ArticlePDF Available

Abstract and Figures

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 with a semi-structured psychiatric interview scheduled on three occasions (within 2 weeks of TBI, i.e., baseline assessment for pre-injury status; 6-months and 12-months post-TBI). This permitted the determination of 6- and 12-month post-injury classifications of membership in three mutually exclusive groups (S-ADHD; pre-injury ADHD; TBI-only). Several executive control measures were administered. Unremitted S-ADHD was present in 17/141 (12%) children at the 6-month assessment, and in 14/125 (11%) children at 12-months post-injury. The study found that children with S-ADHD exhibited deficient working memory, attention, and psychomotor speed as compared to children with pre-injury ADHD. Furthermore, the children with S-ADHD and the children with TBI-only were impaired compared to the children with pre-injury ADHD with regard to planning. No group differences related to response inhibition emerged. Age, but not injury severity, gender, or adaptive functioning was related to executive function outcome. Neuropsychological sequelae distinguish among children who develop S-ADHD following TBI and those with TBI only. Moreover, there appears to be a different pattern of executive control performance in those who develop S-ADHD than in children with pre-injury ADHD suggesting that differences exist in the underlying neural mechanisms that define each disorder, underscoring the need to identify targeted treatment interventions. (JINS, 2014, 20, 971-981).
Content may be subject to copyright.
A preview of the PDF is not available
... 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
Full-text available
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.
... 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
Full-text available
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.
... 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.
Article
Objective: The objective of this study was to examine the impact of preinjury attention-deficit/hyperactivity disorder (PADHD) and secondary ADHD (SADHD) on outcomes after pediatric traumatic brain injury (TBI). Methods: Two hundred eighty-four individuals aged 11 to 18 years hospitalized overnight for a moderate-to-severe TBI were included in this study. Parents completed measures of child behavior and functioning and their own functioning. Linear models examined the effect of ADHD status (PADHD vs SADHD vs no ADHD) on the child's executive functioning (EF), social competence, and functional impairment, and parental depression and distress. Results: ADHD status had a significant effect on EF [F(2,269] = 9.19, p = 0.0001), social competence (F[2,263] = 32.28, p < 0.0001), functional impairment (F[2,269] = 16.82, p < 0.0001), parental depression (F[2,263] = 5.53, p = 0.005), and parental distress (F[2,259] = 3.57, p = 0.03). PADHD and SADHD groups had greater EF deficits, poorer social competence, and greater functional impairment than the no ADHD group. The SADHD group had greater levels of parental depression than the no ADHD and PADHD groups, and the SADHD group had higher parental distress than the no ADHD group. Conclusion: The results highlight the importance of early identification and management of ADHD symptoms after injury to mitigate downstream functional problems. Supporting parents managing new-onset ADHD symptoms may also be important.
Article
The objective was to clarify occurrence, phenomenology, and risk factors for novel psychiatric disorder (NPD) in the first 3-months after mild traumatic brain injury (mTBI) and orthopedic injury (OI). Children aged 8-15 years with mTBI (n=220) and with OI but no TBI (n=110) from consecutive admissions to an emergency department were followed prospectively at baseline and 3 months post-injury with semi-structured psychiatric interviews to document the number of NPDs that developed in each participant. Pre-injury child variables (adaptive, cognitive, and academic function, and psychiatric disorder), pre-injury family variables (socioeconomic status, family psychiatric history, and family function), and injury severity were assessed and analyzed as potential confounders and predictors of NPD. NPD occurred at a significantly higher frequency in children with mTBI versus OI in analyses unadjusted (mean ratio (MR) 3.647, CI95 (1.264, 15.405), p=0.014) and adjusted (MR=3.724, CI95 (1.264, 15.945), p=0.015) for potential confounders. In multi-predictor analyses, the factors besides mTBI that were significantly associated with higher NPD frequency after adjusting for each other were pre-injury lifetime psychiatric disorder, MR=2.284, CI95 (1.026, 5.305), p=0.043; high versus low family psychiatric history, MR=2.748, CI95 (1.201, 6.839), p=0.016, and worse socio-economic status, MR=0.618 per additional unit, CI95 (0.383, 0.973), p=0.037. These findings demonstrate that mild injury to the brain compared with an OI had a significantly greater deleterious effect on psychiatric outcome in the first three-months post-injury. This effect was present even after accounting for specific child and family variables which were themselves independently related to the adverse psychiatric outcome.
