Original Research

Attention-Deficit/Hyperactivity Disorder in a VA Polytrauma Clinic

Fed Pract. 2015 February;32(2):14-20

References

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Not surprisingly, as shown in Table 2, veterans with ADHD compared with those without the diagnosis reported more problems with attention and concentration. The report of more attentional problems is seemingly not accounted for by group differences in reports of pain in general, headaches, sleep disturbance, or memory problems.

Study Strengths

A large sample of veterans constituted this study, and the data were gathered in consecutive referrals to the CJZVAMC PC over a 5-year period. Also, information on a number of comorbidities were captured simultaneously with the polytrauma and ADHD diagnoses, allowing much greater ability to investigate the interaction of multiple comorbidities as well as lingering reports of symptoms following discharge from active military service.

In these authors’ experience, veterans with ADHD benefit substantially from structured treatment interventions that are focused on developing compensatory skills for their problems with attention and impulsivity. Individuals with ADHD typically have a greater need for assistance with planning and organizing, making decisions, problem solving, and regulating their attention and affect. Individuals with ADHD may benefit from treatment strategies focused on ADHD behaviors in conjunction with traditional treatment strategies frequently used in the PC. These strategies include increased case management, medication trials, education regarding ADHD, vocational assistance, and consideration of both the school and work accommodations.

Studies have shown that treatments with stimulants improve functioning and reduce depression and substance use.²¹ In this study, < 5% of individuals with ADHD were taking stimulants at the time they were initially assessed in the PC, whereas the majority were taking stimulants after being referred for ADHD evaluation. Thus, identification of veterans with ADHD has clinical relevance in understanding the specific needs that guide development of individualized treatment plans to promote successful community reintegration.

Limitations

One limitation of the study is the lack of available medical records of historical ADHD diagnoses prior to military service. Also, although DSM-IV criteria for ADHD were operational in the psychodiagnostic clinics for these subjects, because the polytrauma study team did not conduct the evaluations in this sample, uniform diagnostic standards may not have been consistently applied when establishing the ADHD diagnosis. There was a 93% agreement between the 2 methods of diagnosis (ie, report of developmental diagnosis or positive adult evaluation), suggesting that diagnostic precision for ADHD in this study was reasonably accurate.

Community reintegration of individuals with ADHD will likely be challenging, as these individuals often have struggled with functioning in their communities prior to their military service.

Another significant limitation of this study, apart from establishing medical and psychiatric status at the time of the initial referral to the PC, is the omission of functional outcome assessments regarding success of polytrauma treatment initiatives or ultimate community reintegration of successful psychosocial participation or academic and vocational achievements. Future longitudinal outcome studies are needed to determine whether ADHD has a significant impact on clinical outcomes. Of interest, pain was an overwhelmingly common factor (> 90%) for the military population studied at this site. Some degree of disturbance in attentional capacities is common in patients with chronic pain, which may aggravate ADHD symptoms and vice versa. Further investigations are needed to determine the potential functional impact of pain, including use of pain and psychotropic medications, on ADHD symptoms and the combined effect of these symptoms on overall outcome from rehabilitation and reintegration efforts.

Although these findings suggest that polytrauma veterans with ADHD do not have more psychiatric or physical comorbidities than do veterans without ADHD, it is premature to conclude that community reintegration can be optimally managed in the same way for both groups. Community reintegration of individuals with ADHD will likely be challenging, as these individuals often have struggled with functioning in their communities prior to their military service.

Studies of adult ADHD in the U.S. and in other countries have found that it is often associated with substantial impairment in managing the demands of functioning as an adult in society.⁴ Although some theorists have speculated that symptoms of ADHD may have been evolutionarily adaptive to survival in select environments (eg, predatory hunting environments), there is no clear evidence to support such adaptive benefits of the symptom in modern combat environments.^23,24Symptoms of ADHD are typically maladaptive to soldiers transitioning to civilian lives.

Conclusions

This investigation described the demographic and clinical characteristics of OEF/OIF/OND veterans referred for evaluation of TBI to the CJZVAMC PC during 5 years of operation from 2008 through 2012. The aim was to increase provider awareness of possible important variables that may influence recovery and community reintegration. This study may help to form the foundation for future lines of research into variables such as ADHD that may influence outcomes of rehabilitation and reintegration interventions.