Original Article

Journal of Child Neurology

25(4) 409-422
Head Trauma in Children, Part 3: ª The Author(s) 2010
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Clinical and Psychosocial Outcome After DOI: 10.1177/0883073809340697
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Head Trauma in Children

Thomas Kapapa, MD,1 Ulricke Pfister, MD,2 Kathrin König, MD,3

Michael Sasse, MD, PhD,4 Dieter Woischneck, MD, PhD,1
Hans E. Heissler,5 and Eckhard Rickels, MD, PhD3

Abstract
With the aim of determining long-term outcome, the authors approached 38 families (average 2.1 years after trauma) with a ques-
tionnaire, following the acute-clinical treatment of head trauma of their children. Long-term damage was restricted almost exclu-
sively to patients presenting with a Glasgow Coma Score 8. Paresis (16%), cranial nerve damage (13%), incontinence (5%), or
coordinative disturbances (18%) continued. The older children stated that they influenced their life to a great extent (11%).
Furthermore, many had mental and cognitive problems that occur quite frequently even in children with light head trauma and
often only manifest after release from hospital. This causes problems and results in inferior performance (26%), especially at
school, which is further complicated through lengthy periods of absence. The parents, especially, mentioned behavioral problems
such as social withdrawal or aggressive demeanor, which led to tension also inside the family. A persistent vegetative state is rare
after head trauma in children.

Keywords
head trauma, brain injury, rehabilitation, outcome, psychosocial, neurocognitive

Received May 10, 2009. Accepted for publication May 25, 2009.

The improvement in medical care led to a clear increase is also of increasing interest. There was a significant negative
in survival rate even in children with grave head trauma. Yet, impact on school performance after head trauma in comparison
it is precisely these children who frequently have long-term with other students.18,19
damage such as pareses or plegia, mental problems, personality As far as behavior is concerned, immediate environmental
disorders, and behavioral syndromes of posttraumatic epilepsy. influence has proven to have significant impact on further
It is especially the integrative neuropsychological functions— development of children after head trauma. Low socioeco-
such as, information processing speeds, verbal memory and nomic status and disturbed family life proved a bad influence
verbal functions, and memory functions for procedure on long-term outcome, especially if they were already present
steps—which are affected.1-5 Improving long-term outcome prior to the trauma.6,13,15,20-22
after severe head trauma, therefore, still presents a challenge.
As is the case in adults, for children, especially, complete
recovery cannot be assumed following severe head trauma. 1
Department of Neurosurgery, Universitätsklinikum Ulm, Ulm, Germany
Head trauma has a specific impact, when it happens during the 2
Department of Pediatric Medicine, Clementine Hospital, Frankfurt am Main,
time of development and maturing of functional abilities.6-8 Germany
3
The results, among others, are adaptive problems and beha- Department of Traumatology and Neurotraumatology, Allgemeines
Krankenhaus Celle, Celle, Germany
vioral syndromes.9-14 These constitute a special challenge for 4
Department of Pediatric Medicine, Intensive Care Unit, Medizinische
the immediate environment of the child, including family and Hochschule Hannover, Hannover, Germany
friends. The longer these posttraumatic problems continue, the 5
Department of Neurosurgery, Medizinische Hochschule Hannover, Hannover,
more difficult reintegration of the ill child becomes.15 If distur- Germany
bances of functional abilities and challenges presented by the
Corresponding Author:
environment cannot be mastered, it leads to grave problems Thomas Kapapa, Universitätsklinikum Ulm, Steinhövelstrasse 9, 89075 Ulm,
in family life, up to family or parental breakup.16,17 In recent Germany
times, performance of children at school following head trauma E-mail: Thomas.Kapapa@uniklinik-ulm.de

