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Article |

Health-Related Quality of Life During the First Year After Traumatic Brain Injury FREE

Melissa L. McCarthy, ScD; Ellen J. MacKenzie, PhD; Dennis R. Durbin, MD, MS; Mary E. Aitken, MD, MPH; Kenneth M. Jaffe, MD; Charles N. Paidas, MD; Beth S. Slomine, PhD; Andrea M. Dorsch, PhD; James R. Christensen, MD; Ru Ding, MS ; for the Children's Health After Trauma Study Group
[+] Author Affiliations

Author Affiliations: Departments of Emergency Medicine (Dr McCarthy and Ms Ding), Surgery (Dr Paidas), Psychiatry (Dr Slomine), Physical Medicine and Rehabilitation (Dr Christensen), and Pediatrics (Dr Christensen), School of Medicine, and Center for Injury Research and Policy, Bloomberg School of Public Health (Dr MacKenzie), Johns Hopkins University, Baltimore, Md; Department of Pediatrics, School of Medicine, University of Pennsylvania, Philadelphia (Dr Durbin); Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock (Dr Aitken); Departments of Rehabilitation Medicine (Dr Jaffe) and Pediatrics (Dr Jaffe) and Division of Rehabilitation Psychology (Dr Dorsch), Children's Hospital and Regional Medical Center, School of Medicine, University of Washington, Seattle; and Departments of Neuropsychology (Dr Slomine) and Pediatric Rehabilitation Medicine (Dr Christensen), Kennedy Krieger Institute, Baltimore.


Arch Pediatr Adolesc Med. 2006;160(3):252-260. doi:10.1001/archpedi.160.3.252.
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Objectives  To document health-related quality of life (HRQOL) of children with traumatic brain injury (TBI) and to examine the relationship between TBI severity and HRQOL during the first year after injury.

Design  Prospective cohort study.

Setting  Four pediatric level I trauma centers.

Patients  Children with TBI (n = 330).

Main Exposure  Traumatic brain injury.

Main Outcome Measures  A primary caregiver completed telephone interviews at baseline, 3 months, and 12 months to measure the child's HRQOL using the Pediatric Quality of Life Inventory. The HRQOL outcomes were modeled as a function of injury, patient characteristics, and family characteristics using longitudinal, multivariable regression.

Results  A considerable proportion of children had impaired HRQOL at 3 months (42% of children) and 12 months (40% of children) after injury. Multiple dimensions of HRQOL were negatively affected among children with moderate or severe TBI (decrease of 3.7 to 17.6) (P<.05) and did not improve significantly over time. Concomitant lower extremity fractures and spinal injuries resulted in large declines in overall HRQOL, particularly at 3 months after injury (decrease of 12.9 and 8.1, respectively) (P<.05). The HRQOL scores were also reduced by preexisting psychosocial conditions (decrease of 2.9 to 12.3), impaired family functioning (decrease of 5.1 to 6.8), having Medicaid coverage or being uninsured (decrease of 3.1 to 5.5), and single-parent households (decrease of 3.2 to 3.4) (P<.05).

Conclusions  Moderate or severe TBI resulted in measurable declines in children's HRQOL after injury. Injury-related factors impacted HRQOL more compared with patient and family characteristics during the first year after injury.

Figures in this Article

During the past decade, a number of instruments have been developed to measure children's health-related quality of life (HRQOL).19 These instruments have 3 distinguishing features: (1) they measure function at the level of the person (as opposed to the organ or organ system); (2) they measure outcome from the child's or parent's perspective (as opposed to the clinician’s); and (3) they measure health as a multidimensional construct that includes physical, social, and emotional well-being. Furthermore, they can be self-administered or administered over the phone, making them practical for clinical and research applications.10,11

