Minor Head Trauma in Children: An Intervention to Decrease Functional Morbidity

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VOLUME 80 . AUGUST

1987

. NUMBER 2

Pedncs

Minor Head Trauma

in Children:

An Intervention

to Decrease

Functional

Morbidity

Rosemary Casey, MD, Stephen Ludwig, MD, and

Marie C.

McCormick, MD

From the Division of General Pediatrics, the ChlldrerYs Hospital of Philadelphia, the UnWersity of PennsyWania School of Medicine, Philadelphia

ABSTRACT. Minor head trauma is common among chil-then and evokes strong parental reaction. Parents often rush the child to an emergency department or consult their pediatrician by telephone despite the minor nature ofthe injury. In a previous report we showed that children

with minor head trauma appear to have limitations in

their usual daily activities and a high rate of school

absenteeism. This study was a prospective, randomized

trial of an intervention designed to reduce this functional

morbidity after head trauma. Parents in the control group (n = 168) received routine discharge instructions. Parents

in the intervention group (n = 153) received a discharge

interview during which the nurse gave more explicit and behaviorally oriented instructions. The nurse also called intervention parents the next day to reassure them and to urge that the children return to their usual routine.

One month after the injury a questionnaire was

adinin-istered by telephone to assess physical health status,

social or functional limitations, and behavior problems.

The majority of parents (85%) were anxious, and this

was not alleviated by previous experience with head trauma. Triage nurses incorrectly rated one third of the parents as not anxious. Physical health status, role

activ-ity indices, and behavior problems, were similar for the

intervention and control groups 1 month after the head

injury. Subsequent morbidity was highly correlated with parental anxiety. In managing children with minor head trauma, pediatricians and emergency department

physi-cians must focus their discharge instructions on the par-ent’s anxiety, emphasize the minor severity of the injury,

Received for publication April 17, 1986; accepted Sept 11, 1986.

Presented, in part, at the Ambulatory Pediatric Association Meeting in San Francisco, May 1984.

Reprint requests to (RC.) The Children’s Hospital of

Philadel-phia, 34th St & Civic Center Blvd. Philadelphia, PA 19104.

American Academy of Pediatrics.

and urge that the children return to their usual routine. Pediatrws 1987;80:159-164; head trauma, parental

anxi-ety.

Injury occurs daily in the life of a child. In most instances the pain is brief, the child is comforted by the parent, and there is a resumption of normal

activity.

When

minor

trauma

involves

the

head,

there seem to be some different consequences.

Often, it appears that parental reaction to head

trauma is great, leading to telephone consultation

with the child’s physician or a visit to the hospital emergency department. Head trauma accounts for a substantial share of emergency department use (11% of all visits).’ Minor head trauma appears to have some bearing on the child’s subsequent func-tional state. In a previous report,2 we showed that

children with mild head trauma, not associated with

even transient loss of consciousness, appear to have

limitation

in their

usual daily activities and a high

rate of school absenteeism during the month after their head injury.

Why do the parents rush to the emergency

de-partment, and what is the cause of this functional

morbidity?

What

can we do to help these children

and their parents? It is possible that parents are

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Control Group

1. Standard discharge instructions All Patients

1. Triage interview

2. Standard management

Intervention Group Intervention Group All Patients

1. Discharge Interview 1. Telephone call 1. Physical health status

2. Take-home booklet 2. Closure statement 2. ia1/functiona1 status 3. Behavioral problems

_________Ti_________ _____T2_____ _______T3_______

(24h) (imo)

Figure. Study design. only a small percentage of children with head

trauma require hospitalization, parents are given written instructions of signs and symptoms and are implicitly asked to become the skilled observers

without training. In this study, we have tried to

alter this by examining the effect of more explicit and behaviorally oriented instructions.

OBJECTIVES

The objectives of this study were (1) to evaluate an educational intervention with more detailed written instructions explained by a nurse and fol-lowed by her telephone call to reassure parents and

return the child to normal functional status more quickly and (2) to examine parents’

attitudes

to-ward minor head injury and their health care use for this problem.

MATERIALS AND METhODS

The study was a prospective, randomized trial of an intervention to reduce functional morbidity after minor head trauma. The study was performed by

enrolling consecutive patients with minor head trauma. The research staffwas present in the

emer-gency department until 11 PM, seven days a week,

except for occasional absence because of illness or

schedule

conflict.

