Social adjustment after closed head injury: a further follow-up seven years after injury

Caregivers of persons with stroke: their physical and emotional wellbeing

This descriptive study was undertaken as a pilot test for several questionnaires designed to examine the well-being of caregivers of persons with stroke. This predominantly female sample was found to have moderately few physical symptoms, but to be in considerable emotional distress. Nearly half the sample had anxiety and depression scores above the level identified as suspicious for clinically relevant distress as indexed by the Symptom Questionnaire. Anger was also a salient finding: 40% of those questioned scored above the cutoff level for hostility and several caregivers expressed anger verbally during data collection. The degree of psychological distress in these individuals is of importance to all health care professionals and deserves increased attention, both from the perspective of the researcher and from the perspective of the clinician.

Occupational and educational achievements of head injured Vietnam veterans at 15-year follow-up

Little is known about the long-term affects of head injury on achievement. The post-injury educational and occupational achievements of 520 survivors of penetrating head injury in Vietnam (and 85 uninjured controls) were examined 15 years after injury. Most patients (82%) had used Veterans Administration educational benefits to return to school, and many of those (64%) had achieved degrees. Return to work was strongly related to level of educational achievement, particularly among the most severely disabled. Though only 56% of the head injured were gainfully employed, the occupational distribution of those who were working differed little from uninjured controls, or the male labor force. Severity of injury affects educational achievement and return to work, but not the occupational distribution of those who do manage to return. Even the most severely injured can sometimes achieve high educational and occupational levels.

Long-term outcome of head injuries: a 23 year follow up study of children with head injuries

The purpose of the 23 year follow up study was to determine the relationship between trauma variables including measures of head injury and very long-term sequelae. The study included 159 individuals with a mean age 31.40 years, of whom approximately 90% were admitted to hospital with a mild head injury during childhood (mean age 7.96). Extent of head injury was determined by unconsciousness, neurological status, skull fracture, EEG, post-traumatic seizures and a composite measure. The composite measure of neurological variables was the best predictor of long-term outcome. In addition, IQ recorded in the post-acute phase was a reliable predictor of long-term outcome. Of the sample, 32.7% reported physical complaints and 17.6% reported current psychological/psychiatric problems unrelated to the head injury. Subjective sequelae (physical, intellectual and emotional) specified as due to the head injury were reported by 31% of the sample, and the sequelae were found to be related to the extent of the head injury and initial IQ. There were no discernible relationships between attribute variables including premorbid status and age with subjective sequelae. There were, however, significant relationships between subjective sequelae and objective, psychosocial measures of adaptation including educational lag, unemployment, current psychological/psychiatric problems and relationships with family members. Finally, there appeared to be continuity of complaints elicited during the five year follow up of the original project and current sequelae. The severity of the head injury was identified as the primary contributory factor in the reconstitution process and in the prediction of long term outcomes.

The Westmead Head Injury Project. Physical and social outcomes following severe head injury

This study reports the physical outcomes of 181 survivors of severe head injury [Glasgow Coma Score (GCS) 8 or less] following aggressive head injury management which included early triage, evacuation and resuscitation, the use of ventilation in the Intensive Care Unit and intracranial pressure (ICP) measurement and control. At the conclusion of the study period of 2 years after the head injury, 71% had achieved a Glasgow Outcome Score (GOS) of 1, 17% GOS 2, 10% GOS 3 and 2% GOS 4. Physical recovery continued during the 2 years. Locomotor independence was achieved in 93% despite a motor disorder in 59%. About 90% were considered independent for basic life functions, e.g. feeding, bathing, dressing or toileting. Speech disorders were present in 19%. A return to an occupation, either a job or studies, at or below the pre-morbid level was achieved in 68%. Most patients were cared for at home by family or relatives. The majority of patients make a reasonable physical recovery following severe head injury with independence in locomotion and basic life skills. It was our impression that the neuropsychological sequelae of cognitive and behavioural disorders were a major impediment to re-assimilation into society.

Attentional deficits following closed-head injury

Aimed to assess, in the light of current attentional theories, the nature of the attentional deficit in a group of severely traumatically head-injured subjects, relative to a group of orthopaedic rehabilitation patients, and to establish which neuropsychological measures best reflected the deficit. Three separate studies were conducted in order to meet these aims. The first study focused on selective attention; the second, on vigilance or sustained attention; the third, on the Supervisory Attentional System. Results provided no evidence for the presence of deficits of focused attention, sustained attention, or supervisory attentional control, but ample evidence for the presence of a deficit in speed of information processing. Those neuropsychological measures shown to be the best measures of this deficit included the Symbol Digit Modalities Test, simple and choice reaction-time tasks, colour naming and word reading scores on the Stroop, and the Paced Auditory Serial Addition Test.

