Predictors of secondary attention-deficit/hyperactivity disorder in children and adolescents 6 to 24 months after traumatic brain injury

OBJECTIVE: To assess the phenomenology and predictive factors of attention-deficit/hyperactivity disorder (ADHD) after traumatic brain injury (TBI), also called secondary ADHD (SADHD). METHOD: Children without preinjury ADHD 5-14 years old with TBI from consecutive admissions (n = 143) to five trauma centers were observed prospectively from 6 to 12 months (12-month assessment) and from 12 to 24 months (24-month assessment) postinjury with semistructured psychiatric interviews. Injury and preinjury psychosocial variables were assessed. RESULTS: SADHD occurred in 15 of 103 (15%) of participants between 6 and 12 months after injury and 17 of 82 (21%) in the second year after injury. SADHD was significantly (p < .05) comorbid with personality change due to TBI and new-onset disruptive behavior disorders. Preinjury adaptive function was a consistent predictor of SADHD. Regression analyses revealed that preinjury psychosocial adversity was an independent predictor of SADHD in the second year after injury. Neither severity of injury nor lesion location predicted SADHD from 6 to 24 months postinjury. CONCLUSIONS: Determination of preinjury psychosocial adversity and the child's preinjury functioning during the index hospitalization would improve identification of children at highest risk of development of SADHD.     

Recovery from mild traumatic brain injury

BACKGROUND: Fatigue is one of the most frequently reported symptoms after Mild Traumatic Brain Injury (MTBI). To date, systematic and comparative studies on fatigue after MTBI are scarce, and knowledge on causal mechanisms is lacking. OBJECTIVES: To determine the severity of fatigue six months after MTBI and its relation to outcome. Furthermore, to test whether injury indices, such as Glasgow Coma Scale scores, are related to higher levels of fatigue. METHODS: Postal questionnaires were sent to a consecutive group of patients with an MTBI and a minor-injury control group, aged 18-60, six months after injury. Fatigue severity was measured with the Checklist Individual Strength. Postconcussional symptoms and limitations in daily functioning were assessed using the Rivermead Post Concussion Questionnaire and the SF-36. RESULTS: A total of 299 out of 618 eligible (response rate 52%) MTBI patients and 287 out of 482 eligible (response rate 60%) minor-injury patients returned the questionnaire. Ninety-five MTBI patients (32%) and 35 control patients (12%) were severely fatigued. Severe fatigue was highly associated with the experience of other symptoms, limitations in physical and social functioning, and fatigue related problems like reduced activity. Of various trauma severity indices, nausea and headache experienced on the ED were significantly related to higher levels of fatigue at six months. CONCLUSIONS: In conclusion, one third of a large sample of MTBI patients experiences severe fatigue six months after injury, and this experience is associated with limitations in daily functioning. Our finding that acute symptoms and mechanism of injury rather than injury severity indices appear to be related to higher levels of fatigue warrants further investigation.     

Anxiety after severe pediatric closed head injury

OBJECTIVE: To assess the frequency of anxiety symptoms and disorders 1 year after severe pediatric closed head injury (CHI) and to determine the risk factors associated with these postinjury outcomes. METHOD: Ninety-seven subjects were prospectively followed for 1 year after severe CHI (Glasgow Coma Scale Score = 3-8). Assessments of preinjury and 1-year postinjury psychiatric status and psychosocial adversity were conducted. Frequency of anxiety symptoms and disorders 1 year after injury were the outcome measures. Data collection occurred between 1992 and 1996. RESULTS: There was a significant increase in the total number of anxiety symptoms after injury compared with before injury. The most frequent symptoms were overanxious symptoms, followed by obsessive-compulsive symptoms, separation anxiety symptoms, and simple phobia symptoms. There was a trend toward an increase in the frequency of overanxious disorder after injury. Preinjury anxiety symptoms correlated positively with postinjury anxiety symptoms and disorders. Younger age at injury correlated positively with postinjury anxiety symptoms. CONCLUSIONS: One year after severe CHI, children are at risk for a variety of anxiety symptoms and, possibly, overanxious disorder. Preinjury anxiety and younger age at injury are risk factors for these disturbances.     

