Developmental Neurorehabilitation, June 2012; 15(3): 171177

Use of the Kings Outcome Scale for Childhood Head Injury in the evaluation of outcome in childhood traumatic brain injury

SIMON PAUL PAGET1,2, ALEXANDER WILLIAM JOHN BEATH3, ELIZABETH HELEN BARNES4,5, & MARY-CLARE WAUGH1
Kids Rehab, The Childrens Hospital at Westmead, Westmead, Sydney, New South Wales, Australia, 2Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia, 3Faculty of Medicine, University of Newcastle, Newcastle, New South Wales Australia, 4Kids Research Institute, The Childrens Hospital at Westmead, Westmead, Sydney, New South Wales, Australia, and 5NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
(Received 11 January 2012; revised 27 February 2012; accepted 27 February 2012) Abstract Objective: To examine the inter-rater reliability of The Kings Outcome Scale for Childhood Head Injury (KOSCHI) with clinicians of varying experience in paediatric traumatic brain injury (TBI); and to examine change in outcome during longterm follow-up of children following traumatic brain injury (TBI) using KOSCHI. Method: Retrospective assessment of detailed clinic reports of 97 children followed-up by a tertiary specialist paediatric brain injury service. Investigators were blinded to each others scores. Results: Inter-rater reliability was substantial (weighted kappa 0.71) and similar for investigators of varying experience. KOSCHI outcome was strongly associated with markers of injury severity (p 0.028). In longitudinal follow-up, KOSCHI score worsened in 7 (23%) children who were injured under 8 years but in no older children (p 0.02). Conclusion: KOSCHI has high inter-rater reliability for investigators of different experience. Long-term KOSCHI outcome is associated with injury severity. Some young children may develop worse disability over time.
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Keywords: Traumatic brain injury, children, infants, Glasgow Outcome Scale, outcome measures

Introduction Traumatic brain injury (TBI) is a common cause of acquired disability in childhood [1, 2]. Severe TBI can lead to neurological, cognitive, behavioural and/ or social deficits that may result in lifelong disability [35]. As TBI in childhood occurs in the context of a developing central nervous system the final outcome of an injury may not be apparent until adulthood [6]. Severe TBI commonly causes difficulties with learning new skills that may result in increasing disparity between the child and typically developing peers as time progresses [6]. Latent injuries may occur in cognitive processes (e.g. executive function) with deficits that only become apparent later in childhood due to the failure of normal development [7, 8]. Despite evidence of central nervous system plasticity [9], studies have suggested that children injured at a young age have worse cognitive outcomes than older children with similar injury severity [2, 1014]. The measurement

of outcome following childhood TBI is therefore complex. The Kings Outcome Scale for Childhood Head Injury was developed as a paediatric adaptation of the Glasgow Outcome Scale [15] to provide a robust, simple description of outcome after paediatric TBI in the short, medium or long term [16]. The scale has been shown to have moderate inter-rater reliability[16, 17], and has been validated as correlating with predictors of outcome in the short and longer term [17, 18]. The aims of this study were to investigate the inter-rater reliability of KOSCHI with raters of varied experience in paediatric brain injury, and to use KOSCHI to describe recovery patterns in children following long-term follow-up following TBI. We hypothesized that children who are injured early in life are more likely to develop worse disability over time as measured by KOSCHI compared with children who are injured later.

Correspondence: Simon P. Paget, Kids Rehab, The Childrens Hospital at Westmead, Westmead, NSW 2145, Australia. Tel: 61 2 98452819. Fax: 61 2 984550685. E-mail: simon.paget@health.nsw.gov.au ISSN 17518423 print/ISSN 17518431 online/12/0301717 2012 Informa UK Ltd. DOI: 10.3109/17518423.2012.671381

