Short-term efficacy and tolerability of methylphenidate in children with traumatic brain injury and attention problems

Abstract

Purpose

This study aims to investigate the short-term efficacy and tolerability of immediate-release methylphenidate (IR-MPH) in children with a history of traumatic brain injury (TBI).

Methods

Twenty children with TBI (mean age: 12.7 ± 3.1 years) who had clinically significant attention deficit and/or hyperactivity-impulsivity symptoms and twenty children with primary Attention Deficit Hyperactivity Disorder (ADHD) (mean age: 12.3 ± 3.05 years) were included. Study measures, which included the Turgay DSM-IV based ADHD rating Scale (T-DSM-IV-S), Conners’ Parent Rating Scale (CPRS), Conners’ Teacher Rating Scale (CTRS-R) and Clinical Global Impression-Improvement Scale (CGI-I), were completed at the baseline for both of the groups. For the TBI group, study measures and an adverse effect scale developed by the authors were completed 8 weeks after IR-MPH treatment (10 mg dose t.i.d).

Results

No significant difference was found regarding the baseline scale scores between the study groups. Among children with TBI, most of the scores on T-DSM-IV-S, CPRS and CTRS-R were found to improve significantly after MPH treatment, (p < 0.05). 70% (N = 14) of the sample were much improved at the endpoint. MPH was generally well-tolerated (95% had either no adverse effect or mild adverse effects).

Conclusion

In this preliminary open-label study, IR-MPH was found as a safe and effective treatment option for ADHD symptoms after TBI. However, future controlled studies are needed to confirm our findings.

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.