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410
Head trauma not only constitutes a health challenge for chil-
dren but also presents a challenge for their environment and
especially for individual family members.23-25
A child’s brain is still subjected to a maturity process and,
through the resulting neuroplasticity in comparison to adults,
has an increased neuronal reorganization potential. However,
access to this potential is heavily dependent on environmental
support. This is why following systematic and intensive medical
rehabilitation measures in school is of essence to assure optimum
recovery as well as social and scholastic reintegration.26
The rehabilitation begins in the stage of clouding or loss of
consciousness during the hospitalization phase and continues in
a rehabilitation facility specialized in head trauma immediately
following the hospital stay. Throughout the entire rehabilitation
phase, involvement of family members and social environment
becomes especially important to assure compliance, continuity
of recommended treatments, and already achieved recovery
effects beyond the direct medical attention phase. It has been
proven that this type of interaction is of essence for successful
long-term outcome.27
Child survivors of head trauma tend to handle social prob-
lems more with impulsive and egocentrically based solution
strategies than through a cooperative approach.5 Problem iden-
tification capacity at a social level, integrative and creative
abilities for generating problem solutions, and complex deci-
sion making and evaluative processes are all restricted. Nor can
this condition necessarily be considered temporary, it may last
through adulthood.28 Social competency for daily life, there-
fore, remains limited long term.29-31 These observations con-
clude that neuropsychological rehabilitation needs to also
consider the children’s playing behavior and teach aggression
control techniques. It has been observed that children playing
with each other frequently without arguments or fights tend
to call each other ‘‘friends’’ more often.32
The aim of this study was to increase the available data for
children after head trauma, with the assistance of this
questionnaire—in terms of early treatment results, intensive
medical care upon release, and long-term outcome after several
years of postobservation.
Patients and Methods
The retrospectively evaluated data of patients treated for head trauma
at pediatric interdisciplinary intensive care are for the period from
January 1998 to January 2001, inclusive.
Inclusion criteria were the head trauma as defining injury, obliga-
tory intensive care treatment, and an age range of 0 to 16 years. Data
gathered were with respect to demography, accident location, hospital
admission, diagnostic steps, pattern of injury, various score ratings,
surgical treatment, laboratory data, intensive care data, including those
of ventilation and medication administered, and neurological state.33,34
Treatment success upon release was evaluated via Glasgow Out-
come Scale,35 according to general condition, nutritional condition,
state of consciousness, motor response, coordination, strength, cranial
nerve function, occurrence of seizures, speech or speaking disturbances,
headaches, sensory disturbances, mental disturbances, and occurrence
of cerebro-organic psychic syndrome.
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Journal of Child Neurology 25(4)
Table 1. Dichotomization of the Glasgow Outcome Scale and Glas-
gow Coma Scores
Score Description Rating
Glasgow Coma Bad condition on Glasgow Coma
Score 3-8 admission Score  8
Glasgow Coma Good condition on Glasgow Coma
Score 9-15 admission Score > 8
Glasgow Outcome Bad outcome Glasgow Outcome
Score 1 þ 2 Score; Group I
Glasgow Outcome Good outcome Glasgow Outcome
Score 3-5 Score; Group II
Regarding classification of the trauma and impaired consciousness
level, the Glasgow Coma Score was used.36 Patients with severe head
trauma are children with a Glasgow Coma Score 8 at initial identifi-
cation. The Glasgow Coma Score >8 defines a less severe head trauma.
To structure the patient data more easily according to treatment
outcome, we divided the Glasgow Outcome Scale into 2 groups.35
Group I consists of patients with bad neurological outcome, from
Glasgow Outcome Scale classifications 1 and 2. Bad outcome
includes deceased children (Glasgow Outcome Scale ¼ 1) and chil-
dren released in a persistent vegetative state (Glasgow Outcome Scale
¼ 2). Group II consists of children from Glasgow Outcome Scale clas-
sifications 3 to 5, from remnant neurological disability to total recov-
ery. Table 1 outlines the dichotomization of the Glasgow Coma Score
and the Glasgow Outcome Scale.
To follow further progress and remaining impairment of the chil-
dren, a questionnaire was designed for the children and their parents.
The questionnaire for parents includes the questions of the standard
questionnaire Short-Form 36 Health Survey.37 The questionnaire for
parents about their children is divided into the following sections:
financial status, physical problems, clinical report/pathological find-
ings, quality of life, impairment in daily life, neuropsychological per-
formance ability, psychosocial state, education, scholastic abilities,
general state of health and development, and visual scale of health and
development. The questionnaires for the children contain questions
regarding their memory about the accident and the time before and/
or after the trauma, and about physical health and social integration
(Table 2). Both questionnaires were sent to all 38 families where the
children had survived the initial head trauma and subsequent intensive
care unit treatment.
For statistical evaluation, comparative statistical tests and the
regression analysis were used. The study was done with the agreement
of the local ethics commission.
Results
Demography
The following results base on data obtained from 48 children
who—from January 1998 to January 2001 inclusive—were
treated in the pediatric intensive care unit for head trauma.
Of these, 16 (33.3%) were females and 32 (66.7%) were males.
Their age ranged from 19 days to 14.5 years, with the average
age being 5.9 years. The height of the children ranged from 49
to 165 cm, with an average height of 110.07 cm. Minimum
recorded body weight was 4400 g and maximum weight was
55 kg, with an average weight of 22.5 kg.33,34
Kapapa et al
Table 2. Content of Questionnaires for Parents and Children
Questionnaire for Parents Questionnaire for Children
Economic circumstances Memory of trauma
Physical problems Memory of time before/after trauma
Medical findings Physical state
Quality of life Social integration
Daily-life impairment
Neuropsychological
performance
Psychosocial state
Education
Scholastic aptitude
General state of health
General state of development
Visual Health Scale
Visual Development Scale
We received back 24 questionnaires of which only 20 were
completely filled out. This was due to the fact that the child
was too young or that the parents were worried that the trau-
matic accident could be relived by and/or come up again in
the children through the questionnaire. The average time
span between accident and filling out the questionnaire was
2.1 years.
Of the 24 children questioned, 17 had severe head trauma
(Glasgow Coma Score  8) and 7 had mild head trauma (Glas-
gow Coma Score > 8). Average time elapsed after trauma at the
point the questionnaire was 2.1 years.
Glasgow Outcome Scale Course
The comparison between Glasgow Outcome Scale upon release
and at the time of questioning is outlined in Table 3.
Economic Circumstances
The patients of the Glasgow Coma Score group  8 (severe
head trauma), due to graver sequels they experienced, required
more intensive caretaking than the patients of the Glasgow
Coma Score group > 8 (mild head trauma; Table 4). This inten-
sive caretaking, already in hospital, increasingly included phy-
siotherapy, occupational therapy, and speech therapy.
Direct follow-up treatment in the rehabilitation facility took
place for 52.9% of patients. In the outpatient setting, more
intense and longer lasting follow-up treatment—like phy-
siotherapy, occupational therapy, and speech therapy—was
required in comparison to children with mild head trauma, as
were checkups by specialists or in hospital.
Physical Impairment and/or Clinical Findings
Long-term damage was restricted almost exclusively to the
group with patients presenting with a Glasgow Coma Score
 8, whereas it was still more severe than for patients with a
Glasgow Coma Score > 8 (Figure 1).
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411
Table 3. Comparison of Glasgow Outcome Scale Scores on Release
and According to Questionnaire Showing the Common Rehabilitative
Potential on an Average of 2.1 Years After Trauma
Glasgow According to
Outcome Score On Release (N) Questionnaire (N)
2 2 0
3 6 3
4 3 7
5 13 14
Of 17 children with severe head trauma, 6 had paresis/plegia
even years after the event, 5 cranial nerve damage, 2 inconti-
nence, 4 sensory damage, 7 coordination problems, and 5
speech impediments (Table 5).
Of the 7 children with mild head trauma, hypesthesia had
manifested in 3 and speech impediment in 1. Two children had
prophylactic treatment of epilepsy, and no child presented with
manifest seizures. Chronic headache rate was also very low
with only 3 patients reporting it.
Quality of Life and Everyday Life Impairment
The severity of physical complaints dichotomized evenly for
patients with a Glasgow Coma Score  8 between ‘‘mild’’ to
‘‘moderate’’ on one hand and ‘‘severe’’ to ‘‘very severe’’ on the
other (Table 6). The patient group with a Glasgow Coma Score
> 8 on admission still reported ‘‘mild’’ to ‘‘severe’’ physical
complaints.
For patients with severe head trauma, impairment during
day-to-day events at school manifested primarily from paraly-
sis, coordination problems, and decreased levels of physical
and mental staying power. However, decreased levels of men-
tal staying power prevailed in patients presenting with good
condition at admission (mild head trauma). For both the patient
groups, this frequently resulted in increased need for rest and
diminished physical activity levels.
The interpretation of the standard part of the questionnaire
(Short-Form 36) found prevailing psychological versus physi-
cal impairment in all children.
Neuropsychological Performance
Of special significance, and related to increased suffering, is
the concentration and memory problems that were reported
by both the Glasgow Coma Score groups (Table 7). These
often occurred jointly and, in the case of 2 children, were also
associated with time orientation problems. A diminished neu-
ropsychological efficiency level frequently resulted in prob-
lems at school.
Psychosocial State
The children’s psychosocial state constituted another problem
that especially resulted in establishing new and maintaining
existing social contact (Table 8). Following the trauma, a high
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412 Journal of Child Neurology 25(4)