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S. P. Paget et al. intellectual disability or developmental disability or more severe problems with behaviour regulation were classified in category 4a. Children with moderate intellectual disability were classified in category 3b. The original criteria proposed by Crouchman et al. also included outcome description for injuries not related to the brain (e.g. scarring). We attempted to assign outcome purely on the basis of brain injury and disregard other injuries when assigning KOSCHI. Following these discussions, investigators were blinded to each others scores. Clinical reports produced by the paediatric medical imaging department for radiology investigations performed during the immediate period following injury were reviewed. Where Magnetic Resonance Imaging (MRI) images of the brain were available reports of these were used in preference to Computed Tomography (CT) reports. Data Analysis Statistical analysis was performed using SAS version 9.2 (SAS Institute Inc). Agreement between the three investigators was assessed using a weighted kappa, treating the KOSCHI score as categorical variable. Comparison of duration of follow-up was performed using the Wilcoxon rank sum test. To test for association between outcome measured by KOSCHI and brain injury severity (mild/moderate/ severe), the KOSCHI scores assigned by the senior assessor (MCW) at the last (most recent) assessment were divided into Good Recovery (5a,b) and Moderate (4a,b) or Severe Disability (3a,b) and analysed using the chi-squared test. To analyse change in KOSCHI score over time, children were divided into two groups determined by age at injury (age 7 years 11 months or less; age 8 years 0 months or more) consistent with previous studies [10, 2224]. Consecutive KOSCHI scores (senior assessor) were plotted against time after injury for each child. Association between change in KOSCHI score from first to last assessment (senior assessor) and age group was analysed using the chi-squared test.

Methods The study was a retrospective cohort study. The study was approved by the hospital ethics committee (project number: MR 2009-09-08). Participants Information pertaining to children admitted to The Childrens Hospital at Westmead and referred to the (Paediatric) Rehabilitation Department with a diagnosis of traumatic brain injury between 1st January 2003 and 31st December 2004 (2 years) was reviewed. This time span was chosen to allow for up to five years of follow-up following injury. Demographic, clinical and radiological data relating to the injury were collected retrospectively by reference to a departmental database and hospital electronic medical records. Reports at discharge from hospital, subsequent reviews in the multidisciplinary brain injury clinic and neuropsychological assessments were collected. Clinic reports from the brain injury clinic routinely include information about development, school progress and social functioning in addition to a physical assessment and review of symptoms commonly seen following TBI, thus allowing for easy allocation of KOSCHI scores retrospectively. Instruments Severity of brain injury was determined by documented duration of post-traumatic amnesia (PTA) and/or documented Glasgow Coma Scale (GCS) score on admission to hospital. Post-traumatic amnesia duration was measured by the Westmead Post-Traumatic Amnesia Scale (WPTAS) [19], a widely used prospective assessment of PTA, validated in children over the age of 7 years [20]. Mild TBI was defined as GCS 1315 on admission to hospital and PTA duration of less than 1 hour; moderate TBI was defined as GCS 912 on admission to hospital and / or PTA duration between one and 24 hours; severe TBI was defined as GCS 5 9 and/or PTA duration more than one day [21]. KOSCHI scores were retrospectively assigned by all three investigators on the basis of clinic reports, using suggested guidelines [16] (Table I). The three investigators had varying levels of experience: medical student (AJB), paediatric registrar (SPP) and paediatric rehabilitation specialist (MCW). Before examining any patient records, discussions were held about the classification of particular TBI outcomes as suggested by Hawley et al. [18]. We placed children with attention disorders requiring classroom intervention or medication and/or mild problems with behaviour regulation in the moderate disability 4b KOSCHI category. Children with mild

Results A total of 130 patients were referred to the rehabilitation service with a diagnosis of traumatic brain injury during the two-year time period. There was insufficient clinical information available to determine a KOSCHI score in 32 patients. Almost all of these (31) were reviewed by the rehabilitation service as an inpatient with head injury or mild traumatic brain injury, however notes for this consultation were not found and no follow up was performed. In the remaining case no notes were found to

