Biopsychosocial Factors Associated With Attention Problems in Children After Traumatic Brain Injury

Abstract

Objective The aim of this review was to examine biopsychosocial factors associated with an increased risk of attention problems after a traumatic brain injury 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 traumatic brain injury and attention problems. Risk factors for attention problems posttraumatic brain injury examined in all articles were identified and grouped into broad categories of biological, psychological, and social factors. Methodological quality of each study was assessed using the modified Downs and Black checklist. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines from 2009 were used 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 preinjury attention-deficit/hyperactivity disorder, poorer preinjury adaptive functioning, lower socioeconomic status, and poorer family functioning were associated with increased risk of developing attention problems posttraumatic brain injury. Conclusions Development of attention problems after pediatric traumatic brain injury 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 traumatic brain injury. Nonetheless, screening for attention problems in children with risk factors may allow for earlier identification and intervention, minimizing negative impacts of attention problems after traumatic brain injury 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. To Claim CME Credits Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME Objectives Upon completion of this article, the reader should be able to: (1) Describe the importance of recognizing and identifying attention problems after traumatic brain injury in children; (2) Identify risk factors for development of attention problems after pediatric traumatic brain injury; and (3) Recognize gaps in existing literature regarding predictors of attention problems after pediatric traumatic brain injury. Level Advanced Accreditation The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

A Systematic Scoping Review of New Attention Problems Following Traumatic Brain Injury in Children

“…Evidence suggests that both sexes are equally vulnerable (27, 30, 36, 38, 40-42, 46, 48, 49, 52), and poor family functioning was sometimes (42, 45,48) but not always (27,32,46,49,54) a risk factor for SADHD and new attention problems. These conclusions are supported by a recent review that specifically examined biopsychosocial factors associated with attention problems in youth with TBI (23). Due to the lack of topical limitation of a scoping review framework the current review also found evidence to support that commonly concurrent neuropsychological characteristics and behavioral presentation include: (1) co-occurring novel psychiatric problems including ODD, CD (27,45,49), and affective lability (27,33,(47)(48)(49)(50), (2) and reductions in daily functioning (communication, socialization, and adaptive functioning) (17,40,48).…”

“…We identified six existing systematic reviews that included examinations of ADHD or attention problems after pediatric TBI (18)(19)(20)(21)(22)(23). Generally, these reviews report that attention problems are among the most commonly reported problems in individuals with a history of brain injury.…”

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

“…A dimensional approach, by contrast, has suggested that children with more preinjury attention problems show a more pronounced increase in attention problems postinjury compared with OIC. 12,13 Moreover, most studies using a categorial approach treat all cases of ADHD alike and do not examine specific subtypes, although research indicates that most cases of so-called secondary ADHD are primarily inattentive. 10 However, dimensional approaches do not necessarily document clinical levels of impairment.…”

“…Thus, a combination of dimensional and categorical approaches may be needed to better understand the role of inattentive vs hyperactive-impulsive symptoms of ADHD, both as predictors and outcomes in children with TBI. 12 The Asarnow et al meta-analysis 3 points to several other important directions for future research. One direction is to determine whether secondary ADHD, arising after TBI, is best viewed as a phenocopy of primary or developmental ADHD.…”

“…Studies using a categorical approach typically exclude children with preinjury ADHD and treat outcome as a dichotomy, limiting our understanding of how preinjury attention problems and TBI may interact to yield postinjury attention problems. A dimensional approach, by contrast, has suggested that children with more preinjury attention problems show a more pronounced increase in attention problems postinjury compared with OIC . Moreover, most studies using a categorial approach treat all cases of ADHD alike and do not examine specific subtypes, although research indicates that most cases of so-called secondary ADHD are primarily inattentive .…”