Clinical outcome and cognitive impairment in patients with severe head injuries treated with barbiturate coma

This study reports on clinical outcome in 38 patients with severe head injuries (posttraumatic coma for 6 hours or more) treated with barbiturate coma because of intracranial hypertension. Eighteen patients died, 4 patients remained in a severely disabled or a chronic vegetative state, and 16 patients reached the levels good recovery/moderate disability. Six of these patients returned to work or school full time, 4 for half time and 3 were in a rehabilitation program. Fourteen patients were subjected to a comprehensive neuropsychological assessment. All patients except one exhibited varying degrees of cognitive dysfunction and 6 patients had signs of personality change. The quality of life for the majority of surviving patients was relatively good but the positive effects of barbiturate coma therapy in the age groups over 40 years appeared to be limited.

Alcohol, head injury, and neuropsychological function

Evidence is reviewed indicating that the extent of alcohol abuse alone cannot account for the neuropsychological deficits observed in alcoholics, and that alcohol abuse and head injury may interact in some patients to influence neuropsychological status. Alcohol abuse both increases the risk for head trauma and potentiates the resulting brain injury, which can lead to negative neuropsychological consequences. Clinicians involved in the treatment of addiction should assess patients for history of head injury, and neuropsychological deficits consequent to both head injury and ethanol. These deficits may limit patient ability to comply with addiction rehabilitation programs. Conversely, clinicians in acute care and rehabilitation of the sequelae of head trauma should routinely assess their patients for substance abuse, because such abuse can have a significant impact on recovery from brain injury.

Acceptance of disability, work involvement and subjective rehabilitation status of traumatic brain-injured (TBI) patients

A follow-up of 78 TBI patients one to two years after discharge from rehabilitation hospital supported hypothesized correspondence between work involvement and subjective rehabilitation status (SRS). Subjective rehabilitation was defined as the gratification of basic needs: physical well-being, emotional security, and family, social, economic, and vocational needs. Highest SRS was found among patients employed in the open market. Lower SRS was found in patients employed under protected conditions who also reported their work to be much less congruent with their expectations. Unemployed patients living active lives reported higher SRS than unemployed patients living passive lives, but both showed lower SRS than employed patients. Both work involvement and SRS were found to be related to acceptance of disability (AD). However, longitudinal data are needed to ascertain whether AD precedes or follows the other two variables. Both possibilities may be correct.

Outcomes for traumatically brain-injured patients following post-acute rehabilitation programmes

Outcome studies from post-acute cognitive rehabilitation programmes vary widely and mostly emphasize changes in neuropsychological measures. More recently, the functional outcomes of patients following cognitive rehabilitation have been reported. This study describes the functional outcomes of 42 traumatically brain-injured patients (29 male, 13 female: average age 28.6 years, time post-injury 50.3 months) following treatment in a structured out-patient post-acute cognitive rehabilitation programme. The programme consisted of a minimum of 6 weeks of treatment and emphasized improvement of the patients' real-life functional abilities and psychological support. The treatment goals were individually established for each patient. Patient improvement was determined by the accomplishment of treatment goals and differences in pre- and post-treatment functional measures and speech pathology cognitive measures. Follow-up at 6, 12 and 18 months determined the maintenance of treatment effects. There was a significant improvement on patients' functional measures after treatment. Cognitive measures were not significantly different after treatment, but there was a trend towards improvement. Functional improvements were independent of age, neuropathological category, injury severity and time post-injury. It is concluded that post-acute traumatic brain injury treatment aimed at retraining real-life functional abilities exclusive of specific cognitive remediation can lead to long-term improvements in independence.

A leisure-time frame of reference based on a literature analysis

The aims of this study were, through literature analyses, to identify the concept 'leisure time,' to design a model of leisure time and to study the empirical methods used in research literature on leisure time. The data for this article consisted of occupational therapy literature including 48 articles found through a search of the MEDLINE and PsychLIT databases for the period 1975-1989. The methods used for identifying and coding these data based on a set of questions presented by Guba and Lincoln (1985). For discovering the empirical methods used in the material, the work of Ostrow and Caplan (1985) was followed. The data analysis led to the development of a frame of reference of leisure time as used in occupational therapy literature. This model consists of the following dimensions: time, intrinsic motivation, free choice of activity, capability, structure of social and culture environment, leisure-time activity engaged in, goals, pleasure for pleasure's sake, diversion, recreation, relaxation, self-fulfillment, influence on individual, leisure role, leisure behavior, and satisfied harmonious person.

