Original articleShort-term efficacy and tolerability of methylphenidate in children with traumatic brain injury and attention problems
Introduction
Traumatic brain injury (TBI), one of the main causes of morbidity and mortality of childhood, has been shown to result in impaired psycho-social and cognitive functioning [1]. Cognitive deficits may involve problems with attention, memory and executive functions [2], [3], [4]. One to four years after injury, more than one-fifth of children with TBI are under the risk of attention problems [5], [6]. This is much higher than the 5–12% prevalence of developmental Attention Deficit Hyperactivity Disorder (ADHD) [7]. Although not completely established, a terminology is growing recently to define ADHD symptoms after TBI. Attention deficit, hyperactivity and impulsivity symptoms that occur following brain injury, rather than from the neuro-developmental causes, is often referred to as secondary ADHD (S-ADHD) [8]. There is evidence that S-ADHD has some different features from primary ADHD; hyperactivity may be generally less severe, with the inattentive subtype predominating in the first two years post injury [8], [9]. Some studies have shown that severe TBI is more likely to be associated with ADHD symptoms [10], [11], [12]. The possible relationship between TBI lesion characteristics and S-ADHD has not been clarified. It has been shown that lesions in frontal cortex may be related with S-ADHD in the first 6 months, but not from 6 to 24 months after TBI [5], [6]. One study which used susceptibility weighted imaging has found an association between increased lesion number and poorer functioning in neuropsychologic performance including attention and executive functions [4].
Children with TBI and attention problems, frequently having other cognitive deficits including those on perception and memory, usually face academic underachievement [11]. The consequences of attention problems may extend beyond school functioning and can have negative impacts on a child’s social relationships, emotional well-being, self esteem and quality of life [9]. Long-term attention problems have also been reported after TBI. Yeates et al. [10] have found that almost half of children with severe TBI displayed significant attention problems on the Child Behavior Checklist (CBCL) on average 4 years post-injury. Despite the high burden of attention problems in children after TBI, only a limited number of controlled studies, all with small sample size and short duration, have focused on the treatment options [1], [13], [14], [15], [16]. Moreover, all of these studies are from Western countries. While numerous studies have shown that central nervous system (CNS) stimulants are generally a well-accepted treatment for developmental ADHD [17], less is known about their efficacy and tolerability on ADHD after TBI [14], [15], [16]. The main aim of this study was to investigate the short-term efficacy and tolerability of immediate-release methylphenidate (IR-MPH) in children with a history of TBI. The possible relationship between TBI-related variables, including TBI severity and location, and treatment response was also examined.
Section snippets
Sample
The study sample with TBI were recruited from the Pediatric Neurology Clinic of Mersin University School of Medicine Hospital. The inclusion criteria, which was based on the criteria used by Nickles et al. [1], were as follows: (1) Age of 6–18 years. (2) Neurological diagnosis of moderate to severe TBI, with severity based on the initial Glasgow Coma Scale (GCS) Score at presentation to the study hospital. Moderate TBI was defined as the GCS 9 to 12, or the presence of mechanical ventilation for
Results
Mean age of the TBI group was 12.7 ± 3.1 years, 75% (N = 15) were males. Primary ADHD group had a mean age of 12.3 ± 3.05 years and 60% (N = 12) were males. The comparison of demographic findings and baseline scale scores between TBI and primary ADHD groups is shown in Table 1. As seen in the table, no significant difference was found on the baseline parent- and teacher-rated ADHD scale scores between the study groups.
The majority of the TBI group had severe TBI (N = 11, 55%), while nine children had
Discussion
In this preliminary study, no significant difference was found on the baseline parent- and teacher-rated ADHD scale scores between children with TBI and those with primary ADHD. Among children with TBI, IR-MPH was found to be an effective and tolerable treatment option for ADHD symptoms. After 8 weeks of treatment, both the parent- and teacher-rated scale scores were significantly improved. Clinician-rated CGI-I and CGI-S scores were also highly positive and in correlation with the improvement
Conclusion
This preliminary study in Turkish children is an addition to the previous literature showing MPH as an effective and tolerable treatment option in children with TBI and ADHD symptoms. Our findings on IR-MPH also warrant studies with long acting MPH formulations and longer durations of treatment. Pediatric neurologists and psychiatrists must be aware of ADHD after TBI and the high efficacy of MPH in these cases.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
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