Trauma and Adult Attention Deficit
Hyperactivity Disorder
A K
AYA1, Y T
ANER2, B G
UCLU1, E T
ANER4, Y K
AYA5, HG B
AHCIVAN3ANDIT B
ENLI11Department of Orthopaedics and Traumatology, 2Department of Child and Adolescent
Psychiatry, and 3Department of Psychiatry, Ufuk University, Ankara, Turkey;4Health Care
and Sports Centre, Gazi University, Ankara, Turkey; 5Department of Neurology, Bas¸kent
University, Ankara, Turkey
This study investigated the relationship between adult attention deficit hyperactivity disorder (ADHD) and trauma. Fifty-eight adults admitted to hospital with musculoskeletal trauma were evaluated using scales that determine the presence of ADHD in childhood and adulthood. Each patient was also interviewed by an adult psychiatrist and a child and adolescent psychiatrist. The control group consisted of 30 adult patients with complaints other than trauma who did not have a history of repetitive traumas. There were 36 (62.2%) cases of ADHD in the patient group
compared with four (13.3%) in the control group; this difference was statistically significant. When the level of trauma was evaluated, ADHD was identified in 23 of the 26 (88.5%) patients with high energy traumas compared with 14 of the 32 (43.8%) patients with low energy traumas; this difference was also statistically significant. This study shows that patients with adult ADHD are more prone to injuries, particularly high energy traumas such as motor vehicle accidents. Patients who have repeated high energy traumas should be evaluated by a psychiatrist for ADHD.
KEY WORDS: ATTENTION DEFICIT HYPERACTIVITY DISORDER; TRAUMA; ADULT
Introduction
As in most other countries, injury is a leading cause of morbidity and mortality in Turkey. Worldwide, high-velocity trauma is the main cause of death in people aged 18 – 44 years. In 2004, a total of 537 337 traffic accidents were reported in Turkey; these were associated with 4427 deaths and 136 437 injuries.1 This is equivalent to a mortality
rate of 0.06% and an injury rate of 1.90% in the general population.
While behavioural, demographic and vocational factors are well-known risk
factors for sustaining traumatic injury, less is known about the social, demographic and economic determinants of the outcome following injury.2 Risk factors for moderate
to serious traumas include individual factors and environmental factors, plus vehicle factors in accidents involving motor vehicles.3 Individual factors consist of
patient-dependent factors, such as age, gender, country of birth, socioeconomic status, and presence of psychopathology, including alcohol/substance use disorders and other psychiatric conditions.4It has long
been suspected that attention deficit hyperactivity disorder (ADHD) is associated with an increased risk of injury.5ADHD is a
psychopathology characterized by permanent and continuous attention deficit and/or hyperactivity inappropriate to the patient’s developmental level leading to functional impairment in social, academic, occupational and other areas of life. There are three subtypes of the pathology: inattentiveness, hyperactiveness–impulsive-ness, and both of these combined. Diagnosis is made on the basis of the presence of the three core ADHD symptoms – attention deficit, hyperactivity and impulsivity – occurring before the age of 7 years and observed in two or more settings.6
ADHD is a common psychiatric disorder affecting 5 – 10% of children and adolescents.7,8 It continues to manifest
during adulthood in 30 – 70% of cases.9 – 18
Adult prevalence has been conservatively estimated to be 1 – 4.4%.17,19Although boys
are diagnosed with the disorder three to four times as often as girls,20there seem to be far
more similarities than differences in the manifestations of the core symptoms of ADHD in boys and girls.21In the past ADHD
was diagnosed in Western countries more than in other parts of the world, however numerous recent studies confirm that hyperactive, impulsive and inattentive symptoms co-occur as a coherent syndrome in many different cultures and countries.22
In adults, ADHD can have a negative effect on the patient’s overall ability to function.8 Adult patients with this
psychopathology are at risk for developing other psychiatric disorders, such as depression, anxiety disorders, and alcohol and other substance use disorders.23 – 25
Several studies on ADHD and trauma in children have been published.5,11,26,27 It has
been reported that children with ADHD are
more frequently injured than other children and that, without treatment, ADHD often results in increased risk for injuries, automobile accidents, traffic citations, bone fractures and head injuries in adolescence.26,28,29 Only a few studies,
however, have examined trauma and ADHD in adulthood.30The aim of this study was to
investigate the relationship between adult ADHD and trauma.
Patients and methods
PATIENTS
Patients with musculoskeletal trauma treated as outpatients or admitted to Ufuk University Hospital in Turkey between July 2006 and January 2007 were included in the study. Exclusion criteria included pedestrian injuries and non-driver victims of motor vehicle accidents. Each patient was evaluated after the injury as soon as their general health and psychological status made it possible.
The control group consisted of gender-matched patients attending the Orthopaedics and Traumatology Department of Ufuk University with complaints other than trauma who did not have a history of repeat trauma. Written informed consent was obtained from all participants after they had been given full details of the study.