Although numerous studies have documented the neurobehavioral consequences following traumatic brain injury (TBI) in children,1226 only 2 have focused primarily on children's HRQOL.27,28 Interestingly, neither found a significant relationship between the severity of TBI and HRQOL.27,28 Stancin et al27 used the Child Health Questionnaire to measure HRQOL at 4 years after injury among 84 subjects with moderate to severe TBI and 50 children with an orthopedic injury. Although the psychosocial health of children with severe TBI was poorer compared with those with an orthopedic injury when examined alone, no significant differences remained after controlling for socioeconomic and premorbid problems. Coster et al28 also did not find a significant relationship between TBI severity and HRQOL using the Pediatric Evaluation of Disability Inventory among 57 young children with TBI at 6 months after injury. The findings from these 2 studies are surprising given that previous research that has measured neuropsychological and behavioral outcomes among children with moderate to severe TBI has noted significant and persistent deficits in this patient population long after the acute injury.13,15,17,20,24,29,30 It could be that the HRQOL instruments used in the studies by Stancin and colleagues and Coster and colleagues were not sensitive enough to discriminate among different levels of TBI severity, or it could be that HRQOL is more affected by premorbid and family characteristics than injury-related factors.

The purpose of this article is to document HRQOL among children hospitalized with TBI during the first year after injury and to examine the relationship between severity of injury and HRQOL after adjusting for premorbid, socioeconomic, and family characteristics. To do this, we compared the outcomes of children hospitalized with TBI of varying severity using the Pediatric Quality of Life Inventory (PedsQL), an instrument that we previously demonstrated to be a reliable and valid measure of HRQOL among children with TBI.31

STUDY POPULATION

Children aged 5 to 15 years who were discharged alive after being hospitalized 1 or more nights at 1 of 4 level I pediatric trauma center hospitals (Johns Hopkins Hospital, Baltimore, Md; Children's Hospital of Philadelphia, Philadelphia, Pa; Harborview Medical Center, Seattle, Wash; and Arkansas Children's Hospital, Little Rock) for treatment of TBI with an Abbreviated Injury Scale (AIS) severity score of 2 or greater were eligible for the study.32

Children were excluded for the following reasons: (1) they or their parents were non-English speaking; (2) they had a preexisting medical condition that seriously impacted preinjury physical (eg, amputation), psychological (eg, schizophrenia or bipolar disorder), or cognitive (eg, mental retardation or prior TBI-related hospitalization) function; or (3) they were part of a suspected child abuse case. To increase the generalizability of the study and to evaluate the effects of preinjury risk factors on HRQOL, children with preinjury learning disabilities or behavioral problems were eligible.

The sample was stratified by AIS severity to enroll adequate numbers of children with more severe TBI. Consecutive children within each study group were enrolled until there were approximately 95 children with head injuries with AIS scores of 2, 3, and 4. The target number for children with head injuries with AIS scores of 5 was 50 because they are less frequent.

PROCEDURES

The institutional review boards of all of the 4 participating sites approved the study. Between January 15, 2002, and July 31, 2003, the study coordinators identified 536 children with an eligible injury. However, 98 (18%) of the children were deemed ineligible on full review of all of the demographic and injury characteristics. The study coordinators approached all of the eligible children and their families. Those who consented agreed to complete 3 telephone interviews over a 1-year period and to allow pertinent injury and treatment information to be abstracted from the child's medical record.

All of the interviews were conducted by a professional survey research firm with a primary caregiver of the injured child. The first, or baseline, interview conducted within 3 weeks of the initial hospitalization (median, 16 days) was designed to measure the child's preinjury HRQOL and to obtain background information on the child and his or her family. During the baseline interview, the respondent was instructed to think of the child 1 month prior to the injury when answering the HRQOL questions. During the follow-up interviews, the respondent was asked to rate the child's HRQOL during the previous month.

MEASUREMENT

Health-related quality of life was measured with the PedsQL.1,33 The PedsQL was selected over other pediatric HRQOL instruments primarily because it advocates a modular assessment strategy that allows for the integration of generic and disease-specific scales. For this study, the PedsQL generic instrument was supplemented with a cognitive function scale since cognitive dysfunction is a common and serious impairment following TBI.34 Numerous studies31,3542 have confirmed the PedsQL to be a reliable and valid instrument for measuring HRQOL among children with different types of illnesses or injuries, including TBI.

