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Original Investigation
July 12, 2021

Association of Attention-Deficit/Hyperactivity Disorder Diagnoses With Pediatric Traumatic Brain Injury: A Meta-analysis

Author Affiliations
  • 1Department of Psychiatry, University of California, Los Angeles
  • 2Department of Psychology, University of California, Los Angeles
  • 3Brain Research Institute, University of California, Los Angeles
  • 4School of Psychology, Fielding Graduate University, Playa Vista, California
  • 5Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, California
JAMA Pediatr. Published online July 12, 2021. doi:10.1001/jamapediatrics.2021.2033
Key Points

Question  Are traumatic brain injuries associated with increased risk for attention-deficit/hyperactivity disorder?

Findings  This meta-analysis of 24 studies including 12 374 children with traumatic brain injuries found that severe traumatic brain injuries appear to be associated with an increased risk for attention-deficit/hyperactivity disorder compared with noninjured and other injured controls; no association between attention-deficit/hyperactivity disorder and concussions and mild or moderate traumatic brain injury was identified. The rate of pretraumatic brain injury attention-deficit/hyperactivity disorder diagnoses was significantly greater than the incidence of attention-deficit/hyperactivity disorder in the general pediatric population.

Meaning  These findings show that clinicians should carefully review psychosocial and medical issues that antedate a traumatic brain injury that may need to be addressed to adequately treat attention-deficit/hyperactivity disorder symptoms in children with traumatic brain injuries.


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.

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