**3. Neurobehavioral consequences of moderate and severe closed pediatric TBI**

Patients who have suffered moderate or severe TBI exhibit a broad range of possible outcomes, and it is generally not possible to predict the extent of recovery in the initial weeks after the trauma. Traditionally, children have been reported to have better outcomes than adults after TBI. But, unlike in adults, in children the effects of the brain injury on brain function interact with the maturation or development of the child. Skills that are emerging or developing may be affected differently by brain injury from skills that are already established.

However, while fewer focal deficits may be apparent, children appear to develop deficiencies across virtually all areas of higher cognitive functioning. These deficits may not become apparent until later in the child's development. Children with TBI face difficulties because of impaired new learning, inability to take on social cues, and behavioral, educational and schooling problems. Determining the combination of cognitive, behavioral and physical deficits is an important first step in setting goals for rehabilitation.

In our studies of the long-term sequelae of TBI the neurological and neuropsychological assessment of 283 patients aged from 5 to 14 years (201 boys and 82 girls) suffered moderate or severe closed TBI (contusion or diffuse axonal injury) was performed in the period from 6 months to 4 years after TBI [18, 19]. The diagnosis was confirmed during hospitalization in the acute period of head injury. The principal criteria for the severity of the TBI were the Glasgow Coma Scale score and the loss of consciousness duration. Moderate closed head injury was diagnosed in 150 patients (53%) and severe injury in 133 (47%).

During the long-term period of TBI all patients were referred with various complaints, the most common being:


Secondary nocturnal enuresis developed in 16% of patients post-injury and speech and language disorders in 14%.

**189**

of view.

*Neurobehavioral, Cognitive, and Paroxysmal Disorders in the Long-Term Period of Pediatric…*

functioning, adaptive behavior and academic achievement (**Table 1**).

a change in routine and forgetting where things have been placed.

tion, attention control, flexibility, social learning, and self-control.

were suggested to have an impact on ongoing development [24].

There is a direct relationship between general measures of intelligence (IQ ) and the severity of TBI, with IQ being depressed for the more severe end of the severe TBI spectrum. In the milder end of severe TBI, and in moderate TBI, measures of IQ usually return to the normal range and may return to pre-trauma levels [20–22]. Despite this, many children who have suffered severe or moderate closed TBI have significant specific neuropsychological deficits that interfere with optimal cognitive

In moderate or severe cases of TBI, the cognitive functions that are most vulner-

Some of the cognitive disorders are attributable to the specific focus of damage. But residual problems are commonly the consequence of diffuse damage or involvement of axial brain structures that modulate cortical functions. This combination of specific cortical damage and diffuse damage to axial and subcortical structures is responsible for deficits in different higher cerebral functions. Neuropsychological assessments can help to delineate the extent and type of cognitive disability that a

**Memory** is easily damaged by TBI because several brain structures are involved in information-processing, storage, and retrieval. Short-term memory loss is the most common and most troublesome type of memory problem. This can manifest itself as forgetting new information, difficulties in scholastic learning and mastering new skills, repeating the same question over and over, getting details mixed up, forgetting

**Speed of information-processing.** Slowing down the speed at which the brain

**Attention and concentration.** A reduced concentration span after TBI is very common, as is a reduced ability to pay attention to more than one task at the same time. These problems are usually caused by damage to the frontal lobe. Attentional problems tend to get worse when the person is tired, stressed, or worried. When there are problems with concentration, it is difficult to follow instructions, plan

**EF: planning, organizing and problem-solving.** EF is associated with the frontal lobes, which are especially fragile in TBI. EF includes goal-orientated behavior, initia-

In general, executive skills are required in novel and complex situations, where routine responses do not exist. Damage to the frontal lobe can affect these skills, resulting in a subtle set of deficits which have been called "dysexecutive syndrome." This covers problems in making long-term plans, goal setting, and initiating steps to achieve objectives. The ability to stand back and take an objective view of a situation may be lacking, as may the ability to see anything from another person's point

A number of studies have shown persistent cognitive and behavioral deficits following pediatric TBI [17, 23, 24]. A 2-year follow-up suggested that children sustaining severe TBI are particularly vulnerable to impairments in EF. While some recovery took place with time since injury, deficits remained 2 years post-injury and