The PedsQL generic core comprises 23 items that measure 4 health domains: (1) physical functioning, (2) emotional functioning, (3) social functioning, and (4) school functioning. The scales can be aggregated into summary scales of physical health (same as the physical functioning scale), psychosocial health (emotional, social, and school functioning scales), and total health (all of the 4 scales). The PedsQL cognitive function scale comprises 6 items. All of the PedsQL scales have a possible range from 0 (poor health) to 100 (excellent health). Scale scores more than 1 SD below the healthy sample mean are considered impaired.34,40

The child's age, race, health insurance coverage, and the presence of preexisting physical or psychosocial health conditions were obtained from the respondent during the baseline interview. The most prevalent preexisting physical conditions were asthma (18%) and allergies (17%) whereas the most common psychosocial conditions were an attentional problem (12%), a learning disability (11%), and a behavioral problem (7%). The respondent was also queried about his or her age, race, marital status, highest grade in school completed, total annual income of the household, and relationship to the child. Finally, the general functioning scale of the Family Assessment Device was administered to the respondents.43,44 This 12-item scale is a self-reported measure of overall family functioning.4345 The scale has a possible range of 1 to 4, and scores of 2 and higher are considered unhealthy family functioning.

The nature and severity of all of the injuries sustained were characterized according to the AIS.32,46 This scale classifies more than 2000 injuries according to the body region of injury (eg, head, chest, lower extremity), type of structure involved (eg, nerve, vessel, bone), location of injury within the body region (eg, femur, tibia), and nature of injury (eg, abrasion, crush). The AIS grades each injury according to its associated threat to life on an ordinal scale from 1 (minor) to 6 (unsurvivable). Typical head injuries sustained by the study sample included a closed vault fracture (AIS score = 2), comminuted vault fracture or subarachnoid hemorrhage (AIS score = 3), epidural or subdural hematoma (AIS score = 4), or a diffuse axonal injury (AIS score = 5). To reflect overall injury severity, the New Injury Severity Scale score was computed. The New Injury Severity Scale score is the sum of the squares of the 3 most severe injuries sustained.47 The New Injury Severity Scale score ranges from 0 to 75, and higher scores reflect greater severity. Finally, the mechanism of injury, hospital length of stay, and disposition were recorded for all of the subjects.

DATA ANALYSIS

First, we compared those who enrolled with those who did not by different patient and injury characteristics using a χ2 test of homogeneity. We also compared the distribution of different patient, respondent, and family characteristics by the severity of TBI sustained among those who enrolled. Second, we compared the mean PedsQL scale scores among the TBI severity groups by analysis of variance, and we examined the percentage of subjects with HRQOL outcomes that were 1 and 2 SDs lower than general population norms.1,40 Because the PedsQL scale scores of children who sustained head injuries with AIS scores of 2 and 3 were similar, these 2 groups were combined. Throughout this article, head injuries with AIS scores of 2 and 3 are referred to as mild TBI, head injuries with AIS scores of 4 as moderate TBI, and head injuries with AIS scores of 5 as severe TBI.

Finally, to examine the impact of TBI on HRQOL over time controlling for the influence of other factors, generalized estimating equation modeling was used.48 Selected PedsQL scale scores of all of the enrolled subjects were modeled separately as a function of time, head injury severity (maximum AIS score of the head-body region), the presence of an injury with an AIS score of 2 or higher to each other body region, mechanism of injury, Glasgow Coma Scale score, patient characteristics (ie, age, race, sex, preexisting conditions), respondent characteristics (ie, age, race, sex, relationship to child, education), and family characteristics (ie, family functioning, marital status, total household income, health insurance coverage). All of the independent variables were initially forced into the models and dropped sequentially based on their association with the outcomes. Possible interactions were tested and regression diagnostics were examined to evaluate multicollinearity and goodness of fit. Variables were considered statistically significant at P≤.05 and were noted as borderline significant at .05<P≤.10. Only variables that were significant at P≤.10 were included in the final models.