ASSESSMENT OF INJURY
An information form covering demographic characteristics, how the injury occurred and any history of previous accidents or injuries was completed for each patient. Injuries were classified as high- or low-energy traumas, depending on how the injury occurred: simple falls or sports-related injuries were classified as low-energy traumas, whereas motor vehicle accidents and falls from heights of at least 5 m were classified as high-energy traumas.31
Accident and emergency records of all the patients were examined for attendance patterns and diagnoses.
ASSESSMENT OF ADHD
Each study participant was evaluated using psychiatric interviews with an adult psychiatrist (E.T.) and a child and adolescent psychiatrist (Y.T.). Diagnosis of ADHD was made according to DSM-IV-TR diagnostic criteria.6
The presence of ADHD during the patients’ childhood was determined using the Wender Utah Rating Scale (WURS).3,31
This is a self-evaluation scale consisting of 25 items with five Likert-type responses scoring 0 – 4 points. A cut-off of 36 points was used for the classification of adults as having had ADHD during childhood with the aim of achieving a sensitivity of 82.5% and a specificity of 90.8%, in accordance with a study by Öncü et al.32 on the validity and
safety of the Turkish version of the WURS. In addition, the Adulthood ADHD Diagnosis and Evaluation Scale was used to make a diagnosis of ADHD during adulthood.33,34
The validity and safety of the Turkish version of this scale (Adult ADD/ADHD DSM IV-Based Diagnostic Screening and Rating Scale), studied by Günay et al.,33has a cut-off
score of 50. It consists of three subscales: attention deficit, hyperactivity/impulsivity, and attention deficit/ADHD.
DATA ANALYSIS
The study participants were evaluated with regard to sex, intensity of the trauma, repeated trauma history, and diagnosis made by clinical interview and test scores. Statistical evaluations were performed using SPSS® version 11.0 (SPSS Inc., Chicago, IL,
USA). The χ2 test was used to compare
categorical variables and Mann–Whitney U-tests were used to compare numerical
variables. A P-value < 0.05 was considered to be statistically significant.
Results
A total of 58 musculoskeletal trauma patients, comprising 37 males and 21 females aged 18 – 70 years (mean 35 years, 5 months) were included in the study. Controls consisted of 30 patients, comprising 16 males and 14 females aged 18 – 70 years (mean 38 years, 6 months). There was no statistically significant difference between the two groups with regard to age or sex. The patients were evaluated 1 – 21 days (mean 7 days) after injury.
Patient details, including trauma details, are shown in Tables 1 and 2. Low-energy traumas resulted in injuries such as distal radius fractures, hip fractures or Achilles tendon ruptures, whereas high-energy traumas resulted in injuries such as femur, tibia or vertebra fractures and organ trauma involving the head, abdomen or chest.
The ADHD scores were confirmed by clinical evaluation; the results are given in Table 3. Childhood ADHD was identified in significantly more (P = 0.001) of the patient group than the control group (Table 3). Adult ADHD was also significantly more (P = 0.001) frequent in the patient group than the control group (Table 3).
When the patients were grouped according to the level of trauma, the rate of adult ADHD was significantly higher (P = 0.002) in those who had sustained high-energy trauma than in those who sustained low-energy trauma (Table 4). When examined according to gender, the relationship between high-energy trauma and adult ADHD was found to be statistically significant in men (P = 0.014) but not in women.
In studying the relationship between repetitive trauma and adult ADHD, the rate
TABLE 1:
Characteristics and type of injury in adult musculoskeletal trauma patients and controls
Controls (n = 30) Patients (n = 58) Gender Female 14 (46.7%) 21 (36.2%) Male 16 (53.3%) 37 (63.8%) Age (years) 18 – 50 24 (80.0%) 48 (82.8%) 51 – 70 6 (20.0%) 10 (17.3%) Type of injury Simple fall 27 (46.5%) Sport-related 4 (7.0%)
Fall from height 5 (8.6%)
Traffic-related 19 (32.8%)
Miscellaneous 3 (5.2%)
TABLE 2:
Types of trauma in adult musculoskeletal trauma patients
Types of trauma Patients (n = 58)
Distal radius fracture 11 (19.0%)
Tibia fracture 11 (19.0%)
Femur fracture (including femoral neck) 9 (15.5%)
Vertebra fracture 5 (8.6%)
Forearm fracture 5 (8.6%)
Humerus fracture 5 (8.6%)
Other fractures (acetabulum, clavicle, rib, hand) 7 (12.1%)
Ligament ruptures (achilles, knee) 3 (5.2%)
Shoulder dislocation 2 (3.5%)
Patients (n = 58) Controls (n = 30) χ2 P-value Childhood ADHD Present 37 4 20.32 0.001 Absent 21 26 Adult ADHD Present 36 4 18.94 0.001 Absent 22 26 TABLE 3:
Childhood and adult attention deficit hyperactivity disorder (ADHD) in adult musculoskeletal trauma patients and controls
of adult ADHD was significantly higher (P = 0.001) in those with repeat trauma compared with those with a single trauma (Table 4).
