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41ournal ofNeurology, Neurosurgery, and Psychiatry
1993;56:410-415
Long-term outcome of head injuries: a 23 yearfollow up study of
children with head injuries
Harry Klonoff, Campbell Clark, Pamela S Klonoff
Department ofPsychiatry, Universityof British
Columbia,Vancouver, BritishColumbia, CanadaH KlonoffC ClarkBarrow
NeurologicalInstitute, St. Joseph'sHospital and MedicalCentre,
Phoenix,Arizona, USAP S KlonoffCorrespondence to:Professor
Klonoff,University of BritishColumbia, FairmontMedical Building,
706-750West Broadway, Vancouver,British Columbia, CanadaV5Z
1H6.
Received 7 February 1992and in revised form6 July 1992.Accepted
20 July 1992
AbstractThe purpose of the 23 year follow upstudy was to
determine the relationshipbetween trauma variables including
mea-sures of head injury and very long-termsequelae. The study
included 159 individ-uals with a mean age 31-40 years, ofwhom
approximately 90% were admittedto hospital with a mild head injury
dur-ing childhood (mean age 7.96). Extent ofhead injury was
determined by uncon-sciousness, neurological status, skullfracture,
EEG, post-traumatic seizuresand a composite measure. The
compositemeasure of neurological variables wasthe best predictor of
long-term outcome.In addition, IQ recorded in the post-acute phase
was a reliable predictor oflong-term outcome. Of the sample,32-7%
reported physical complaints and17*6% reported current
psychological/psychiatric problems unrelated to thehead injury.
Subjective sequelae (physi-cal, intellectual and emotional)
specifiedas due to the head injury were reportedby 31% of the
sample, and the sequelaewere found to be related to the extent
ofthe head injury and initial IQ. Therewere no discernible
relationships bet-ween attribute variables including pre-morbid
status and age with subjectivesequelae. There were, however,
signifi-cant relationships between subjectivesequelae and
objective, psychosocialmeasures of adaptation including
educa-tional lag, unemployment, current psy-chological/psychiatric
problems andrelationships with family members.Finally, there
appeared to be continuityof complaints elicited during the five
yearfollow up of the original project and cur-rent sequelae. The
severity of the headinjury was identified as the primary
con-tributory factor in the reconstitutionprocess and in the
prediction of longterm outcomes.
(7 Neurol Neurosurg Psychiatry 1993; 56:410-415)
Despite extensive research on the diverseeffects of head
injuries, particularly mild headinjuries, there is a profound
paucity of verylong-term outcome studies in children sus-taining
traumatic brain injuries. In 1967 aprospective study of 231
children who sus-tained closed head injuries was initiated.
Insubsequent years a number of publications
including the final results of the five year fol-low up study
were published.'2 The currentstudy is a 23 year follow up of the
childrenincluded in the original project. The purposeof the study
was to determine the relationshipbetween trauma variables including
measuresof extent of head injury and very long-termsequelae.The
acute neurological, cognitive, emo-
tional and physical sequelae of closed headinjury34 including
mild head injuries5 are welldocumented for children' and adult6
samples.
Recent interest has focused on the shortand long-term outcome
following traumaticbrain injury. Publications range from the
sub-acute phase of one month after the headinjury,7 to follow up
for periods up to fouryears,8 and late outcome studies from six
to15 years post-trauma.9-" No published studyhas evaluated outcome
as long as 23 yearsafter injury. In addition, no study has
docu-mented the long-term consequences of headinjury from childhood
to adulthood in thesame patient sample.
