Psychiatric Comorbidity

Several studies have reported a risk of new psychiatric disorders following pediatric TBI (Brown et al. 1981; Max et al. 1997a, 1998c). For instance, Bloom et al. (2001) found that 58% of their sample devel oped a novel psychiatric disorder after a TBI. Max et al. (1997b, 1997c, 1997d, 1998e) conducted a series of studies following the development of new psychiatric disorders in a cohort of children with TBI at 3, 6, 12, and 24 months postinjury They found 46% of the participants met criteria for a new psychiatric disorder at 3 months, 24% at 6 months, 37% at 12 months, and 35% at 24 months postinjury. The most common psychiatric diagnoses were opposi-tional defiant disorder (ODD), attention-deficit/hy-peractivity disorder (ADHD), and organic personality syndrome (now termed personality change due to TBI). Factors that predicted the presence of a psychiatric disorder at 2 years postinjury included injury severity, preinjury family functioning, and preinjury psychiatric history. Max et al. (2000, 2001) conducted additional studies specifically addressing the diagnosis of personality change due to TBI. These studies documented that personality change due to TBI is relatively common after severe TBI but rare after mild/moderate TBI. Interestingly, the development of personality change has been found to be predicted by severity of injury, adaptive and intellectual deficits, and secondary ADHD but not by measures of psychosocial adversity, such as family functioning (Max et al. 2000).

The occurrence of externalizing behavior disorders, such as ADHD, ODD, and conduct disorder (CD), has been replicated in other studies. Max et al. (1998d) investigated the prevalence of disruptive behavior disorders following TBI and found that 42% of their sample developed ADHD after the injury and 34% developed ODD/CD. Children who developed ODD/CD had significantly more impaired family functioning than those who did not develop one of these disorders. A separate study showed that persistent ODD symptoms were related to injury severity, whereas ODD symptoms during the first year postinjury were more related to psychosocial variables (Max et al. 1998a). Additional studies have documented the emergence of ADHD symptoms following pediatric TBI (Levin et al. 2007; Massagli et al. 2004; Yeates et al. 2005).

Investigators have also examined the emergence of internalizing disorders following pediatric TBI and have documented the emergence of obsessive-compulsive symptoms (Grados et al. 2008; Vasa et al. 2002), generalized anxiety (Luis and Mittenberg 2002; Vasa et al. 2002), separation anxiety (Luis and Mittenberg 2002; Vasa et al. 2002), and depressed mood (Luis and Mittenberg 2002) after pediatric TBI. Max et al. (1998b) examined the devel opment of posttraumatic stress disorder (PTSD) symptoms following pediatric TBI and found that few children develop full diagnostic criteria for PTSD, although PTSD symptoms are common. Additional studies have documented the emergence of PTSD symptoms after TBI (Gerring et al. 2002; Levi et al. 1999). Predictors of postinjury PTSD symptoms are injury severity and premorbid internalizing symptoms (Gerring et al. 2002; Max et al. 1998b) as well as social disadvantage (Levi et al. 1999).

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