Of the 438 children eligible for the study, 381 (87%) consented and 330 (75%) enrolled. Children who did not enroll were more likely to lack health insurance (10%) than those who enrolled (<1%) (P<.05). In addition, children who did not enroll were hospitalized longer than those who enrolled (8.3 vs 5.3 days, respectively) (P≤.01). Of the 330 who enrolled, 302 (92%) completed the interview at 3 months and 288 (87%) completed the interview at 12 months. Seventeen subjects (5%) did not complete either follow-up interview. Those who were not followed up were more likely to be younger, nonwhite, and part of a single- parent household compared with those who were followed up (P≤.05) (data not shown).

Table 1 and Table 2 display the patient, respondent, and family characteristics of the sample by the severity of TBI sustained. The mean age of all of the enrolled subjects was 10.4 years (range, 5.1-15.9 years). Subjects were more likely to be male (69%), white (69%), and in good health prior to the injury (89%). There were no significant differences in patient characteristics by the severity of TBI sustained (all P>.10). The respondents for children with severe TBI were more likely to be the father (31%) compared with respondents for children with mild (12%) or moderate (13%) TBI (P≤.05). A greater proportion of respondents for children with mild TBI had not completed high school (24%) than respondents for children with moderate (11%) or severe (10%) TBI (P = .001). Finally, the respondents for children with moderate and severe TBI reported better preinjury family functioning (94% and 93%, respectively) than respondents for children with mild TBI (79%) (P<.05) (Table 2).

Table Graphic Jump LocationTable 1. Percentage Distribution of Patient Characteristics of Subjects by Traumatic Brain Injury Severity
Table Graphic Jump LocationTable 2. Percentage Distribution of Respondent and Family Characteristics of Subjects by Traumatic Brain Injury Severity

Traffic-related injuries (39%) and falls (36%) were the most common injuries (Table 3). The mean New Injury Severity Scale score was 21 (range, 4-66). Subjects with severe TBI were significantly more likely to sustain a thoracic (33%), abdominal (17%), spinal (17%), or upper extremity (26%) fracture than subjects with mild TBI (AIS score = 2) (4%, 3%, 3%, and 9%, respectively) (P<.01).

Table Graphic Jump LocationTable 3. Percentage Distribution of Injury Characteristics of Subjects by Traumatic Brain Injury Severity

Children with severe TBI had significantly poorer HRQOL scores after injury (P≤.05) than children with mild TBI, except for social functioning (not significantly different at 3 months only [P = .15]) and emotional functioning (not significantly different at 3 or 12 months [P = .51 and P = .15, respectively]) (Table 4). When comparing children with severe TBI with those with moderate TBI, physical functioning was the only significant difference at both 3 and 12 months after injury (P≤.05).

Table Graphic Jump LocationTable 4. Mean Pediatric Quality of Life Inventory Scores by Traumatic Brain Injury Severity*

Using the total PedsQL score as an overall measure of HRQOL, Figure 1 displays the proportion of children with impaired HRQOL by TBI severity. Overall, a considerable proportion of children had impaired HRQOL at 3 months (42%) and 12 months (40%) after injury. At 3 months after injury, more children with mild TBI (64%; relative risk = 1.3; 95% confidence interval, 1.1-1.5) or moderate TBI (58%; relative risk = 1.3; 95% confidence interval, 1.1-1.7) had normal HRQOL compared with children with severe TBI (35%). Similarly, at 12 months after injury, HRQOL of a relatively small proportion of children with severe TBI was normal (37%) compared with the other TBI groups (relative risk = 0.4; 95% confidence interval, 0.2-0.7).

Place holder to copy figure label and caption
Figure 1.

Percentage of subjects with impaired health-related quality of life by traumatic brain injury (TBI) severity at baseline, 3 months after injury, and 12 months after injury. The health-related quality of life is measured by the total Pediatric Quality of Life Inventory score. Severely impaired indicates 2 SDs below the general population norm; impaired, 1 SD below the general population norm.