Children

eligible

for

the

study

included those 6 months to 14 years of age who had

sustained minor head trauma within 24 hours of

their visit. Patients with loss ofconsciousness, skull

fracture,

child

abuse,

or hospital

admission

were

excluded. A nurse

administered

a ten-minute

triage

questionnaire to all parents immediately after their

arrival in the emergency department. This triage data include (1) a history of the child’s injury and

reason for bringing the child to the hospital, (2) the parent’s self-reported anxiety level, and (3) their

perception

of the

injury’s

severity.

At the

end

of

the interview, the nurse recorded her rating of the parent’s anxiety.

The study design is shown in the Figure. All

children received standard medical management and were then randomly assigned to a control group or an intervention group. Parents in the control

group received routine discharge instructions. These consisted of a printed list of symptoms for which the child should return to the emergency

department.

Parents

in the

intervention

group

re-ceived a discharge interview during which the nurse

explained a take-home booklet of symptoms to

ex-pect and instructions to follow. The child’s name was written in the booklet and, in an introductory paragraph, it was stressed that head injuries are common and that the child would be perfectly nor-mal. Graphic illustrations of a child with each symptom were presented. For example, blurred vi-sion was depicted by a child watching a distorted

picture on the television. In reassuring the parents,

the nurse reviewed the signs to look for and quali-fled the symptoms as to their likelihood. The nurse also called the parents in the intervention group 24

hours later to check on the child’s progress, to

reassure them again, and to bring closure to the

event by telling them the child could return to school.

Parents in both groups were interviewed by

tele-phone 1 month later to assess the child’s physical health status, social or functional limitations, and behavioral problems. Health status measures were those used in the Rand Health Insurance Study.4 Physical health status questions address the child’s

current

and

prior

health,

the

parent’s

perceptions

of the child’s susceptibility to illness, and the par-ents’ level of concern about the child’s health. The physical health indices are “current health,”

“resis-tance/suceptibiity,”

and

“prior

health.”

These

three indices are summed for each child to give a “general health ratings index.”4 In the Rand Health Insurance Study, social health refers to the quality of the child’s interpersonal interactions with sig-nificant others. The functional status items were

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role activity index can be 0 for no limitations or 1 for one or more limitations in daily activities.4 In other words, the role activity index represents the

percentage of children with one or more limitations

in their daily activities. The behavior question-naires used were Carey’s Infant and Toddler Tem-perament Scales5’6 (ages 6 months to 2311/12

months);

Behavioral

Screening

Questionnaire

of

Richman and Graham7 (ages 2 years to 411/12 years), and Behavior and Mental Health Surve? of Shep-herd et al8 (ages 5 to 14 years).

Analysis of the data was done by using a t test to compare the mean scores of the patients in the

intervention and control groups. The correlation

coefficient “ywas used to measure the association between parental anxiety and the injury’s severity,

previous experience with head trauma, and the nurse’s rating of parental anxiety. Cochran’s method of combining evidence from fourfold tables was used to analyze the relationship between pa-rental anxiety and subsequent morbidity.9

RESULTS

The study enrollment was 340, but 19 were ex-cluded because ofskull fracture, hospital admission, child abuse, or loss of consciousness. There were

153 patients in the intervention group and 168

patients

in

the

control

group.

The

sociodemo-graphic characteristics of the study population are

shown in Table 1. There were no differences be-tween the intervention and control groups for these characteristics or for triage data.

When asked how they felt about the accident,

85% of parents said they were moderately or very anxious. Thirty-nine percent of these parents rushed to the hospital immediately. Parental anxi-ety was not alleviated by previous experience with head trauma. One third of the children had had

TABLE 1. Sociodemographic Characteristics of Study Population

Characteristic

Intervention Group

(n = 153)

Control

Group

(a = 168)

Total (n = 321) Child

Age (mean yr ± 4.67 ± 3.6 4.28 ± 3.6 4.47 ± 3.6

SD)

Race (% black) 78.4 77.4 77.9

Sex (% boys) 67.3 70.8 69.2

Chronically ill 10.5 11.3 10.9

(%)

Handicapped 1.3 0.6 0.9

(%)

Parent

Age (mean yr ± 28.7 ± 8.8 28.2 ± 7.2 28.5 ± 8.0

SD)

Education (% 56.9 61.3 59.2

sl2yr)

previous head injuries, and 78% of these injuries had been mild according to the parents. There was a significant association between the parent’s

per-ception of this injury’s severity and their anxiety level (P = .002). Uncertainty led to anxiety in that

parents who were unable to rate severity (50%)

reported significantly more anxiety than those who

could rate severity (P = .007). Parent’s self-reported anxiety and the nurse’s rating of parental anxiety

disagreed

33% of the time

despite

statistical

corre-lation (‘y = .64, P = 001).

