Refer children for supportive services when recovering from severe illnesses such as traumatic brain injury (TBI) and burns. These conditions require multimodality support for the children to reaccommodate into their social position

Refer children for supportive services when recovering from severe illnesses such as traumatic brain injury (TBI) and burns. These conditions require multimodality support for the children to reaccommodate into their social position: Excerpt from Avoiding Common Pediatric Errors

Author: Ellen Hamburger, MD

What to Do - Take Action

Children recovering from severe injuries, such as TBI and burns, are very likely to experience a range of neuropsychiatric and behavioral responses that require a multidisciplinary approach to assessment and treatment. Posttraumatic stress disorder (PTSD) is the psychiatric disorder that has been most clearly established as a sequela to these injuries, affecting as many as one third of patients. TBI patients are also at high risk for attention deficit disorder andcognitiveimpairment,as wellas the mood, anxiety,andconduct disorders known to affect all patients who suffer severe illness. Intervention with appropriate therapy has improved long-term outcome and function.

The age of the child and the extent and nature of the injury will determine the modalities required to provide support for the child and his or her family in recovery and return to school and home. In most cases, emotional recovery is successful but slower than physical recovery after severe injury. An understanding of the range of sequelae and risk factors for adverse long-term outcome is important in coordinating the necessary multimodal rehabilitative approach. The following are factors are associated with children having a more difficult recovery:
• Prior history of trauma, particularly head injury
• Pre-existing mental health disorder, especially anxiety or depression
• Parental history of trauma
• Serious family problems such as history of abuse or neglect, parental mental illness, or substance abuse
• Chaotic social environment, including extreme poverty or community violence.

Psychologicalevaluationiswarrantedforseverelyinjuredpatients.Children may experience acute stress disorder (ASD) or PTSD. The diagnosis of PTSD is made after a child experiences an injury that causes him or her to react with intense fear, helplessness, or horror and meets symptom criteria in three primary clusters (re-experience of the event, avoidance or numbing, hyperarousal). Children with ASD (which occurs within the month after trauma) have similar symptoms but also experience dissociative symptoms (feelings that they are detached from their bodies, or that their surroundings are unreal or dreamlike). Children with ASD are at high risk for PTSD.

A large percentage of children develop conduct, sleep, mood, or anxiety disorders that require psychiatric intervention through medication and/or cognitive therapy. Child life staff can address the internalizing behaviors that are common in young injured children. Social withdrawal and depressivebehaviorsareoftensuccessfullyaddressedthroughplay.Physicaltherapy to address physical limitations is important for physical as well as psychological recovery from injury. Children often avoid activities that they fear will produce pain, but exercise has been shown to improve long-term outcome in lung function, avoidance of contractures after burns, and overall exercise tolerance. Palliative care is also an important part of rehabilitation. TBI and burn patients often suffer pain long after the injury, which can contribute to depression and inability to return to normal activity.

Social work involvement is critical in the recovery phase. Parents may have difficulties coping with the injury and its aftermath and even suffer PTSD themselves. Understanding the nature of the home environment as well as anticipating challenges in planning for return to school are both important in guiding a successful adaptation to postinjury life for the child and family. Families will likely need help identifying community resources andanticipatingthelongadjustmentperiodthatawaitsthemonreturnhome with their child.

Suggested Readings

Stoddard FJ, Ronefeldt H, Kagan J, et al. Young burned children: the course of acute stress and physiological and behavioral responses. Am J Psychiatry. 2006;163:1084–1090.
Stoddard FJ, Saxe G. Ten-year research review of physical injuries. J Am Acad Child Adolesc Psychiatry. 2001;40(10):1128–1145.
Zatzick DF, Grossman DC, Russo J, et al. Predicting posttraumatic stress symptoms longi tudinally in a representative sample of hospitalized injured adolescents. J Am Acad Child Adolesc Psychiatry. 2006;45(10):1188–1195.

Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

More About Traumatic Brain Injury

• Back to disease: Traumatic Brain Injury: Introduction
• Next Book Extract About Traumatic Brain Injury: Brain Injury, Traumatic (The 5-Minute Pediatric Consult)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

 » Next page: Brain Injury, Traumatic (The 5-Minute Pediatric Consult)

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