Cognitive and Behavioral Sequelae of Mild Head Injury in Children

(1)

Cognitive

and Behavioral

Sequelae

of Mild

Head

Injury

in Children

Polly E. Bijur,

PhD, MPH;

Mary

Haslum,

PhD; and

Jean

Golding,

PhD

From the Albert Einstein College of Medicine, Bronx, New York; Bristol Polytechnic and University of Bristol, England

ABSTRACT. Data from a longitudinal study of 13 000

British children were used to assess the sequelae of mild head injury 1 to 5 years after injury. One hundred

four-teen children with parental reports of mild head injury

treated with ambulatory care or admission to hospital for one night were compared with 601 children with limb fractures, 605 with lacerations, 136 with burns, and 1726

children without injury. Scores at age 10 were adjusted for intelligence, aggressive and hyperactive behavior at age 5, sex, socioeconomic status, and six other social

factors. Children with head injuries were statistically

indistinguishable from uninjured children on all

out-comes except teacher’s report of hyperactivity. After con-trol of hyperactivity at age 5 and the social and personal

factors, the head-injured children’s mean hyperactivity score was four tenths of a standard deviation above that of the uninjured children. Children with lacerations and

burns scored as badly or worse on measures of

intelli-gence, mathematics, reading, and aggression as the chil-then with head injuries. The small magnitude of the hyperactivity association coupled with the overall nega-tive results suggests that mild head injury in school-aged children does not have an adverse effect on global

meas-ures of cognition, achievement, and behavior 1to 5 years

after injury. Pediatrics 199086:337-344; accidents, aggres-sion, child, hyperkinesis, wounds and injuries.

It can be estimated that each year 375 000 US children and adolescents younger than the age of

17 years sustain head injuries that require medical care or restricted activity.’ Approximately 95 000 of these injuries result in damage to the brain.2 The majority of these head injuries can be considered mild, as most are treated in the outpatient

depart-Received for publication Jul 5, 1989; accepted Oct 3, 1989. Portions of this manuscript were presented at the American

Pediatric Society and Society for Pediatric Research Annual Meeting, Washington, DC, May 5, 1988.

Reprint requests to (P.E.B.) Albert Einstein College of Medicine,

Rose F. Kennedy Center, 1410 Pelham Pky 5, Bronx, NY 10461.

PEDIATRICS (ISSN 0031 4005). Copyright C 1990 by the

American Academy of Pediatrics.

ment, emergency room, or doctor’s office.”3 It has been noted that pediatric head trauma is an “emo-tionally charged form of injury” which parents as-sociate with abrupt behavior change, loss of intel-lectual functioning, and sudden death.4 For the physician, the management of mild head injury poses a challenge: to avoid burdening the patient and the medical care system with unnecessary care, while at the same time identifying and treating those patients who need more intensive attention.

A number of studies have found that behavioral and cognitive problems are associated with moder-ate to severe head injury. The most conclusive findings are from studies of children in coma for 24 hours or more. There is evidence of decrements in memory,5 school perforrnance, and Performance

IQ9”#{176};

increased anger-, disinhibited behavior; and hyperactivity.”2

As there is considerable evidence that moderate to severe injuries can result in persistent adverse outcomes, it is of interest to determine whether the more common, minor injuries also result in im-paired behavior or cognition. Two studies have suggested that children with moderate to minor head injuries perform less well on several timed tasks than children without head injuries.7”3 A 1-week follow-up of 228 emergency room patients, half of whom were younger than 16, showed that while the majority ofpatients had physical sequelae that persisted to 1 week, self-reported behavior change and memory loss were reported by only 3.9% and 1.3%, respectively, of the sample.’4 In contrast, a second study of minor head trauma treated in the emergency room found that 1 month after injury there was little physical morbidity but significantly more behavioral problems than in an uninjured population.4

(2)

of the mother, large family size, preexisting behav-ioral problems) are also associated with poor cog-nitive and behavioral functioning.”52’ Previous studies of minor head injuries have failed to ade-quately take into account the differential distribu-tion of social, personal, and familial factors that may affect cognition, behavior, and risk of injury. Two methods of doing this include statistical ad-justment for potentially confounding variables and comparison of head-injured children with those who have injuries not involving the head. An advantage of the comparison with other injured children is that factors associated with injury that are poorly measured, or unmeasured, are controlled by the design of the study.