Developmental levels of social cognition in head-injury patients

Ten adults, who had sustained a closed head injury, were interviewed regarding their self-understanding, concepts of persons, and interpersonal negotiation strategies. Responses were evaluated in terms of developmental levels of social cognition. Levels of interpersonal negotiation strategies were significantly lower than levels of self-understanding, descriptions of psychological characteristics of self were at a significantly higher level than descriptions of active and physical characteristics of self. Within interpersonal conflict situations, proposed solutions were at a significantly lower level than the justifications offered for the solutions. In general, developmental levels of social cognition were comparable to levels exhibited by non-clinical samples of adolescents. The two areas in which the head-injury patients appeared to perform at a significantly higher level than adolescents were their justifications for their proposed solutions to the interpersonal conflict situations and their ability to express the emotional consequences of interpersonal conflict.

Maternal reporting of behaviour following very severe blunt head injury

Mothers of 40 very severely head injured male subjects rated their son's behaviour on the Current Behaviour Scale and their ratings were compared with mothers' ratings of 40 control male subjects. The scale was able to discriminate the two groups, by utilising two factors--loss of emotional control and loss of motivation. The mothers' level of emotional distress was closely related to their reporting of loss of emotional control in their sons, but reporting of loss of motivation, or lowered arousal, was strongly predicted by the functional disability of the son. The utility of refining the measurement of post-trauma behaviour is discussed.

Comparison of minor and severe head injury emotional sequelae using the MMPI

The Minnesota Multiphasic Personality Inventory (MMPI) was administered to 73 patients with traumatic brain injury to objectively evaluate emotional status. Profile analysis indicated that many patients were suffering from emotional disturbance. Higher distress levels were evident among those with minor head injury relative to severe head injury. Observed MMPI profiles for these two head injury groups were consistent with previous research and expectations related to the typical consequences of the post-concussion syndrome. The potential value of the MMPI with the head injury population as well as the need for cautious interpretation and integration of impressions derived from other sources is discussed.

The relationship between social skill and family problem-solving following very severe closed head injury

This study examined the relationship between level of social skill and family problem-solving behaviour in a group of 18, community dwelling, very severe closed head injury (CHI) patients who had suffered their injury at least 18 months previously, and who were still in contact with rehabilitation services. The main findings of this study were a positive relationship between CHI patients' level of social skill and their rate of positive effect, and an inverse relationship between the CHI patients' level of social skill and the rate of facilitative behaviour displayed by relatives during problem-solving interactions. It is suggested that socially unskilled CHI patients may be more demanding to interact with, and that this may cause a significant burden for their relatives.

The head injured adolescent: a case report and review of the issues

Closed head injuries in adolescents are a common problem with potentially disastrous consequences to multiple areas of functioning. Through a case presentation and literature review, this paper considers treatment issues and research applications in an adolescent population with closed head injuries. Suggestions for understanding the symptom constellations are made and directions for future research and service delivery are given.

Coping and family functions after closed head injury

Cognitive deficits associated with closed head injury (CHI) have been well studied. Less attention has been directed to the emotional consequences of CHI and subsequent attempts to cope with major life events. CHI typically constitutes a catastrophic injury, yet few studies have examined coping strategies used by individuals after CHI or the effects of CHI on family functioning that may mediate coping. Previous workers have speculated that time since injury is a crucial determinant of coping; however, this has not been investigated with regard to CHI. In this preliminary investigation, 40 patients with CHI were compared with 17 neurologically intact controls. The CHI group was divided into two groups according to time since injury. It was found that patients with CHI used information seeking as their most dominant coping strategy regardless of their time since injury. Patients with CHI had higher family cohesion scores than control subjects. Implications of these findings for psychological response to CHI are discussed.