Cognitive complaints after mild traumatic brain injury: things are not always what they seem

OBJECTIVE: To compare nonreferred, emergency department (ED)-admitted mild traumatic brain injury (MTBI) patients with and without self-reported cognitive complaints on (1) demographic variables and injury characteristics; (2) neuropsychological test performance; (3) 12-day self-monitoring of perceived cognitive problems; and (4) emotional distress, physical functioning, and personality. METHODS: (Neuro)psychological assessment was carried out 6 months post-injury in 79 patients out of a cohort of 618 consecutive MTBI patients aged 18-60, who attended the ED of our level I trauma centre. Cognitive complaints were assessed with the Rivermead Postconcussional Symptoms Questionnaire (RPSQ). In addition, patients monitored concentration problems and forgetfulness during 12 consecutive days. RESULTS: Self-reported cognitive complaints were reported by 39% of the patients. These complaints were strongly related to lower educational levels, emotional distress, personality, and poorer physical functioning (especially fatigue) but not to injury characteristics. Severity of self-reported cognitive complaints was neither associated with the patients' daily observations of cognitive problems nor with outcome on a range of neuropsychological tests. CONCLUSION: Self-reported cognitive complaints were more strongly related to premorbid traits and physical and emotional state factors than to actual cognitive impairments. In line with previous work, this suggests that treatment of emotional distress and fatigue may also reduce cognitive complaints. Cognitive outcome assessment of symptomatic MTBI patients should not be restricted to checklist ratings only, but also include a (neuro)psychological screening. In addition, daily monitoring of complaints is a useful method to gather information about the frequency and pattern of cognitive problems in daily life.     

Long-term neuropsychological outcomes following mild traumatic brain injury.

Mild traumatic brain injury (MTBI) is common, yet few studies have examined neuropsychological outcomes more than 1 year postinjury. Studies of nonreferred individuals with MTBI or studies with appropriate control groups are lacking, but necessary to draw conclusions regarding natural recovery from MTBI. We examined the long-term neuropsychological outcomes of a self-reported MTBI an average of 8 years postinjury in a nonreferred community-dwelling sample of male veterans. This was a cross-sectional cohort study derived from the Vietnam Experience Study. Three groups matched on premorbid cognitive ability were examined, those who (1) had not been injured in a MVA nor had a head injury (Normal Control; n = 3214), (2) had been injured in a motor vehicle accident (MVA) but did not have a head injury (MVA Control; n = 539), and (3) had a head injury with altered consciousness (MTBI; n = 254). A MANOVA found no group differences on a standard neuropsychological test battery of 15 measures. Across 15 measures, the average neuropsychological effect size of MTBI compared with either control group was -.03. Subtle aspects of attention and working memory also were examined by comparing groups on Paced Auditory Serial Addition Test (PASAT) continuation rate and California Verbal Learning Test (CVLT) proactive interference (PI). Compared with normal controls, the MTBI group evidenced attention problems in their lower rate of continuation to completion on the PASAT (odds ratio = 1.32, CI = 1.0-1.73) and in excessive PI (odds ratio = 1.66, CI = 1.11-2.47). Unique to the MTBI group, PASAT continuation problems were associated with left-sided visual imperceptions and excessive PI was associated with impaired tandem gait. These results show that MTBI can have adverse long-term neuropsychological outcomes on subtle aspects of complex attention and working memory.     

Polysomnographic and quantitative EEG analysis of subjects with long-term insomnia complaints associated with mild traumatic brain injury.

OBJECTIVE: The aims of this study were (1) to characterise the extent and nature of disrupted sleep in individuals with long-term sleep complaints subsequent to mild traumatic brain injury (MTBI), and (2) to determine whether sleep disturbances in MTBI subjects were more characteristic of psychophysiological, psychiatric, or idiopathic insomnia. METHODS: Nine MTBI patients (27.8 months post-injury; SD=15.5 months) and nine control subjects underwent polysomnographic testing and completed self-report questionnaires on sleep quality. Power spectral (FFT) analysis of the sleep onset period was conducted, with both the power and variability in power being quantified. RESULTS: Individuals with MTBI exhibited long-term sleep difficulties, along with various cognitive and affective abnormalities. The MTBI group had 4% less efficient sleep (p=0.019), shorter REM onset latencies (p=0.011), and longer sleep onset latencies, although the latter were highly variable in the MTBI group (F-test: p=0.012). FFT analysis revealed greater intra-subject variability in the MTBI group in sigma, theta, and delta power during the sleep onset period. CONCLUSIONS: MTBI patients with persistent sleep complaints differ significantly from controls on a number of electrophysiological outcomes, but could not be easily classified into existing insomnia subtypes. SIGNIFICANCE: Sleep disturbances can persist well after the injury in a subset of patients with MTBI.     