Graphic Jump Location

Figure 2 compares the mean total PedsQL scores of the different study groups at 12 months after injury with scores for children with different medical conditions.1,3438,4042,49,50 Health-related quality of life of children with mild TBI is similar to that of children with type 1 diabetes mellitus.49 Health-related quality of life of children with moderate TBI is most similar to that of children who survived acute lymphoblastic leukemia whereas HRQOL of children with severe TBI most resembled that of children who were seen at a rheumatology or oncology clinic.34,42,50

Place holder to copy figure label and caption
Figure 2.

Mean health-related quality of life (HRQOL) scores among different study samples. The HRQOL is measured by the total Pediatric Quality of Life Inventory score. TBI indicates traumatic brain injury; asterisk, the HRQOL was measured at 12 months after injury.

Graphic Jump Location

Table 5 displays the changes in HRQOL scores associated with different risk factors. Of note, the type and severity of injuries sustained are associated with the greatest reductions in HRQOL at 3 and 12 months after injury. Children with moderate or severe TBI had significantly poorer physical, cognitive, psychosocial, and overall HRQOL scores compared with children with mild TBI (all P<.10). Furthermore, there is a significant interaction effect between type and severity of injury and time. At 3 and 12 months after injury, the presence of a concomitant lower extremity fracture (decrease of 24.1 and 7.3, respectively), upper extremity fracture (decrease of 8.9 and 7.8, respectively), concomitant spinal injury (decrease of 13.2 and 7.7, respectively), or severe TBI (decrease of 11.7 and 9.6, respectively) (P<.05) was associated with the largest decrements in physical function. Although the impact of a concomitant lower extremity fracture and a concomitant spinal injury (ie, spinal fracture or dislocation) on physical function lessened over time, the impact of a concomitant upper extremity fracture or severe TBI did not. A similar pattern was noted for psychosocial function and overall HRQOL; however, the magnitude of the impact was not as strong (except for TBI), and only the impact of the concomitant lower extremity fracture lessened over time. None of the associated injuries to other body regions significantly influenced HRQOL (all P>.10). There was also a strong dose-response relationship noted between the severity of TBI and cognitive function (Figure 3).

Place holder to copy figure label and caption
Figure 3.

Adjusted mean cognitive score by traumatic brain injury (TBI) severity. Scores were adjusted for associated injury, mechanism of injury, patient characteristics, and family characteristics.

Graphic Jump Location
Table Graphic Jump LocationTable 5. Estimated Change in Health-Related Quality of Life Scores Associated With Each Characteristic*

The only patient characteristic to demonstrate a significant relationship to HRQOL was the presence of a preexisting psychosocial condition, which was associated with a significant reduction in all of the dimensions of HRQOL (range of decrease, 2.9-12.3) (P≤.05).

Although none of the respondent characteristics significantly influenced HRQOL, several family characteristics did. The HRQOL scores of children who came from single-parent households were significantly lower than those of children who lived with both parents or 1 parent and a partner (range of decrease, 3.2-3.4) (P≤.05). Similarly, unhealthy family functioning was associated with a significant reduction in HRQOL (range of decrease, 5.1-6.8) (P≤.05). Finally, children who were covered by Medicaid or were uninsured had poorer HRQOL outcomes compared with children with private health insurance (range of decrease, 3.1-5.5) (P≤.05). Family income was significantly related to HRQOL when examined alone (subjects with lower family income had poorer HRQOL outcomes compared with subjects from higher income households), but because of its strong correlation to health insurance coverage and marital status, it did not remain significant in the multivariable model (all P>.10; data not shown).

This is the first study to our knowledge to document the HRQOL outcomes during the first year after injury of a cohort of children who sustained TBI severe enough to warrant hospitalization, and we found that the severity of injury significantly impacted HRQOL. Our findings are consistent with other studies1220,2226 that have examined neuropsychological and behavioral outcomes following TBI. All of the dimensions of HRQOL measurably declined among children who sustained severe TBI and did not improve over time. With the exception of physical function, multiple dimensions of HRQOL were also negatively impacted among children who sustained moderate TBI.