Follow-up data were

collected

for 63%

(204)

of

the patients during a telephone interview 1 month

after the injury. Nonrespondents did not differ from

respondents on the variables collected during the triage interview.

The physical symptoms that parents believed were related to the child’s head injury are presented in Table 2. Overall, physical symptoms were rare.

Patients

in the

control

group

had

more

physical

complaints. One or more physical symptoms in the month after the head trauma were reported for 12% of the control patients v 8% of the intervention patients. However, this difference was not statisti-cally significant (P = .63).

Health status of the children 1 month after the head trauma is summarized in Table 3. Intervention

and control groups were similar on physical health measures and role activity indices.

Absenteeism was high with 29% of the preschool children and 40% of the 5- to 14-year-old children missing one or more days of school or play group in the month after the head injury because of poor health. This was higher than the 10% absenteeism

rate for grade school and 19% for middle schools as reported by the School District of Philadelphia. Among the preschool-aged children, the control group’s absenteeism rate (37%) was twice that of the intervention group (19%), but the difference was not statistically significant.

Behavioral

problems

are summarized

in Table

4.

Intervention and control groups were similar in

TABLE 2. Physical Symptoms 1 Month After Head

Trauma

Symptom

Intervention Group (n = 103)

Control Group (n - 101)

Headache Difficulty walking Difficulty seeing Difficulty speaking Increased appetite Unsteady balance Vomiting

Patients with 1 symptom

5 1 1 1 1 0 0 8 9 0 0 0 1 1 2 12*

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TABLE 3. Health Status 1Month After Head Trauma

% (No.) of % (No.) of Total Standard

27.6 (21) 13.1 (5)t

27 (23) 2.7 (165)

TABLE 5. Parental Anxiety and Morbidity FollowingHead Trauma

Intervention Group

Not

Anxious Anxious Anxious Anxious (n = 86) (n = 12) (n = 85) (n =9)

Physical symptoms

Headache(%) 6 0 11 0

Neurological symptoms (%) 9 0 13 0

All symptoms (%) 9 0 15 11

School absenteeism: Ages 5-14 yr (n = 36) (n = 4) (n = 34) (n =3)

(%with1dabsent) 31 0 12 0

Role activity index*

Ages 6mo-4/i2 3T1 0.13 0 0.12 0.33

AgeS-l4yr 0.29 0 0.15 0

* Role Activity Index: 0, child has no limitations in daily activities; 1, child has one or

more limitation in daily activities.

their incidence of behavior problems following mi-nor head trauma.

When the data were stratified according to the parent’s initial self-rating of anxiety, it is apparent that most subsequent morbidity occurred among children of anxious parents (Table 5). Parents who were unable to rate their own anxiety were excluded from this analysis. Because overall morbidity was

low, analysis of this four-way table with Cochran’s

x2

method failed to reveal statistically significant

association.

Intervention Health

Measures*

Group (n = 103)

Control Group (n = 101)

Physical

Current health 10.81 ± 1.52 10.46 ± 2.05

R.esistance/su8cep- 7.59 ± 2.31 7.69 ± 1.92

tibility

Prior health 8.27 ± 2.43 7.90 ± 2.50

General health 26.67 ± 4.31 26.05 ± 4.79

rating index

Social: Role activity 0.17 ± 0.38 0.16 ± 0.37t

index

* Physical health indices are similar to those reported for

healthy children.4 Role activity index: 0, child has no limitations in daily activities; 1, child has one or more

limitations in daily activities.

t

Patients with head trauma report significantly more limitation than do healthy children.2

TABLE 4. Behavioral Problems After Minor Head

Trauma*

% (No.) in

Control

Group

23.7 (9)

26.8 (11)

% (No.) in Intervention

Age (yr) Group

____

_____

2-5 31.6 (12) 5-14 27.3 (12)

* Results are % ofchildren with deviance score more than or equal to standard. No. is number of children.

t

Behavioral Screening Questionnaire7 (deviance = score 10).

:1:

Behavior and Mental Health Surve? (deviance = score

7).

DISCUSSION

This study was limited to children who had sus-tamed minor head trauma by excluding patients with transient loss of consciousness, skull fracture, or concussion. However, the majority of parents

(85%) rated themselves as moderately or very

anx-ious when they arrived in the emergency depart-ment. Previous experience with head trauma did not alleviate parental anxiety. This was probably because parents did not feel competent enough to judge the severity of the child’s injury or they did

not want to be responsible for making important

decisions.

