Traumatic Brain Injury And ADHD

  • Veronika Hoskova Bachelor’s in psychology – BSc (Hons), Newcastle University
  • Chandana Raccha MSc in Pharmacology and Drug Discovery, Coventry University

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Introduction

Traumatic brain injury (TBI)

Traumatic brain injury (TBI) can be caused by several factors such as a bump, blow or jolt with high force to the head, often accompanied by an object, which causes the injury to pierce the skull and enter the brain. However not all blows or jolts to the brain area cause TBI, in fact, it is not the case in most cases. TBI in research is often separated into three categories based on severity: mild, moderate, and severe.

There are also different types of TBI:

  • Primary = immediate damage to the brain after the injury
  • Secondary = the injury develops over the course of time after the initiated impact because of bodies reaction after the trauma
  • Penetrating = object enters the skull entering the brain tissue, this typically causes damage only in a specific brain area
  • Non-penetrating = also known as blunt TBI, the force is strong enough to move the brain within the skull, this can lead to larger damage across the brain1

Attention deficit hyperactivity disorder

Attention Deficit Hyperactivity Disorder (ADHD), as the name suggests patients diagnosed with ADHD present with decreased attention, hyperactivity, and impulsivity. ADHD is a very common spectrum type mental health disorder. This means that there are traits of this disorder in everyone, but only from a certain amount up it is classified as a psychiatric disorder. ADHD affects most aspects of a patient's life from academic and professional achievements to interpersonal relationships.2

The relationship between TBI and ADHD

The scientific literature suggests an association between TBI and ADHD. However it is unclear whether being diagnosed with ADHD increases the risk of experiencing TBI, or if a history of TBI increases the likelihood of subsequently developing ADHD. Below are summarised findings of several studies on this topic:

Asarnow et al. (2021) – Association of Attention-Deficit/Hyperactivity disorder diagnoses with Paediatric Traumatic Brain Injury (A Meta-analysis)3

  • No significantly increased rates of ADHD diagnosis following Concussion, Mild or Moderate TBI
  • Significantly increased rates of ADHD diagnosis following severe TBI

Biederman et al. (2015) – Mild Traumatic Brain Injury and Attention-Deficit Hyperactivity Disorder in Young Student Athletes4

  • Participants with mild TBI were found to have significantly higher rates of ADHD compared to healthy controls
  • Interestingly in all cases, ADHD was diagnosed prior to having TBI, which suggests that ADHD may increase the risk of having TBI
  • Only one participant started developing signs of ADHD after suffering a mild TBI

Yeates et al. (2021) – Advances in understanding the association between Pediatric Traumatic Brain Injury and Attention-Deficit Hyperactivity Disorder5

  • This is just a review of several previous studies
  • In most children, ADHD was diagnosed prior to TBI, and the rate of TBI of higher in ADHD patients than in healthy controls

Ilie et al. (2015) – The association between traumatic brain injury and ADHD in a Canadian adult sample6

  • 6.6% of the sample (3 993 adults) currently had ADHD and suffered TBI earlier in their life, and 5.9% of the sample reported having a history of both ADHD and TBI
  • Adults with a history of TBI had a greater likelihood of currently having ADHD or having a history of having ADHD diagnosis compared to controls
  • There was a stronger association between a history of TBI and ADHD diagnosis in younger adults (18-29 years old)

Narad et al. (2018) – Secondary Attention-Deficit/Hyperactivity Disorder in children and adolescents 5 to 10 years after Traumatic Brain Injury7

  • Children with a history of TBI (even in less severe forms) have an increased risk of developing problems with attention even years after the injury
  • Severe TBI was associated with a significantly larger risk of ADHD when compared to the control group, however, these findings were not significant for participants who experienced mild or moderate TBI

Reasons why ADHD may lead to TBI

There are many reasons why patients with ADHD may be at a greater risk of suffering TBI, mainly due to the fact that the main symptoms of ADHD (decreased attention, hyperactivity, and impulsivity) can lead to unintended accidents caused by either for example not paying attention to a task, making impulsive possibly careless decisions, and being hyperactive, which in itself means more moving around, and therefore a higher risk of bumping into our surroundings.5,6

Reasons why TBI may lead to ADHD

It is hard to specify why TBI may lead to ADHD, due to the fact that TBI is highly individual, meaning that each TBI may affect different brain areas, based on the nature of the injury. For example TBI can cause memory impairment, attention deficits, issues with speech articulation, negative mood and impulsiveness,7. Also external factors such as socioeconomic situation, as patients from poorer families were found at an increased risk of developing ADHD after suffering TBI which as previously mentioned can cause attention, and behavioural problems7.