In our clinical sample, the majority of patients who had suffered traumatic frontal lobe lesions demonstrated various manifestations of dysexecutive syndrome,

performs information-processing is often due to diffuse axonal damage of the brain pathways. This results in problems such as not understanding fast speech, being unable to absorb instructions first time around, and not being able to quickly

able are memory, attention, speed of information processing, visuospatial and perceptual abilities, language skills, EF in particular. **Table 2** outlines the peculiarities of the TBI effects on the cognitive functioning and development of children

*DOI: http://dx.doi.org/10.5772/intechopen.93733*

(**Table 2**).

child may experience.

formulate a reply to a question.

ahead, or be organized.

#### *Neurobehavioral, Cognitive, and Paroxysmal Disorders in the Long-Term Period of Pediatric… DOI: http://dx.doi.org/10.5772/intechopen.93733*

There is a direct relationship between general measures of intelligence (IQ ) and the severity of TBI, with IQ being depressed for the more severe end of the severe TBI spectrum. In the milder end of severe TBI, and in moderate TBI, measures of IQ usually return to the normal range and may return to pre-trauma levels [20–22]. Despite this, many children who have suffered severe or moderate closed TBI have significant specific neuropsychological deficits that interfere with optimal cognitive functioning, adaptive behavior and academic achievement (**Table 1**).

In moderate or severe cases of TBI, the cognitive functions that are most vulnerable are memory, attention, speed of information processing, visuospatial and perceptual abilities, language skills, EF in particular. **Table 2** outlines the peculiarities of the TBI effects on the cognitive functioning and development of children (**Table 2**).

Some of the cognitive disorders are attributable to the specific focus of damage. But residual problems are commonly the consequence of diffuse damage or involvement of axial brain structures that modulate cortical functions. This combination of specific cortical damage and diffuse damage to axial and subcortical structures is responsible for deficits in different higher cerebral functions. Neuropsychological assessments can help to delineate the extent and type of cognitive disability that a child may experience.

**Memory** is easily damaged by TBI because several brain structures are involved in information-processing, storage, and retrieval. Short-term memory loss is the most common and most troublesome type of memory problem. This can manifest itself as forgetting new information, difficulties in scholastic learning and mastering new skills, repeating the same question over and over, getting details mixed up, forgetting a change in routine and forgetting where things have been placed.

**Speed of information-processing.** Slowing down the speed at which the brain performs information-processing is often due to diffuse axonal damage of the brain pathways. This results in problems such as not understanding fast speech, being unable to absorb instructions first time around, and not being able to quickly formulate a reply to a question.

**Attention and concentration.** A reduced concentration span after TBI is very common, as is a reduced ability to pay attention to more than one task at the same time. These problems are usually caused by damage to the frontal lobe. Attentional problems tend to get worse when the person is tired, stressed, or worried. When there are problems with concentration, it is difficult to follow instructions, plan ahead, or be organized.

**EF: planning, organizing and problem-solving.** EF is associated with the frontal lobes, which are especially fragile in TBI. EF includes goal-orientated behavior, initiation, attention control, flexibility, social learning, and self-control.

In general, executive skills are required in novel and complex situations, where routine responses do not exist. Damage to the frontal lobe can affect these skills, resulting in a subtle set of deficits which have been called "dysexecutive syndrome." This covers problems in making long-term plans, goal setting, and initiating steps to achieve objectives. The ability to stand back and take an objective view of a situation may be lacking, as may the ability to see anything from another person's point of view.

A number of studies have shown persistent cognitive and behavioral deficits following pediatric TBI [17, 23, 24]. A 2-year follow-up suggested that children sustaining severe TBI are particularly vulnerable to impairments in EF. While some recovery took place with time since injury, deficits remained 2 years post-injury and were suggested to have an impact on ongoing development [24].

In our clinical sample, the majority of patients who had suffered traumatic frontal lobe lesions demonstrated various manifestations of dysexecutive syndrome,

*Advancement and New Understanding in Brain Injury*

different stages of brain development.

**pediatric TBI**

rehabilitation.