Use of the Kings Outcome Scale for Childhood Head Injury in the evaluation
Table I. KOSCHI category definitions (4). KOSCHI category 1. Death 2. Vegetative Definition

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The child is breathing spontaneously and may have sleep/wake cycles. He may have non-purposeful or reflex movements of limbs or eyes. There is no evidence of ability to communicate verbally or nonverbally or to respond to commands. (a) The child is at least intermittently able to move part of the body/eyes to command or make purposeful spontaneous movements; for example, confused child pulling at nasogastric tube, lashing out at carers, rolling over in bed. May be fully conscious and able to communicate but not yet able to carry out any self care activities such as feeding. (b) Implies a continuing high level of dependency, but the child can assist in daily activities; for example, can feed self or walk with assistance or help to place items of clothing. Such a child is fully conscious but may still have a degree of post-traumatic amnesia. (a) The child is mostly independent but needs a degree of supervision/actual help for physical or behavioural problems. Such a child has overt problems; for example, 12 year old with moderate hemiplegia and dyspraxia insecure on stairs or needing help with dressing. (b) The child is age appropriately independent but has residual problems with learning/behaviour or neurological sequelae affecting function. He probably should have special needs assistance but his special needs may not have been recognised/met. Children with symptoms of post-traumatic stress are likely to fall into this category. (a) This should only be assigned if the head injury has resulted in a new condition which does not interfere with the childs well being and/or functioning; for example:  Minor headaches not interfering with social or school functioning  Abnormalities on brain scan without any detectable new problem  Prophylactic anticonvulsants in the absence of clinical seizures  Unsightly scarring of face/head likely to need cosmetic surgery at some stage  Mild neurological asymmetry but no evidence of affect on function of limb. Includes isolated change in hand dominance in young child. (b) Implies that the information available is that the child has made a complete recovery with no detectable sequelae from the head injury.

3. Severe disability

4. Moderate disability

5. Good recovery

document the assessment. One further child died soon after initial review in intensive care and before starting a rehabilitation program. These 33 children were excluded from further analysis. The remaining patients consisted of 97 children, 69 (71%) of whom were male, with a median age of 7.9 years (interquartile range (IQR) 3 years - 13 years 1 month). The median length of hospital stay was 8 days (IQR 519 days, range 1180 days). Falls were the most common cause of injury (31 cases (32%)), followed by motor vehicle accidents (30 cases (31%)), sport-related injuries (19 cases (20%)), non-accidental injury (13 cases (13%)), assault (3 cases (3%)), and other (1 case (1%)). Thirty-nine children were assessed on only one occasion and six children had six annual assessments. Median duration of follow-up was 1.3 years following injury (IQR 0.2 to 4.6 years). There was a trend for children injured under 8 years of age to receive longer followup (median 1.7 years IQR 0.24.9 years) than children 8 years or older (median 1.1 years IQR 0.23.5 years) (p 0.2). Glasgow Coma Scale (GCS) score on presentation to hospital was documented in 74 (76%) children, and duration of PTA was documented in

26 (27%) patients. Using widely accepted criteria [21], 32 (33%) children were assessed to have sustained a mild TBI, 14 (14%) moderate TBI and 36 (37%) a severe TBI. Those with severe TBI were discriminated by GCS in 17 cases and PTA in 19 cases. PTA lasted under seven days in six cases, between 7 and 28 days in seven cases and in six cases lasted longer than 28 days. In a further fifteen (15%) children severity of injury was unable to be ascertained using GCS or PTA criteria, all of whom were under 5 years of age at the time of injury. Reports of radiological investigations of the brain, completed during the acute period following injury, were available in 85 (88%) children (computed tomography (69 cases), magnetic resonance imaging (16 cases)) and in all children with severe TBI. Common findings were subdural (30 cases, 35%), subarachnoid (13 cases, 15%) and extradural (21 cases, 25%) haemorrhages and frontal (26 cases, 31%), temporal (16 cases, 19%) and parietal (11 cases, 13%) focal lesions (mainly contusions). Evidence of diffuse axonal injury was noted in four children, all of whom had severe TBI.