Article
To the Editor We read the meta-analysis by Asarnow et al¹ with great interest. In their systematic review including the largest number of articles and participants on the topic to date, the authors point to dose and duration effects of the association of traumatic brain injury (TBI) with attention-deficit/hyperactivity disorder (ADHD) incidence that can help inform the care of adult ADHD. The authors found an association of severe TBI with ADHD incidence: 18.8% (95% credible interval, 9.3-32.1) for 1 year or less postinjury, which increased to 35.5% (95% credible interval, 20.6-53.2) after 1 year postinjury.¹ This article reignites readers’ interest in the etiology and evolution of ADHD. Traditionally, ADHD is considered a neurodevelopmental disorder with various gestational, perinatal, and genetic factors predisposing to the illness.² Recent studies have shown that TBI may be associated with the development of ADHD in children and youth, which some call secondary ADHD.³ However, to our knowledge, no studies have been done in adults older than 25 years. The results of the study by Asarnow et al¹ incline us to investigate potential organic causes of adult ADHD, such as TBI. This has important clinical implications.
Article
Importance There are conflicting accounts about the risk for attention-deficit/hyperactivity disorder (ADHD) following traumatic brain injury (TBI), possibly owing to variations between studies in acute TBI severity or when ADHD was assessed postinjury. Analysis of these variations may aid in identifying the risk. Objective To conduct a meta-analysis of studies assessing ADHD diagnoses in children between ages 4 and 18 years following concussions and mild, moderate, or severe TBI. Data Sources PubMed, PsycInfo, and Cochrane Central Register of Controlled Trials (1981-December 19, 2019) were searched including the terms traumatic brain injury, brain injuries, closed head injury, blunt head trauma, concussion, attention deficit disorders, ADHD, and ADD in combination with childhood, adolescence, pediatric, infant, child, young adult, or teen. Study Selection Limited to English-language publications in peer-reviewed journals and patient age (4-18 years). Differences about inclusion were resolved through consensus of 3 authors. Data Extraction and Synthesis MOOSE guidelines for abstracting and assessing data quality and validity were used. Odds ratios with 95% credible intervals (CrIs) are reported. Main Outcomes and Measures The planned study outcome was rate of ADHD diagnoses. Results A total of 12 374 unique patients with TBI of all severity levels and 43 491 unique controls were included in the 24 studies in this review (predominantly male: TBI, 61.8%; noninjury control, 60.9%; other injury control, 66.1%). The rate of pre-TBI ADHD diagnoses was 16.0% (95% CrI, 11.3%-21.7%), which was significantly greater than the 10.8% (95% CrI, 10.2%-11.4%) incidence of ADHD in the general pediatric population. Compared with children without injuries, the odds for ADHD were not significantly increased following concussion (≤1 year: OR, 0.32; 95% CrI, 0.05-1.13), mild TBI (≤1 year: OR, 0.56; 0.16-1.43; >1 year: OR, 1.07; 95% CrI, 0.35-2.48), and moderate TBI (≤1 year: OR, 1.28; 95% CrI, 0.35-3.34; >1 year: OR, 3.67; 95% CrI, 0.83-10.56). The odds for ADHD also were not significantly increased compared with children with other injuries following mild TBI (≤1 year: OR, 1.07; 95% CrI, 0.33-2.47; >1 year: OR, 1.18; 95% CrI, 0.32-3.12) and moderate TBI (≤1 year: OR, 2.34; 95% CrI, 0.78-5.47; >1 year: OR, 3.78; 95% CrI, 0.93-10.33). In contrast, the odds for ADHD following severe TBI were increased at both time points following TBI compared with children with other injuries (≤1 year: OR, 4.81; 95% CrI, 1.66-11.03; >1 year: OR, 6.70; 95% CrI, 2.02-16.82) and noninjured controls (≤1 year: OR, 2.62; 95% CrI, 0.76-6.64; >1 year: OR, 6.25; 95% CrI, 2.06-15.06), as well as those with mild TBI (≤1 year OR, 5.69; 1.46-15.67: >1 year OR, 6.65; 2.14-16.44). Of 5920 children with severe TBI, 35.5% (95% CrI, 20.6%-53.2%) had ADHD more than 1 year postinjury. Conclusions and Relevance This study noted a significant association between TBI severity and ADHD diagnosis. In children with severe but not mild and moderate TBI, there was an association with an increase in risk for ADHD. The high rate of preinjury ADHD in children with TBI suggests that clinicians should carefully review functioning before a TBI before initiating treatment.
Article
Traumatic brain injury (TBI) is the leading cause of acquired disability in children, and attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental sources of disability.¹,2 The association between TBI and ADHD has been a topic of controversy, which Asarnow et al³ address in their systematic review and meta-analysis in this issue of JAMA Pediatrics. They focus on whether the risk of ADHD increases after TBI, but also present data bearing on the question of whether ADHD is itself a risk factor for TBI. Importantly, their analysis shows a “dose-related” association between TBI severity and postinjury ADHD, with a significantly elevated risk of ADHD among children with severe TBI compared with an other injured control (OIC) group of children and children with mild TBI within 1 year postinjury, and with a noninjured control (NIC) group, OIC, and children with mild TBI more than 1 year postinjury. In addition, their analyses show no increase in postinjury ADHD in children with concussion, mild TBI, or moderate TBI compared with the rate in the NICs or OICs. They also note that the rate of preinjury ADHD was higher in children with TBI than in the general population, although not higher than among samples of the NIC or OIC groups. These findings have important clinical implications, highlighting the need to assess for ADHD in children with TBI, especially those with severe injuries, but also to take a careful history to determine whether symptoms of ADHD predate the injury.