In general, a favorable outcome is possible in children more often than adults even after severe TBI. Nevertheless, neurological, cognitive, behavioral, emotional, and socio-psychological consequences can be observed in the long-term period of TBI in children and adolescents. The complexity of pediatric TBI is due to the heterogeneity of its pathophysiology and depends on the age of impact, influencing

**3. Neurobehavioral consequences of moderate and severe closed** 

differently by brain injury from skills that are already established.

150 patients (53%) and severe injury in 133 (47%).

4. attention deficit and distractibility (74%)

2. chronic fatigability and decrease in endurance (88%)

complaints, the most common being:

3.memory problems (82%)

6.behavioral problems (62%)

7.motor restlessness (60%)

speech and language disorders in 14%.

8. sleep disorders (61%).

1.frequent headaches (95% of cases)

Patients who have suffered moderate or severe TBI exhibit a broad range of possible outcomes, and it is generally not possible to predict the extent of recovery in the initial weeks after the trauma. Traditionally, children have been reported to have better outcomes than adults after TBI. But, unlike in adults, in children the effects of the brain injury on brain function interact with the maturation or development of the child. Skills that are emerging or developing may be affected

However, while fewer focal deficits may be apparent, children appear to develop deficiencies across virtually all areas of higher cognitive functioning. These deficits may not become apparent until later in the child's development. Children with TBI face difficulties because of impaired new learning, inability to take on social cues, and behavioral, educational and schooling problems. Determining the combination of cognitive, behavioral and physical deficits is an important first step in setting goals for

In our studies of the long-term sequelae of TBI the neurological and neuropsychological assessment of 283 patients aged from 5 to 14 years (201 boys and 82 girls) suffered moderate or severe closed TBI (contusion or diffuse axonal injury) was performed in the period from 6 months to 4 years after TBI [18, 19]. The diagnosis was confirmed during hospitalization in the acute period of head injury. The principal criteria for the severity of the TBI were the Glasgow Coma Scale score and the loss of consciousness duration. Moderate closed head injury was diagnosed in

During the long-term period of TBI all patients were referred with various

5.learning difficulties at school with academic underachievement (73%)

Secondary nocturnal enuresis developed in 16% of patients post-injury and

**188**


#### **Table 1.**

*Impairments in behavioral adjustment, school education, and social competence in the long-term following traumatic brain injury.*

including poor planning and organizational skills, problems with initiation/inhibition, impaired problem-solving skills, inability to shift mental sets (inflexibility, perseverations), attention disturbances and impulsivity, impaired working memory, impaired temporal organization of behavior, impaired social behavior and affective changes, and disturbances of motor control.

Children with moderate to severe TBI have displayed poorer outcomes compared to children with orthopedic injuries in all neuropsychological domains at an extended follow-up (mean 4 years). Some recovery occurred during the first year post injury, but recovery reached a plateau after that time. Further recovery was uncommon after the first year [25]. Deficits in EF, pragmatic language skills and social problem-solving were the long-term social outcomes [26].

**Speech and language disorders.** Motor speech disorders are common in the acute period of TBI but tend to show considerable improvement with time. They include oral-motor apraxia, dysarthria, and difficulties with breath control resulting in short length of utterance, whispering, or a monotonous voice [27].

Language function may be impaired secondary to cognitive dysfunction or specific language deficits. Disorganized language secondary to impaired cognition is most common following TBI in its acute period. Although classic aphasias are rarely seen in pediatric TBI, aphasic symptoms are. These include the inability to name objects or remember names, word-retrieval problems, and auditory and reading comprehension deficits [28].

**191**

also very common after TBI.

Perceptual and motor skill

Executive functioning

**Table 2.**

*Neurobehavioral, Cognitive, and Paroxysmal Disorders in the Long-Term Period of Pediatric…*

learning required in school increases. Attention a. Deficits in the focus, division, and ability to sustain attention may mean distractibility from play, study, or road safety.

Memory a. Young children are unlikely to report a difficulty spontaneously.

d. The task is to acquire skills.

language development.

concentration.

Processing speed a. Decrement in processing speed which can be mistakenly attributed to lack of

b. Child may have difficulty developing attentional control.

b. The younger child has acquired less knowledge previously.

up—a minor problem can develop into a major difficulty.

5–6 years are likely to regain these skills due to plasticity.