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S. P. Paget et al. time (range 3.1 to 6.0 years). Reasons identified for the decrease in score were: intellectual disability not identified during early follow-up (n 4), new behavioural problems (n 2) and the development of late-onset seizures (n 1).

Table II. Inter-rater reliability of KOSCHI score for three investigators of varying experience. Investigators 1 and 2 1 and 3 2 and 3 CI Confidence Interval Weighted Kappa (95% CI) 0.71 (0.650.76) 0.71 (0.650.77) 0.71 (0.660.77)

Discussion This study describes the outcome of a cohort of children following TBI using KOSCHI as the primary outcome measure. It is one of a few studies to investigate the relationship between injury severity and KOSCHI [17, 18] and the first to our knowledge to attempt describing how KOSCHI score changes with time during long-term follow-up after paediatric TBI. Our results add further evidence of good correlation between traditional measures of TBI severity (Glasgow Coma Scale score and duration of posttraumatic amnesia) and KOSCHI outcome for up to six years following injury. Our results also highlight the variability in outcome following TBI. The majority of children with severe TBI (58%) were classified as having a moderate disability (KOSCHI 4a, 4b) at follow-up, but a large minority (33%) were judged as having a good outcome, with 14% classified as having no detectable sequelae from their injury (KOSCHI 5b). Conversely, 37% of children with mild TBI were classified as having a moderate disability (KOSCHI 4a, 4b) at outcome, with the remainder classified as having a good outcome. With the relatively wide range in variability of outcome, it is perhaps not surprising that Calvert et al. [17] found KOSCHI outcome attributed at discharge from hospital a poor predictor of neurobehavioural problems occurring more than six months after injury. Hawley et al. [18] reported similar KOSCHI outcomes to ours in a postal questionnaire sent to families whose children had previously been admitted to hospital with traumatic brain injury. In their study, 22% of children were judged to have a (KOSCHI 5a, 5b) good outcome following severe TBI, and 43% of children a moderate disability (KOSCHI 4a,4b) following mild TBI. There is good evidence that younger children have a poorer outcome than older children following TBI, particularly in cognitive function [2, 1012, 14, 24, 25]. It has been hypothesized that this may be due to a combination of factors including increased vulnerability to injury, greater effect on later neuronal development and damage to systems responsible for skill acquisition [12]. Some authors have also suggested that children who sustain a TBI early in life may grow into a deficit that may only become apparent as they grow older [6, 8, 12, 25]. However others have suggested that differences between

Inter-rater Reliability There were a total of 267 clinical assessments. Interrater reliability, as measured by weighted kappa was substantial, with no differences between investigators of different experience (Table II). Outcome KOSCHI score Outcome KOSCHI score was defined as the senior assessors KOSCHI score at the most recent assessment. Outcome KOSCHI for the 97 children studies, and those with mild, moderate or severe TBI are shown in Figure 1. Children with mild TBI (20, 63%) or moderate TBI (9, 64.3%) were significantly more likely to have good recovery (KOSCHI 5a, 5b) than those with severe TBI (12, 33%) (p 0.028). Only children with severe TBI had outcomes in the severe disability (KOSCHI 3b) group (3, 8% of severe TBI group). There were fifteen children for whom the severity of TBI was unable to be assigned. These children were all under the age of 5 years and 12 (80%) were under the age of 1 year at the time of their injury. The majority (11, 73%) of these children were assessed to be in the moderate disability (KOSCHI category 4a and 4b) group with a minority in a good recovery (KOSCHI category 5a and 5b) group (4, 37%). Change with KOSCHI score over time The results were analysed with respect to change in KOSCHI score over time. Children who were assessed on more than one occasion (n 58) were divided into two groups determined by age at injury (less than 8 years; 8 years or older). Consecutive KOSCHI scores (senior assessor) were plotted against time after injury for each child (Figure 2a, 2b). Almost half of children (28, 48%) had no change between their first and last KOSCHI scores. However, in 7 (23%) children under 8 years but in no children 8 years or over, KOSCHI score decreased (maximum of 2 KOSCHI subcategories) (p 0.02) (Table III). All of the 7 children were injured young in life (range 0.1 to 3.4 years) and were followed over a longer than average period of