Parental

anxiety

was correlated with per-ceived severity, and those parents who could not rate the injury’s severity were most likely to be anxious. Thus, our findings suggest that a major

parental

concern

is defining

the

severity

of their

child’s head injury. Levy’#{176}has shown how parental

fears that a child was “vulnerable” account for

many of their medical visits, and in her study 40% of the children were not vulnerable by medical criteria. Parental concerns that trigger the medical

encounter

are

often

unrecognized

by the

medical

staff. In our steady, the nurses incorrectly rated

one third of the parents as not anxious. It is well

known’#{176}” that lack of recognition of parental

anx-iety and underlying concerns can lead to high

vol-ume use of expensive emergency services which do

not really meet the patient’s or the parent’s needs.

Parental anxiety appears to be closely related to

the morbidity found among children who had

sus-tamed minor head trauma. In this study, all of the

school absenteeism and all of the limitations in

daily activities for school-aged children occurred

among these whose parents were initially very anx-ious about the injury. There are two possible expla-nations for this association between parental anx-iety and subsequent functional morbidity. First, the morbidity may have preceded the emergency de-partment visit. The behavioral and social problems

Control Group

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noted in our study have been called the “new mor-bidity.”2 Nader et al’3 and Starfield et al’4 showed that children with new morbidity problems make

greater use of medical care resources for reasons

other than behavioral, educational, and family problems. In the study by Nader et al’3 children

with new morbidity problems were more likely than their schoolmates to seek medical attention for minor trauma and other illness. The second expla-nation for our results could be that the morbidity was determined by anxious parents who kept their

children home from school and limited their daily

activities. The questions from the Rand Health Insurance Study4 provide a parent-generated health status. The physical health indices reported by parents of the head trauma patients were identical with those reported by parents of healthy children in the Rand Health Insurance Study. If the high incidence of behavioral problems and activity lim-itations in this study were due to overreporting by anxious parents, this should also have been

re-flected in the physical health status measures.

Our data show a trend for fewer physical symp-toms related to the head trauma among patients in the intervention group. However, our intervention

failed to significantly decrease the behavioral and

functional problems that followed the minor head trauma. Several reasons for this can be postulated. First, the overall morbidity was lower than

ex-pected, and, thus, the sample sizes in this study

may have been inadequate. Given the 10% physical morbidity, each group would have to have 474

pa-tients to detect a 5% decrease in morbidity among

the intervention patients with a = .05, fi = .80.

Second, the measures may not have been sensitive enough to detect subtle changes in behavioral and psychosocial problems. Although the scales used in the Rand Health Insurance Study4 are the best available, experience with these measures is limited. The main pediatric experience with these measures has been in the Health Insurance Experiment.’5 Starfield and Dutton,’6 in their critique ofthe Rand

Health Insurance Experiment, noted that the Rand

measures of health status were not well suited to picking up the impact of differential use of health care. These measures may not have been sensitive enough to detect subtle differences in health be-tween our intervention and control groups. Third, the intervention may not have been potent enough to impact on this highly anxious group of parents who sought emergency treatment for their children

after minor head trauma. Perhaps, the intervention

was focused on the wrong problem. The work of

Horwitz et al17 and Beautrias et al’8 suggest that

these parents were already stressed in their per-sonal lives and they may require a different

ap-proach focused more on their underlying concerns. Future research is needed to explore the causes of

parental anxiety about minor head trauma and to

develop the appropriately targeted interventions.

IMPLICATIONS

Minor head trauma in children is associated with significant functional morbidity. The etiology of this morbidity is not clear, but our results indicate that it is highly correlated with parental anxiety. The intervention described here proved to be no more effective than the routine discharge sheet handed out to parents. To return these children to their usual routines, pediatricians and emergency

department physicians must try to determine the

parents’ underlying concerns, emphasize the minor severity of the injury, and focus discharge instruc-tions on parental anxiety as well as the signs and

symptoms of minor head trauma.

ACKNOWLEDGMENTS

This work was supported by a grant from the RObert Wood Johnson Foundation.

We thank Susan Weller, PhD, for statistical

consul-tation, and Rose Beato for typing the manuscript.