Table 4. Medical Circumstances and Utilization of Rehabilitative Sources After Release

GCS  8 GCS > 8

(N ¼ 17) % (N ¼ 7) %

In hospital Physiotherapy 10 58.8 1 14.3

Ergotherapy 4 23.5 1 0.1
Speech therapy 1 5.8 0 0
Rehabilitation stay Yes 9 52.9 0 0
Length of rehabilitation 3 months 3 17.6 0 0
6 months 1 5.8 0 0
1 year 5 29.4 0 0
Medical aids/restructuring of flat Yes 2 11.8 1 0.1
Doctor visits due to head trauma after release None 4 23.5 3 42.9
Minimum 1  per year 5 29.4 1 14.3
Minimum 2  per year 6 35.3 1 14.3
Minimum 1  per month 3 17.6 0 0
Primary follow-up Pediatrician/general practitioner 11 64.7 2 28.6
Specialist (outpatient) 8 47.0 1 14.3
Hospital 7 41.2 1 14.3
Further/subsequent rehabilitation Yes 3 17.6 1 14.3
After rehabilitation and/or hospital stay Physiotherapy 10 58.8 1 14.3
Ergotherapy 6 35.3 1 14.3
Speech therapy 3 17.6 0 0
Therapy from . . . to . . . postrelease from 6 months 2 11.8 2 28.6
hospital or rehabilitation
1 year 2 11.8 0 0
3 years 6 35.5 0 0

Note: GCS, Glasgow Coma Score.

Speach or speaking disorder

Chronic headache

Coordinative disturbances

Sensory disturbance

Incontinence

Cranial nerve impairments

Paresis/Plegia

Epilepsy/Seizure

0 1 2 3 4 5 6 7
N

GCS > 8 (N = 7) GCS ≤ 8 (N = 17)

Figure 1. Physical complaints/medical findings of long-term outcome with prevailing impairments in the group of initial Glasgow Coma
Score  8.

proportion of the children became more introvert, sad, and impatience and aggressive behavior, which the patients’ envi-
calm, tended to withdraw often, and increasingly engaged in ronment often reports as being very stressful. Sleep disorders
passive activities. Especially worth noting here is the increased were rarely reported.

