI has generally been linked to more significant problems in cool and hot SR, 5,31 there are inconsistencies. 4,29,32 These inconsistencies may be related in part to the inherent heterogeneity of TBI and the challenges of using the Glasgow Coma Scale (GCS) as a marker of severity. Therefore, improved characterization of clinical markers and predictors of impairment, including markers such as neuroimaging, would assist in determining those at greater risk. ...
Article
Traumatic brain injury (TBI) produces microstructural damage to white matter pathways connecting neural structures in pre-frontal and striatal regions involved in self-regulation (SR). Dorsal and ventral frontostriatal pathways have been linked to cognitive ("cool") and emotional ("hot") SR, respectively. We evaluated the relation of frontostriatal pathway fractional anisotropy (FA) 2 months post-TBI on cool and hot SR assessed 7 months post-TBI. Participants were 8-15 years of age, including children with uncomplicated mild TBI (mTBI; n = 24), more severe TBI (complicated-mild, moderate, severe [cms]TBI; n = 60), and typically developing (TD) children (n = 55). Diffusion tensor tractography was used to map frontostriatal pathways. Cool SR included focused and sustained attention performance, and parent-reported attention, whereas hot SR included risk-taking performance and parent-reported emotional control. Multivariate general linear models showed that children with cmsTBI had greater parent-reported cool and hot SR difficulties and lower dorsal and ventral FA than TD children. Focused attention, risk taking, and emotional control correlated with FA of specific dorsal and ventral pathways; however, only the effect of TBI on focused attention was mediated by integrity of dorsal pathways. Results suggest that frontostriatal FA may serve as a biomarker of risk for SR difficulties or to assess response to interventions targeting SR in pediatric TBI and in broader neurodevelopmental populations.
... The presence of SADHD after TBI is associated with poorer performance on measures of attention, executive function, and memory 1 year postinjury. 12,[19][20][21] However, previous research is hampered by a lack of consideration of the effects of SADHD, independent of premorbid ADHD, on longterm outcomes. While premorbid ADHD is known to be associated with worse outcomes following early childhood TBI, the implications of SADHD for longterm recovery of cognitive and behavioral functions are unclear. ...
Article
Objective: To examine the impact of secondary attention-deficit/hyperactivity disorder (SADHD) on long-term global and executive functioning in adolescents after traumatic brain injury (TBI). Setting: Three tertiary cared children's hospitals and 1 general hospital. Participants: One hundred twenty children (TBI: n = 54; orthopedic injury: n = 66) without preinjury ADHD evaluated approximately 6.8 years postinjury. Design: Cross-sectional data analysis from a prospective, longitudinal study. Main measures: Outcomes included functional impairment (Child and Adolescent Functional Assessment Scale) and executive functioning (Behavior Rating Inventory of Executive Function [BRIEF]). Results: SADHD moderated the association of injury type with the BRIEF-Behavioral Regulation Index (F1,113 = 4.42, P = .04) and the Child and Adolescent Functional Assessment Scale (F1,112 = 8.95, P = .003). TBI was only associated with poorer outcomes in the context of SADHD. SADHD was also associated with poorer outcomes on the BRIEF-Global Executive Composite (F1,113 = 52.92, P < .0001) and BRIEF-Metacognitive Index scores (F1,113 = 48.64, P < .0001) across groups. Adolescents with TBI had greater BRIEF-Global Executive Composite scores than those with orthopedic injury (F1,113 = 5.00, P = .03). Conclusions: Although SADHD was associated with poorer functioning across groups, its adverse effects on behavioral regulation and overall functioning were amplified following TBI. TBI + SADHD may confer an elevated risk for significant impairments in early adolescence.
... There are intricate links between TBI and ADHD: ADHD can be a consequence of TBI, but it is also a risk factor for TBI, and can be complicated by the injury. 168 Since ADHD is common in offender groups, studies of TBI in these populations should consider the contribution of this condition. In a non-TBI study, intervention with medication for ADHD in offenders led to a 30% reduction in criminality, possibly owing to improved impulse control. ...
Chapter
Traumatic brain injury (TBI) constitutes a major cause of death and disability, and the World Health Organization (WHO) has projected that traumatic brain injury will be one of the leading causes of mortality and morbidity by 2020. In low- and middle-income countries the incidence of TBI is increasing, subsequent to increased motorization. It is, however, particularly vulnerable road users (pedestrians, cyclists) where the risk is greatest. In higher income countries, children, young adults, and elderly patients have the highest rate of TBI and a substantial increase in incidence of TBI in elderly patients as a result of falls has been noted. Nevertheless, TBI is a disease that affects the population of all ages and is referred to as ‘a silent epidemic’. Knowledge of the epidemiology of TBI is essential to inform healthcare planning and to target prevention campaigns appropriately. In this chapter we will summarize global TBI epidemiological perspectives and reflect on the burden that TBI imposes on health economics and society. We will review current classification systems, outcome measures, and prognostic models for TBI.