REFERENCES

1. Rivara FP: Childhood injuries: III. Epidemiology of non-motor vehicle head trauma. Dev Med Child Neurol

i984;26:81-87

2. Casey R, Ludwig 5, McCormick MC: Morbidity following minor head trauma in children. Pediatrics 1986;78:497-502

3. Bass LW, Cohen RL: Ostensible versus actual reasons for

seeking pediatric attention: Another look at the parental ticket of admission. Pediatrics 1982;70:870-874

4. Eisen M, Donald CA, Ware JR, et al: Conceptualization and Measurement ofHealthfor Children in the Health Insurance

Study,

Rand publication No. R-2313-HEW. Santa Monica, CA, Rand Corp, 1980

5. Carey WB, McDevitt SC: Revision of the infant tempera-ment questionnaire. Pediatrics 1978;61:735-739

6. Fullard W, McDevitt SC, Carey WB: Assessing tempera-ment in 1 to 3 year old children. J Pediatr Psychol

1984;9:205-217

7. Richman N, Graham PJ: A behavioral screening question-naire for use with three year old children: Preliminary

fmding. J Child Psychol Psychiatry 1971;12:5-33

8. Shepherd M, Oppenheim B, Mitchell S (eds): Childhood Behaviourand MentoJHealth. New York, Grune & Stratton, mc, 1971

9. Fleiss JL: Statistical Methods for Rates and Proportions.

New York, John Wiley & Sons mc, 1973, pp 108-239 10. Levy JC: Vulnerable children: Parents’ perspectives and the

use of medical care. Pediatrics i980;65:956-963

11. Korsch B: The pediatrician’s approach to his patient. Am J Die Child 1973;126:146-148

12. Haggerty RI, Roghmann KJ, Pleas B (eds): Child Health

and the Community. New York, John Wiley & Sons, Inc, 1975, pp 316-321

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school and community health care resources for behavioral, 16. Starfield B, Dutton D: Care, costs and health: Reactions to

educational, and social-family problems. Pediatrics and reinterpretation of the Rand findings. Pediatrics

1981;67:53-60 1985;76:614-621

14. Starfield B, Gross E, Wood M, et at: Psychosocial and 17. Horwitz 5, Morgenstern H, Berkman LF: The impact of psychosomatic diagnoses in primary care of children. Pedi- social stress and social networks on pediatric medical care

atrics 1980;66:159-167 use. Med Care i985;23:946-959

15. Valdez RB, Brook RH, Rogers WH, et al: Consequences of 18. Beautrais AL, Fergusson DM, Shannon FT: Life events and cost-sharing for children’s health. Pediatrics i985;75:952- childhood mothidity A prospective study. Pediatrics

961 1982;70:935-940

SOME COMMENTS ABOUT SAMUEL JOHNSON’S EARLY EDUCATION AS

DESCRIBED

BY JAMES

BOSWELL

James Boswell (1740-1795) published his great work entitled the Life of SamuelJohrzson in 1791. The book proved Boswell’s extraordinary aptitude and

talent as a biographer.

Among the many details of Dr. Johnson’s early education, Boswell recorded

the following comments.1

He began to learn Latin with Mr. Hawkins, usher, or undermaster of Lichfield school, “a man (said he) very skilful in his little way.” With him he continued two years, and

then rose to be under the care of Mr. Hunter, the head-master, who, according to his

account, “was very severe, and wrong-headedly severe. He used (said he) to beat us unmercifully; and he did not distinguish between ignorance and negligence; for he would beat a boy equally for not knowing a thing as for neglecting to know it. He would ask a boy a question, and if he did not answer it, he would beat him, without considering

whether he had an opportunity of knowing how to answer it. For instance, he would call

upon a boy, and ask him Latin for a candlestick, which the boy could not expect to be

asked. Now, sir, if a boy could answer every question, there would be no need of a master to teach him....”

He [Johnson] discovered a great ambition to excel, which roused him to counteract

his indolence. He was uncommonly inquisitive; and his memory was so tenacious that he never forgot any thing that he either heard or read. Mr. Hector [a schoolfellow]

remembers having recited to him eighteen verses, which, after a little pause, he repeated

verbatim, varying only one epithet, by which he improved the line.

He never joined with the other boys in their ordinary diversions: his only amusement

was in winter, when he took a pleasure in being drawn upon the ice by aboy barefooted,

who pulled him along by a garter fixed round him; no very easy operation, as his size

was remarkably large. His defective sight, indeed, prevented him from enjoying the

common sports: and he once pleasantly remarked to me, “how wonderfully he had

contrived to be idle without them.” Lord Chesterfield, however, has justly observed in

one of his letters, when earnestly cautioning a friend against the pernicious effects of

idleness, that active sports are not to be reckoned idleness in young people and that the

listless torpor of doing nothing alone deserves that name. Of this dismal inertness of

disposition, Johnson had all his life too great a share. Mr. Hector relates that “he could

not oblige him more than by sauntering away the hours of vacation in the fields, during

which he was more engaged in talking to himself than to his companion.”

Noted by T.E.C., Jr, MD

REFERENCE

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1987;80;159

Pediatrics

Rosemary Casey, Stephen Ludwig and Marie C. McCormick

Minor Head Trauma in Children: An Intervention to Decrease Functional Morbidity

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