There is a broad spectrum of types of accidents (from the use of baby walkers to motorcycles), involving infants, children, and adolescents, which are frequently associated with traumatic brain injury and coma. It has been variously reported that head trauma is one of the most common causes of hospitalization in the pediatric age group; accounting for approximately 200,000 hospital admissions annually. Approximately 4,000 children in the United States die each year as a result of head injuries, and 50,000-90,000 sustain permanent functional impairments. There are increasing concerns about the possible subtle, but, significant sequelae of less severe types of head trauma (brain injury without coma) among children and adolescents. The "bottom line" is a need to be concerned about any severity of brain injury as a potential for children incurring pervasive neuropsychological, educational, social, and vocational complications.

In younger children, falls are the primary cause of head injury. There has been a significant rise in the incidence of accidents resulting in traumatic brain injury and coma among adolescents and young adults between ages 15 and 24 years. Older children and adolescents are perhaps at higher risk for accidental head injury, because of their relatively frequent recreational use of motorcycles, three-wheel all-terrain vehicles, bicycles, on-line roller blades, and skateboards, (usually without the use of an appropriate helmet). However, approximately 70% of the accidents associated with closed head trauma and coma can be attributed to motor vehicle accidents. Medical, surgical and technological advances in trauma management have undoubtedly improved survival rates for victims of head injury. Head trauma and coma, for more than 24 hours, generates particular concerns related to long-term challenges for the healthcare team. Survivors of this type of injury generally experience a myriad of lifelong post-traumatic complications.

"Survivors," in its broadest connotation, includes the victim, the family, the educational system, and the community. The pervasive, multifaceted psychosocial residuals of significant head trauma and coma mandates the need for a major consideration of the challenge "after acute care, then what?" The myriad of chronic complications includes disruption of family dynamics, impaired educational-vocational performances, inappropriate social and personal interactions, and ultimately compromised psychosocial capacities.

The relationship between length of coma and subsequent pathologies has been recognized. Coma for less than 24 hours, is infrequently associated with permanent neuropsychological complications (excluding focal injury of the brain). However, coma for less than six weeks in duration, in over 90% of children, is generally associated with varying degrees of compromised "independent function." A variety of less obvious sequelae may be observed, often presenting as lifelong impairments which adversely influence the quality of independent function.

A spectrum of post-injury complications have been identified, as a result of head trauma and coma:

• Physical-neuromotor skill deficits
• Perceptual difficulties (including attention disorders)
• Short-term and long-term memory deficits
• Neuropsychological impairments
• Speech/language problems (including word retrieval difficulties)
• Educational (learning) difficulties
• Behavior and personality changes
• Socialization and employment difficulties
• Poor self-concept and lack of self-confidence

Several studies suggest that traumatically brain-injured patients are much more seriously handicapped by emotional and personality disturbances, than by residual physical and cognitive disabilities. The psychosocial complications interfere with the survivor adhering to rules and responsibilities of 'daily living' at home and in the workplace. The literature further attests to major shortcomings in developing adequate coping strategies, to maintain a quality of life.

In summary, to respond meaningfully to the question of "Head Trauma: After Acute Care, Then What?," one must be acutely cognizant of both the short-term and long-term sequelae, which may significantly impair "independent function." Continued vigilance in enhancing the quality of life for survivors often transposes clinical responsibilities from critical care and rehab specialists to long-term management by primary healthcare providers. The primary healthcare provider is expected to serve as an advocate for the patient; providing continuity of care, comprehensive management guidance, and periodic monitoring. The range of 'new' responsibilities often includes, in part:

• Parent and family understanding of the etiology of language, behavior, and emotional changes exhibited by the patient.
• Explanations and assistance for developing special education programs, as well as recommending developmental interventions.
• Providing guidance in obtaining necessary counseling programs for patient and family.
• Securing vocational guidance for the older patient.

Head trauma and coma in children and adolescents is a catastrophic event. "Survival" often engenders lifelong interventions, in order to maintain some degree of independence, positive self-esteem, and a quality of life. "After Acute Care, Then What?" can only be answered as a reflection of the degree of vigilance in providing long-term supports to meet the patients evolving comprehensive individual needs.