Facilitation of memory performance through induced semantic processing in survivors of severe closed-head injury

This study examined whether survivors of severe closed-head injury (CHI) show a relative benefit in memory for words that are processed semantically versus words that are processed physically or acoustically. Sixteen long-term CHI patients and 14 demographically matched controls were administered a Levels of Processing paradigm involving detection of semantic (categorical), physical (letter), or acoustic (rhyme) features of to-be-remembered words. Semantic processing enhanced recognition memory and cued recall in the CHI patients, but the degree of facilitation was reduced relative to controls. The results indicate that attention to semantic features facilitates memory performance in survivors but may require greater cognitive effort. Implications for the remediation of memory impairments following CHI are discussed.

Trends in hospitalized discharge rates for head injury in Maryland, 1979-86

Hospital discharge data from all acute care hospitals in Maryland were used to examine trends in hospitalized head injury incidence and outcome by severity. From 1979 to 1986, discharge rates increased by 3.4/100,000 per year; the largest percent increase was for more severe injuries. Discharge rates increased the most for adults ages 15-24 and ages 75+ but declined for children ages 0-4. Coinciding with the increase in head injury discharges was a decrease in the hospital case-fatality rate across all severity groups.

Return to work (RTW) after head injury

This study explored return to work (RTW) after head injury from survey data on 177 cases of head injury. Although 45% of the sample study did engage in some work-related activity only 19% were in competitive employment positions. Factors which were related to RTW after head injury were: age when injured, sex, length of loss of consciousness and Likert ratings of learning, motor and ambulation impairment. Many of those who did return to competitive employment did so in less demanding positions than held pre-injury. Limitations of the current study and suggestions for future research are ventured.

Clinical applications of the Matching Familiar Figures Test: impulsivity vs. unilateral neglect

Impulsivity is a common consequence of brain damage, one with negative prognostic implications. To attempt to study the incidence of impulsivity after lateralized cerebral lesions, 93 patients (50 RBD, 43 LBD) and 24 normal controls were administered the Matching Familiar Figures Test, a visual match-to-sample task in a multiple-choice format. The groups differed significantly (RBD less than LBD less than Controls) with respect to accuracy (visual-perceptual skill). Average response latency scores of the brain-damaged groups were slightly, but not significantly, lower than that of Controls. Although more than one-third of the RBD showed a tendency to respond rapidly, reduced response latency in RBD patients may be due, not to impulsivity per se, but, rather, to incomplete visual scanning characteristic of neglect. The present results illustrate the hazards of interpreting neuro-psychological test scores without consideration of pertinent processing variables.

Psychosocial sequelae of closed head injury: effects on the marital relationship

Head injury frequently produces physical and psychological sequelae involving cognitive, behavioural, and personality disturbances which are chronic and perhaps even permanent. Clinically, it is apparent that the marital relationships of head injury patients face initial disruption as well as ongoing challenges in dealing with the physical, neuropsychological, and emotional changes post-injury. However, there is little empirical data to substantiate these observations. In this study, the marital relationships of 55 male head injury patients were assessed, based on the spouse's self-report obtained through interview and questionnaires. The sample was divided into three groups according to the severity of the injury: mild (N = 10), moderate (N = 25) and severe (N = 20). Based on a one-way multivariate analysis of variance, dyadic consensus, affectional expression, and overall dyadic adjustment were significantly lower for wives in the severe group than the moderate group. Affectional expression was also lower in the severe group than the mild group. Stepwise multiple regression analysis determined that 47% of the variance of overall dyadic adjustment could be accounted for by three variables (multiple R = 0.69, p less than 0.001). Dyadic adjustment was greater when wives reported a lower level of financial strain, perceived their spouse to have a relatively low level of general psychopathology or maladjustment, and when the injury was relatively mild based on GCS scores. The implications for intervention in rehabilitation at the marital level are highlighted.

Memory deficit after closed head injury

This paper reviews research concerning impairment of memory during the early and late stages of recovery from closed-head injury (CHI). Posttraumatic and retrograde amnesia are discussed, including direct measurement, rate of forgetting and evoked potential correlates. Studies of residual memory deficit in survivors of CHI are reviewed, including the effects of severity and chronicity of injury and features such as utilization of semantic features to guide recall. The evidence for relatively preserved motor and pattern analyzing skills after severe CHI is presented and the implications for rehabilitation are discussed.

Psychiatric disorders following closed head injury: an overview of biopsychosocial factors in their etiology and management

Head trauma in our society is a common occurrence, resulting in significant expenditure of societal resources. Psychiatric consequences following the injury may be the cause of significant disability during the recovery process. While nearly any psychiatric symptom or disorder may occur following head injury, there are a few common complications which are reviewed in this article. Biopsychosocial factors reported to play a role in the etiology of post-traumatic psychiatric dysfunction are reviewed, diagnostic issues are discussed, and new findings regarding treatment are reviewed.

