Advances in Understanding the Association Between Pediatric Traumatic Brain Injury and Attention-Deficit/Hyperactivity Disorder

Abstract

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 al 3 address in their systematic review and metaanalysis 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.The Asarnow et al study 3 has several strengths. These include the largest number of studies included in a systematic review on this topic to date (n = 24) and a substantial number of participants, including 12 374 unique patients with TBI and 43 491 unique controls. Another strength is the modern bayesian meta-regression analysis, which considers prior probabilities in an explicit fashion, as well as the sensitivity analyses, which addressed potential concerns about pooled severity groups for TBI samples, the association with less informative prior distributions, and whether the results were related more to specific studies. One minor shortcoming is that the estimates in the meta-analysis do not take diagnostic method for ADHD into account. The sensitivity analyses suggest that diagnostic method can have a substantial influence on estimates of ADHD prevalence. A specific comparison of estimates using standard structured psychiatric interviews with those using symptom rating scales or unstructured clinician diagnoses would have been informative. Another minor shortcoming was the absence of a specific test of the doseresponse relationship between severity of TBI and ADHD. The inclusion of a specific linear contrast for this purpose would have been instructive.

Understanding Associations Between Attention-Deficit/Hyperactivity Disorder and Traumatic Brain Injury—Reply

“…That a substantial number of patients with histories of severe TBI in our article presented with the same ADHD symptoms as children with primary ADHD without histories of TBI underscores this point. As Yeates et al noted in the editorial accompanying our article, “Secondary ADHD is…a common occurrence in other childhood disorders affecting the brain, including low birthweight, fetal alcohol, autism spectrum disorder, epilepsy, and various inflammatory disorders.” To amplify a point made in our article, while the etiology of ADHD in children following a TBI is almost certainly organic, there are psychosocial risk factors (eg, learning and behavior problems and family discord) that predated the TBI that clearly persist afterward, as well as a variety of psychosocial factors arising from the child’s TBI (eg, parental distress, psychological trauma, and missing school) that are often more important than the initial acute injury severity in determining long-term outcomes.…”

Deep phenotyping of socio-emotional skills in children with typical development, neurodevelopmental disorders, and mental health conditions: Evidence from the PEERS

“…Based on such approaches, global estimates suggest 50-60% of children with neurodevelopmental disorders, (NDDs) [32,33] and 10% of children in the general population experience impaired social competence [34]. Elevated risk of impaired social competence is also reported in children with acquired brain injury [35][36][37][38][39], epilepsy [40], chronic illness [41], learning disabilities [42], attention-deficit/hyperactivity disorder (ADHD) [43], and anxiety [44]. Consequences of deficits in social competence include social isolation and exclusion, bullying, lack of satisfying friendships, behavior problems and poor quality of life.…”

Returning to education after childhood acquired brain injury: Learning from lived parental experience

“…As shown above, many CYP in the study had a range of difficulties and 83% of CYP had at least three areas of deficit post-ABI. Research also demonstrates high levels of pre-existing vulnerabilities/comorbidities in the ABI population including ADHD (Eme, 2014;Hoarea & Beattieb, 2003;Max et al, 2004;Yeates et al, 2021), and many CYP also face ongoing medical complications/treatments which may create additional needs or further RtEs, for example, ongoing oncology treatments, hydrocephalus, arteriovenous malformation and cavernoma management. Parents remind us that it is essential to create child-centered pathways and systems responsive and adaptive to the complexity of individual needs, ensuring CYP can continue to make educational progress at intensities and levels suiting their recovery, progress with neurorehabilitation and emerging development.…”