The aim of this study was to assess whether there are any adverse sequelae of mild head injury in children that can be distinguished from preexisting behavioral or cognitive status and the effects of the social milieu.

METHOD

The subjects of this study are a subsample of the 1970 British Birth Cohort, which consists of ap-proximately 13 000 children born in 1 week in 1970. The parents of these children were extensively in-terviewed by health visitors from the National Health Service at the time of the children’s 5th and 10th birthdays under the auspices of the Child Health and Education Study (CHES).22’23 A struc-tured interview with the parents was used to obtain the information about the children’s injuries. When the children were 10 years of age, the parents were asked the following question:

Since the fifth birthday, has the child had an accident

requiring medical advice and treatment? Please include accidents at home, in school, on the road and elsewhere,

accidental ingestion of medicines/poisons, burns/scalds, eye injuries, near-drowning, bad cuts, and other injuries, with and without unconsciousness. If yes, please state total number of accidents.

Codes were assigned to the parental descriptions of the injuries and diagnoses by trained coders using the International Classification of Diseases, 9th re-vision (ICD-9).24 The name and address of the hospital was requested of all parents who reported an injury resulting in hospitalization. These hos-pita! records have been obtained and were used to assess the validity of the parental reports.

Five groups of children were selected for analysis: those with head injury, limb fractures, burns, lac-erations, and a sample of children without injury between ages 5 and 10. The head-injury subgroup included all children whose parents reported one or more head injuries diagnosed as concussion (ICD-9

code 850) or with loss of consciousness (ICD-9 code 780 and a head injury code: 800, 801, 803, 804, 851 to 854) when the child was between the ages of 5 and 10 years and who received ambulatory treat-ment or hospitalization for one night (n = 114).

Except when loss of consciousness was explicitly stated, it was not possible to identify the symptoms that led to a diagnosis of concussion reported by the parents. However, a review of hospital records of children reported as having concussions in this survey indicated that in the presence of one or more of the following symptoms subsequent to head in-jury, the injury was reported as a concussion: loss of consciousness, vomiting, amnesia, drowsiness, headache, dizziness, nausea.

The head-injured children were compared with children with other types of injury between ages 5 and 10-children with limb fractures (ICD-9 codes 810 to 829; n = 601), children with burns (ICD-9

codes 940 to 949; n = 136), and children with

lacerations of the limbs (ICD-9 codes 880 to 884, 890 to 894; n = 605)-and with a random sample

of 1726 children from the 6014 children who had no injuries between ages 5 and 10 years. Children with multiple injuries from a single accident or multiple accidents were assigned to an injury group using the following hierarchy: head injury, burn, fracture, laceration. Children in the injury subgroups were only included if they received am-bulatory care for their injuries or if they were hos-pitalized for one night or less. Other inclusion cri-teria for all five groups were as follows: no head injury between birth and age 5 years, mother pres-ent at the interview, family primarily English speaking, mother identified her country of origin as the United Kingdom, child never in residential care, more than half of the behavioral data available, and singleton birth.

When the children were 5 and 10 years of age, the parents completed the Rutter Child Behavior Questionnaire, and at age 10, teachers also an-swered questions from both the Rutter and Conners questionnaires.25’26 Scales measuring aggressiveness and overactivity were derived through factor analy-sis of data from 1912 children from the 1970 British Birth Cohort. The scales of aggression included items such as “frequently fights with other chil-dren” and “often destroys own or others’ belong-ings.” The mother’s scales of overactivity included items such as “very restless, often running or jump-ing up and down, hardly ever still.” The overactivity scales at age 10 included items relating to inatten-tiveness (eg, inattentive, easily distracted) as well as to overactivity. The behavioral scores were all standardized to a mean of zero and a standard

