Original Research

Attention-Deficit/Hyperactivity Disorder in a VA Polytrauma Clinic

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

References

1. Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in U.S. soldiers returning from Iraq. N Engl J Med. 2008;358(5):453-463.

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.

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Discussion

In this study, there was a 10.6% prevalence of ADHD in 690 OEF/OIF/OND combat veterans. This rate is considerably higher than estimates of prevalence of ADHD in adults (4.4%) made from a nationwide survey and worldwide prevalence estimates of 2.5% to 3.5%.^4-6 Still, the current prevalence finding is consistent with a recent finding of ADHD in previous deploying U.S. soldiers military samples (10.4%).¹⁸The high prevalence of ADHD in the current clinic population argues for increased provider awareness of this condition as a possible factor in postdeployment adjustment assessments.

Changes in prevalence estimates of ADHD may represent increased awareness of the condition over this interval of time, professional drift in the application of diagnostic criteria, or changes in societal attitudes about acceptability in pursuing treatment for the condition. For example, in nationwide surveys in 2003, 2007, and 2011, the CDC identified an increase from 7.8% to 9.5% to 11%, respectively, in diagnoses of ADHD in childhood.¹⁹ Also, considering that the current sample was predominantly male and the prevalence of ADHD in males is higher than in females, one might expect a higher ADHD prevalence rate in this study than that in the general population. In this regard, the ADHD prevalence rate in males remains comparable to that estimated by recent CDC survey data.¹⁹

When estimating ADHD population prevalence in the future, it is worth noting that a change in the diagnostic criteria for ADHD has occurred in DSM-5. Specifically, the age at which critical symptoms must be present to make the diagnosis of ADHD has been increased from age 7 years to age 12 years, and the number of critical symptoms to meet hyperactivity-impulsivity criteria has been lowered from 6 to 5 in older adolescents and adults.²⁰ These changes in the diagnostic criteria for ADHD will have the net effect of increasing estimates of prevalence of ADHD.

The 73 individuals with an ADHD diagnoses in this study were found to have less education and be slightly younger than were the veterans who did not have an ADHD diagnosis. This finding is not unexpected, as individuals with ADHD are known to struggle in school and often drop out of high school and pursue alternative means of getting an equivalency degree or certification.²¹ Early departure from high school can be followed by earlier enlistment in the military. Prior studies by Krauss and colleagues found similar findings in an ADHD study of military recruits (ie, they were less likely to have education beyond a high school degree).⁷

ADHD and TBI

Given problems with attention, impulsivity, and high levels of aggressive behaviors associated with ADHD, individuals with ADHD have been found to be at higher risk for accidental injuries, including TBI, than are individuals without ADHD.^21,22 Thus, soldiers with ADHD may be at greater risk for TBI during their time in the military. In the current sample, although veterans with ADHD showed a trend toward having more TBIs prior to joining the military relative to non-ADHD veterans, the veterans with ADHD had a similar rate of TBIs during their time in the military relative to non-ADHD veterans.

Although individuals with ADHD are reported to have a higher prevalence of mental health issues than does the general public, this was not evident in the current sample.²¹ Veterans with ADHD in this study did not have a disproportionate prevalence of PTSD, depression, anxiety, or substance abuse.

There was a nonsignificant trend for more individuals with an ADHD diagnosis compared with those without the diagnosis to report experiencing pain during the 30 days prior to their evaluation in the PC. Although not statistically significant, this finding would not be unexpected, in that individuals with ADHD are known to show less tolerance for frustration relative to that of the general population.²¹ In the current study, reports of pain in the ADHD group correlated with reports of being irritable and easily annoyed (r = .27, P = .024), but no correlation was observed with reports of poor frustration tolerance (r = .04, P = .74). Still, of note, > 90% of the OEF/OIF/OND veterans in this study, regardless of their ADHD diagnosis, reported pain symptoms of some type. The high prevalence of pain symptoms in this sample is consistent with a previous study that found pain to be one of the most common problems in polytrauma patients.¹⁰