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Kapapa et al 413

Table 5. Physical Complaints/Medical Findings After Release, With Table 7. Occurrences of Neuropsychological Impairments
Prevailing Impairments in Children With Initial Glasgow Coma Score  8
GCS  8 GCS > 8
GCS  8 GCS > 8 (N ¼ 17) % (N ¼ 7) %
(N ¼ 17) % (N ¼ 7) %
Orientation problems Time 2 11.8 0 0
Regular medication 2 11.8 0 0 Space 0 0 0 0
(eg, anticonvulsants) Person 0 0 0 0
Paresthesia 3 17.6 0 0 Concentration problems 10 58.8 3 42.9
Cranial nerve damage 5 29.4 0 0 Memory problems 6 35.3 1 14.3
Limited field of vision 2 11.8 0 0
Paresis/plegia of 1 extremity 4 23.5 0 0 Note: GCS, Glasgow Coma Score.
Hemiparesis/hemiplegia 1 5.8 0 0
Tetraparesis/tetraplegia 1 5.8 0 0
Lack of balance 5 29.4 1 14.3 children had to repeat a class and further 2 patients were down-
Tremors 1 5.8 1 14.3 graded to a lower school level on account of lasting mental
Ataxia, no paralysis of 1 5.8 0 0 impairment. Nine of the children required an additional private
extremities tutor to compensate for periods of absence and deficits caused
Lasting headache 3 17.6 0 0 by decreased neuropsychological efficiency.
Dizziness 2 11.8 0 0
Seizures 0 0 0 0
Incontinence (bladder/rectum) 2 11.8 General State of Health and Development
Hyperesthesia 3 17.6 3 42.9
Hypesthesia 1 5.8 0 0 Comparative questioning about the state of health, 1 year after
Coordination problems 6 35.3 1 14.3 the head trauma and then at the time of the questionnaire,
Problems making self understood showed an improvement for both the Glasgow Coma Score
Only via mimic/gestures 2 11.8 0 0 groups. For children with severe head trauma, especially Glas-
Speech unclear 3 17.6 1 14.3 gow Coma Score  8, the level could be improved. In the first
Increased stumbling/bumping 2 11.8 0 0 year following the trauma, 6 children of the first group reported
Note: GCS, Glasgow Coma Score. a bad-to-very-bad state of health. Later, this improved to only
1 child reporting this condition.
Development deficits were determined only for children
Table 6. Quality of Life and Daily-Life Impairment
belonging to the group with a Glasgow Coma Score  8. For
GCS  8 GCS > 8 29.4% of these patients, the trauma had resulted in develop-
(N ¼ 17) % (N ¼ 7) % ment deficits. By means of a visual health and development
scale, parents were asked to determine the value currently
Physical None 6 35.3 5 71.4
problems Slight 6 35.3 0 0 achieved by their child with respect to state of health and/or
Moderate 2 11.8 1 14.3 age-related state of development (Figures 2 and 3). By means
Severe 3 17.6 1 14.3 of a visual health and development scale, parents were asked
Very severe 1 5.8 0 0 to determine the value currently achieved by their child with
Limitations in Moderate 4 23.5 0 0 respect to state of health and/or age-related state of develop-
daily events Severe 3 17.6 1 14.3 ment. For 3 of the questionnaires, this task was not or only par-
Problems at Moderate 6 35.3 1 14.3
tially completed.
school Severe 2 11.8 1 14.3
Lack of stamina, Sometimes 8 47.0 2 28.6
physical, or Always 3 17.6 0 0
mental Children’s Questionnaire About the Trauma
Lack of Strength 1 5.8 0 0 This part of the questionnaire was filled out either by the
Physical stamina 4 23.5 1 14.3 children themselves or on their direct behalf. When asked
Body control 4 5.8 0 0
about memory lapses, 8 of 15 children with severe head trauma
Need for rest Less 0 0 1 14.3
More 4 23.5 1 14.3 (Glasgow Coma Score  8) reported that they had no memory
More physically 5 29.4 1 14.3 of the accident, 3 also reported retrograde amnesia, and 2
active before reported anterograde amnesia that included the hospital stay
trauma (Table 10). Of the 5 children with mild head trauma (Glasgow
Coma Score > 8), 2 reported amnesia with additional retrograde
Note: GCS, Glasgow Coma Score.
and 1 with additional anterograde components.
Frequent thoughts of the accident or hospital stay were
Education and Scholastic Abilities reported by 26.7% of children with a Glasgow Coma Score
Many of the school-age children had lengthy periods of  8 and by even 60% of children with a Glasgow Coma Score
absence from school on account of the trauma (Table 9). Two > 8. When asked about their frame of mind, patients of both

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414 Journal of Child Neurology 25(4)

Table 8. Psychosocial State After Head Trauma and Impairments

GCS  8 (N ¼ 17) % GCS > 8 (N ¼ 7) %

Solitary pursuits Rare 1 5.8 0 0

Frequent 5 29.4 1 14.3
Passive recreational activities Rare 0 0 0 0
Frequent 7 41.2 0 0
Mental state Rarely full of drive 3 17.6 1 14.3
Often nervous 4 23.5 1 14.3
Often downcast 3 17.6 1 14.3
Often discouraged/sad 4 23.5 1 14.3
Often exhausted 11 64.7 2 28.6
Probability of falling asleep 1 5.8 1 14.3
Probability of sleeping through the night 1 5.8 1 14.3
Nightmares 1 5.8 1 14.3
Offer food 0 0 0 0
Parenteral nutrition 0 0 0 0
Eats less 0 0 1 14.3
Eats 4 23.5 0 0
More withdrawn 0 0 1 14.3
Fewer friends 0 0 0 0
Quieter than before 1 5.8 1 14.3
More aggressive 6 35.3 1 14.3
Broods about illness 1 5.8 0 0
Impairment of social contacts Medium 10 58.8 1 14.3
(family/friends/neighbors)
A lot 3 17.6 1 14.3
Behavior inside the family More introvert 5 29.4 0 0
Often withdrawn 1 5.8 1 14.3
With friends More introvert 3 17.6 1 14.3
Often withdrawn 3 17.6 0 0
More impatient With family 7 41.2 2 28.6
With friends 3 17.6 1 14.3

Note: GCS, Glasgow Coma Score.