A reticulo-frontal disconnection syndrome

Persistent executive deficit, usually seen following prefrontal damage, is reported in a patient recovering from head trauma. Repeated neuroradidological examinations failed to reveal a lesion within the frontal lobes, but a circumscribed lesion in the ventral mesencephalic tegmentum was found. It is proposed that the observed syndrome was caused by damage to mesencephalic reticular nuclei and their projections into prefrontal cortex. The concept of a "reticulo-frontal disconnection syndrome" is introduced and its possible role in head trauma and schizophrenia discussed.

Conceptual encoding following severe closed head injury

This investigation examined whether survivors of severe closed head injury encode semantic properties of to-be-remembered words and the relationship of such processing to frontal lobe functioning. Fourteen patients enrolled in rehabilitation and 12 controls were administered the Release from Proactive Inhibition paradigm involving trials of recalling words from the same category followed by a shift to a new category or continued presentation of identical material. Similar to the controls, patients demonstrated a facilitation in recall when the category shifted. An association between the amount of release and frontal lobe functioning (as evaluated by neuropsychological tests and magnetic resonance imaging) was not compelling and depended upon the particular measure of release that was utilized. Pending replication in a larger, more representative sample, we suggest that conceptual encoding is relatively preserved in long-term survivors. The failure to find a robust relationship between frontal lobe pathology and semantic encoding is discussed in light of other investigations suggesting an association.

Psychosocial outcome for the survivors of severe blunt head injury: the results from a consecutive series of 100 patients

A consecutive series of 100 severely blunt head injured subjects was followed up six years after trauma and the level of psychosocial reintegration was determined for 87 subjects. Three-quarters of the series were classified as demonstrating major disability, having either a Poor Reintegration (33%) or a Substantially Limited Reintegration (43%); the remaining one-quarter of the series attained a Good Reintegration. The level of reintegration was related to the Glasgow Outcome Scale classification, although a one-to-one correspondence between the Glasgow Outcome Scale and the Psychosocial Disability Scale was not found: each of the Moderate Disability and Good Recovery groups was fairly evenly divided between a better and worse level of reintegration. Specific aspects of the subjects' psychosocial reintegration in employment, interpersonal relationships, functional independence, social contacts and leisure interests are described and the implications of the findings for the provision of extended care services to meet the long term needs are discussed.

Psychosexual consequences of traumatic brain injury: methodology and preliminary findings

A methodology to systematically assess the psychosexual consequences of traumatic brain injury was developed and applied to a group of 21 male patients. A majority of the sample reported negative changes in sexual behaviour, including decreased sex drive, erectile function and frequency of intercourse. Common personality changes included depression, reduced self-esteem and a perceived decline in personal sex appeal. However, despite these changes in sexual behaviour, there was evidence that the quality of their marital relationships was preserved. Furthermore, there was no evidence of a relationship between the level of affect and sexual behaviour.

Do young patients have worse outcomes after severe blunt head trauma?

The influence of age on very late outcome was examined in 40 patients who had received very severe blunt head trauma (post-traumatic amnesia greater than or equal to 1 month), and who were aged 15-44 years when injured. The patients were first seen on average 4.5 months after injury and then at two follow-up examinations in their homes 2.5 and 10-15 years after the trauma. There was no significant correlation between age when injured and post-traumatic amnesia. The frequency of 13 late cognitive, behavioural, social and subjective problems was examined at the second follow-up and compared with the observations made 2.5 years after injury. A statistical analysis indicated that the younger the patient the higher the risk of late behavioural and emotional sequelae. The results have been related to information and observations obtained from the home visits.

Social interaction and speed of information processing following very severe head-injury

Eighteen adults who had suffered a very severe closed head-injury more than 18 months previously and required long-term rehabilitative support were compared with a closely matched control group. Unlike previous studies, which have reported negative personality change involving an increase in aversive behaviour, our behavioural observation data suggest that a global reduction in behavioural productivity, or negative symptomatology, characterizes social interaction by this group. This resulted in their being judged less socially skilled, less likeable and less interesting, and thus less reinforcing to interact with. Speed of information processing was specifically impaired for the closed head-injury group, although this did not correlate with global behavioural ratings of social interaction behaviour. It is suggested that low behavioural productivity may be associated with family burden, and that the low quantity of social interaction experienced by severely head-injured adults may reflect the unreinforcing nature of their interactions.