Discussion
Several studies have documented the effect of co-morbidity on survival and the length of hospitalization after trauma, but the effect of pre-existing illnesses or disorders has seldom been reported.26,35 – 39 Studies into the
causative factors relating to injury-prone patients have demonstrated that one specific causative factor is the presence of ADHD. Some studies have shown that children with ADHD are more frequently injured than other children.5 Fischer et al.30 studied
driving behaviour and outcomes in hyperactive children followed into young adulthood and reported significant differences between the hyperactive and control groups in terms of driving behaviour, performance and history of adverse driving outcomes. More of the hyperactive group than the control group had been prosecuted for reckless driving, driving without a license, hit-and-run crashes or their licenses had been suspended or revoked. These findings support those of the present study in terms of the relationship between driving accidents
and ADHD.
Patients with ADHD are admitted more frequently to accident and emergency departments. In the present study, most of the patients who were diagnosed as ADHD told us that they were called ‘clumsy’ by their parents and friends. DiScala et al.26
compared the differences in injuries requiring hospital admission between children with pre-injury ADHD and those with no pre-injury conditions. They reported that transport-related injuries (motor vehicle occupant, pedestrian, bicycle, motorcycle, all-terrain vehicles/recreational vehicles) were more frequent amongst ADHD patients, representing 59.6% of all the injury causes in this group compared with 49.8% in the ‘no pre-injury conditions’ group. As a consequence of the high energy impact of transport-related injuries, the children with ADHD sustained injuries to multiple body regions more frequently, were injured more severely and experienced head injury more often than children who had no pre-injury conditions. This has important consequences in terms of the extent of disability that might result. These findings are similar to those of the present study which found that ADHD was more frequent in patients with high-energy injuries and severe trauma, such as
Adult ADHD
Present Absent χ2 P-value Trauma level High energy (n = 26) 23 3 10.17 0.002 Low energy (n = 32) 14 18 Repeat trauma Present (n = 26) 24 2 18.30 0.001 Absent (n = 32) 12 20 TABLE 4:
Trauma level and incidence of repeat trauma in adult musculoskeletal trauma patients with or without adult attention deficit hyperactivity disorder (ADHD)
femur or vertebra fractures caused by motor vehicle accidents or falls from height.
Bijur et al.40 identified aggression as
opposed to hyperactivity as a cause of injury, but had earlier reported both aggression and hyperactivity as having increased the risk of injury. Aggression was not evaluated as a risk factor in the present study. Langley et al.41 reported that very active, though not
hyperactive, children have a higher risk of injuries than normally active children. Davidson et al.42reported ‘conduct disorder’
as opposed to hyperactivity as a cause of injury.
Hoare and Beattie5 found a significantly
increased rate of attendance at the accident and emergency department for children with ADHD. Even when allowing for greater referral rates in males, boys still attend the accident and emergency department more frequently than girls.43,44We found a similar
result in the present study, with men being more prone to high energy injuries than women. Patients with ADHD were also more likely to attend more than once, although certain socioeconomic factors, especially deprivation, have been implicated in frequent attendance at the accident and emergency department.45
In the present study, four out of 30 controls were diagnosed as having adult ADHD. Although this rate seems high when compared with an overall population rate of 4%, the exact prevalence of ADHD in adults is still unclear. Epidemiological studies of adults in the community who warrant a diagnosis of ADHD have shown that 40% were being treated for other psychiatric diagnoses, whereas only about 10% were identified as having ADHD and were receiving treatment for this condition.19ADHD therefore appears to be
under-diagnosed.
The prevalence rate of 4% reflects only
adults who met the DSM-IV-TR criteria for active ADHD; the actual rate is thought to be higher.19In a study conducted on 966 adults
in whom narrow and broad criteria were used to diagnose ADHD, 2.9% of the sample had ADHD when narrow criteria were used and 16.4% of the sample were found to have ADHD when broad criteria were used.46
Prevalence estimates of ADHD can vary, therefore, depending on the measures used. The rate amongst the controls in the present study is within the range reported in the literature. In addition, ADHD is known to be higher in the adult male population than the adult female population;47 the majority
of the study sample and, therefore, the gender-matched controls consisted of males. When these findings are taken into consideration, a prevalence rate of four out of 30 with ADHD in the control group of the present study seems acceptable. Since the rate of ADHD in the patient group was statistically significantly higher than in the control group, the high rate of ADHD in the controls does not seem to have affected the results or conclusions of the present study.
Many studies have shown a relationship between ADHD and trauma in childhood and many children who have ADHD will continue to have this disorder in adulthood. The present study demonstrates that this relationship between ADHD and trauma also occurs in adults. Patients with repeated traumas, particularly high-energy traumas such as motor vehicle accidents, may need to be referred for psychiatric consultation. One of the limitations of the present study was the sample size; multicentre studies with a greater sample size are needed to clarify the relationship between ADHD and trauma.
Conflicts of interest
No conflicts of interest were declared in relation to this article.
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Author’s address for correspondence
Dr Alper Kaya
Faculty of Medicine, Ufuk University, Mevlana Caddesi, Balgat, Ankara, Turkey. E-mail: alperkaya@yahoo.com