Table 9. Education and Scholastic Aptitude After Head Trauma

GCS  8 (N ¼ 17) % GCS > 8 (N ¼ 7) %

Not school-age before trauma but now 5 29.4 2 11.8

Not school-age before or after trauma 2 11.8 4 23.5
Repetition of a grade 2 11.8 0 0
Downgraded to the next lowest school type 0 0 0 0
Downgraded to secondary school 2 11.8 0 0
Absences at school None 1 5.8 0 0
3 months 5 29.4 2 11.8
6 months 1 5.8 0 0
1 year 2 11.8 0 0
Scholastic performance pre- and posttrauma Worse ! Better 0 0 0 0
Better ! Worse 7 41.2 0 0
Private tuition since the trauma 6 months 3 17.6 1 5.8
1 year 2 11.8 0 0
1½ years 3 17.6 0 0
Note: GCS, Glasgow Coma Score.

groups frequently replied ‘‘silly,’’ ‘‘fidgety,’’ and ‘‘argumenta- mild head trauma (Glasgow Coma Score > 8). At admission,
tive.’’ A general feeling of unwellness (during the previous headaches and abdominal pain were reported by 53.3% of
week) was reported by 73.4% of patients with severe head children with a Glasgow Coma Score  8 and even by 60%
trauma (Glasgow Coma Score  8) and by 40% of patients with of children with a Glasgow Coma Score > 8.

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Kapapa et al 415

81-100

61-80

41-60

21-40

0-20

0 1 2 3 4 5 6 7 8

GCS > 8 (N = 7) GCS ≤ 8 (N = 17)

Figure 2. State of health according to visual scale (100 ¼ Best possible state of health; 0 ¼ Worst possible state of health) describing
preponderance of good state of health according to long-term outcome.

81-100

61-80

41-60

21-40

0-20

0 1 2 3 4 5 6 7 8

GCS > 8 (N = 7) GCS ≤ 8 (N = 17)

Figure 3. Age-related development according to visual scale (100 ¼ Development according to Age, 0 ¼ Highly delayed development) with
prevailing good developmental outcome after head trauma.

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416 Journal of Child Neurology 25(4)

Table 10. Children’s Replies About Mood, Friends, and Global Impairment Impression

GCS  8 (N ¼ 17) % GCS > 8 (N ¼ 7) %

Memory lapse (1 child too young) Time before trauma 3 20 2 40

Trauma itself 8 53.3 2 40
Time in hospital 4 26.7 1 20
Time in rehabilitation 0 0 0
Frequent thoughts of trauma/hospital 4 26.7 3 60
Dreams of hospital/trauma Sometimes 5 33.3 2 40
Often 0 0
Frame of mind Often sad 3 20 1 20
Often lonely 2 13.3 1 20
Often silly 6 40 4 80
Often fidgety 5 33.3 5 100
Often argumentative 7 46.7 2 40
Often unhappy 0 0 0 0
Felt ill during the last week Sometimes 7 46.7 2 40
Often 4 26.7 0 0
Head/stomach ache during the last week Sometimes 7 46.7 3 60
Often 6 40 0 0
Since/because of trauma Lost friends 5 33.3 0 0
New friends 9 60 2 40
More arguments with friends 0 0 1 20
Friends ruthless 2 13.3 0 0
Friends are kind 8 53.3 1 20
Friends annoy me 0 0 1 20
Note: GCS, Glasgow Coma Score.

When asked about their friends, only children with severe
head trauma (Glasgow Coma Score  8) reported that they had
lost friends due to the trauma. Worth noting here is that only
children with mild head trauma (Glasgow Coma Score > 8)
reported that their friends annoyed them or that they quarreled
with their friends.
The number of children with a Glasgow Coma Score > 8 is
to be regarded with care in this category because there were
only 5 of them.
Discussion
Study Design
In the period between January 1998 and January 2001, we
treated a total of 48 children with head trauma requiring inten-
sive care; 38 children survived. Treatment was undertaken
according to a concept developed for elevated intracranial pres-
sure therapy and was oriented on cerebral perfusion
pressure.33,34
The entire course of treatment of the children was evaluated.
This included pre-hospital and in-hospital care as well as long-
term results that were—on average 2.1 years after the trauma
had happened—obtained from the questionnaire. The results
of the study were neither distorted nor impaired in their validity
through any kind of intervention like, for instance, the influ-
ence of specialist medical therapy studies.
Because the duration of the study was restricted to 3 years,
each child presenting with severe head trauma that required
intensive care became part of the study. This allowed for as
many cases as possible to come under investigation.
To allow for different grades of severity of the injury when
interpreting treatment outcome, individual control groups with
semipopulations had to be established (eg, all children with a
Glasgow Coma Score  8 or with cerebral edema).
For determining long-term outcome, unfortunately we were
unable to access the primary hospital’s outpatient unit records
because there is no such unit that would have monitored the
children at regular intervals following their head trauma. For
this reason, a detailed questionnaire had to be created and sent
to the patients. While it provides us with detailed information
on the individual patients, follow-up time ranges between sev-
eral months and 3 years posttrauma. It would be desirable in
this context, however, to have available comparison of children
with identical injury patterns, at equal time intervals.
Outcome
Despite medical advances over the last decades—especially in
the area of intensive care medicine—and a consecutive
decrease in hospital morbidity for severe head trauma during
childhood, morbidity rates are still very high with 15% to
35%.38-40 There are now a rising number of children who sur-
vive with different grades of neurological deficits. Several
studies, looking at early outcome (at release from hospital) and
also at long-term outcome (6 months to 23 years), have dealt
with the occurrence of residual damage following head trauma
and its course.41,42 It was shown that the severity of residual