Summary

In summary, the scientific literature shows that there is a clear relationship between ADHD and TBI, however, as of now it is unclear whether ADHD can increase the likelihood of suffering TBI, or whether ADHD can be caused by TBI. In general, the symptoms of ADHD such as decreased attention, hyperactivity and impulsivity can increase the risk of TBI. And depending on the nature and severity of TBI, there is a potential for the development of ADHD symptoms, due to damage or changes to specific brain areas. So in conclusion we know that the two diagnoses are more likely to be co-occurrent, however we do not know why.

FAQs

Does TBI make ADHD worse?

Yes, TBI can theoretically worsen ADHD, as damage or changes to brain structure can lead to a change in behaviour, attention, etc., which can cause or worsen the symptoms of ADHD7.

Should I take ADHD meds with a TBI?

Firstly please consult a relevant, qualified medical professional on this matter, however if you are just curious Methylphenidate is an active substance in most types of ADHD medicine, and it is safe and in some cases even recommended  to be taken during the course of recovery from TBI. 

Is ritalin good for TBI?

As Ritalin contains methylphenidate, it was found to be safe to use during the course of recovery from TBI. In fact it was even found to be beneficial as it can decrease mental fatigue8. Methylphenidate was even found to improve executive function in patients with TBI9. Executive function is a cognitive function we can think of as something like a CEO of the brain, it is in charge of most of the brain's cognitive processes, such as behaviour etc. But again please consult a licensed medical professional prior to taking Ritalin while recovering from TBI.

References

  1. Traumatic Brain Injury (TBI) | National Institute of Neurological Disorders and Stroke [Internet]. [cited 2024 Jun 7]. Available from: https://www.ninds.nih.gov/health-information/disorders/traumatic-brain-injury-tbi.
  2. Harpin VA. The effect of ADHD on the life of an individual, their family, and community from preschool to adult life. Arch Dis Child. 2005; 90 Suppl 1(Suppl 1):i2-7. https://doi.org/10.1136/adc.2004.059006
  3. Asarnow RF, Newman N, Weiss RE, Su E. Association of Attention-Deficit/Hyperactivity Disorder Diagnoses With Pediatric Traumatic Brain Injury: A Meta-analysis. JAMA Pediatr. 2021; 175(10):1009–16. https://doi.org/10.1001/jamapediatrics.2021.2033
  4. Biederman J, Feinberg L, Chan J, Adeyemo BO, Woodworth KY, Panis W, et al. Mild Traumatic Brain Injury and Attention-Deficit Hyperactivity Disorder in Young Student Athletes. J Nerv Ment Dis [Internet]. 2015 [cited 2024 Jun 7]; 203(11):813–9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4626306/.
  5. Yeates KO, Max JE, Narad ME. Advances in Understanding the Association Between Pediatric Traumatic Brain Injury and Attention-Deficit/Hyperactivity Disorder. JAMA Pediatrics [Internet]. 2021 [cited 2024 Jun 7]; 175(10):1001–3. Available from: https://doi.org/10.1001/jamapediatrics.2021.2038.
  6. Ilie G, Vingilis ER, Mann RE, Hamilton H, Toplak M, Adlaf EM, et al. The association between traumatic brain injury and ADHD in a Canadian adult sample. Journal of Psychiatric Research [Internet]. 2015 [cited 2024 Jun 7]; 69:174–9. Available from: https://www.sciencedirect.com/science/article/pii/S002239561500237X.
  7. Narad ME, Kennelly M, Zhang N, Wade SL, Yeates KO, Taylor HG, et al. Secondary Attention-Deficit/Hyperactivity Disorder in Children and Adolescents 5 to 10 Years After Traumatic Brain Injury. JAMA Pediatrics [Internet]. 2018 [cited 2024 Jun 7]; 172(5):437–43. Available from: https://doi.org/10.1001/jamapediatrics.2017.5746.
  8. Johansson B, Wentzel A-P, Andréll P, Odenstedt J, Mannheimer C, Rönnbäck L. Evaluation of dosage, safety and effects of methylphenidate on post-traumatic brain injury symptoms with a focus on mental fatigue and pain. Brain Inj. 2014; 28(3):304–10.
  9. Al-Adawi S, Al-Naamani A, Jaju S, Al-Farsi YM, Dorvlo ASS, Al-Maashani A, et al. Methylphenidate improves executive functions in patients with traumatic brain injuries: a feasibility trial via the idiographic approach. BMC Neurology [Internet]. 2020 [cited 2024 Jun 8]; 20(1):103. Available from: https://doi.org/10.1186/s12883-020-01663-x.

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Veronika Hoskova

Bachelor’s in psychology – BSc (Hons), Newcastle University

Veronika is a MRes Neuroscience student at Newcastle university, working on research regarding cold-water therapies for mental health alongside her studies.

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