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Figure 1 KOSCHI score assigned by senior assessor at the lastest assessment for 97 children with traumaticbrain injury.

children who sustain a severe TBI early in life and typically developing peers stabilise between five and ten years following the injury [24]. Our results give some support to the growing into a deficit hypothesis in that a decrease in KOSCHI score during follow-up was seen in one quarter (n 7) of children who sustained a TBI early in life (before 8 years) and not seen in any older children (p 0.02), most commonly due to the development of intellectual disability during follow-up. However, more (almost one third) of young children had an increase in KOSCHI score during follow-up, suggesting that this is by no means a universal phenomenon. The subgroups of children of different ages presented in our study were relatively small, and such do not lend themselves to robust statistical analysis. It may also be that the KOSCHI scale lacks the sensitivity required to detect change in disability levels for children with less severe disability. To examine both of these issues, a larger study with longer follow up would be beneficial. We agree with other authors that the KOSCHI was easy and rapid to score even for clinicians with limited experience in brain injury. The inter-rater reliability for our study was higher than that reported in previous studies [16, 17]. The reasons for this are unclear; however it may have been influenced by discussions that were held between the authors prior to starting the study to discuss using the KOSCHI scale. In addition, the reports used to allocate the scores were mostly derived from a dedicated multidisciplinary brain injury clinic. It may be therefore,

that there was more detailed information in these reports and this allowed easier attribution of KOSCHI score than in previously published studies. Some outcomes of childhood TBI were less easy to categorise using the current KOSCHI criteria and we agree with Hawley et al. [18] that the scale could benefit from further clarification in this regard. This study involved a selective group of children with problems following traumatic brain injury and referred to a specialist paediatric brain injury service. It is therefore likely that children with persistent problems are over-represented, when compared to population-based studies. This may account for the large proportion of children with persistent disability following mild TBI. The retrospective nature of the data collection may add additional bias toward those patients with persistent problems: follow-up is likely to be longer in those who either have injuries earlier in life, or who have ongoing problems as a result of their injury. Furthermore, we have assumed that the outcome for those patients who were discharged (or lost to follow-up) during the period remained stable following their last review, but this may not be the case. Median follow-up was around six months longer for younger children than for older children. It is also possible that our follow-up duration was not long enough to describe increasing disability beyond six years following injury. This may be most pertinent for those injured in early life.

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Figure 2 (a) Change in KOSCHI scores over time for 30 children aged 58 years at injury and (b) Chanhe in KOSCHI scores over time for 28 children aged 4 8 years at inhury.

Table III. Change in KOSCHI score (first to last) following TBI in 58 children admitted to a tertiary rehabilitation facility. Age 58 years 4 8 years Total Decreased 7 0 7 No change 14 14 28 Increased 9 14 23 Total 30 28 58

Conclusion We found that KOSCHI a useful method of rapidly assigning a global outcome measure for children following TBI, although we feel that some of the

categories would benefit from clarification to incorporate some of the common difficulties noted following TBI. In addition to its clinical use, KOSCHI may also be useful in evaluation of service delivery, where more detailed outcome assessments are less amenable to quantitative analysis. Outcome following childhood traumatic brain injury, as measured by KOSCHI is associated with established markers of injury severity. KOSCHI outcome stays stable over time for most children injured at an older age but almost one quarter of children injured under the age of eight display more severe disability over time as a worsening KOSCHI score. The use of KOSCHI in longer-term,

Use of the Kings Outcome Scale for Childhood Head Injury in the evaluation prospective studies would help to clarify these differences in outcome further.

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Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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