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Original Investigation
March 19, 2018

Secondary Attention-Deficit/Hyperactivity Disorder in Children and Adolescents 5 to 10 Years After Traumatic Brain Injury

Author Affiliations
  • 1Division of Physical Medicine and Rehabilitation, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 2Medical student, University of Cincinnati College of Medicine, Cincinnati, Ohio
  • 3Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
  • 4Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 5Department of Psychology, University of Calgary, Calgary, Alberta, Canada
  • 6Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
  • 7Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
  • 8Biobehavioral Health Center, Nationwide Children’s Hospital Research Institute, Nationwide Hospital, Columbus, Ohio
  • 9Department of Pediatrics, The Ohio State University, Columbus
  • 10Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
  • 11Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
JAMA Pediatr. Published online March 19, 2018. doi:10.1001/jamapediatrics.2017.5746
Key Points

Question  What factors are associated with the development of secondary attention-deficit/hyperactivity disorder in children 5 to 10 years after traumatic brain injury?

Findings  In this cohort study that included 187 children, severe traumatic brain injury and lower levels of maternal educational level were significantly associated with increased risk for secondary attention-deficit/hyperactivity disorder. Family dysfunction was significantly associated with increased risk in patients with traumatic brain injury but not in patients with orthopedic injury.

Meaning  Injury and environmental factors were associated with risk of secondary attention-deficit/hyperactivity disorder, with new onset up to 6.8 years after injury, highlighting the importance of identifying risk and promoting long-term follow-up of patients with high risk for secondary attention-deficit/hyperactivity disorder.

Abstract

Importance  After traumatic brain injury (TBI), children often experience impairment when faced with tasks and situations of increasing complexity. Studies have failed to consider the potential for attention problems to develop many years after TBI or factors that may predict the development of secondary attention-deficit/hyperactivity disorder (SADHD). Understanding these patterns will aid in timely identification of clinically significant problems and appropriate initiation of treatment with the hope of limiting additional functional impairment.

Objective  To examine the development of SADHD during the 5 to 10 years after TBI and individual (sex, age at injury, and injury characteristics) and environmental (socioeconomic status and family functioning) factors that may be associated with SADHD.

Design, Setting, and Participants  Concurrent cohort/prospective study of children aged 3 to 7 years hospitalized overnight for TBI or orthopedic injury (OI; used as control group) who were screened at 3 tertiary care children’s hospitals and 1 general hospital in Ohio from January 2003 to June 2008. Parents completed assessments at baseline (0-3 months), 6 months, 12 months, 18 months, 3.4 years, and 6.8 years after injury. A total of 187 children and adolescents were included in the analyses: 81 in the TBI group and 106 in the OI group.

Main Outcomes and Measures  Diagnosis of SADHD was the primary outcome. Assessments were all completed by parents. Secondary ADHD was defined as an elevated T score on the DSM-Oriented Attention-Deficit/Hyperactivity Problems Scale of the parent-reported Child Behavior Checklist, report of an ADHD diagnosis, and/or current treatment with stimulant medication not present at the baseline assessment. The Family Assessment Device–Global Functioning measurement was used to assess family functioning; scores ranged from 1 to 4, with greater scores indicating poorer family functioning.

Results  The analyzed sample included 187 children with no preinjury ADHD. Mean (SD) age was 5.1 (1.1) years; 108 (57.8%) were male, and 50 (26.7%) were of nonwhite race/ethnicity. Of the 187 children, 48 (25.7%) met our definition of SADHD. Severe TBI (hazard ratio [HR], 3.62; 95% CI, 1.59-8.26) was associated with SADHD compared with the OI group. Higher levels of maternal education (HR, 0.33; 95% CI, 0.17-0.62) were associated with a lower risk of SADHD. Family dysfunction was associated with increased risk of SADHD within the TBI group (HR, 4.24; 95% CI, 1.91-9.43), with minimal association within the OI group (HR, 1.32; 95% CI, 0.36-4.91).

Conclusions and Relevance  Early childhood TBI was associated with increased risk for SADHD. This finding supports the need for postinjury monitoring for attention problems. Consideration of factors that may interact with injury characteristics, such as family functioning, will be important in planning clinical follow-up of children with TBI.

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