Article
Objective: The aim of this review was to examine biopsychosocial factors associated with an increased risk of attention problems after a traumatic brain injury (TBI) in children. Design: A systematic review of the literature was conducted using data sources of MEDLINE, PsycINFO, and Cinahl up to August 30, 2020. Literature primarily examined pediatric patients with TBI and attention problems. Risk factors for attention problems post-TBI examined in all papers were identified and grouped into broad categories of biological, psychological, and social factors. Methodologic quality of each study was assessed using the Modified Downs and Black checklist. PRISMA Guidelines from 2009 were utilized in completing this review. Results: Forty articles met inclusion criteria for this study. Overall findings were mixed but suggested that younger age at injury, presence of pre-injury ADHD, poorer pre-injury adaptive functioning, lower SES, and poorer family functioning were associated with increased risk of developing attention problems post-TBI. Conclusion: Development of attention problems after pediatric TBI is complex and influenced by an array of biologic, environmental/social, injury-related, and host factors. Evidence is mixed and further study is needed to better understand the relationships between these factors and how they influence attention after TBI. Nonetheless, screening for attention problems in children with risk factors may allow for earlier identification and intervention, minimizing negative impacts of attention problems after TBI in children. Limitations of this study included heterogeneity of studies and overall low to moderate methodological quality of studies included as measured by the Modified Downs and Black Checklist.
Article
Objective To study identified rates of long-term behavior problems in children with traumatic brain injury (TBI) compared to children with only orthopedic injuries and risk factors and correlates for new behavior problems following TBI. Methods Sample included children with severe TBI (n = 42), moderate TBI (n = 41), and orthopedic injuries only (ORTHO;n = 50). The baseline assessment measured child behavior, adaptation, and neuropsychological, academic, and family functioning. Follow-ups were conducted at 6 and 12 months and at an extended follow-up a mean of 4 years after injury. Results The prevalence of caseness, defined as elevated behavior problem ratings, was higher in one or both TBI groups than in the ORTHO group at each follow-up (e.g., 36% of severe TBI group, 22% of moderate TBI group, and 10% of ORTHO group at extended follow-up). Most instances of postinjury-onset caseness at the extended follow-up were evident within the first year after TBI. Predictors were severe TBI, socioeconomic disadvantage, and preinjury behavioral concerns. Concurrent correlates included weakness in working memory and adaptive behavior skills, poorer behavior and school competence, and adverse family outcomes. Conclusions Postinjury-onset caseness is persistent, risks are multifactorial, and correlates include child dysfunction and family sequelae.
Article
• It is important for genetic, epidemiologic, and nosological studies to determine accurate rates of lifetime psychiatric diagnoses in patient and nonpatient populations. As part of a case-control family study of major depression, lifetime psychiatric diagnoses were made for 1,878 individuals. Sources of information used in making diagnostic estimates included direct interview, medical records, and family history data systematically obtained from relatives. Diagnostic estimates were made by trained interviewers, experienced clinicians, and by computer program. The results indicate that it is possible to make lifetime best estimate diagnoses reliably among both interviewed and noninterviewed individuals for most diagnostic categories and that diagnoses based on interview data alone are an adequate substitute for best estimate diagnoses based on all available information in a limited number of diagnostic categories.
Article
Objective: To characterize children who develop Secondary Attention Deficit Hyperactivity Disorder (S-ADHD) after severe and moderate closed head injury (CHI) according to neuroimaging variables. Method : Ninety-nine children from 4-19 years who suffered severe and moderate CHI were prospectively followed for a year after injury. Premorbid psychiatric status was determined by administration to the parent of a structured psychiatric interview. This interview was readministered 1 year after injury to determine the presence of post-closed head injury S-ADHD. An MRI was performed 3 months after injury to define lesion locations and volumes. Results : A set of multiple logistic regression models determined that the odds of developing S-ADHD were 3.64 times higher among children with thalamus injury, and 3.15 times higher among children with basal ganglia injury. There was no significant difference in lesion volumes in any of the locations of interest between the group who developed S-ADHD and the group who did...
Individuals diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) present with a wide array of cognitive and behavioral deficiencies. Over the past few decades, researchers have proposed a variety of theoretical models to account for and to better characterize this highly heterogeneous disorder. This paper reviews the recent literature on the neural and neurocognitive determinants of ADHD and emphasizes the importance of conceptualizing the disorder within a developmental framework. Implications for treatment are discussed.