Language a. Language is central to the child's sociocultural and intellectual development.

a. Problems are common in the acute period of TBI.

adversely affect social and scholastic functioning.

a. Longer term difficulty with executive skill development.

b. This impairment will have a pervasive effect on education as the pace of

c. New learning deficits can have a cumulative effect as the child fails to keep

b. Children losing language due to left hemisphere damage before the age of

c. Complete recovery is less likely with injury after the critical period of

b. Psychomotor slowness and dyspraxia may develop after TBI, which can

b. Frontal lobes are still developing late into the second decade of life.

c. Difficulties may become apparent in later childhood and adolescence.

Among our pediatric patients, in the long term after moderate or severe closed TBI only 14% had speech and language problems, including aphasic symptoms in 8% and dysarthric symptoms in 6% of cases. Impairments in communication may include slowed speech, dysfluency, word-finding difficulties, insufficient quality of conversation (producing fewer words or sentences with simple structures, tendency to use gestures while speaking), and poor comprehension of complex or long expressions. Thus, a clear difference between children and adults is that while the effects of the TBI are immediately obvious in adults, children's development is disordered after

**Motor disorders.** Severe motor deficits, including hemiparesis and impaired balance and steadiness are common in the acute period of TBI in children, with rapid recovery occurring in the first weeks or months post-injury. It is only in children who sustain very severe TBI that such motor deficits persist. Although motor outcome in the mild end of the severe TBI group is generally good, abilities rarely return to normal. Even if a classic motor examination appears normal, there will usually be deficits related to speed of performance [29]. Balance problems are

injury and some deficits may take a considerable time to appear.

*Effects of traumatic brain injury on cognitive functioning and development in children.*

*DOI: http://dx.doi.org/10.5772/intechopen.93733*

*Neurobehavioral, Cognitive, and Paroxysmal Disorders in the Long-Term Period of Pediatric… DOI: http://dx.doi.org/10.5772/intechopen.93733*


#### **Table 2.**

*Advancement and New Understanding in Brain Injury*

a. Irritability, temper tantrums, episodes of aggressive behavior

b. Impulsivity, disinhibition, physical restlessness

c. Fluctuations of mood

d. Impaired goal-directed behavior, decreased interest in the achievement of good results in different tasks and

e. Indecision, restraint, feelings of inferiority and

f. Dependent on others, unable to stick up for self

g. Does not perceive entirely the results of his/ her behavior, does not modify his/her reactions

activities

failure

**Table 1.**

*traumatic brain injury.*

including poor planning and organizational skills, problems with initiation/inhibition, impaired problem-solving skills, inability to shift mental sets (inflexibility, perseverations), attention disturbances and impulsivity, impaired working memory, impaired temporal organization of behavior, impaired social behavior and affective

*Impairments in behavioral adjustment, school education, and social competence in the long-term following* 

**Behavior School education Social contacts and relations** 

a. Academic underachievement, accumulated knowledge is dissimilar and fragmentary

b. Difficulties in entering schoolwork, poor performance with inconsistency and inflexibility

c. Slowed thinking, difficulties in remembering new information and sustaining attention on tasks,

d. Inaccurate, makes a lot of careless mistakes, fails to finish

e. Unable to use other people's help to complete schoolwork or other

f. Difficulties with use of acquired information and skills, drawing conclusions and generalizations

distractibility

assignments

assignments

**with peers**

interactions

others

ing treatment

a. Difficulties in co-operating with others and in understanding the rules of social

b. Poor judgment and deficient self-control leading to mistakes in contacts with

c. Limited social activity due to becoming easily tired, lack of energy, residual neurological deficit, ongo-

d. Social activities (such as hobbies, games, sports, trips etc.) are limited or avoided due to behavioral and cognitive difficulties

e. Is behind peers in the acquisition of independent behaviors and skills socially

f. Loss of friends, increased risk of social isolation

valued for age

Children with moderate to severe TBI have displayed poorer outcomes compared to children with orthopedic injuries in all neuropsychological domains at an extended follow-up (mean 4 years). Some recovery occurred during the first year post injury, but recovery reached a plateau after that time. Further recovery was uncommon after the first year [25]. Deficits in EF, pragmatic language skills and

**Speech and language disorders.** Motor speech disorders are common in the acute period of TBI but tend to show considerable improvement with time. They include oral-motor apraxia, dysarthria, and difficulties with breath control resulting

Language function may be impaired secondary to cognitive dysfunction or specific language deficits. Disorganized language secondary to impaired cognition is most common following TBI in its acute period. Although classic aphasias are rarely seen in pediatric TBI, aphasic symptoms are. These include the inability to name objects or remember names, word-retrieval problems, and auditory and reading

social problem-solving were the long-term social outcomes [26].

in short length of utterance, whispering, or a monotonous voice [27].

changes, and disturbances of motor control.