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Kapapa et al
damage concurs with the severity of the injury and the initially
defined Glasgow Coma Score and that it is a decisive factor for
the first step toward recovery.39,43 Long-term outcome, how-
ever, is especially determined by patient-related factors such
as age at the time of accident, level of maturity, and family
support.27
Keenan et al report that for 112 post head trauma children
according to the Paediatric Overall Performance Category
Scale, there was a positive outcome for 64.9% of the children
and a bad outcome for 35.1%.44,45 Twenty-two children who
were released in a bad state according to the Paediatric Overall
Performance Category Scale, and 4 of 10 children who had
been classified as moderately impaired, improved to classifica-
tion good within 2 years. Three children presented with addi-
tional impairment after 2 years. Physiotherapies, more than
once a week, were provided during the first year to 38.6% and
during the second year to 28.1% of the children. Less than once
per week or no physiotherapy at all was the case in 61.4%
during the first year and 71.9% during the second year. The
amount of occupational therapy and ergotherapy is similar to
that of physiotherapy. In contrast, the weekly or more than
weekly number of speech therapies rises from 12.3% during the
first year to 29.8% during the second year.45 This means that
the less the physical impairment, the more is the cognitive
impairment.
Rehabilitation Phase
On account of the severity of different injury in children with
head trauma, the duration hospital stay varies greatly. For our
patients, they ranged between 2 and 54 days, with the average
being 16.6 days.
During their hospital stay, already, rehabilitation measures
were initiated for 50% of the children, in the manner of occu-
pational therapy and/or speech therapy. This assists recovery
and is a preliminary step toward the subsequent and targeted
rehabilitation treatment in a rehabilitation facility specializing
in children with head trauma.26,46 Following initial acute care,
39.5% of our injured children were immediately transferred on
to rehabilitation for further in-hospital treatment. Average
rehabilitation stay was 8 months, which corresponds to results
obtained from other studies.47
A total of 58.8% of children with severe head trauma under-
went outpatient rehabilitation treatment lasting, for the most
part, 2 years and 28.6% of children with mild head trauma
required an average of 6 months of outpatient recovery support.
Recovery and rehabilitation success for 63.2% of our
patients were evaluated on an average of 2.1 years
posttrauma through our questionnaire. Fifty percent of parents
of severely injured children reported a near-optimum state of
health as well as age-related development of their child (Fig-
ures 2 and 3). Of the less severely injured children, all of them
achieved a near-optimum state of health, while age-related
development, however, was impaired with a reading of 17%.
In a previous study, 38.7% of children were released as
healthy and 39.3% with residual impairment.40 After an
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417
average period of 8 years, 24 of 27 children released with resi-
dual neurological impairment presented with persistence of the
complaints.
According to Montgomery et al, and following a hospital
stay of approximately 14 days, 96% of children with severe
head trauma received subsequent outpatient treatment. A
follow-up 3 years later found persistent neurological damage
for 68.8% of the participants.48 This means that we can only
presume total recovery for 31.2% of the children.
The above-mentioned order of events provides reason to
presume that, while inpatient as well as outpatient rehabilita-
tion options might be good, they are not being sufficiently used.
Especially in case of children with severe head trauma, inpati-
ent rehabilitation treatment must be advised. Furthermore, the
outpatient option should be expanded further for all head
trauma patients, especially in view of duration of treatment
because it is especially children in their developmental process
who benefit greatly from this.27
Putting these recommendations into practice, however, is
only possible to a limited extent due to the discrepancy between
supply and demand and increased savings policies in the health
care sector.
Glasgow Outcome Scale
For a rough evaluation of treatment outcome, it is primarily the
Glasgow Outcome Scale or its extended version, the Glasgow
Outcome Scale–Extended, which has established itself as an
evaluation tool at international level.35,49 Retrospectively, it
was determined for each child at the day of release. Children
with good treatment outcome prevailed (Glasgow Outcome
Scale 3-5, Glasgow Outcome Scale Group II) by far, at
70.8%, over the 29.2% bad outcome (Glasgow Outcome Scale
1 and 2; Glasgow Outcome Scale Group I). For their own stud-
ies, other authors report even more favorable results with up to
90% of children in Glasgow Outcome Scale Group II.39,50,51
For the Glasgow Outcome Scale-Extended, Eilander reports
an average result of 3.5 for a group consisting of 145 children
with head trauma (2.4 to 15.7 years posttrauma). For children
who actually survived the head trauma, it was 4.9 years.51 This
means that a complete recovery is rare. Nonetheless, many
children after head trauma display the ability of reestablishing
a certain degree of independence. Eilander even states that an
occurrence of persistent vegetative state after head trauma in
children is very rare.51 We can confirm this finding through our
own data.
The returned questionnaires assisted us in evaluating a fur-
ther value on the Glasgow Outcome Scale for 24 of our patients
and therefore to compare the respective short- and long-term
treatment results (Table 11). Looking at the 5-stage Glasgow
Outcome Scale, positive development can be recorded for all
children except 1, a patient who was downgraded by 1 stage
due to hearing impairment and sleep disorder diagnosed at a
later stage. One child improved by 2 stages, followed by 7 chil-
dren who improved by 1 stage. For the remaining 15 patients,
417
418 Journal of Child Neurology 25(4)

Table 11. Neurological State for Early and Long-Term Outcome

Glasgow Coma Score  8 Glasgow Coma Score > 8

Neurological State Release (%) Questionnaire (%) Release (%) Questionnaire (%)