(3)

At age 5, the English Picture Vocabulary Test,

the

British

version

of the

Peabody

Picture

Vocab-ulary Test, was used to assess overall intelligence.27 At age 10, the Word Definitions, Recall of Digits, Similarities, and Matrices subtests of the British Abilities Scale28 were used to assess intelligence. At age 10, the children were given a shortened version of the Einburgh Reading Test and a vocabulary test, the Child Health and Education Study Lan-guage Pictorial Comprehension Test, which is based on the English Picture Vocabulary Test. A mathematics test, the Friendly Maths Test, was devised for the study. This test covered knowledge, concepts, and applications in arithmetic, geometry, algebra, and statistics. The British Abilities Scale, reading, mathematics, and vocabulary tests were all standardized to a mean of 100 and a standard deviation of 15.

Personal, familial, and social factors that were controlled analytically included sex of the child; socioeconomic status, which includes social class of the father, education of the father and mother, or social class and education of the mother if she was head of household; housing quality; age of the mother; the maternal malaise inventory, a measure of mother’s psychologic and somatic status25; em-ployment of the mother; number of siblings in the household at age 5; number of non-accident-related hospitalizations of the child from birth to 5; and number of other injuries between birth and 5.

One-way analysis of variance was used to com-pare the means between groups, and analysis of covariance was used to compare the mean outcome measures between the groups while adjusting for potentially confounding variables. The Scheffe#{233}cri-tenon (P = .05 for all pairwise comparisons follow-ing a significant F test) was used to test the differ-ences between pairs of groups.3#{176}

RESULTS

Validity

of Parental

Report

of Head Injuries

Forty-nine (43%) of the children who met the head injury criteria were admitted to the hospital for one night. Hospital records were located for 38 children. Of these, 35 records indicated head injury with one or more symptoms associated with intra-cranial injury: 23 children had hospital records that noted vomiting, 17 had a history of unconscious-ness, 11 had head injury with drowsiness, 6 with amnesia, 7 with headache, 4 with dizziness, 3 with confusion, and 2 with nausea. Thirty ofthe children had histories of unconsciousness, amnesia, or vom-iting. The histories of unconsciousness were mostly qualitative and indicated brief periods of uncon-sciousness (eg, “momentarily knocked

uncon-scious,”

“knocked

out

for

approximately

5

mm-utes,” “probably unconscious for a very brief period”). Of the 38 cases, there were 2 with no mention of symptoms indicative of intracranial in-jury and 1 that was illegible.

Social

and Personal

Characteristics

The children with head injuries differed from the uninjured children on several of the social and personal factors (Table 1). The head-injured chil-dren had significantly higher aggression scores at age 5, before their head injuries, and they had significantly more hospitalizations (not related to injuries) from birth to age 5 than the uninjured children. These children also had somewhat higher socioeconomic status, although this finding was not statistically significant. Although there was consid-erable variability among the injury groups, com-pared with their uninjured peers they had higher aggression and hyperactivity scores at age 5, more injuries from birth to age 5, and mothers who were younger and had higher depression scores; they were also more likely to be male. The children with burns and lacerations had the lowest socioeconomic status, the worst housing, and the largest number of siblings.

Cognition,

Achievement, and Behavior

The children with head injuries were indistin-guishable from the uninjured children on all the outcomes except teacher’s rating of hyperactivity, as shown in Tables 2 through 5. The head-injured children had the highest mean score on mother’s rating of hyperactivity of all the groups and they also had higher levels of aggressive behavior and lower academic achievement than the uninjured children; however, none of these differences was statistically significant. The five groups of children had significantly different means on all of the out-comes studied, before adjustment for the covariates. However, all but one of the statistically significant pairwise comparisons were between the uninjured children and those with lacerations or burns.

