How to manage Attention Deficit Hyperactivity Disorder (ADHD) in a patient who has suffered a concussion?

Managing ADHD Post-Concussion

Patients with ADHD who are taking stimulant medications should continue their ADHD treatment during concussion recovery, as stimulants appear to facilitate symptom resolution and do not prolong recovery time. 1

Acute Phase Management (First 24-48 Hours)

• Implement brief cognitive and physical rest for 24-48 hours only, then transition immediately to active rehabilitation rather than prolonged rest, which can worsen outcomes. 2, 3
• Continue ADHD stimulant medications during the acute phase if the patient was taking them pre-injury, as discontinuation may worsen both ADHD and concussion symptoms. 1
• Avoid NSAIDs and use acetaminophen-only for analgesia due to theoretical intracranial bleeding risk. 3

Active Rehabilitation Phase (After 48 Hours)

Sub-Symptom Threshold Aerobic Exercise

• Initiate graded aerobic exercise below the symptom exacerbation threshold at least once weekly for minimum 4 weeks, which demonstrates positive effects on headaches, executive dysfunction, and emotional symptoms. 4, 5
• Progress intensity and complexity gradually while monitoring for symptom exacerbation. 2

Cognitive Rest and School Accommodations

• Implement graduated return-to-learn with specific accommodations: shortened school days, reduced workloads, extended time for assignments and tests, and postponement of standardized testing. 2, 4
• Avoid complete cognitive rest beyond 48 hours, as this may impair recovery. 5
• Reduce exposure to screens, video games, and loud music if these exacerbate symptoms. 2

ADHD-Specific Considerations

Medication Management

• Do not discontinue stimulant medications during concussion recovery, as research shows athletes with ADHD taking psychostimulants have similar symptom resolution times to non-ADHD controls, while untreated ADHD patients have prolonged recovery. 1
• Athletes with treated ADHD show equivalent visual motor speed and reaction time scores to controls post-concussion, while untreated ADHD patients show persistent deficits. 6

Neurocognitive Testing Interpretation

• Expect lower baseline scores on verbal memory, visual memory, visual motor speed, and reaction time in patients with ADHD, even when treated with stimulants. 6
• Use ADHD-specific baseline comparisons rather than general population norms when interpreting post-concussion neurocognitive testing. 6
• Youth with ADHD show greater magnitude of decline in verbal memory and visual motor speed from pre-injury to post-injury testing compared to controls. 7

Management of Persistent Symptoms (Beyond 3 Weeks)

Interdisciplinary Coordinated Rehabilitation

• Implement treatment from at least two healthcare disciplines meeting at least weekly for minimum 4 weeks for symptoms persisting beyond 3 weeks, as this demonstrates strongest evidence for persistent symptoms. 4
• This approach shows positive effects on overall symptom burden, physical functioning, emotional symptoms, quality of life, and return to work outcomes. 4

Domain-Specific Interventions

• Initiate individual cognitive behavioral therapy at least 1 hour weekly for minimum 4 weeks to address emotional reactivity, concentration difficulties, and memory issues that overlap with ADHD symptoms. 4
• Implement vestibular rehabilitation (habituation, adaptation, balance training) if vestibular dysfunction is present. 4, 5
• Provide cervical spine manual therapy for persistent neck pain and headaches. 4, 5
• Obtain formal oculomotor evaluation for vergence, accommodative, and eye movement dysfunction given concentration difficulties. 4

Return-to-Play Protocol

• No return to play on the day of injury under any circumstances. 2
• Use a graded 5-step program with each step taking minimum 24 hours: light aerobic exercise → sport-specific training → non-contact drills → full contact practice → return to normal activity. 2
• Athletes must be completely asymptomatic off all medications before beginning the return-to-play protocol. 2
• For any symptom recurrence during the graded protocol, return to the previous asymptomatic level. 2

Critical Pitfalls to Avoid

• Do not discontinue ADHD stimulant medications based on the assumption they will prolong recovery—evidence shows the opposite effect. 1
• Do not assume all cognitive symptoms are concussion-related in patients with pre-existing ADHD, as untreated ADHD compounds executive dysfunction. 4
• Do not continue passive treatments indefinitely—active rehabilitation with graded exercise is essential, especially beyond 3 weeks. 4
• Do not allow return to play while taking any medications for concussion symptoms, though ADHD medications prescribed pre-injury should be continued. 2

Prognostic Factors

• ADHD diagnosis is associated with 16-17% longer recovery time for both return-to-learn and return-to-sport compared to non-ADHD athletes. 8
• Female gender, high early symptom burden, and younger age are additional risk factors for prolonged recovery in ADHD patients. 4, 8
• However, one large prospective cohort study found no difference in recovery times between ADHD and non-ADHD adolescents, suggesting variability in outcomes. 9
• Stimulant treatment appears to mitigate the prolonged recovery associated with ADHD diagnosis. 1