**190**

comprehension deficits [28].

*Effects of traumatic brain injury on cognitive functioning and development in children.*

Among our pediatric patients, in the long term after moderate or severe closed TBI only 14% had speech and language problems, including aphasic symptoms in 8% and dysarthric symptoms in 6% of cases. Impairments in communication may include slowed speech, dysfluency, word-finding difficulties, insufficient quality of conversation (producing fewer words or sentences with simple structures, tendency to use gestures while speaking), and poor comprehension of complex or long expressions. Thus, a clear difference between children and adults is that while the effects of the TBI are immediately obvious in adults, children's development is disordered after injury and some deficits may take a considerable time to appear.

**Motor disorders.** Severe motor deficits, including hemiparesis and impaired balance and steadiness are common in the acute period of TBI in children, with rapid recovery occurring in the first weeks or months post-injury. It is only in children who sustain very severe TBI that such motor deficits persist. Although motor outcome in the mild end of the severe TBI group is generally good, abilities rarely return to normal. Even if a classic motor examination appears normal, there will usually be deficits related to speed of performance [29]. Balance problems are also very common after TBI.

In our cohort of patients, neurological assessment revealed hemiparesis in only 4% and symptoms of ataxia in 46%. The severity of these motor disorders was defined as mild or moderate. However, 100% of children in the long-term period following moderate or severe closed TBI manifested balance problems and subtle neurological signs when examined using Denckla's battery for gross and fine motor functions [30]. Like children with ADHD, they demonstrated poor performance in both types of this battery tasks, including walking a line and sustaining postures/stations, or repetitive or successive movements for hands and feet (fine motor proficiency).

**Psychiatric disorders.** Pediatric TBI is associated with increased risk for the development of psychiatric disorders. The rates of newly diagnosed psychiatric disorders among pediatric patients suffered TBI were as high as 49% compared with 13% in samples of children with orthopedic injury [31]. The psychiatric sequelae of TBI, both behavioral (externalizing) and emotional (internalizing), vary with the severity and location of injury, the phase of recovery, the premorbid conditions and personality of the patient, and the psychosocial environment [9, 32].

Our study included 104 adolescent patients (58 male and 46 female) aged 12 to 19 years, who were examined within 6 months to 4 years after undergoing closed TBI of moderate and severe degrees [19]. The presence and severity of psychiatric disorders was evaluated before and after the TBI. In the long-term period of TBI, emotional and behavioral disorders were diagnosed in 55% of the adolescent patients (**Table 3**). Among internalizing disorders, a high percentage (30%) of patients with anxiety disorders (simple phobias, obsessive-compulsive and generalized anxiety disorders) was found. Mood disorders in the form of depressive states (17%) were two times more common in girls than in boys. In the majority of cases mood disorders and anxiety disorders developed after TBI—that is, TBI served as a causative factor for their development.

Attention deficit hyperactivity disorder (ADHD) occurred in 30% of the examined patients, with less frequent conduct disorder (9%) and oppositional defiant disorder (6%). It should be noted that the manifestations of ADHD in all cases were observed even before TBI, as well as most cases of conduct disorder and oppositional-defiant behavior. Thus, the presence of externalizing disorders before TBI demonstrates their role as premorbid and predisposing conditions and a serious risk factor for TBI. On the other hand, in all those cases a significant deterioration of behavior was observed after the TBI compared with degree of behavioral problems before the injury.

ADHD, defined by developmentally inappropriate and impairing levels of inattention and/or hyperactivity-impulsivity in multiple settings, is reported to be the most common externalizing psychiatric disorder among children with a history of TBI, with a prevalence of about 20–30% [31, 33], compared with the pediatric population prevalence of 5–8%. The studies have demonstrated that children with a history of TBI, even those with less severe injuries, have an increased risk for the development of new-onset attention problems even many years after injury. TBI severity was correlated with increased risk of secondary ADHD with strongest associations in severe TBI. Additional findings about the association of poor family functioning with the development of attention problems after TBI support the importance of allocating resources to the injured child's family throughout recovery [33].