(4)

TABLE 1. Social and Personal Characteristics of the Sample*

Characteristic No Injuries (n = 1726)

Head Injury (n = 114)

Burns (n = 136)

Fractures (n = 601)

Lacerations (n = 605)

P

Socioeconomic status .00 ± .99 .13 ± .98 -.34 ± .74t -.02 ± .98 -.14 ± .96t <.001 Quality of housing .03 ± 1.00 -.04 ± 1.08 -.16 ± .96 .01 ± .95 -.10 ± 1.00 <.05

Mother’s age 26.21 ± 5.36 25.06 ± 5.04 25.64 ± 5.99 25.79 ± 5.14 25.27 ± 5.36t <.01

Mother’s depression 4.12 ± 3.46 4.29 ± .53 4.64 ± 3.49 4.40 ± 3.59 4.64 ± 3.59t <.05 Number of siblings 1.44 ± .98 1.43 ± .89 1.62 ± 1.11 1.44 ± .94 1.64 ± 1.12t <.001

Mother’s full-time 11.6 17.5 10.9 11.4 15.1 <.05

work(% full-time)

Sex of child

(%

male) 43.6 64.9t 50.7 51.9t 64.8t <.001

No. of hospitalizations .26 ± .64 .50 ± .85t .26 ± .62 .30 ± .69 .27 ± .63 <.01 No. of injuries birth to .34 ± .61 .52 ± .79 .55 ± .77t .52 ± .77t .57 ± .86t <.001

5y

Aggression score at 5 y -.12 ± .91 .28 ± 1.24t .03 ± .86 .10 ± 1.05t .26 ± 1.12t <.001 Hyperactivity score at -.04 ± .97 .00 ± 1.06 .09 ± 1.02 .06 ± 1.03 .17 ± 1.05t <.001

5y

Verbal intelligence at .10 ± .94 .11 ± .94 -.14 ± .88 .03 ± .95 -.07 ± .94 <.001 5 y:I:

* Results are given as mean ± SD unless otherwise noted. Actual number of subjects varies for different measures

because of missing data.

t

Significantly different from no-injury group, Scheff#{233}criterion.

:1:

English Picture Vocabulary Test.

TABLE 2. Cognitive Outcomes by Injury Group: Unadjusted and Adjusted Means*

Injury Group

British Ability Scale CHE St Language Co sion Test

mprehen-n Unadjusted Adjusted n Unadjusted Adjusted

Mean Mean Mean Mean

No injury 1374 101.4 100.9 1395 101.6 101.2

Head injury 91 102.2 101.0 92 102.2 101.1

Burns 107 95.3 97.8 96 98.4 100.3

Fractures 466 100.4 100.4 479 101.8 101.6

Lacerations 504 96.9 98.1 512 99.2 100.2

F 11.17 5.44 3.54 .80

P <.001 <.001 <.01 .53

* Adjusted for sex of the child, socioeconomic status, housing quality, age of the mother,

maternal malaise inventory, employment of the mother, number of siblings in the house-hold at age 5, number of non-accident-related hospitalizations of the child from birth to 5, number of other injuries between birth and 5, and English Picture Vocabulary Test at age 5.

t

CHES, Child Health and Education Study.

§

Significantly different from no-injury group, Scheff#{233}criterion.

TABLE 3. Acade mic Ac hievement by Injury Group: Unadjusted and Adjusted Means*

Injury Group Friendly Maths Test Edinburgh Reading Test

n Unadjusted Adjusted Mean Mean

n Unadjusted Adjusted Mean Mean Noinjury 1392 101.3 100.7 1398 102.1 101.2

Head injury 92 99.6 98.7 92 99.1 98.6

Burns 108 95.7t 97.9 109 97.Ot 99.5

Fractures 475 100.2 100.1 479 100.5 100.5 Lacerations 512 97.8t 99.0 513 96.7t 98.5t

F 7.64 2.63 14.14 4.85

P <.001 .03 <.001 .001

maternal malaise inventory, employment of the mother, number of siblings in the

house-hold at age 5, number of non-accident-related hospitalizations of the child from birth to 5, number of other injuries between birth and 5, and English Picture Vocabulary Test at age 5.

(5)

TABLE 4. Measures of Aggression by Injury Group: Unadjusted and Adjusted Mean?