Long-term morbidities following self-reported mild traumatic brain injury

The objective of this study was to examine the prevalence of long-term psychiatric, neurologic, and psychosocial morbidities of self-reported mild traumatic brain injury (MTBI). A cross-sectional cohort sample of three groups was examined: those who had not been injured in a motor vehicle accident nor had a MTBI (n = 3,214); those who had been injured in an accident but did not have a MTBI (n = 539); and those who had a MTBI with altered consciousness (n = 254). Logistic regression analyses were used to model odds ratios for the association between group and outcome variables while controlling demographic characteristics, comorbid medical conditions, and early-life psychiatric problems. Compared with uninjured controls, MTBI increased the likelihood of depression and postconcussion syndrome. MTBI also was associated with peripheral visual imperceptions and impaired tandem gait. Similarly, the MTBI group had poorer psychosocial outcomes including an increased likelihood of self-reported disability, underemployment, low income, and marital problems. Results suggest that MTBI can have adverse long-term psychiatric, neurologic, and psychosocial morbidities.     

Predictors of attention-deficit/hyperactivity disorder within 6 months after pediatric traumatic brain injury

OBJECTIVE: To assess the phenomenology and predictive factors of attention-deficit/hyperactivity disorder (ADHD) after traumatic brain injury (TBI), also called secondary ADHD (SADHD). METHOD: Children without preinjury ADHD 5-14 years old with TBI from consecutive admissions (n = 143) to five trauma centers were observed prospectively for 6 months (baseline and 6 months), with semistructured psychiatric interviews. Injury severity, lesion characteristics, and preinjury variables including psychiatric disorder, family psychiatric history, family psychiatric history of ADHD, family function, socioeconomic status, psychosocial adversity, and adaptive function were assessed with standardized instruments. RESULTS: SADHD in the first 6 months after injury occurred in 18 of 115 (16%) of returning participants. All subtypes of ADHD occurred. Socioeconomic status (p = .041) and orbitofrontal gyrus lesions (p = .005) independently significantly predicted SADHD. CONCLUSIONS: These findings are consistent with research on developmental ADHD that implicate psychosocial factors and prefrontal structural and functional differences between those with and without the disorder.     

Neuropsychological Functioning in Chronic Fatigue Syndrome and Mild Traumatic Brain Injury: A Comparison

Persons with chronic fatigue syndrome (CFS) (n = 30), individuals who had sustained a mild traumatic brain injury with postconcussive symptoms (MTBI) (n = 33), and healthy controls (n = 20), who were age-and education-matched, were compared on measures of complex information processing, attention/concentration, memory, and higher-order cognitive processes. MTBI and CFS patients demonstrated a similar deficit in complex information processing and verbal learning. Overall, however, individuals who suffered a MTBI demonstrated a greater degree of impairment than did individuals with CFS and healthy controls. Implications for treatment and future research are discussed.     

Cognitive complaints after mild traumatic brain injury: Things are not always what they seem

ObjectiveTo compare nonreferred, emergency department (ED)-admitted mild traumatic brain injury (MTBI) patients with and without self-reported cognitive complaints on (1) demographic variables and injury characteristics; (2) neuropsychological test performance; (3) 12-day self-monitoring of perceived cognitive problems; and (4) emotional distress, physical functioning, and personality.Methods(Neuro)psychological assessment was carried out 6 months post-injury in 79 patients out of a cohort of 618 consecutive MTBI patients aged 18–60, who attended the ED of our level I trauma centre. Cognitive complaints were assessed with the Rivermead Postconcussional Symptoms Questionnaire (RPSQ). In addition, patients monitored concentration problems and forgetfulness during 12 consecutive days.ResultsSelf-reported cognitive complaints were reported by 39% of the patients. These complaints were strongly related to lower educational levels, emotional distress, personality, and poorer physical functioning (especially fatigue) but not to injury characteristics. Severity of self-reported cognitive complaints was neither associated with the patients' daily observations of cognitive problems nor with outcome on a range of neuropsychological tests.ConclusionSelf-reported cognitive complaints were more strongly related to premorbid traits and physical and emotional state factors than to actual cognitive impairments. In line with previous work, this suggests that treatment of emotional distress and fatigue may also reduce cognitive complaints. Cognitive outcome assessment of symptomatic MTBI patients should not be restricted to checklist ratings only, but also include a (neuro)psychological screening. In addition, daily monitoring of complaints is a useful method to gather information about the frequency and pattern of cognitive problems in daily life.     