In follow up studies, enduring neuropsy-chological deficits have
been reported.6 Othercommonly identified problems at follow upare
in the areas of behavioural dysfunction,including anxiety,
depression and social with-drawal.8'3' Families identify the
behaviouralchanges as the most enduring and trouble-some compared
with the physical and cogni-tive sequelae.9
Increasingly, studies have evaluatedchanges in work status after
head injury.Results are variable, but most studies report
asignificant degree of unemployment orreduced work capacity.9 '1-'7
Several studieshave evaluated factors affecting return towork after
head injury. Decreased rates ofemployment have been found with
increasedseverity of injury, as measured by length ofcoma,'5 by
initial Glasgow Coma Scale score8and length of post-traumatic
amnesia."'Greater cognitive dysfunction has also beenrelated to
poorer vocational outcome.'920A growing body of literature has
evaluated
predictors of outcome after head injury,including severity of
head injury and age attime of trauma.4 It has been suggested
thatchildren sustaining brain injuries showimproved neurological
and cognitive recoverycompared with older age groups.4 -23
Onestudy, however, reported no significant rela-tionship between
age and outcome.24
Typically, the recovery of patients sustain-ing head injury has
been determined by inter-viewer ratings.25 The best known of these
is
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Long-term outcome of head injuries: a twenty three yearfollow up
study of children with head injunres
Table 1 Demographic charactenrstics of cohort at time ofhead
injury (n=159)
CharacteristicsAge (years)Mean 7-96SD 3-28Range 2-7-15-9
Educational placement (%)Pre-school 29-6Primary (lower
secondary) 60-3Secondary (upper secondary) 10-1
Occupations of fathers (%)Professional and semi-professional
24-5Clerical and skilled 44-1Semi-skilled and unskilled
27-6Unemployed 3-8
Agent of injury (%)Automobile 44Fall 48Other 8
Length of hospitalizationMean days 12 7
Litigation (%) 21-4Pre-morbid anomalies (%) 27-0Multiple
injuries (%) 26-4Musculoskeletal 19-5Abdomen 2-5Ears/nose 1-9Eyes
1*3Skin 0-6Respiratory 0-6
the Glasgow Outcome Scale.26 Recently,research has started to
focus on outcomebased on patient interviews,8 and psychoso-cial
changes in head injured adults usingquestionnaire data from
patients comparedwith their families.27
Methods and resultsThe initial project set out to
investigateprospectively a head-injured group of chil-dren from the
time of trauma to the fifth yearafter trauma, within the context of
antecedentfactors (pre-morbid anomalies, age, sex), cir-cumstances
at time of head injury (extent ofinjury) and consequence factors
(education,interpersonal transactions, sequelae). Theoriginal
sample comprised 231 children- 147boys and 84 girls-with a mean age
of 8-32years at the time of the head injury. Childrenincluded in
the project were consecutiveadmissions to two university
hospitalsbetween August 1967 and November 1968with a diagnosis of
head injury. The number
Table 2 Neurological indicators of extent of head injury
(%/6)
Loss of Neurological Skull EEGConsciousness status fracture
rating Seizure
Not proven or No clinical None Normal/ Absentmomentary evidence
of Equivocal
trauma(52-2) (24 5) (59-7) (40 3) (93 7)
Unconsciousness5 minutes to 5 minutes to less Simple Minimal
Petit malless than than 30 minutes linear abnormal30 minutes or
concussionor
skull fracture(simple)
(37-1) (60 4) (22 0) (38-4) (4 4)Unconsciousness
more than more than Basal/ Moderate/ Grand30 minutes 30 minutes
depressed marked mal
or abnormalconcussionor
skull fracture(basal/depressed)with
other symptoms(for example aphasia)
(107) (15-1) (18-3) (21-3) (1 9)
of re-examinations varied among the groupand 117 children were
examined during thefifth year of follow up.
During 1990-91, 175 (76%) of the indi-viduals included in the
original project weretraced by a variety of means and 159
(91%)volunteered to participate in the currentstudy. Of the
remaining 16, contacts weremade with parents or relatives but the
mem-ber of the cohort did not return telephonecalls. A university
approved consent form wascompleted by the volunteers who were
inter-viewed. Geographic locations of the cohortincluded Canada,
USA, Europe, Australiaand the Middle East. The senior author
inter-viewed all the volunteers either in person(n = 82) or by
telephone (n = 77). In twoinstances information was provided by a
par-ent with the volunteer, while in two addition-al instances only
the parent providedinformation because of the volunteer's
mentalstatus.A standardised interview was conducted
with a predetermined format. Details of theoriginal data base
obtained during admissionto hospital and on follow up were
unknownto the interviewer and the volunteer. Any dif-ference
therefore in subjective impressionsshould be randomly distributed
among thosewith or without elicited sequelae.