Injury Group Mother’s Report Teacher’s Report

n Unadjusted Mean Adjusted Mean n Unadjusted Mean Adjusted Mean Noinjury Headinjury Burns Fractures Lacerations F P 1678 113 134 596 595 -.07 .13 .18 .07 .23t 10.76 <.001 .01 .01 .11 .03 .08 .86 .49 1469 95 113 515 532 -.11 .14 .27t .04 .24t 15.74 <.001 -.07 .06 .25t .03 .16t 7.17 <.001

maternal malaise inventory, employment of the mother, number of siblings in the house-hold at age 5, number of non-accident-related hospitalizations of the child from birth to

5, number of other injuries between birth and 5, and mother’s report of child’s aggression

at age 5.

t Significantly different from no-injury group, Scheff#{233}criterion.

TABLE 5. Measu res of H yperactivity by Injury Grou p: Unad justed and Adjusted Means*

Injury Group Mother’s Report Teacher’s Report n Unadjusted Adjusted

Mean Mean

n Unadjusted Adjusted Mean Mean No injury Head injury Burns Fractures Lacerations F P 1680 113 134 595 597 -.07 -.02 .20 .17 .17 .10 .06 .03 .23t .11 12.38 3.31 <.001 .01 1469 95 113 515 532 -.10 -.05 .43t .36t .24t .19 .03 .01 .23t .13t 17.65 7.59 <.001 <.001

maternal malaise inventory, employment of the mother, number of siblings in the

house-hold at age 5, number of non-accident-related hospitalizations of the child from birth to 5, number ofother injuries between birth and 5, and mother’s report ofchild’s hyperactivity at age 5.

t Significantly different from no-injury group, Scheff#{233}criterion.

achievement, and behavior than the uninjured con-trol subjects.

Place of Treatment

of Head Injury

All the cognitive and behavioral outcomes at age 10 were compared between children with head in-juries resulting in ambulatory care and those

re-suiting in hospitalization. There were no statisti-cally significant differences and no consistent pat-tern to the findings: for some outcomes those who received ambulatory care had worse scores, and for other outcomes those admitted to hospital had worse scores.

Age at Time of Head Injury

The injuries occurred throughout the 5-year period; therefore, it was possible that deficits in children with more recent head injuries might have been obscured by inclusion of children with earlier injuries who had subsequently recovered. To ad-dress this issue, the mean cognitive and behavioral

measures at age 10 of the head-injured children were analyzed by age of the child at the time of the injury (Table 6). There were two statistically sig-nificant linear relationships between age of injury and mathematics achievement and mother’s report of hyperactivity; however, the direction of these relationships indicated that more recent head in-juries were associated with higher mathematic

scores and less hyperactive behavior than earlier head injuries. It is clear from the data presented in Table 6 that there is no overall pattern of associa-tion that suggests that children with more recent head injuries had worse outcomes than children injured earlier.

DISCUSSION

(6)

TABLE 6. Cognitive and Behavioral Measures at Age 10 by Age of Child at Time of

Head Injury*

Age of Chil d at Time of Head Injury Pt

5-6 6-7 7-8 8-9 9-10

(n = 5) (n = 20) (n = 25) (n = 29) (n = 35)

British Ability Scale 102.6 97.3 99.1 104.3 104.4 .13

Mathematics 93.5 94.2 94.8 102.2 104.3 .006

Reading 97.3 96.7 96.0 99.8 101.8 .19

Aggression

Parent’s report .74 .16 .16 .01 .10 .44

Teacher’s report .48 .80 .26 -.17 .24 .82

Hyperactivity

Parent’s report .84 .53 .35 -.08 .05 .02

Teacher’s report .39 .51 .34 .28 .57 .76

* Number of cases varies because of missing data.

t Significance of test of linear component of variance.