Employment after severe head injury: do the Manpower Services Commission schemes help?

This paper describes the use of Manpower Services Commission (MSC) employment rehabilitation schemes by a series of severely head injured people. Most of those who achieved employment did so without making use of MSC schemes. A majority of those using MSC schemes remained unemployed at last follow-up. Those attending MSC schemes were more likely to have been in education at the time of injury. Some of those previously in work used schemes, but only after they had already failed at work or had had a long period out of work. MSC schemes may fail to meet the needs of the head-injured because many are too short or use is made of them at too long an interval after the injury. They do not cater well for special training and the flexible approach that is necessary for successful employment rehabilitation of those suffering from brain injury. The priority is for training schemes that can be carried out within the workplace and for support and incentives to employers to help head-injured people return to their previous work.

Family response in head injury: denial ... or hope for the future?

Denial is often seen as a major obstacle to successful adaptation in the family of the head-injured. In fact, it is typically inadequately understood in the rehabilitation setting. The term is frequently used in a simplistic way, with the social and cultural factors behind the denial, particularly the stigma of head injury, not examined or confronted. There is very little hard data on what constitutes successful family adaptation over the long term. Professionals have a tendency to focus exclusively on the patient's deficits and the family's difficulties, ignoring the positive ways in which people cope. This article suggests that there is a need for a paradigm shift, based on the transactional theory of stress and coping, in which denial is seen as a positive response in some situations. Instead of becoming locked into trying to dispel what is usually called denial and adopting an adversary stance to the family, it may be more beneficial for rehabilitation staff to work together with family members to understand why head injury is so difficult to deal with, develop positive models for living with the sequelae, and encourage hope for the future.

The financial trauma of head injury

One hundred parents and 50 spouses of head-injured persons responded to a survey on adjustment issues after head injury. The information they provided on financial matters is presented. Medical costs, legal fees, and other expenses are reported, both in total costs since the insult and in current yearly costs. Percentages of parents and spouses having to find employment, borrow money, lose possessions, and declare bankruptcy are also presented. Financial benefits such as Worker's Compensation and legal settlements are considered. Finally, mean reduction of income for the head-injured person and for the family is examined. The financial impact of head injury is varied in both source and in amount, though for many the cost is overwhelming.

Influence of injury severity on quality of survival after head injury

The relationship between severity of injury [as determined by the Glasgow Coma Scale (GCS)] and the quality of survival (as determined by neuropsychological measurements and work return) were investigated in 54 conscious survivors within 16 months following head injury. While severely head injured (GCS less than or equal to 8) patients had more neuropsychological impairments in areas of intelligence, attention, memory, visuomotor speed, and motor skills than those with mild injuries (GCS greater than 8), performances after both types of injury were below normative levels in areas of learning, memory, and visuomotor speed. Unemployment increased after both severe and mild injuries, while employment status changed more frequently after severe injuries. Age had a minimal effect on neuropsychological and employment outcomes after minor head injuries (GCS greater than 13). The findings suggest that regardless of acute severity, closed head injury influences long-term quality of survival.

Return to work and social adjustment after traumatic head injury

During follow-up of 485 adult patients with mainly mild head injury 27% of the patients were unemployed after an observation period of 3-5 years (mean 4.0 years). The length of sick leave during the last 3 years was longer than for a control group. Reduced physical capacity and time of sick leave during the last 3 years were the variables which were most closely associated with unemployment at follow-up. The long term family life, contact with friends and income were less favourable in the head injured patients than in the control group.

The neurobehavioural rating scale: assessment of the behavioural sequelae of head injury by the clinician

To investigate the inter-rater reliability and validity of the Neurobehavioural Rating Scale at various stages of recovery after hospitalisation for closed head injury, we studied 101 head trauma patients who had no antecedent neuropsychiatric disorder. The results demonstrated satisfactory inter-rater reliability and showed that the Neurobehavioural Rating Scale reflects both the severity and chronicity of closed head injury. A principal components analysis revealed four factors which were differentially related to severity of head injury and the presence of a frontal lobe mass lesion. Although our findings provide support for utilising clinical ratings of behaviour to investigate sequelae of head injury, extension of this technique to other settings is necessary to evaluate the distinctiveness of the neurobehavioural profile of closed head injury as compared with other aetiologies of brain damage.