... Children who suffer from any kind of TBI are three times more likely to be diagnosed with ADHD than uninjured peers (Schachar, Levin, Max, Purvis, & Chen, 2004), and it is expected that more severe injuries increase this likelihood. Despite many similarities with developmental ADHD in terms of behavioral presentation, a study comparing the neuropsychological performance of children who develop secondary ADHD due to TBI compared to those already with developmental ADHD and TBI-only controls, found significantly greater planning difficulties weaker working memory, and slow and imprecise divided attention for those in the secondary ADHD group (Ornstein et al., 2014). ...
Chapter
Traumatic Brain Injury (TBI) is defined as an alteration in brain function, produced after focal or diffuse brain damage caused by external biomechanical forces. TBI severity is classified on a continuum, ranging from mild to moderate to severe, and about 80% of TBIs are mild. They are one of the leading causes of mortality in the world, constituting a major health and socioeconomic problem. TBIs affect individuals of all ages, with epidemiological research identifying gender (i.e., being a man) and age (i.e., children 0–4, older adolescents 15–19, and older adults ≥65 years old) as the demographic variables associated with higher risk of TBI. The neural, cognitive, behavioral, and social outcomes of TBI have been well studied. One of the most debilitating outcomes regards the presentation of executive dysfunctions post-injury, as adequate executive functioning is associated with independent living, return to work or school, and other activities including accessing and progressing through rehabilitation. This chapter reviews the research on the effects of TBI, particularly mild TBI, on executive functioning and across the lifespan, with an emphasis on four vulnerable groups: children and adolescents (pediatric TBI), and in adults (occupational TBI, sports-related concussions, and military TBI). Despite the potential multitude of impairments associated with executive functioning following TBI, there are interventions that have shown to be effective for restitution of function. We address these areas toward the end of the chapter, focusing on interventions aimed at regaining self-awareness, and remediating attention, problem-solving, and metacognition.
... Deficits in EF differ between children who experience SADHD, those who have pre-injury ADHD, and those who sustain a TBI without SADHD. Particularly, children with SADHD demonstrate greater impairments in attention and working memory compared to those with pre-injury ADHD and TBI-only; these children also showed impaired psychomotor speed at both 6-and 12-month followups, while attention deficits emerged at 12 months, suggesting that deficits in attention are not simply due to slowed cognition (Ornstein et al., 2014). SADHD is associated with slower response times and poorer planning abilities than those with primary ADHD. ...
... SADHD is associated with slower response times and poorer planning abilities than those with primary ADHD. These findings indicate different underlying mechanisms between pre-injury ADHD and SADHD and suggest that different treatments may be necessary for SADHD (Ornstein et al., 2014). While it may be possible to differentiate between primary and secondary ADHD with neuropsychological testing, studies have found that children with both pre-and post-injury ADHD have increased difficulties with attention, EF (e.g., reaction time, response inhibition) and memory following TBI (De la Torre et al., 2017;Sinopoli & Dennis, 2012;Sinopoli, Schachar, & Dennis, 2011;Slomine et al., 2005). ...
... The primary goal of this study was to investigate the effects of methylphenidate on longterm executive and neuropsychological functioning in children with attention problems following TBI. Children with ADHD following TBI (either SADHD or primary ADHD plus TBI) have greater problems in these areas compared to those with primary ADHD alone or TBI without SADHD (Ornstein et al., 2014); therefore, it is critical to understand how treatment with stimulants influences EF, which has not previously been examined in this population. Additionally, we wanted to understand the relationship between methylphenidate associated changes in lab-based neuropsychological measures of attentional control, processing speed, and EF and parent-or self-report measures of everyday EF behaviors (i.e., in a real-world setting rather than laboratory-based measures obtained in a controlled environment) (Gioia, Isquith, Guy, & Kenworthy, 2000) in this population. ...
Article
Objective: To investigate the effects of methylphenidate on long-term executive and neuropsychological functioning in children with attention problems following TBI, as well as the relationship between methylphenidate associated changes in lab-based neuropsychological measures of attentional control, processing speed, and executive functioning and parent- or self-report measures of everyday executive functioning. Method: 26 children aged 6-17 years, who were hospitalized for moderate-to-severe blunt head trauma 6 or more months previously, were recruited from a large children's hospital medical center. Participants were randomized into a double-masked, placebo-controlled cross-over clinical trial. Participants completed a comprehensive neuropsychological battery and parent- and self-report ratings of everyday executive functioning at baseline, and at 4 weeks and 8 weeks following upward titration of medication to an optimal dose or while administered a placebo. Results: Methylphenidate was associated with significant improvements in processing speed, sustained attention, and both lab-based and everyday executive functioning. Significant treatment-by-period interactions were found on a task of sustained attention. Participants who were randomized to the methylphenidate condition for the first treatment period demonstrated random or erratic responding, with slower and more variable response times when given placebo during the second period. Conclusion: Results indicate that methylphenidate treatment is associated with positive outcomes in processing speed, sustained attention, and both lab-based and everyday measures of executive functioning compared to placebo group. Additionally, results suggest sustained attention worsens when discontinuing medication.