of minor head injury. Two studies have documented abnormal computed tomographic findings in a sub-stantial number of children with minimal to no disturbance of consciousness, raising the possibility that there may be associated functional abnormal-ities.32’33 In a review of the subject, Boll and Barth marshaled data from animal studies to support the argument that minor head injuries leading to mm-imal or no alteration of consciousness can result in degenerative brain changes which, in turn, are as-sumed to be the cause of the cognitive and behav-ioral deficits observed in clinical and epidemiologic data. Kraus, in a study of the epidemiology of brain injury, wrote that “there is growing evidence in the literature that even mild, uncomplicated brain in-jury may result in physical, mental, or behavioral changes”292

Much of the epidemiologic and clinical evidence cited to support these arguments is problematic. Some of the data derive from adult studies, which are not directly relevant to children.337 Studies and reviews used as evidence of adverse sequelae of minor head injury include injuries that cannot be considered minor.7.12.m Inference from many of the studies is impaired by the lack of comparison groups, inadequate matching of control subjects to head-injured subjects, and lack of information about premorbid functioning.

The study described in this paper is unique in that it describes long-term cognitive, academic, and behavioral functioning in children who experienced injuries of relatively the same severity; there are measures of behavior and cognition before the in-jury; there is extensive control for the many social

and personal factors that distinguish injured from uninjured children; and children with injuries not related to the head were used for comparison with the head-injured children. The findings from this study provide little evidence for any global cognitive or academic impairment that is specifically

attrib-utable to mild head injury or for any impact of mild head injury on aggressive behavior 1 to 5 years after the injury. While the mean reading and math achievement scores of the head-injured children were somewhat lower than those of the uninjured children, and their mean aggression and hyperac-tivity scores were higher, the magnitude of these differences was small, and only one of the differ-ences between the head-injured and the control children was statistically significant.

If the design of this study had not included chil-dren with other types of injuries, the worse aca-demic achievement ofthe head-injured children and their higher level of behavioral problems, even in the absence of statistical significance, might have been interpreted as suggesting a small but real effect of intracranial damage. The finding that chii-dren with burns and lacerations performed as badly or worse on most of the cognitive and behavioral measures than the head-injured children makes it more difficult to ascribe the observed deficits in the head-injured children to presumed intracranial damage.

(7)

biased in this way. While the observed association between hyperactivity in school at age 10 and head injuries may reflect a causal relationship, it could also reflect a scenario in which children who were not reported as hyperactive by their parents at age 5 became more active and less attentive in school between age 5 and 10, and then, as a result of the increased hyperactivity, became more vulnerable to injury.

Of eight measures of potentially adverse out-comes, we found only one that was even suggestive of excess morbidity in the head injury group. Why did we not identify more adverse sequelae? It could be that there are subtle effects of these injuries that could not be detected with the measures of cogni-tion, academic achievement, and behavior used in this study. While it is possible that there may be subtle deficits associated with mild head injury, the clinical significance of this knowledge is limited if the deficits are not expressed in reduced academic achievement or increased behavioral difficulties. Another possible explanation of our generally neg-ative results is that there are some early deficits followed by complete recovery of function which were obscured by including children whose injuries occurred up to 5 years before the assessment of their cognitive and behavioral functioning. How-ever, if this were true, we would have expected to have seen a linear relationship between recency of the injury and the cognitive and behavioral func-tioning at age 10, a relationship we did not observe. Finally, it may be that even though the head injuries included in this study were ones in which there was parental report of concussion or unconsciousness, it is possible that many were truly trivial injuries with little to no involvement of the brain. However, the medical records of the children admitted to hospital for one night indicate that most of the injuries reported as concussion by the parents had some indication of intracranial injury, most fre-quently vomiting and/or a history of unconscious-ness. While similar records are not available for those treated as outpatients, the finding that the children who were hospitalized were not consist-ently more impaired than those who were not hos-pitalized suggests that their injuries were of similar severity.