Table 1 describes the demographic charac-teristics of the cohort
of 159 adults at thetime of trauma.
Although the Glasgow Coma Scale is nowwidely used to determine
the severity of headinjury, this project was conducted before
itsdevelopment. Therefore, four uni-dimension-al neurological
indexes (length of uncon-sciousness, skull fractures, EEG ratings2
andpost-traumatic seizures) and one global mea-sure (neurological
status) were used as indi-cators of the extent of head injury. The
lastmeasure was derived from the medical opin-ion of one examiner.
These variables andrespective percentages are itemised in table
2.
In addition to the ratings of each variablefrom 1 to 3, a
composite score of 5-15 wasalso derived by summing the 5 variables.
Thecomposite score ranged from 5-13 with amedian of 7, with the
following distribution:5-8 (63-5%); 9-10 (27-6%); 11-13 (8-9%).The
initial neuropsychological examination
revealed a mean (SD) IQ of 103-0 (15-0),with a range from 46 to
136. The fifth yearfollow up mean (SD) IQ was 111-2 (11-7),with a
range from 77 to 137.
Table 3 describes the current demographicand personal-social
characteristics of thecohort.
Health historySubsequent (recurrent) head injuries werereported
by 15-1% (8-8% with loss of con-sciousness) of the sample and the
number ofsuch head injuries were as follows: 1-10-7%;2-2-5%;
3-1-3%; 4-0-6%.
Table 4 summarises the 66 interveningphysical complaints (not
mutually exclusive)specified by the sample as unrelated to thehead
injury. The physical complaints were
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2Klonoff,Clark, Konoff
Table 3 Current demographic and personal-socialcharacteristics
(n=159)
CharacteristicsAge (years)MeanSDRange
Male:Female (n)Education (%)Grades 7-9 (lower secondary)Grades
10-12 (upper secondary)Post-secondary (tertiaryvocational
professional)
Bachelors degreesPost-graduate degrees
Grade failure (retention) (%)Marital status
(%)Married/common-lawSingleDivorced/separated
Occupation (%)Professional and semi-professionalClerical and
skilledSemi-skilled and unskilledHomemakerStudent
Employment status (%)Full timePart
timeHomemakerStudentDisability unrelated to traumaUnemployed
Interpersonal relationships (%)Strained relationship with
spouseStrained relationship with family members
Leisure activities restricted (%)Alcohol problem
(%)PastCurrent
Illicit drug use (%)Past socialPast heavyCurrent socialCurrent
heavy
Contact with legal authorities (%)One criminal chargeMultiple
criminal charges
31 403-23
25-40105:54
7-650 3
28-910-13-1
25-8
59-228-911-9
27-138-427-64.42-5
80-17-34.42-51.93 8
11-917-930-2
10-14-4
2 56 3
15 12-5
17-02-64-4
itemised in a systems schema.28 However,some of these complaints
reported by 32-7%of the sample may be related to the
multipleinjuries sustained at the time of the headinjury or in a
number of instances, subse-quent head injuries. Seizures were
reportedby one individual who had a severe headinjury in 1989 and
dizzy spells were reportedby another individual who had
relativelysevere head injuries in 1976 and 1990.
Resolved psychological/psychiatric prob-lems specified as
unrelated to the initial headinjury were reported by 31-4% of the
sample.The 60 reported problems (not mutually
Table 4 Physical complaints unrelated to head injury(n=159)
System Complaints Frequency
Neurological Seizures 1Dizzy spells 1
Musculo-skeletal Leg/back pain 20Arthritis 8
Head and Neck Headaches 5Neck pain 3Thyroid 2
Ears/Nose Reduced hearing 4Sinusitis 2
Abdomen Colitis 1Crohn's disease 1Hepatitis 1Ulcers 1Liver 1
Skin Psoriasis/eczema 3Chest and Lungs Asthma 8Lymphatic
Lymphoma 1Heart/Blood vessels Rheumatic fever 2Metabolism Diabetes
1
exclusive) were categorised as: emotional dis-orders (40'0%);
problems with spouse orchild (36&6%); problems with
parents(15'0%); substance abuse (5 0%); and rela-tionships in
general (3-4%).
