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Outcomes after head injury

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Long term outcome after head injury in childhood is variable and children with even mild head injuries may have persisting cognitive and behavioural problems. Follow-up studies have suffered from the absence of widely accepted outcome measures. The Glasgow Outcome Scale provided such a measure for adults and the King’s Outcome Scale for Childhood Head Injury (KOSCHI, described in Archives in 2001) has been proposed as a standardised outcome measure for children. The KOSCHI has been used in a study of head-injured children in Stoke-on-Trent (

).

Between November 1992 and December 1998 a total of 986 children were admitted to hospital in Stoke with head injury and 12 died. A questionnaire was sent in 1998 to parents of 974 surviving children aged 5–15 years at the time of injury and 526 satisfactory responses were received.. Head injuries were classified as mild (<15 minutes unconsciousness, Glasgow Coma Scale (GCS) 13–15), moderate (>15 minutes unconsciousness, GCS 9–12), or severe (>6 hours unconsciousness, GCS 3–8). The KOSCHI scoring system has five categories: (1) death, (2) vegetative, (3) severe disability (A or B), (4) moderate disability (A or B), and (5) good recovery (A or B). (In subcategories, A implies a less satisfactory outcome than B.) Of the 526 children whose parents returned a completed questionnaire 419 had had mild head injury, 58 moderate, and 49 severe. Mean follow up was 2.2 years. Severe disability (KOSCHI score 3) was reported for four children, all with severe head injury and good recovery (KOSCHI score 5) for 270 (51%). Good recovery occurred in 57% after mild head injury, 36% after moderate, and 22% after severe head injury. Complete recovery (KOSCHI score 5B) occurred in 97 children (18%; 21%, 10%, and 4%)*. Social deprivation was associated with poorer outcome. The presence or absence of skull fracture did not influence outcome. Eight children (five, one, and two) developed epilepsy.

Few children changed school because of the head injury but special educational needs (SEN) were identified in 40 (23, 2, and 15). Parents reported that SEN provision had been made for 26 children. Ninety-eight children (19%; 16%, 28%, and 35%) had difficulties with schoolwork and 96 (18%; 17%, 24%, and 23%) had been disciplined for bad behaviour at school. Only 209 teachers (40%; 33%, 55%, and 77%) knew about the child’s head injury. Change of personality was reported for 148 children (28%; 21%, 46%, and 69%). Headaches, temper outbursts, and mood swings each occurred in some 13–18% of children after mild head injury becoming more frequent (up to 28%-36%) after severe head injury. These symptoms were uncommon among 45 control children.

Forty-three per cent of children with mild head injury had moderately severe persisting disability but many are not followed up. The authors of this paper suggest that a system of postal follow up with a questionnaire incorporating the KOSCHI checklist might identify children who need to be reassessed.

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Footnotes

  • * All series are: total; mild, moderate, and severe.

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