Paresis/plegia 44.4 35.3 0 0

Cranial nerve damage 14.8 29.4 9.1 0
Incontinence NA 11.8 0 0
Seizures 3.7 0a 0 0
Dysarthria/speech impediment 44.4 29.4 0 14.3
Lack of balance NA 29.4 NA 42.8
Coordination problem 33.3 41.2 9.1 14.3
Sensory disturbance 3.7 23.5 18.1 42.9
Mental problems 51.9 58.8 27.3 42.8
Sleep disorders NA 17.6 NA 42.9
Chronic pain 7.4 17.6 0 0
Note: NA, not filled out.
a
Two children received prophylactic anticonvulsants.

slow progress could partially be recorded, which did not lead to
a change of stage.
Residual Neurological Impairment During the Course
Because there is no uniform program for the aftercare of chil-
dren with craniocerebral trauma, centers specializing in treat-
ment of the same have plenty of data available about early
treatment outcome but often have only minimal information
about long-term outcome.
From hospital, the children are released either directly to
their homes or to a rehabilitation facility and, subsequently, are
treated by local pediatricians. Only rarely—and then mostly for
children with significant residual neurological impairment—is
there an outpatient treatment via the initial hospital.
Severe impairments such as paresis, plegia, or posttraumatic
epilepsy are mostly associated with severe head trauma, occur
primarily during the acute posttraumatic stage, and are tended
accordingly on a medical basis.39,48 Many other impairments
such as behavior problems, personality changes, and
cognitive-intellectual impairment, however, are frequently not
noticed during the early stages.52,53 This applies especially
when they only manifest lightly following mild head trauma.41
Many of the problems only become evident once the children
have returned to their usual environment and daily life.52
Ruijs et al, 2 years posttrauma, found problems at school in
60% of patients with severe head trauma. Later stage personal-
ity and behavioral changes occurred in over 50% of all head
trauma patients. While the initial neurological and psycho-
reactive changes regressed in most of the cases, symptoms such
as headache, vertigo, problems concentrating, loss of trust, tre-
pidation, and fatigue usually persisted.52
Max et al, when investigating newly developed psychiatric
disorders, obtained corresponding results. They established a
correlation in the early posttraumatic stage between psychiatric
problems and lack of family support as well as mental illness in
the family with low intelligence quotient.42,54 These problems
present primarily (52%) as external (hyperactivity,
antagonism) or as a mix between external and internal (20%),
while purely internally manifesting problems such as trepida-
tion and depression were rare (4%). In the long-term view,
regression occurred primarily in internally manifesting
behaviors.54
When questioning family members, they stated that beha-
vioral problems were longer lasting and more severe conse-
quences when compared with physical and cognitive residual
damage.42
The results of our study are largely in accordance with those
in the above-mentioned works. We were also able to establish a
clear connection between initial severity of injury according to
the Glasgow Coma Score and residual neurological impair-
ment. The following was exclusively restricted in children
with severe head trauma (Glasgow Coma Score  8): pareses,
plegia, incontinence, seizures, and chronic headache. Further-
more, cranial nerve damage, speech impediments, coordination
problems, and mental problems were disproportionately high in
this group when compared to children with mild head trauma
(Glasgow Coma Score > 8).
For many of the complaints, progression even occurred after
the hospitalization phase or there was a later stage manifesta-
tion. This includes coordination problems and mental disor-
ders, which dominated in the group of severely injured
children, as well as vertigo, sensory disturbances, and sleep dis-
orders. At 42%, the latter prevailed in less seriously injured
children. Chronic headache occurred only in children with a
Glasgow Coma Score  8. Here, an increase in patient numbers
from 7.4% to 17.6% was observed.
It is not only the physical limitations but especially mental
problems such as concentration and memory disorders—with
related lack of stamina—that cause problems for the children
in their daily lives and especially also at school (Table 6).
Quality of Life Following Childhood Head Trauma
Classical treatment targets such as, reduction of symptoms or
increased survival rates have been expanded over the last

