Clinical features

Cognitive and behavioural

The most common long-term outcomes of traumatic brain injury are cognitive and behavioural changes. Immediately after emerging from a coma, the child will be unable to form new memories. The time, from the accident to the time when new memories emerge, is referred to as post-traumatic amnesia. The length of coma and the duration of post-traumatic amnesia are especially important in regard to the extent of cognitive recovery. Moreover, there is a strong inverse relationship between subsequent IQ and duration of coma. The persistence of cognitive deficits is correlated with the duration of post-traumatic amnesia; the more persistent deficits follow more than 3 weeks of post-traumatic amnesia. Persistent verbal memory impairment is reported as long as 10 years after injury in up to one-quarter of those studied. Psychiatric symptoms in adults occur more often following focal frontal-lobe traumatic brain injury than injury to other cerebral areas. In children, Rutter (36) reported behavioural disinhibition after severe closed traumatic brain injury characterized by over-talkativeness, ignoring social conventions, impulsiveness, and poor personal hygiene.

Psychiatric

Psychiatric outcomes can be divided into those that occur during the early phases of recovery and those that occur later. The earliest psychiatric sequelae are found before the termination of post-traumatic amnesia. During this time, behavioural and affective symptoms are linked to the neurological presentation. The most common psychiatric diagnosis is delirium. Symptoms include short attention span, agitation, hallucinations, and disturbances in the sleep-wake cycle.

Subsequent occurrence of post-traumatic psychiatric symptoms is linked to the severity of the injury, its location, the child's behavioural and emotional features prior to the accident, and the psychosocial interactions of the family members during the recovery phases. The more severe the traumatic brain injury, the greater the likelihood of psychiatric sequelae. All children in one prospective study of severely injured children who had premorbid psychiatric conditions showed post-traumatic psychiatric disorders. k? Moreover, over half the children in this group who had no premorbid symptoms prior to the accident had developed psychiatric symptoms during a 28-month, follow-up period. The greatest premorbid risks for psychiatric disorder were previous difficulties with impulse control and disruptive behaviour. In addition, a prior history of family dysfunction increased the risk for later symptomatology. The range of disorders (38,39 and40) includes attention-deficit hyperactivity disorder, disruptive behaviour,(4!) post-traumatic mood disorders (both depressive and manic symptoms), post-traumatic stress disorder, (42ยป and family dysfunction.(43,44)

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