Consequences of non-neurological injury in children

Consequences of non-neurological injury in children

Physical injury and disability in children may have secondary consequences for neuropsychological development. The possible causes include secondary neurological insult and chronic stress secondary to altered appearance and psychosocial experiences. Thermal injury and craniofacial injury or abnormality may involve such risks, singly or in combination, that may not be considered when seeking the basis of presenting symptoms in either the acute or chronic stage after insult. Clinical attention is focused upon the primary physical presentation, which is appropriate, but there should be awareness and subsequent evaluation of secondary physical and or psychological insult in children because of the implications for neuropsychological development.

In an early clinical study, Warlow and Hutton (1969) [1] described six children with acute neurological disturbances: Lowered consciousness level, epilepsy or cerebral oedema. The authors concluded that such neurological signs are not uncommon up to 4 months after insult. Recent studies have reported similar findings; Solem et al. (1977) reported 25% of 60 cases had neurological complications [2]; Deveci et al. (2002) found abnormal neurophysical status and abnormal SPECT scans in two children following electrical injury [3].

As with many other conditions, improved acute medical care has lowered mortality from thermal injury in children. In contrast, morbidity is likely to be higher but, as with other populations, estimates are subject to methodological problems of outcome measurement. For example, Warlow and Hutton (1969) suggested that: ‘If … mild cases of early burns encephalopathy have been unrecognised in the past then it follows that most of them must have recovered …’ [1], p. 982]. Unfortunately, that may not always be the case. From the psychological perspective Ramakrishnan et al. (2004) reviewed the outcome of 459 burns patients, concluding ‘In spite of gross disfigurement and sequelae only adolescent children required psychosocial rehabilitation’ [4], p. 145].

Among the problems identified were addiction, school drop-out and violent behaviour. It is reasonable to note the symptom overlap between the effects of neurological and psychological insult. It is notable that treatment was also deemed necessary for the parents of the younger (4–12 years) patients. The effects of maternal mental health upon a child's brain state have been well documented. But methodological problems abound in this field, including short-term follow-up, small sample size, selection bias, lack of standardized outcome measures, high attrition and lack of injury severity control. An additional problem is inadequate age-differentiation and a failure to adopt a neurodevelopmental approach when evaluating outcome. The unique vulnerability of the immature brain may interact with the nature and severity of burn, as well as secondary psychosocial factors, in the development of neuropsychological impairment. Time since insult remains a critical factor in determining outcome in children; deficits and delays not manifest immediately may appear gradually, after a quiescent period, as the consequences of aberrant development unfold. Such potential risks necessitate that assessments of condition and prognosis include age, time and function in order to demonstrate the absence or presence of impairment.

Chronic stress may arise from a variety of acute and chronic sources, including wound care, residual scarring, peer rejection, educational performance or progress difficulties, and may precipitate neuropsychiatric disorder or exacerbate it in already vulnerable individuals. Gilboa (2001) suggested that: ‘It is a continuous traumatic stress reaction, beginning with the traumatic event of the injury, continuing during hospitalisation, which involves severe pain and anxiety, and includes emotional difficulties after discharge, upon returning to normal life’ [5], p. 335]. Stress and emotional disorder clearly have neurophysiological correlations, which may adversely influence development. Brain regions associated with stress include the prefrontal cortex and hippocampus. These areas are associated with fundamental aspects of development in children, including sleep, learning, emotional and social adjustment.

Neuropsychological consequences of burns or craniofacial abnormality in children may arise from a variety of direct and or indirect factors and at varying intervals after injury. Children of all ages require regular and coordinated follow-up from a neurodevelopmental perspective by an inter-disciplinary team. Without appropriate types and levels of assessment and care, the potential for significant morbidity and unnecessarily poor quality of life is substantial.