Current psychological/psychiatric problemsspecified as unrelated
to the initial headinjury were reported by 17-6% of the sample.The
33 reported problems (not mutuallyexclusive) were categorised as:
emotional dis-orders (42A4%) including one chronic schizo-phrenic;
problems with spouse or child(21-2%); substance abuse (12-1%);
problemswith parents (9 1%); relationships in general(9 1%); and
sleep problems (6 1%).A comparison of those in the sample
listing
no psychological/psychiatric problems orspecifying problems both
in the past and thepresent, revealed the following: 62-3% listedno
problems at any time; 11-3% listed prob-lems both in the past and
present; 20- 1% list-ed a problem in the past but not
currently;and, 6&3% did not list a problem in the pastbut did
currently.Mood was determined during the interview
by asking individuals to rate their mood on ascale from one to
10 where one would be verydepressed and 10 very happy. The
distribu-tion was distinctly skewed towards the upperend of the
scale with a median rating of 7.
Stressors were reported by 53-5% of thesample and the number
ranged from 1-4.The 119 identified stressors were distributedamong
the following: work (30 3%);spouse/child (16-8%); finances (15-1%);
psy-chological (12-6%); relationships (8 4%);physical (7 6%);
parents (5 9%); livingarrangements (2 5%); and substance
abuse(0-8%).
Outcome measuresThe subjective measure of outcome wasderived
from the complaints by the respon-dents elicited during the
interview whenasked whether they had noted post-accidentsequelae.
The reported subjective sequelaewere then categorised as physical,
intellectualand emotional. The physical complaints wereitemised in
a systems schema.28 The intellec-tual complaints included
difficulties withlearning, memory, intellectual functioningand
slowed thinking. The emotional com-plaints included anxiety,
depressive andbehavioural disorders and problems with self-esteem
and feelings of rejection.The details of the sequelae are itemised
in
table 5. Fifty individuals (31%) reported 96sequelae: 36 were
physical, 30 intellectualand 30 emotional. The subjective
sequelaewere distributed as follows: 1 -(17%), 2-(8%), 3 -(2%), 4
-(2%), 5 -(1%), and 7-(1 %). The overlap of sequelae among the
50individuals was: exclusively intellectual and/oremotional (27);
intellectual and/or emotionalas well as physical ( 11); and
exclusivelyphysical (12).Of the 7 physical systems, the highest
number of subjective sequelae were recordedunder neurological,
with two individualsreporting seizures: one is still on
anti-convul-
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Long-term outcome ofhead injuries: a twenty three yearfollow up
study of children with head injuries
Table S Types of subjective sequelae (n=SO)
System Complaints Frequency
PhysicalNeurological Coordination or speed 4
Seizures 2Handedness changed 2Dizziness 1Speech 1
Musculo-skeletal Arthritis/osteoarthritis 3Back pain 2Leg/hip
pain 2Leg shorter/deformity 2
Head and Neck Headaches 3Plate area sensitive 3Neck pain 1
Eyes Diplopia 2Retinal damage 1Fields/depth perception 2
Ears/Nose Tinnitus/sinusitis 2Abdomen Kidney/spleen 2Skin
Sweating 1Intellectual
Learning problems/disabilities 12Memory/attention/concentration
10Intelligence/brain affected 4Thinking/problem solving slowed
4
EmotionalAnxiety disorders Anxieties, phobias, nightmares
8Depressive disorders Depression 6
Depression with suicidal thoughts 3Bereavement, breakup of
family 3
Self esteem problems Insecure/self-conscious/introverted
5Parent-child problems Rejection by parent(s) 2Behaviour disorders
Aggression (as child) 2
Pyromania (as child) I
sant medication and the seizures are currentlycontrolled,
whereas the other is not on med-ication and does not have a recent
history ofseizures. The second most frequent area ofsequelae was
derived from the musculoskele-tal system, followed by sequelae
regardinghead and neck.Among the intellectual sequelae, the
most
frequent complaint was difficulty in leaming,followed by
problems with memory or con-centration, and in turn followed by
state-ments that intelligence had been adverselyaffected, and
finally a slowing of thoughtprocesses. Among the emotional
sequelae,depression was the most frequent complaint.Three of those
reporting depression indicateda history of accompanying suicidal
ideationand two were currently experiencing suicidalthoughts.