Our results suggest that there is a strong relationship between the severity of TBI and HRQOL during the first year after injury. Coster et al28 may not have found a significant association between TBI severity and HRQOL during the first 6 months after injury because the majority of their patients sustained mild TBI. In a multivariable analysis, Stancin et al27 also did not find a relationship between TBI severity and HRQOL as measured by the Child Health Questionnaire. Although it could be that the Child Health Questionnaire is not sufficiently sensitive for children with TBI, it seems more likely that the relationship between TBI severity and HRQOL weakens over time. Since numerous studies16,17,20,2224 have demonstrated that children with severe TBI have persistent long-term deficits that should negatively impact HRQOL, it will be important in future research to measure HRQOL outcomes multiple times over a long follow-up period to determine how HRQOL and the factors that influence it change over time.

The results of this study demonstrate the importance of measuring the impact of associated injuries on children's health. The poorest HRQOL outcomes were among children who sustained TBI and an associated extremity fracture or spinal injury (ie, spinal fractures or dislocations). These results concur with earlier studies51,52 that noted that a significant proportion of children who sustained an extremity injury had physical and role limitations 1 year later. We also found that a small but significant proportion of children with extremity fractures, particularly lower extremity fractures, had impaired HRQOL at 1 year after injury.53 MacKenzie et al54 also found that among adult trauma patients, injuries to the head, spine, or extremities (particularly lower extremities) were more frequently associated with functional limitations after injury compared with injuries to other body regions.

Children with moderate or severe TBI had worse physical and psychosocial functioning during the first year after injury compared with children with mild TBI. Evidence that children who sustain moderate to severe TBI are at higher risk of developing a psychiatric disorder after injury is beginning to accumulate.55,56 Other researchers13,15,29,57,58 have also found that children who sustain moderate to severe TBI exhibit more depressive symptoms, behavioral problems, and difficulties at school compared with children with an orthopedic injury.

With increasing TBI severity, parents reported more cognitive dysfunction. Moreover, the cognitive dysfunction persisted over time. Our results concur with numerous other studies14,16,20,30,59,60 that have described cognitive deficits at 1 year after injury among children who sustain moderate to severe TBI.

The presence of a preexisting psychosocial condition was associated with a reduction in many domains of HRQOL, even after adjusting for preinjury function. Other studies19,61,62 involving trauma patients have also noted the importance of controlling for the presence of comorbidities when examining the impact of an injury on HRQOL.

During the first year after injury, unhealthy family functioning, single-parent households, and being uninsured or covered by Medicaid all had a small but negative impact on children's HRQOL. These results are consistent with those of other studies15,18 that have also found that preinjury family functioning influences different health outcomes after TBI. It could be that single-parent households have fewer resources (ie, financial and/or social) available to devote to a child's recovery compared with 2-parent households. Similarly, financial resources could also explain why the HRQOL outcomes were poorer among children covered by Medicaid or who were uninsured. Stancin et al27 noted a significant association between socioeconomic status and HRQOL. Contrary to the results of other studies,15,29,63 we did not find a significant interaction effect between family characteristics and the severity of TBI sustained.

The results of this study must be considered in the context of several limitations. First, preinjury HRQOL scores were obtained shortly after injury, which could have biased the respondent's perceptions. Although the preinjury HRQOL scores were not significantly different among the study groups when examined alone, the multivariable regression results showed that the parents of children with severe TBI reported better preinjury HRQOL compared with that which the parents of the children with an extremity fracture reported. While this may reflect a small overestimation of preinjury function, an estimate is important to have when evaluating injury sequelae.15 Second, HRQOL was based on a primary caregiver's perspective; future research should incorporate the child's perceptions of his or her HRQOL. Finally, we may have underestimated the reduction in HRQOL as a result of severe TBI or a lack of health insurance since children with either of these characteristics were less likely to participate.

Despite these limitations, this study illustrates that it is possible to use a brief instrument to assess a child's physical and psychosocial health following TBI. While it is not feasible to conduct in-depth follow-up assessments on all children who sustain TBI severe enough to warrant hospitalization, it may be that an instrument such as the PedsQL can help clinicians to monitor the recovery of children following different types of injuries and to systematically identify those in need of further evaluation and services.

