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Brain Injury and Misdiagnosis

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Misdiagnosis of Psychiatric Disorders Secondary to Brain Injury: ODD, OCD, ADHD

Robyn Smith

Penn State College of Medicine

2002

I. Traumatic Brain Injury: General information

Prevalence:

Traumatic Brain injury in children and adolescents is a major public health problem in the US.

Each year, an estimated 2 million people sustain a head injury. About 500,000 to 750,000 head injuries each year are severe enough to require hospitalization, involving the annual hospitalization for about 100,000 children under the age of 15.

Preschool- age children are the second highest risk group for brain injury. And 2/3 of children under 3 who are physically abused suffer traumatic brain injuries. (Savage, NHIF pediatric task force)

Head injury is most common among males between the ages of 15-24, but can strike, unexpectedly, at any age. Many head injuries are mild, and symptoms usually disappear over time with proper attention. Others are more severe and may result in permanent disability. Sometimes the deficits are mild and go unnoticed and others may not exhibit their effects until years after the injury.

Causes of TBI:

Motor vehicle accidents account for an estimated 28% of traumatic brain injuries; sports/physical activity account for 20%; assaults are responsible for 9%; 43% are due to "other" reasons. However, when considering those brain injuries severe enough to require hospitalization, virtually half (49%) are caused by motor vehicle accidents.²

Consequences of Brain Injury:

Cognitive Deficits-Shortened attention span, short-term memory problems, problem solving or judgment deficits, inability to understand abstract concepts. Loss of sense of time and space, identity of self and others. There may also be an inability to accept more than one- or two-step commands simultaneously.

Motor Deficits-Paralysis, poor balance, lower endurance, and reduction in the ability to plan motor movements and poor coordination.

Perceptual Deficits-Possible changes in hearing, vision, taste, smell and touch, loss of sensation of body parts, left or right side of body neglect. The individual may have difficulty understanding where limbs are in relation to body.

Speech Deficits -Speech that is not clear as a result of poor control of the speech muscles (lips, tongue, teeth, etc.) and poor breathing patterns.

Language Deficits-Difficulty expressing thoughts and understanding others. This may include problems identifying objects and their function as well as problems with reading, writing, and ability to work with numbers. It is important to note that although pronunciation may be normal, what is being said may be inappropriate. Speech therapy may be necessary to work with the language problems.

Social Difficulties-Impaired social capacity resulting in self-centered behavior in which both empathy and self-critical attitudes are greatly diminished.

Regulatory Disturbances-Fatigue and/or changes in sleep patterns. Also loss of bowel and bladder control.

Personality Changes-Apathy and decreased motivation. Emotional lability, irritability, depression. Disinhibition, which may result in temper flare-ups, aggression, cursing, lowered frustration tolerance, and inappropriate sexual behavior.

Almost all of these symptoms mimic those seen with the most commonly diagnosed psychiatric disorders. Studies show that there is a clear association between mild to severe head injury and the development of psychiatric disturbance. Therefore, “it is important that the clinician be aware of what psychiatric complications can be expected from known instances of brain disorder.” (Shaffer)

II. Effects on Children

“Children are just as vulnerable as adults, it just takes longer for the effects of trauma to be seen in a child… Too often children that sustain brain injury early in life look “well” at that moment in time, but as the child gets older and their brain matures more serious cognitive and behavioral problems emerge.” (Savage, NHIF Pediatric task force)

“Children who have survived a head injury even without any gross motor or perceptual sequelae have higher rates of psychiatric disturbance than non-injured children.” Further studies will show whether this increased vulnerability also depends on genetic and environmental factors. (Shaffer, Organicity in Child Psychiatry)

Noticing signs of brain injury in children may be more difficult because they have less developed communication skills. The child may feel some symptoms, but cannot express them. The following list contains things you may notice in your child that can indicate brain injury:

Listlessness, lack of energy
Irritability
Change in eating habits
Change in the way they play
Altered performance in school
Lack of interest in favorite toys
Loss of skills, such as toilet training
Loss of coordination and balance

III. What do Studies Suggest?

ODD: Oppositional Defiant Disorder and Symptomatology After Traumatic Brain injury: A prospective Study.

Goal: Prospectively study the course of ODD symptomatology in children and adolescents in the first 2 years after traumatic brain injury (TBI).

Results/Conclusions:

· 20-40% of children and adolescents exhibit an increase in oppositional defiant behavior at points during the 2 years after the TBI. At every assessment, a substantial minority (21%-41%) of subjects experienced an increase in ODD symptoms compared to pre-injury status.

· ODD symptoms reached a peak at 1 year after the injury and the tapered by 2 years, however remained increased from pre-injury levels.

· Change in ODD symptomatology from pre-injury status was significantly influenced by socioeconomic status after the first 3 months of TBI. Socioeconomic status independently predicted total ODD symptoms at 6 and 12 months.

· Only 2 years after the injury was severity of the injury a significant predictor of change in ODD symptoms.

· Pre-injury family functioning significantly predicted total ODD symptoms throughout the first year.

· In contrast to a similar study done with ADHD symptoms, psychosocial factors (family functioning) seem to be important for the prediction of ODD symptoms, whereas the severity of brain damage is a particularly important predictor of ADHD symptoms.

Other thoughts:

· This validity of this study was limited by its small sample size. Replication of these findings with a larger sample size is needed before these results can be generally accepted.