Neurobehavioral effects from TBI differed by age at injury. Preschool children showed increasing ADHD and affective problems during the first year after injury [34]. Younger age at TBI was found to be a risk factor for adverse outcomes in specific psychosocial and EF domains. Preschoolers and school-age children were vulnerable to TBI adverse effects in terms of reduced emotional control, elevated emotional and affective symptoms, and behavior problems [35]. These

**193**

*Neurobehavioral, Cognitive, and Paroxysmal Disorders in the Long-Term Period of Pediatric…*

Anxiety disorders 30 5 25 Mood disorders 17 2 15 Attention deficit hyperactivity disorder 30 30 — Oppositional defiant disorder 6 5 1 Conduct disorder 9 7 2 *Note: The gray shade in Table 3 illustrates prevailing of firstly diagnosed externalizing psychiatric disorders in* 

**with the disorder**

**% of patients with the disorder**

**After the TBI**

**Before the TBI**

findings regarding attention and emotional control are of particular importance for later self-regulation of behavior and academic achievements after TBI [36]. Executive dysfunction and psychosocial difficulties are likely to contribute to the lower functional academic skills in younger children and emergence of increased

*Emotional and behavioral disorders in adolescents aged 12–19 years, developed before and after closed* 

Thus, TBI is a major cause of neurobehavioral disability among children and adolescents. Studies of outcomes 1 to 3–4 years post-injury reveal that moderate or severe pediatric TBI leads to difficulties in adaptive functioning, behavioral problems, deficits in academic and cognitive skills [9, 11–13, 15–29, 31–33]. Neurobehavioral sequelae frequently fail to resolve completely over time and thus are of particular concern to children's parents, teachers and health care professionals. Poor outcomes of TBI sustained in early childhood may be explained considerably by the timing of injury in a period of rapid brain and behavioral development [24, 38]. Identification of vulnerability periods to the effects of TBI is crucial to promote aware-

ness of appropriate referral for rehabilitation and school-based services [38].

**4. Paroxysmal disorders in the long-term period of pediatric TBI**

significantly increase in the presence of paroxysmal disorders.

is a focus of research and clinical attention [39–41].

The vulnerability of structures of the immature brain associated with TBI can be also manifested in paroxysmal disorders: post-traumatic headache, post-traumatic epilepsy, subclinical epileptiform activity on the EEG. It is noteworthy, cognitive and behavioral disorders in children and adolescents in the long-term period of TBI

**Post-traumatic headache (PTH)**. Headache following traumatic brain injury (TBI) of any severity has been the most common physical symptom described and

It is easy to establish the relationship between a headache and TBI when the headache develops immediately or in the first days after trauma has occurred. On the other hand it is very difficult when a headache develops weeks or even months after trauma, especially when the majority of these headaches have the pattern of tension-type headache and the prevalence of this type of headache in the population is very high. Frequently, headache that results from head trauma is accompanied by other symptoms such as dizziness, difficulty in concentration, fatigue, anxiety and insomnia. This constellation of symptoms is known as the post-traumatic or postconcussion syndrome; among them, headache is usually the most prominent [42].

*DOI: http://dx.doi.org/10.5772/intechopen.93733*

**Emotional and behavioral disorders Total (%) of patients** 

*patients before the TBI and internalizing psychiatric disorders after the TBI.*

academic problems years after TBI [37].

**Table 3.**

*traumatic brain injury.*

*Neurobehavioral, Cognitive, and Paroxysmal Disorders in the Long-Term Period of Pediatric… DOI: http://dx.doi.org/10.5772/intechopen.93733*


*Note: The gray shade in Table 3 illustrates prevailing of firstly diagnosed externalizing psychiatric disorders in patients before the TBI and internalizing psychiatric disorders after the TBI.*

#### **Table 3.**

*Advancement and New Understanding in Brain Injury*

motor proficiency).

causative factor for their development.

problems before the injury.

