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Traumatic Brain Injury in Children and Adolescents

Traumatic Brain Injury in Children and Adolescents

Traumatic brain injury (TBI) in children and adolescents (hereafter referred to as children) is a major public health problem. The incidence of TBI in children younger than 15 years is 400 cases per 100,000 each year. Psychiatrists have a crucial role in the management of young persons who have a TBI.

In children with a TBI or other injuries, such as orthopedic injury fractures, there is a high rate of preinjury psychiatric disorders, which may predispose them to being injured. Furthermore, postinjury psychiatric disorders are also common and should be managed.1 It is important for psychiatrists to be knowledgeable about pediatric TBI not only because it is so common but also because understanding the correlates of new-onset disorders might shed light on pathophysiological mechanisms of corresponding psychiatric disorders in children who are not injured.

Pediatric TBI psychiatric research studies have examined new-onset psychiatric disorders in general as well as specific new-onset psychiatric disorders. The rationale for the more general approach (lumping) has been to determine patterns that are common to problematic versus relatively benign psychiatric outcomes. Furthermore, new-onset psychiatric disorders are heterogeneous, and comorbidity is common; thus, only large studies have sufficient power to analyze correlates of specific disorders. The reasoning for investigating more specific psychiatric syndromes or symptoms (splitting) is related to the need to advance understanding in pathophysiology, appropriate diagnosis, and treatment.

What new information does this article provide?

? This article reviews preinjury and postinjury psychiatric disorders in terms of clinical phenomenology, neuroimaging lesion correlates, and psychopharmacological therapy and psychotherapeutic approaches.

What are the implications for psychiatric practice?

? The primary implication is a call to practitioners to embrace the challenge of treating children with a TBI, given the concentration of preinjury and postinjury psychopathology in these patients.

The term "novel psychiatric disorders" was coined to facilitate the study of postinjury psychiatric disorders because of the high frequency of preinjury psychiatric disorders in injured children. Novel psychiatric disorders encompass disorders that emerge after injury in children with no preinjury psychiatric disorder and also new disorders that emerge in children with preinjury disorders. For example, a child with preinjury ADHD in whom MDD develops after the injury would be considered to have a novel psychiatric disorder, while a child with preinjury MDD in whom a new episode of depression develops would not be classified as such.

Depending on the postinjury time interval analyzed, the novel psychiatric disorder has been significantly related to severity of the TBI, preinjury family function, intensity of family psychiatric history, socioeconomic status, lifetime preinjury psychiatric disorder of the child, and preinjury adaptive function. Other than severity of the TBI, all these correlates of a novel psychiatric disorder are integral considerations in case formulations conducted by psychiatrists on uninjured patients.

Injury severity is typically classified according to the Glasgow Coma Scale (GCS), which is a measure of responsiveness in the acute postinjury phase. The scale ranges from 15, which represents normal responsiveness, to 3, which indicates complete unresponsiveness in eye opening, verbalization, and motor function. Severe TBI is typically defined as a GCS score of 3 to 8, a score of 9 to 12 suggests moderate TBI, and mild TBI is a score of 13 to 15. Mild TBI is further classified, depending on the presence or absence of brain neuroimaging evidence of intracranial damage, into "complicated mild" TBI and "uncomplicated mild" TBI. Accumulated findings have shown that novel psychiatric disorders occur after severe TBI, moderate or mild TBI, and orthopedic injury fracture controls in 54% to 63%, 10% to 21%, and 4% to 14% of children, respectively.1

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