A head injury is a distressing and frightening event to children and parents alike. While there is little doubt that severe injuries can cause adverse cognitive and behavioral sequelae, results from this study suggest that head injuries reported as con-cussion, and which result only in ambulatory care or hospitalization of one night, do not have a dis-cernible effect on general measures of intelligence, achievement, and aggression measured 1 to 5 years

after the injury. While there was some suggestion of excess hyperactivity in the head-injured children in these data, the small size of the association taken in the context of the overall findings of the study does not warrant deviating from the traditional pediatric view of minor head injury as an unfortu-nate but generally benign event of childhood, to be treated on the individual level with reassurance about a favorable outcome. Even without firm evi-dence of long-term global sequelae of minor head injuries, the immediate pain, anxiety, and distress associated with minor head injury, and the adverse outcomes associated with severe head injury, are compelling reasons for support of public health measures to reduce the severity of head injury, including promotion of bicycle helmet use, previ-sion of shock-absorbing surfaces where children play, and improved product design.

ACKNOWLEDGMENTS

This research was supported by grants from the De-partment of Health and Social Security (UK), the De-partment of Education and Science (UK), the National Institute of Child Health and Human Development (USA), and the William T. Grant Foundation.

We gratefully acknowledge the contribution of the

Regional and District Health Authorities, Health Boards, and health visitors throughout England, Scotland, and Wales and all academic staff who have been involved in the preparation and development of the Child Health and Education Study data sets.

REFERENCES

1. National Center for Health Statistics. Collins JG. Types of injuries and impairments due to injuries, United States. Vito.! and Health Statistics. Series 10, No. 159. Washington,

DC: US Government Printing Office; November 1986:1-74. Dept of Health and Human Services publication (PHS)

87-1587

2. Kraus JF, Fife D, Cox P, et al. Incidence, severity and external causes of pediatric brain injury. AJDC. 1986;140:687-693

3. Manheimer DI, Dewey J, Mellinger GD, et al. 50,000 child-years of accidental injuries. Public Health Rep.

1966;81:519-533

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

5. Levin HS, Benton AL, Grossman RG. Neurobehavioral

Con-sequences of Closed Head Injuries. New York, NY: Oxford

University Press; 1982

6. Heiskanen 0, Kaste M. Late prognosis ofsevere brain injury in children. Dev Med Child Neurol. 1974;16:11-14

7. Klonoff H, Low MD, Clark C. Head injuries in children: a prospective five year follow-up. J Neurol Neurosurg

Pay-chiatry. 1977;40:1211-1219

8. Filley CM, Cranberg MD, Alexander MP, Hart EJ. Neuro-behavioral outcome after closed head injury in childhood

and adolescence. Arch Neurol. 1987;44:194-198

9. Chadwick 0, Rutter M, Shaffer D, Shrout PE. A prospective study of children with head injuries, IV: specific cognitive deficits. J Clin Neuropsychol. 1981;3:1O1-120

(8)

Neuropsycholog-ical deficits following head injury in children. J Clin

Neu-ropsychol. 1984;6:269-286

1 1. Black P, Jeffries J, Blumer D, et al. The posttraumatic syndrome in children. In: Walker AE, Caveness WJ, Critch-ley M, eds. The Lzte Effects of Head Injury. Springfield, IL:

Charles C Thomas; 1969:142-149

12. Brown G, Chadwick 0, Shaffer D, et al. A prospective study of children with head injuries, III: psychiatric sequelae.

Psychol Med. 1981;11:63-78.

13. Gulbrandsen GB. Neuropsychological sequelae oflight head injuries in older children 6 months after trauma. J Clin

Neuropsychol. 1984;6:257-268

14. Coonley-Hoganson R, Sachs N, Bindu D, et al. Sequelae associated with head injuries in patients who were not hospitalized: a follow-up survey. Neurosurgery.

