Original Research

Attention-Deficit/Hyperactivity Disorder in a VA Polytrauma Clinic

A large-scale study suggests that veterans with attention-deficit/hyperactivity disorder may benefit from structured treatment interventions focused on developing compensatory skills for their attention and impulsivity issues.

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

Author(s):

Judith B. Kosasih, MD

Thomas A. Hammeke, PhD

Peter Graskamp, PhD

Kelly Owsiany, MS, SPC

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References

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2. Screening and Evaluation of Possible Traumatic Brain Injury in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans. Washington, DC: Dept of Veterans Affairs; 2010. VHA Directive 2010-012.

3. Polytrauma System of Care. Washington, DC: Dept of Veterans Affairs; 2013. VHA Handbook 1172.01.

4. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716-723.

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9. Theeler BJ, Flynn FG, Erickson JC. Headaches after concussion in US soldiers returning from Iraq or Afghanistan. Headache. 2010;50(8):1262-1272.

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Traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) are considered the signature injuries in veterans of the military operations in Iraq and Afghanistan.¹ In 2007, the VA implemented the Polytrauma System of Care (PSC) to provide comprehensive screening, evaluation, and treatment of these multifaceted injuries.^2,3 The VA defined polytrauma as “two or more injuries to physical regions or organ systems, one of which may be life threatening, resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability.”³ The VA intended the PSC to provide a national system of integrated care to meet the unique needs of these combat service members.

In addition to the comprehensive evaluation and treatment of traumatic injuries, a critical mission of the PSC is to facilitate the reintegration of injured combat veterans into their home communities. Optimal community reintegration requires that the clinician also assess premorbid comorbidities, which may affect postdeployment adjustments. Attention-deficit/hyperactivity disorder (ADHD), with an estimated adult prevalence of 4.4% in the U.S. and 2.5% to 3.4% worldwide, is a common disorder in the general adult population that often is associated with chronic social and vocational adjustment difficulties.^4-6 The increasing recognition that this disorder often persists into adulthood is of significance to veterans, largely young and male, who have left military service and are reintegrating into college and community job settings.⁷ Despite growing interest in adult ADHD, little is known about its prevalence and correlates in the veteran population.

The prevalence of ADHD in the Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) veteran polytrauma population has not been adequately studied. Studies have found that combat veterans with or without confirmed TBI diagnosis commonly have similar overlapping symptoms, such as memory problems, difficulty concentrating, poor attention, and sleep problems associated with other comorbidities such as pain, PTSD, ADHD, and other mental health diagnoses.^8-14 Increased awareness of various clinical variables would enhance understanding of the population characteristics and specific needs for education and management.

To begin to address the lack of information about ADHD in the VA polytrauma population, this study aimed to (1) identify the prevalence of ADHD in veterans referred to the Clement J. Zablocki (CJZ) VAMC Polytrauma Clinic (PC) in Milwaukee, Wisconsin; (2) describe demographic characteristics of polytrauma veterans with ADHD; (3) determine the comorbidity relationship between ADHD and TBI, PTSD, depression and anxiety disorders, and substance abuse; and (4) determine whether individuals with ADHD compared with those without ADHD report more physical and emotional symptomatic distress with particular attention given to reports of pain, headaches, and problems with attention and concentration, memory, and sleep.

Methods

The study population consisted of 690 OEF/OIF/OND soldiers and veterans who received a comprehensive TBI evaluation in the CJZVAMC PC from January 1, 2008, to December 31, 2012. Referrals to the PC were made by primary care physicians (PCPs) when OEF/OIF/OND veterans or service members enrolled at a VA facility for health care or transferred their care from another VA facility.

Either a prior diagnosis of TBI established by a qualified provider or positive responses to a 4-question screening tool for TBI prompted a referral to the PC. The 4 questions sought to establish (1) events that may increase risk of TBIs; (2) immediate symptoms following the event; (3) new or worsening symptoms following the event; and (4) current symptoms.¹ Referrals to the clinic most commonly came from PCPs at the CJZVAMC and its associated community-based outpatient clinics but occasionally came from mental health service providers.

Study Design

The CJZVAMC Institutional Review Board approved this study. A population database was developed from a review of medical records, clinical interviews of patients, and completion of standard intake forms during the veterans’ initial evaluations in the CJZVAMC PC. The database aimed to abstract patient information relevant for understanding and treating the population seen in the clinic. The database contained information related to demographics, injury parameters, neurobehavioral and PTSD symptoms, past and current mental health disorders, substance abuse history, pain symptoms, and developmental history (eg, ADHD, learning disability).

Prior to the PC intake interview, each veteran completed a packet of preclinic questionnaires that included information concerning deployment-related injury exposure and history; the 22-item Neurobehavioral Symptom Inventory (NSI), which assessed physical, cognitive, and emotional symptoms; current pain symptoms; and the Posttraumatic Stress Disorder Checklist-Civilian Version (PCLC).^15,16 Intake interviews in the CJZVAMC PC were typically conducted with a minimum of 2 specialties present (physical medicine/rehabilitation and neuropsychology) and occasionally as many as 4 specialties present (also including health psychology and social work). Data collection and abstraction for the database were derived by all specialties present and assisted by the polytrauma program technician.