· A characteristic lesion or neuroimaging correlate in ODD symptomatology after TBI has yet to be found. Only nonspecific changes in the bicaudate ratio were found in this study. PET scans may eventually shed new insight.

· Influence of psychosocial factors appears greater than severity of injury to account for symptom change in ODD after TBI in children and adolescents. More research needed.

OCD: Obsessive-Compulsive Disorder and Traumatic Brain Injury: Behavioral, Cognitive, and Neuroimaging Findings.

Goal: Evaluate behavior and cognition in a series of patients who developed OCD after suffering a TBI.

Results:

· OCD is an important consequence of TBI regardless of severity. 6/10 patients studied developed OCD after suffering mild TBI.

· 5/6 with mild TBI had normal neurological exams. All 6 patients had normal MRI scans. Two patient’s PET scans showed decreased perfusion rates in the left frontotemporal region or inferior parietal cortices bilaterally. Thus, patterns of cognitive deficits suggest dysfunction of frontal-subcortical circuits.

· Phenotypes of the OCD in the group studied showed that the content of OCD symptoms was similar to that reported in previous patients with post-traumatic OCD. Although some unusual symptoms were present such as obsessional slowing and compulsive exercising. Most common symptoms included:

o Obsessions: aggressive behavior 100%, contamination 80%, symmetry/exactness 60%.

o Compulsions: checking 100%, washing/cleaning 90%, repeating 80%.

o Associated behaviors: pathological doubt 70%, indecisiveness 60%, overvalued sense of responsibility 60%, avoidance 60%.

· Correlates with previous studies that anxiety and heightened emotional arousal after TBI can precede OCD symptoms. All patients in this study with mild TBI had GAD and PTSD before the onset of OCD.

Conclusions:

Symptoms of post traumatic OCD closely parallel that of OCD patients without head trauma. The injuries in this study were mostly mild and most had negative imaging scans at the time of injury, therefore TBI as the etiology of OCD may easily go unnoticed.

Further studies are needed to confirm these results due to this experiment’s small sample size.

ADHD: Fetal Alcohol exposure and attention: Moving beyond ADHD.

Clinical descriptions of children with fetal alcohol syndrome (FAS) often cite ADHD as a central feature of the child’s behavioral characteristics.

ADHD is a clinical diagnosis that is not based on neurocognitive tests of attention, but relies on clinical observation and on parent and teacher reports.

Goal: Examine the effect of prenatal alcohol exposure on attention factors, and the relationship between these factors and the ADHD diagnosis.

Results:

· FAS-FAE and ADHD groups had similar scores on intelligence testing and both were lower than those in the control group and the alcohol-exposed but not affect group.

· The conventional ADHD clinical diagnostic model effectively identified those children with ADHD by using standard checklists. This indicates that these traditional measures were accurate in identifying children with the ADHD diagnosis.

· FAS-FAE children scores were similar to that of the control group when using the clinical diagnostic model, suggesting that prenatal alcohol exposure was not associated with ADHD as it is usually clinically diagnosed.

· On attention related factors:

ADHD children performed least well on measures of focused and sustained attention. These children were also more impulsive and had more pronounced behavioral problems.

FAS-FAE children performed least well on measures of encoding and shifting attention. These children were less impulsive and had few significant behavioral problems.

Conclusions: This suggests that although their impairment of global intelligence was similar, these two groups of children had unique attentional profiles even though they both exhibit inattentive qualities. Their behavioral problems also differed.

More research is needed since previous longitudinal studies have shown deficits in focus and sustained attention in alcohol-exposed subjects and ADHD-like behavior in FAS-FAE patients. Researchers may need to integrate a multifaceted approach that moves beyond characterizing behavioral effects as ADHD, but also drawing information from developmental psychology to confirm the diagnosis.

IV. Conclusion:

“The first sign of the consequences of brain injury in children are most often personality and behavioral changes… All too often the symptoms are misdiagnosed as symptoms related to hyperactivity and ADHD, Conduct disorder or ODD, OCD, etc. It should always be considered that the behavioral changes noted in a child might be the result of brain injury and not a separate psychological disorder.” (Fischer; Traumatic Brain injury in children and adolescents)

References

Coles, Claire D. (2001) Fetal alcohol exposure and attention: Moving beyond ADHD. Alcohol Research and Health; Washington.

DeBonis, David., Ylvisaker, Mark. (Feb.2000) Executive function impairment in adolescence: TBI and ADHD. Topics in Language Disorders; Gathersburg.

Rubinstein, Boris., Schaffer, David (Dec. 1985). Organicity in Child Psychiatry: Signs, Symptoms, and Syndromes. Psychiatric Clinics of North America. Volume 8, No. 4. pp.755-777.

Obssesive-Compulsive Disorder and Traumatic Brain Injury: Behavioral, Cognitive, and Neuroimaging Findings (2001). Neuropsychiatry, Neuropsychology, and Behavioral Neurology. Volume 14, No.1. pp. 23-31. Lippincott Williams & Wilkins. Inc.

Oppositional Defiant Disorder Symptomatology After Traumatic Brain Injury: A Prospective Study (June 1998). The Journal of Nervous and Mental Disease. Volume 186, No. 6. pp. 325-332. Lippincott Williams & Wilkins. Inc.

Online Information:

http://www.brainevaluation.com/articles/neuroissues.html.

Neuropsychological Issues for Children at Risk- Barbara C. Fisher, Ph.D.

Traumatic Brain Injury in Children and Adolescents- Brabara C. Fisher, Ph.D.

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