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ADHD and acquired brain injury

Natalie Mackenzie discusses the need for greater understanding of the two conditions



Natalie Mackenzie, director at BIS Services, on the need for a deeper understanding of the relationship between the two conditions


Over the past few years, we have received an increasing number of referrals for clients with severe TBI, who upon assessment, display several ‘classic’ ADHD symptoms and traits.

Of course, the dysexecutive nature of TBI mimics that of the ADHD brain and behaviour. Are they symptoms ADHD or an indication of frontal damage. Are both at play? Is there a premorbid diagnoses of ADHD or ADD,or similar co morbidities?

What says the historical assessment of school and childhood behaviour? How do we know what is causing the attention deficits and executive functioning errors?

Does it matter? No. Do we approach the client with the same techniques as ‘classic’ TBI deficits or ‘classic’ ADHD interventions? No. Why? The same reason as always, each brain is unique. 

Each individual is unique. Each brain injury is unique. Each ADHD brain is unique.

There is a specialism in understanding the additional challenges that a co-existing diagnoses of these two brings.

An understanding of why the usual tools might not be up to the job in hand. Here at BIS Services, however, we have the exact combination needed.

Almost 20 years experience in brain injury rehabilitation, including neurodiverse clients, coupled with formal training as a certified ADHD life coach.

Alongside a talented pool of cognitive rehabilitation assistants who have personally and professionally experienced neurodiversity. The perfect mix.

I embarked upon a year’s international training as an ADHD life coach, simply to ensure that there was no stone left unturned, as it were, when determining the input that our diverse clients need.

I had studied neurodiversity and ADHD and other conditions before, but not a deep dive into it, from a very different perspective.

The training undertaken in motivational interviewing over the years has always proved a very useful tool and approach, and I felt it would complement the coaching approach well, with many overlapping similarities in terms of client led conversations.

What I wasn’t expecting, and what I have not experienced in any of my formal training to date, was being in a cohort of nearly 90 per cent neurodiverse individuals, many of whom diagnosed later in life, being sidelined or mistaken as lacking motivation, naughty or (my biggest gripe), non-compliant.

Their insights were invaluable. As luck would have it also, the principal had a son with ADHD and had sustained a TBI in earlier life, a fellow student with a father with the same, and another with another child with ADHD and multiple concussions.

What was even more striking, was them embarking on their own self-discovery through our discussions, that their loved ones were displaying some similar challenges in addition to their ADHD, which were being ‘missed’ or side-lined, but that were a significant difference due to their brain injuries.

For these families, on the patient side of the model, they soon felt that the ADHD had worsened, was exacerbated, and made more complicated by the TBI, but that the presence of the ADHD led to medical professionals dismissing the cognitive impacts of subsequent TBIs and vice versa.

This was particularly prevalent with the multiple concussions “Oh, she has ADHD, the mTBI hasn’t affected their cognition.”

Families are frustrated, and the understanding of both diagnoses is greatly

lacking in both the neuro-rehab and ADHD fields.

That’s not to say this is a purposeful lack of interest, but simply there doesn’t seem to be much in the way of an evidence base to support the required specialist interventions needed.

When one embarks upon a research drive regarding the prevalence of ABI and ADHD, you are met with a very swiftly delivered list of search results that state things along the lines of “Brain injury as a cause of ADHD” or “ADHD increases risk of brain injury” or similar.

What we do not find much of, if anything, without extensive research, is the impact of a brain injury on a pre-existing ADHD diagnoses and vice versa.

Any incidence seems to get mixed together in one big muddle, with an even more troubling medley of reasons of why the risk-taking behaviour of ADHD results being a precursor for brain injury.

My interest in the topic led me to further discussion at the international ADHD conference in Dallas last autumn, presenting “ADHD and Brain injury: Rare unicorns, or the missing piece”.

I hope to travel to Baltimore again this year to present on this further.

Research findings whilst I was preparing predominantly favoured studies of children with ABI and secondary ADHD diagnoses, adult populations were scant.