In our cohort of patients, neurological assessment revealed hemiparesis in only 4% and symptoms of ataxia in 46%. The severity of these motor disorders was defined as mild or moderate. However, 100% of children in the long-term period following moderate or severe closed TBI manifested balance problems and subtle neurological signs when examined using Denckla's battery for gross and fine motor functions [30]. Like children with ADHD, they demonstrated poor performance in both types of this battery tasks, including walking a line and sustaining postures/stations, or repetitive or successive movements for hands and feet (fine

**Psychiatric disorders.** Pediatric TBI is associated with increased risk for the development of psychiatric disorders. The rates of newly diagnosed psychiatric disorders among pediatric patients suffered TBI were as high as 49% compared with 13% in samples of children with orthopedic injury [31]. The psychiatric sequelae of TBI, both behavioral (externalizing) and emotional (internalizing), vary with the severity and location of injury, the phase of recovery, the premorbid conditions and

Our study included 104 adolescent patients (58 male and 46 female) aged 12 to 19 years, who were examined within 6 months to 4 years after undergoing closed TBI of moderate and severe degrees [19]. The presence and severity of psychiatric disorders was evaluated before and after the TBI. In the long-term period of TBI, emotional and behavioral disorders were diagnosed in 55% of the adolescent patients (**Table 3**). Among internalizing disorders, a high percentage (30%) of patients with anxiety disorders (simple phobias, obsessive-compulsive and generalized anxiety disorders) was found. Mood disorders in the form of depressive states (17%) were two times more common in girls than in boys. In the majority of cases mood disorders and anxiety disorders developed after TBI—that is, TBI served as a

Attention deficit hyperactivity disorder (ADHD) occurred in 30% of the examined patients, with less frequent conduct disorder (9%) and oppositional defiant disorder (6%). It should be noted that the manifestations of ADHD in all cases were observed even before TBI, as well as most cases of conduct disorder and oppositional-defiant behavior. Thus, the presence of externalizing disorders before TBI demonstrates their role as premorbid and predisposing conditions and a serious risk factor for TBI. On the other hand, in all those cases a significant deterioration of behavior was observed after the TBI compared with degree of behavioral

ADHD, defined by developmentally inappropriate and impairing levels of inattention and/or hyperactivity-impulsivity in multiple settings, is reported to be the most common externalizing psychiatric disorder among children with a history of TBI, with a prevalence of about 20–30% [31, 33], compared with the pediatric population prevalence of 5–8%. The studies have demonstrated that children with a history of TBI, even those with less severe injuries, have an increased risk for the development of new-onset attention problems even many years after injury. TBI severity was correlated with increased risk of secondary ADHD with strongest associations in severe TBI. Additional findings about the association of poor family functioning with the development of attention problems after TBI support the importance of allocating

Neurobehavioral effects from TBI differed by age at injury. Preschool children

showed increasing ADHD and affective problems during the first year after injury [34]. Younger age at TBI was found to be a risk factor for adverse outcomes in specific psychosocial and EF domains. Preschoolers and school-age children were vulnerable to TBI adverse effects in terms of reduced emotional control, elevated emotional and affective symptoms, and behavior problems [35]. These

resources to the injured child's family throughout recovery [33].

personality of the patient, and the psychosocial environment [9, 32].

**192**

*Emotional and behavioral disorders in adolescents aged 12–19 years, developed before and after closed traumatic brain injury.*

findings regarding attention and emotional control are of particular importance for later self-regulation of behavior and academic achievements after TBI [36]. Executive dysfunction and psychosocial difficulties are likely to contribute to the lower functional academic skills in younger children and emergence of increased academic problems years after TBI [37].

Thus, TBI is a major cause of neurobehavioral disability among children and adolescents. Studies of outcomes 1 to 3–4 years post-injury reveal that moderate or severe pediatric TBI leads to difficulties in adaptive functioning, behavioral problems, deficits in academic and cognitive skills [9, 11–13, 15–29, 31–33]. Neurobehavioral sequelae frequently fail to resolve completely over time and thus are of particular concern to children's parents, teachers and health care professionals.

Poor outcomes of TBI sustained in early childhood may be explained considerably by the timing of injury in a period of rapid brain and behavioral development [24, 38]. Identification of vulnerability periods to the effects of TBI is crucial to promote awareness of appropriate referral for rehabilitation and school-based services [38].