418
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Kapapa et al
decade to include more patient-oriented criteria.55 The World
Health Organization recommended extending the definition
of health to include emphasis on psychological and social com-
ponents.56 There is now rising interest in psychological and
social consequences of childhood head trauma.57 The concept
of health-related quality of life is now used in medicine to
define life quality concept. Health-related quality of life, in
medicine, includes an accumulation of criteria such as goals,
values, and principles. These include, for instance, how safe
and long a given life is, a clearly defined state of health, free-
dom to seize opportunities, or personal and societal recogni-
tion. Yet, health-based quality of life is also related to other
quality of life definitions such as, availability of economic
resources, to reach an optimum of culturally or self-defined tar-
gets. All these criteria are used in medicine to get an idea about
quality of life.58 Frequent hospital stays, several surgical proce-
dures, and uncertainty about the further course of the disease all
adversely influence the recovery process.59,60 The child’s
thoughts and feelings are important for further therapy defini-
tion. Neither the medical treatment nor the medical outcome
in itself is capable of defining the quality of life for a child sur-
vivor of head trauma. Standard questioning of the children and
their parents about the quality of life of the children assists in
determining the quality of life after head trauma. Despite the
inherent problems, determination of quality of life for the par-
ents should happen simultaneously because it influences the
definition of that of the children.61 For most toddlers, life
means playing; while parents often have a different view. There
are currently numerous life quality instruments available such
as, the Child Health Questionnaire, the Child Health and Illness
Profile, the Questionnaire for measuring health-related Quality
of Life in Children and Adolescents, the TNO-AZL Children’s
Quality of Life Questionnaire, the How are you? Question-
naire, and the Health-Related Quality of Life Questionnaire
(Vécu et Santé percue de l’Adolescent).62-67
Our study showed considerable impairment of health-
related quality of life, especially in psychological areas.
Neuropsychological and Psychosocial Consequences
Child survivors of head trauma often have an increased need
for rest and they tend to withdraw more often. Parents reported
that their children more frequently engage in solitary pursuits
and passive spare time activity than they did prior to the
trauma. This introvertness impairs social contacts with friends
and acquaintances and also causes problems within the family
(Table 8).
Yet, the children not only stand out through their introvert-
ness, many of them tend toward aggressive behavior, impul-
siveness, irritability, agitation, confusion, apathy, emotional
lability, and impatience.68-71 Together with the described cog-
nitive performance impairments, these noticeable problems
occur especially in children who were younger than 2 years
of age at the time of the head trauma.53 This behavioral change
and mental impairment manifests itself especially at school.
Additionally, on account of the lengthy periods of absence
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419
during hospitalization and rehabilitation, the children lack con-
nection to ongoing study content. The results were months of
private tuition and even the need for repeating entire grades.
In extreme cases, a downgrading to a lower school level even
ensued (Table 9). These results match those obtained from
other studies.23 Chadwick et al report that, during the rehabili-
tation process of children, there is a cognitive performance
peak 2 years after a severe head trauma.72 In the course of fur-
ther maturing, however, these children present with increasing
cognitive performance limitations when compared to others of
their own age.1,69,73 However, these types of limitations may be
contained well through the application of targeted rehabilita-
tion measures.74 Compared to other children of the same age
not affected by an accident, these limitations include deteriora-
tion of intelligence, limitations in memory functions, speaking,
nonverbal abilities, attention span, and executive func-
tions.13,74 Although the precise influential factors remain
unclear in this, the process can last up to 5 years.69
Yet, not only had the children who had been through head
trauma experienced psychiatric problems, Montgomery et al,
in 55% of their siblings, also found behavioral problems in the
form of rising fears, worsening of performance at school, and
increased withdrawal.48 Overall, one third of families showed
a negative impact on family dynamics. Twenty-two percent
of parents reported that their own relationship had increasing
tension and that sometimes these even resulted in separation
or divorce. Only 28% of families reported that the trauma of
their child had no or only little impact on family life.48 This
showed just how important it is to provide professional support
to families of children who had an accident, especially because
solid family support is one of the most important defining fac-
tors for long-term outcome in these children.75
Social isolation experienced by child head trauma survivors
constitutes a solid problem for rehabilitation.76 It can be
explained by impaired social competency and limited psycho-
social abilities of the children.31,77,78 This type of isolation not
only affects the child but it can even lead to isolation of the
entire family.79 Nassau and Drotar80 described that children
with central nervous system impairment such as, seizures or
epilepsy are less accepted than healthy children of their age
group. Loss of friends plays a decisive role in this. Several
studies report, for instance, that the number of friends depends
on the severity of the head trauma.81 Prigatano and Gupta82
studied children with an average age between 10 and 11 years
(generally 1 year post head trauma) to determine their psycho-
social competencies and number of friends. The percentage of
children with 4 friends decreases with the severity of the
trauma. In this, time elapsed since the trauma occurred is of
no significance. Children who perform well at school, academi-
cally and athletically, tended to have more friends. The severity
of the trauma has no influence on the amount of time the chil-
dren spend playing with other children.82 Max et al report,
however, that the number of friends prior to the head trauma,
and also the occurrence of sociophobic behavior, is essential
when evaluating psychosocial aspects in regard to the number
of friends post head trauma.83
419
420
Targeted rehabilitation of the so-called Friend Competen-
cies for children with head trauma, hence, is the base for further
social behavior and integration.32
The sociodemographic and socioeconomic background of
the family of child survivor of head trauma is also an important
factor for ongoing family and social rehabilitation and integra-
tion.84-87 The so-called milieu factors such as being part of a
social minority, education level of the parents, social family
support, family size, stressful family events, and poverty need
to be listed here.88 Poverty, here, has an especially great influ-
ence. If both parents are working, parental- and rehabilitation-
supporting care takes a back seat.45 Family-based rehabilita-
tion, furthermore, has also proven to be difficult when there
factors such as parents having jobs with a low societal standing,
unmarried parents, and/or single-parent homes.89
To help the child succeed in achieving the best possible rein-
tegration into society after head trauma, psychosocial deficits
leading to behavior problems need to be recognized. This
includes shortcomings in the area of defining the social prob-
lem, generating alternative strategies, choice and implementa-
tion of specific strategies, and, last but not least, evaluation of
the consequences of a given action.90 The rehabilitation facil-
ity, hence, needs to focus on that social ability that serves for
generating alternative, nonaggressive problem solutions.
Overall, it has been shown that Restitutio ad integrum is
extremely rare following severe head trauma. Furthermore, a per-
sistent vegetative state is also very rare after childhood head
trauma. Children, even after severe head trauma, have a chance
of reestablishing their independence. The rehabilitation of child
survivors of head trauma does not only place high demands on
reestablishing physical functions, considerable rehabilitative
effort, for the sake of the child and the family, also need to go into
recovery and/or handling of behavioral changes. Furthermore,
however much we invest in research for further development
of therapies and rehabilitation measures, we need not forget acci-
dent prevention also. The most successful therapy of head trauma
is still the prevention of the accident in the first place.
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