1984;14:315-317

15. Nyman G. Infant temperament, childhood accidents and hospitalization. Clin Pediatr (Phiki). 1987;26:398-404

16. Davidson LL. Hyperactivity, antisocial behavior, and child-hood injury: a critical analysis ofthe literature. JDev Behav Pediatr. 1987;8:335-340

17. Bijur P. Golding J, Haslum M, et al. Behavioral predictors of injury in school-age children. AJDC. 1988;142:1307-1312 18. Nathorst-Westfelt JA. Environmental factors in childhood

accidents: a prospective study in Goteborg, Sweden. Acts

Paediatr Scand. 1982;291(suppl):1-75

19. Brown GW, Davidson S. Social class, psychiatric disorder of mother, and accidents to children. Lancet. 1978;1:378-380

20. Beautrais AL, Fergusson DM, Shannon FT. Childhood ac-cidents in a New Zealand birth cohort. Aust Paediatr J. 1982;18:238-242

21. Bijur P, Golding J, Kurzon M. Childhood accidents, family size and birth order. Soc Sci Med. 1988;26:839-843

22. Butler NR, Golding J, Howlett B. From Birth to Five: A Study of the Health and Behaviour of Britain’s Five Year

Old.s. Oxford, England: Pergamon Press; 1986

23. Child Health and Education Study. First report to the Department of Health and Social Security on the 10 year follow-up. Bristol, England Department of Child Health, University of Bristol; 1982

24. World Health Organization. International Ckzssification of

Diseases: Manual of the International Classification of Dis-eases, Injuries, and Causes of Death. 9th rev. Geneva, Swit-zerland: World Health Organization; 1978;1

25. Rutter M, Tizard J, Whitmore K. Education, Health and

Behaviour. London, England: Longman Group Ltd; 1970 26. Conners CK. A teacher rating scale for use in drug studies

with children. Am J Psychiatry. 1969;126:152-156

27. Brimer MA, Dunn LM. Manual For The English Picture Vocabulary Test. Bristol, England: Educational Evaluation Enterprises; 1963

28. Elliott CD, Murray DJ, Pearson LS. British Ability Scales, Manual 3: Directions for Administration and Scoring. Wind-sor, England: National Foundation for Educational Re-search; 1979

29. Godfrey Thompson Unit for Educational Research. Manual

of Instructions for the Edinburgh Reading Test Stage 4.

Sevenoaks, England: Hodder and Stoughton Educational; 1977

30. Neter J, Wasserman W. Applied Linear Statistical Models.

Homewood, IL: Richard D. Irwin mc, 1974.

31. Behrman RE, Vaughan VC, Nelson WE. Nelson Textbook of Pediatrics. 13th ad. Philadelphia, PA: WB Saunders Co; 1987

32. Zimmerman RA, Bilaniuk LT. Computed tomography in pediatric head trauma. J Neuroradiol. 1981;8:257-271

33. Rivara F, Tanaguchi D, Parish RA, et al. Poor prediction of positive computed tomographic scans by clinical criteria in symptomatic pediatric head trauma. Pediatrics.

1987;80:579-584

34. Boll TJ, Barth J. Mild head injury. Psychiatr Dev.

1983;1:263-276

35. Rimel R, Geordani B, Barth J, et al. Disability caused by minor head injury. Neurosurgery. 1981;9:221-228

36. Rutherford W, Merrett J, McDonald J. Sequelae of concus-sion caused by minor head injury. Lancet. 1977;1:1-4

37. Cook J. The post-concussional syndrome and factors influ-encing recovery after minor head injury admitted to hospital.

Scand J Rehabil Med. 1972;4:27-30

38. Goldstein FS, Levin HS. Intellectual and academic outcome following closed head injury in children and adolescents: research strategies and empirical findings. Dev Neuropsy-choL 1985;1:195-214

RELY

ON PARENTS’

OBSERVATIONS

“Developmental screening” has become an invention of the generations of developmental paediatricians since the sequence of normal development was described. These descriptions were translated into scales of normal and abnor-mal development and applied to whole populations of children. The wide variation of “normal,” the difficulty of showing it, and the poor predictive value of early developmental tests have resulted in a system with false positives and negatives. The commonsense solution-to rely on and respond to parental observations-has now been endorsed. . . [and is] supported. . .by an increasing body of research results. Those carrying out surveillance of children’s develop-ment will need to move away from their crayons and one inch cubes and cultivate new skills in history taking and observation.

Polnay L.Brit Med J. 1989;299:1351-1352. Editorial.

(9)

1990;86;337

Pediatrics

Polly E. Bijur, Mary Haslum and Jean Golding