Anxiety disorders followed in termsof frequency, followed by
problems with selfesteem, then rejection by parents, and
finallybehaviour disorders (pyromania and aggres-sion) during
childhood.
There was a significant relationship(Kendall's Tau 0 19, p <
0.01) betweenphysical sequelae reported as directly relatedto the
head injury and physical complaintsidentified as unrelated to the
head injury.Specifically, 12-6% of the sample reportedboth physical
sequelae and physical com-plaints unrelated to the trauma, 20-
1%reported physical sequelae but no physicalcomplaints unrelated to
the trauma, 18-9%reported no physical sequelae but
physicalcomplaints unrelated to the trauma, and48-4% reported
neither. These findings areunderstandable in view of the
multipleinjuries sustained by 26-4% of the sample.
Relationships between extent of head injury andoutcomeThe first
analysis evaluated the relationships
between the trauma variables and subjectivesequelae (physical,
intellectual and emotion-al). Table 6 summarises the
correlationmatrix and as may be noted the compositemeasure was the
most discriminating regard-ing long-term subjective sequelae. This
inturn was followed by the neurological variableand seizures and
finally fractures as predictorsof sequelae. Unconsciousness was of
limitedpredictive value and EEG was of no predic-tive value.The
second analysis evaluated the relation-
ship between initial IQ and subjective seque-lae, and the
findings are also summarised intable 6. A comparison of those
individualswho either reported or did not report seque-lae in each
of the three areas revealed signifi-cantly lower IQs for those with
sequelae inboth the intellectual and emotional areas.The third
analysis evaluated the relation-
ship between attribute variables which pur-portedly relate to
the outcome of head injuryand the findings are summarised in table
7.While only 3 of the 21 correlations were sig-nificant, this is
greater than chance expectan-cy. Physical sequelae were
significantlyrelated to the agent of injury and
subsequentlitigation, and these are understandable.
Therelationships between intellectual sequelaeand subsequent head
injuries is also quitepredictable.The purpose of the fourth
analysis was to
determine whether the presence of subjectivesequelae had any
measurable effects uponobjective and psychosocial measures of
adap-tation. The individuals reporting sequelae(n = 50) were
therefore compared on desig-nated demographic, health and
psychosocialvariables with individuals reporting no seque-lae (n =
109). Significant differences werefound in grade failures/retention
(40% for thesequelae group vs 19% for the non-sequelaegroup, x2 =
6-65, p < -0 1), work status (12%vs 2-8% of unemployed
respectively,X2 = 3-89, p < 0-05), current
psychological/psychiatric problems (32% vs 11 9% respec-tively, x2
= 7-96, p < 0.01) and strained rela-tionships with family
members (24% vs15-6% respectively, x2 = 3-95, p < 005).