Too hard to control: compromised pain anticipation and modulation in mild traumatic brain injury

Mild traumatic brain injury (MTBI) is a vulnerability factor for the development of pain-related conditions above and beyond those related to comorbid traumatic and emotional symptoms. We acquired functional magnetic resonance imaging (fMRI) on a validated pain anticipation task and tested the hypotheses that individuals with a reported history of MTBI, compared with healthy comparison subjects, would show increased brain response to pain anticipation and ineffective pain modulation after controlling for psychiatric symptoms. Eighteen male subjects with a reported history of blast-related MTBI related to combat, and eighteen healthy male subjects with no reported history of MTBI (healthy controls) underwent fMRI during an event-related experimental pain paradigm with cued high or low intensity painful heat stimuli. No subjects in either group met diagnostic criteria for current mood or anxiety disorder. We found that relative to healthy comparison subjects, after controlling for traumatic and depressive symptoms, participants with a reported history of MTBI showed significantly stronger activations within midbrain periaqueductual grey (PAG), right dorsolateral prefrontal cortex and cuneus during pain anticipation. Furthermore, we found that brain injury was a significant moderator of the relationship between anticipatory PAG activation and reported subjective pain. Our results suggest that a potentially disrupted neurocognitive anticipatory network may result from damage to the endogenous pain modulatory system and underlie difficulties with regulatory pain processing following MTBI. In other words, our findings are consistent with a notion that brain injury makes it more difficult to control acute pain. Understanding these mechanisms of dysfunctional acute pain processing following MTBI may help shed light on the underlying causes of increased vulnerability for the development of pain-related conditions in this population.     

Factors influencing outcome following mild traumatic brain injury in adults.

This study aimed to investigate outcome in adults with mild traumatic brain injury (TBI) at 1 week and 3 months postinjury and to identify factors associated with persisting problems. A total of 84 adults with mild TBI were compared with 53 adults with other minor injuries as controls in terms of postconcussional symptomatology, behavior, and cognitive performance at 1 week and 3 months postinjury. At 1 week postinjury, adults with mild TBI were reporting symptoms, particularly headaches, dizziness, fatigue, visual disturbance, and memory difficulties. They exhibited slowing of information processing on neuropsychological measures, namely the WAIS-R Digit Symbol subtest and the Speed of Comprehension Test. By 3 months postinjury, the symptoms reported at 1 week had largely resolved, and no impairments were evident on neuropsychological measures. However, there was a subgroup of 24% of participants who were still suffering many symptoms, who were highly distressed, and whose lives were still significantly disrupted. These individuals did not have longer posttraumatic amnesia (PTA) duration. They were more likely to have a history of previous head injury, neurological or psychiatric problems, to be students, females, and to have been injured in a motor vehicle accident. The majority were showing significant levels of psychopathology. A range of factors, other than those directly reflecting the severity of injury, appear to be associated with outcome following mild TBI.     

Impact of early intervention on outcome following mild head injury in adults

BACKGROUND: The impact of mild head injury is variable and determinants of outcome remain poorly understood. Results of previous intervention studies have been mixed. OBJECTIVES: To evaluate the impact on outcome of the provision of information, measured in terms of reported symptoms, cognitive performance, and psychological adjustment three months postinjury. METHODS: 202 adults with mild head injury were studied: 79 were assigned to an intervention group and were assessed one week and three months after injury; 123 were assigned to a non-intervention control group and were seen at three months only. Participants completed measures of preinjury psychological adjustment, concurrent life stresses, post-concussion symptoms, and tests of attention, speed of information processing, and memory. Subjects seen at one week were given an information booklet outlining the symptoms associated with mild head injury and suggested coping strategies. Those seen only at three months after injury did not receive this booklet. RESULTS: Patients in the intervention group who were seen at one week and given the information booklet reported fewer symptoms overall and were significantly less stressed at three months after the injury. CONCLUSIONS: The provision of an information booklet reduces anxiety and reporting of ongoing problems.     

Attentional and executive functioning following mild traumatic brain injury in children using the Test for Attentional Performance (TAP) battery

The interpretation of the data regarding cognitive outcome in children who have suffered from mild traumatic brain injury (MTBI) remains currently controversial. The aim of the present study is to explore attentional and executive functioning in 6-12-year-old children who experienced a MTBI. A total of 15 children with MTBI and 15 matched noninjured children participated in the study. Attentional tasks using the Test for Attentional Performance battery were administered one year after the injury. In comparison to the noninjury children, MTBI children performed less accurately on selective attentional and updating tasks. These preliminary findings support the view that MTBI can have an impact on specific attentional functioning in children one year postinjury.     