My presented piece cites a number of findings, that are too extensive for this piece, but some notable findings include:

Attention-deficit/hyperactivity disorder secondary to traumatic brain injury (ADHD/TBI) is one of the most common neurobehavioral consequences of TBI, occurring in 20 per cent to 50 per cent of individuals post-injury.

This again highlights the need for further investigation of client history, the majority of my clients had no pre-injury diagnoses.

TBI could result in psycho-neurological changes that increase the chances of ADHD developing.

Others have hypothesised that having ADHD could increase an individual’s risk of falling or having an accident that could cause a TBI.

Due to the positive associations suggested in research between a lifetime diagnoses of TBI and both current and past ADHD, it is clear that further research is required to increase further understanding of the connection and how it affects the development an treatment of ADHD and TBI.

Children who have had a serious head injury are more likely to develop ADHD — but new research suggests that symptoms may not develop for up to a decade later.

Narad’s research looked at 187 children with no prior history of ADHD who were hospitalised due to either TBI or other accidents.

Of the 187 children, 48 eventually met the definition for secondary ADHD, roughly 25 per cent of the group.

The risk for developing the disorder was, in cases of severe TBI, four times higher than the rest of the children. Even children with less severe head injuries were also at risk of developing symptoms many years later.

Individuals with premorbid ADHD performed significantly worse than their matched counterparts on several tests of attention, processing speed, and working memory, and were significantly more likely to produce profiles later rated as impaired by independent, board-certified clinical neuropsychologists.

In addition, time from traumatic injury to testing was found to be negatively correlated with neurocognitive performance.

Secondary ADHD relates to symptoms of hyperactivity, impulsivity and attention-deficit disorder.

The following are secondary symptoms of ADHD: irritability, forgetfulness, disorganisation, low frustration tolerance, emotional lability, temper tantrums and aggressive, defiant behaviour, problems with visual and/or auditory perception, learning difficulties, impaired social relationships with parents, teachers, friends. Anything familiar?

So, if there are so many similar symptoms presenting for those with ADHD and Acquired Brain Injury individually, surely one could simply apply the same processes when working with clients with the dual diagnosis? Quite simply, no.

These same applications will simply not suffice. Clients will often be written off as non-complaint, unmotivated or disengaged.

When they are often quite the opposite, but unable to communicate such.

Secondary ADHD presentation will mimic more classic presentation, but with increased lack of motivation, increased executive dysfunction and decreased attentional skills. Do not write these individuals off in their desire to maintain change.

No matter the timeline of diagnoses, the approach will require adaption, and increased education regarding the complexities of acquired brain injury and its variability alongside an understanding of ADHD.

The impact of the frontal lobe paradox on a neurodiverse brain is enormous, and a topic for a whole other piece.

The impact of this and awareness in an ABI/ADHD brain brings some tricky behaviours, not seen in a ‘typical’ ADHD presentation.

As we see the incidences of ADHD diagnoses increasing, there is a parallel trend within brain injury prevalence across the globe.

As we delve into the reasons for the correlations, there are a number of questions raised as to the impact of each on one another.

There is a significant impact of any injury on the ADHD brain, and subsequent challenges for managing the effects of ADHD on daily function.

A note here as well regarding the prevalence of ADHD in the criminal system, alongside the high rate of ABI in the same population – I certainly see an increase in law breaking behaviours in our neurodiverse clients.

Again, another topic for another day. As is the further complexities of the female ADHD brain, exacerbated by a TBI and the hormonal fluctuations, makes for another real interest area of mine.

Even more niche understanding is required by MDTs further with this population, which is certainly growing.

There is a niche approach to supporting and empowering the injured ADHD brain.

A toolbox of executive functioning tools is only the beginning, the methodology and adaptability of using those tools is even more paramount.

It is key for anyone involved in supporting both adults and children with ADHD to understand the impact of acquired brain injury on the ADHD brain and behaviours, and vice versa.

At BIS Services, our expert and specialist approaches allow us to pre-empt, expect and relish the additional challenges of the even more diverse ABI ADHD brain and we have a plethora of techniques to aid in rehab and recovery, for both clients and their families.