Nodifferences were found for past but
resolvedpsychological/psychiatric problems, physicalcomplaints,
substance abuse or contact withlegal authorities.The fifth analysis
dealt with continuity of
complaints during the twenty three year inter-val between the
original project and the cur-rent study. In the published five year
followup project,2 parents of the 117 childrenreported on average
0-89 complaints from thefollowing: personality and mood,
headachesand dizziness, memory and learning, sensory-motor, and
fatigue and sleep. In the currentstudy, the 159 adults reported on
average060 sequelae, and these were categorised asphysical,
intellectual and emotional. Of the159 individuals included in the
current study,93 also had complaints in the initial project.The
informants, however, were different asduring the initial project
information aboutcomplaints was provided by a parent, general-
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Klonoff, Clark, Klonoff
Table 6 Relationships between subjective sequelae and trauma
variables as well as initialIQ (Kendall's Tau and t test)
Subjective sequelae
Trauma variables Physical Intellectual Emotional
Unconscious 0-12 0 04 0-21**Fracture 0 19** 0 20** 0-20**EEG -
0-02 0 07 - 0 06Neurological 0-13* 0-21** 0 35***Seizures 0-20** 0
25*** 0 18*Composite 0 17*** 0 23*** 0 28***Initial IQ - 0 05
-0-21** - 0 17*Initial IQ non-sequelae group 103 5 104 7 104
2Initial IQ sequelae group 99 9 93 3 98 6t value 1 07 3 57**
2.37*
*p
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Long-tern outcome of head injuries: a twenty three yearfollow up
study of children with head injuries
so that by the fifth follow up a majority of thechildren had
improved substantially. Withrespect to the reconstitution process,
thequestion posed initially was whether this wasa function of the
severity of head injury, indi-vidual differences in disposition,
subsequentenvironment or an interaction of these vari-ables. Based
on the long-term findings of thecurrent study, individual
differences in dispo-sition have not been identified as
particularlyrelevant. Intervening life events while inordi-nately
complicated are undoubtedly interac-tive, but with the available
information it isnot possible to go beyond this statement.However,
the severity of the head injury hasbeen identified as the primary
contributoryfactor in the reconstitution process. The cur-rent
study extends this relationship in the pre-diction of even long
term outcomes.Furthermore, the presence of long term sub-jective
sequelae is consistent with objectiveindicators of social
adaptation.
This research was supported by the Insurance Corporation
ofBritish Columbia, British Columbia, Canada. We wish toexpress our
appreciation to Mrs Vinetta Lunn for her creativeapproach in
tracing individuals and invaluable assistance, toMr Don Gilbert for
his consistent support, and to Mrs MaryKlonoff for assisting with
the manuscript.
1 Klonoff H, Paris R. Immediate short-term and residualeffects
of acute head injuries in children. In: Reitan R,Davison LA, eds.
Clitical neuropsychology: current statusand applicatiotns.
Washington: Winston, 1974:179-210.
2 Klonoff H, Low MD, Clark C. Head injuries in children:a
prospective five year follow-up. Jf Neurol NeurosurgPsychiatry
1977;40:1211-9.
3 Levin HS, Grafman J, Eisenberg HM, eds.Neurobehavioral
recovery fromi head injury. New York:Oxford University Press,
1987.
4 Levin HS, Benton AL, Grossman RG. Neurobehavioralconsequences
of closed head injury. New York: OxfordUniversity Press, 1982.
5 Levin HS, Eisenberg HM, Benton AL, eds. Mild headinjury. New
York: Oxford University Press, 1989.
6 Jennett B, Teasdale G. Managemnent of head
inijuries.Philadelphia: FA Davis, 1981.
7 McLean A, Dikmen S, Temkin N, et al. Psychosocialfunctioning
at one month after head injury. Neurosurgery1984;14:393-9.
8 Klonoff PS, Snow WG, Costa LD. Quality of life inpatients two
to four years after closed head injury.Neurosurgery
1986;19:735-43.
9 Thomsen IV. Late outcome of very severe blunt headtrauma: a
10-15 year second follow up. J NeuirolNeurosuirg Psychiatry
1984;47:260-8.
10 Oddy M, Coughlan T, Tyerman A, et al. Social adjust-ment
after closed head injury: A further follow-upseven years after
injury. Jf Neurol Neuirosurg Psychiatry1985;48:564-8.
11 Costeff H, Groswasser Z, Goldstein R. Long-term follow-up
review of 31 children with severe closed head trau-ma. J7 Neurosurg
1990;73:684-7.
12 Tate RL, Fenelon B, Manning ML, et al. Patterns of
neu-ropsychological impairment after severe blunt headinjury. Nerv
Menit Dis 1991; 179:117-26.
13 Lishman WA. Brain damage in relation to psychiatric
dis-ability after head injury. Br J Psychiatry
1968;114:373-410.