Test-retest practice effects and test score changes of the WAIS-R in recovering traumatically brain-injured survivors

A group of adult TBI subjects who were tested at approximately 2, 4, 8, and 12 months postinjury with the WAIS-R were compared with a matched control group of similar adult TBI survivors who were tested twice with the WAIS-R at approximately 2 and 12 months postinjury. No significant differences were noted between the two groups on numerous preinjury, injury, or postinjury variables. Both groups demonstrated significant gains in both IQ and subtest scaled scores at 1 year postinjury. Significantly greater change scores were demonstrated in the experimental group than in the control group, suggesting possible test-retest practice effects in Performance IQ and several subtests. Trend analyses detected both linear and quadratic recovery curves, with recovery slowing by the third evaluation. Implications of results for clinical practice are discussed.     

Evaluating the role of botulinum toxin in the management of focal hypertonia in adults

OBJECTIVES: To investigate the effects of EMG guided botulinum toxin (BTX-A) on impairment and focal disability in adults presenting with focal hypertonia. METHODS: A prospective, randomised, double blind, placebo controlled, parallel group trial was carried out with standardised assessment before and at 3 week intervals until 12 weeks after injection, in patients with focal hypertonia affecting upper or lower limbs. Botulinum toxin or placebo was injected with EMG guidance after multidisciplinary assessment. The modified Ashworth scale of spasticity, percentage passive range of joint motion, subjective rating of problem severity, the Rivermead motor assessment scale, a timed 10 metre walk (lower limb patients), nine hole peg test (upper limb patients), and a modified goal attainment scale were used as outcome measures. The patients were 52 adults; 34 male, 18 female; mean age 40.31, range 16-79 years; mean duration of symptoms 35 months (range 3 months to 22 years). Diagnoses included cerebrovascular accidents (23), head injury (12), incomplete spinal cord injury (six), tumour (five), cerebral palsy (three), and anoxic episodes (three). RESULTS: For each variable an overall score for the treatment period was computed by summing the scores from the 3, 6, 9, and 12 week assessments. These overall scores were significantly better in the treated group for the Ashworth scale, percentage passive range of movement, Rivermead lower limb, and subjective rating of problem severity. The significant treatment effect on the Ashworth scale was seen on analysis of variance (ANOVA) at 3 weeks and the subjective rating of problem severity at 3 and 6 weeks. The goal attainment scale score in both groups was similar at 12 weeks. CONCLUSION: Selective use of botulinum toxin to weaken muscles can lead to a reduction in resistance to passive movement about a distal limb joint. This allows for improvements in passive range of movement and focal disability, particularly in patients presenting with focal spasticity of the lower limb.     

Correlates of persistent postconcussional disorder: DSM-IV criteria versus ICD-10

Controversy surrounding the causation of symptom complaints after mild traumatic brain injury (MTBI) is reflected by the existence of alternative diagnostic criteria for postconcussional syndrome (PCS) in the International Classification of Diseases (ICD) and postconcussional disorder (PCD) in the Diagnostic and Statistical Manual of Mental Disorders-4th edition (DSM-IV). Previous studies of persisting symptoms have employed various symptom checklists rather than uniform criteria-based diagnoses. This is the first prospective study of persisting symptom complaints using the formal diagnostic criteria for PCD and PCS and comparing these criteria sets in terms of prevalence, relationship to potential compensation, and emotional/functional status. In this prospective study, an unselected series of adults with uncomplicated MTBI (N = 139) was assessed at 6 months postinjury with a brief neuropsychological battery and measures of psychiatric symptoms/disorders, social support/community integration, health-related quality of life, and global outcome. In parallel analyses, participants with PCD/PCS were compared to those without the disorder. Potential compensation was an equally significant factor in both criteria sets. Persistent PCS criteria were met 3.1 times more frequently than persistent PCD criteria. Significant racial differences in fulfilling PCD/PCS criteria were found. No differences in emotional/functional status patterns or global outcome were found between the criteria sets except for minor dissimilarities in the social/community integration domain. The results demonstrate that despite large differences in the frequency of patients meeting the two diagnostic criteria sets, a clear basis for preferring either the PCD or PCS criteria remains to be determined.