14 Levin HS, Grossman RG. Behavioral sequelae of closedhead
injury: a quantitative study. Arch Neuirol 1978;35:720-6.
15 Rimel RW, Giordani B, Barth JT, et al. Moderate headinjury:
completing the clinical spectrum of brain trau-ma. Neurosurgery
1982;11:344-51.
16 McKinlay WW, Brooks DN, Bond MR. Post-concussion-al symptoms,
financial compensation and outcome ofsevere blunt head injury. J'
Neuirol Neurosurg Psvchiatry1983;46:1084-91.
17 Kreutzer JS, Wehman PH, Harris JA, et al. Substanceabuse and
crime patterns among persons with traumaticbrain injury referred
for supported employment. BrainInj 1991;5:177-87.
18 Lewin W, Marshall TF, Roberts AH. Long-term outcomeafter
severe head injury. BMJ7 1979;2:1533-8.
19 Rimel RW, Jane JA. Characteristics of the
head-injuredpatient. In: Rosenthal M, Griffith ER, Bond MR,Miller
JD, eds. Rehabilitation of the head-injured aduilt.Phila: FA Davis,
1983:9-21.
20 Levin HS, Gary HE, Eisenberg HM, et al. Neuro-behavioral
outcome one year after severe head injury.J7 Neurosurg
1990;73:699-709.
21 Eiben C, Anderson T, Lockman L, et al. Functional out-come of
closed head injury in children and youngadults. Arch Phys Med
Rehabil 1984;65:168-70.
22 Mahoney WJ, D'Souza BJ, Haller JA, et al. Long-termoutcome of
children with severe head trauma and pro-longed coma. Pediatrics
1983;71 :756-62.
23 Alberico AM, Ward JD, Choi SC, et al. Outcome aftersevere
head injury: relationship to mass lesions, diffuseinjury and ICP
course in pediatric and adult patients.J Neurosuirg
1987;67:648-56.
24 Berger MS, Pitts LH, Lovely M, et al. Outcome fromsevere head
injury in children and adolescents. _7Neurosurg 1985;62:194-9.
25 Levati A, Farina ML, Vecchi G, et al. Prognosis of severehead
injuries. Neurosurg 1982;57:779-83.
26 Jennett B, Bond M. Assessment of outcome after severebrain
damage. Lancet 1975;1:480-4.
27 Hendryx PM. Psychosocial changes perceived by
closed-head-injured adults and their families. Arch Phvs MedRehabil
1989;70:526-30.
28 Seidel HM, ed. Mosby's guide to physical examninatinon,
2nded. St Louis: Mosby Year Book, 1991.
29 Edna TH, Cappelen J. Late postconcussional symptomsin
traumatic head injury: An analysis of frequency andrisk factors.
Acta Neurochir 1987;86: 12-7.
30 Klonoff H. Head injuries in children: predisposing fac-tors,
accident conditions, accident proneness and seque-lae. AmJ_y Public
Health 1971;61:2405-17.
31 Chadwick 0, Rutter M, Shaffer D, et al. A prospectivestudy of
children with head injuries. IV: Specific cogni-tive defects. 37
Clin Neuropsychol 1981;3: 101-20.
32 Kraus JF, Fife D, Cox P, et al. Incidence, severity
andexternal causes of pediatric brain injury. Am. _7 Dis
Child1986;140:687-93.
33 Annegers JF. The epidemiology of head trauma in chil-dren.
In: Shapiro K, ed. Pediatric head trauma. NewYork: Futura
Publishing, 1983:1-10.
34 Fabian AA, Bender L. Head injury in children: predispos-ing
factors. Amil Orthopsychiatn- 1947;17:68-79.
35 Salcido R, Costich JF, Conder R, et al. Recurrent
severetraumatic brain injury: series of six cases. Amner _7 PhvsMed
Rehabil 1991;70:215-9.
415 on A
pril 4, 2021 by guest. Protected by copyright.
http://jnnp.bmj.com
/J N
eurol Neurosurg P
sychiatry: first published as 10.1136/jnnp.56.4.410 on 1 April
1993. D
ownloaded from
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