Correspondence: Melissa L. McCarthy, ScD, 5802 Smith Ave, Davis Bldg, Room 220, Baltimore, MD 21209 (mmccarth@jhmi.edu).

Accepted for Publication: September 15, 2005.

Author Contributions: Dr McCarthy had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Children's Health After Trauma (CHAT) Study Group Institutions and Investigators: Johns Hopkins University, Baltimore, Md, Melissa McCarthy, ScD; Ellen MacKenzie, PhD; Charles Paidas, MD; Beth Slomine, PhD; James Christensen, MD; Ronald Berk, PhD; Susan Ziegfeld, MSN, CRNP; Vinita Misra Knight, MPH, CSTR; University of Pennsylvania, Philadelphia, Dennis Durbin, MD, MS; University of Arkansas for Medical Sciences, Little Rock, Mary Aitken, MD, MPH; Patricia Korehbandi, RN, MS, CHES; University of Washington, Seattle, Kenneth Jaffe, MD; Patricia Klotz, RN, BSN; Andrea Dorsch, PhD; Kennedy Krieger Institute, Baltimore, Beth Slomine; James Christensen; Children's Hospital of Philadelphia, Philadelphia, Eileen Houseknecht, RN, BSN; Arkansas Children's Hospital, Little Rock, Donna Parnell, RN, MNSc.

Funding/Support: This study was funded by grant R49/CCR319701 from the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Ga.

Acknowledgment: We would like to express our appreciation to the study coordinators who worked hard to successfully recruit all of the injured children and families involved. They are Mss Eileen Houseknecht, Patricia Klotz, Patricia Korehbandi, Vinita Misra Knight, Donna Parnell, and Susan Ziegfeld.

Varni  JWSeid  MKurtin  PS PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations Med Care 2001;39800- 812
PubMed Link to Article
Daltroy  LHLiang  MHFossel  AHGoldberg  MJPediatric Outcomes Instrument Development Group, The POSNA pediatric musculoskeletal functional health questionnaire: report on reliability, validity, and sensitivity to change J Pediatr Orthop 1998;18561- 571
PubMed Link to Article
Landgraf  JMAbetz  LAWare  JE The CHQ User's Manual 1st ed. Boston, Mass Health Institute, New England Medical Center1996;
Torrance  GWFeeny  DHFurlong  WJBarr  RDZhang  YWang  Q Multiattribute utility function for a comprehensive health status classification system: Health Utilities Index Mark 2 Med Care 1996;34702- 722
PubMed Link to Article
Msall  MEDiGaudio  KRogers  BT  et al.  The Functional Independence Measure for Children (WeeFIM): conceptual basis and pilot use in children with developmental disabilities Clin Pediatr (Phila) 1994;33421- 430
PubMed Link to Article
Starfield  BBergner  MEnsminger  M  et al.  Adolescent health status measurement: development of the Child and Health Illness Profile Pediatrics 1993;91430- 435
PubMed
Haley  SMCoster  WJLudlow  LHHaltiwanger  JTAndrellos  PJ Pediatric Evaluation and Disability Inventory (PEDI): Development, Standardization and Administration Manual 1st ed. Boston, Mass New England Medical Center Hospitals Inc, PEDI Research Group1992;
Stein  REJessop  DJ Functional status II(R): a measure of child health status Med Care 1990;281041- 1055
PubMed Link to Article
Kaplan  RMAnderson  JPWu  AWMathews  WCKozin  FOrenstein  D The Quality of Well-being Scale: applications in AIDS, cystic fibrosis, and arthritis Med Care 1989;27S27- S43
PubMed Link to Article
Ware  JE Conceptualization and measurement of health-related quality of life: comments on an evolving field Arch Phys Med Rehabil 2003;84(suppl 2)S43- S51
PubMed Link to Article
Andresen  EMMeyers  AR Health-related quality of life outcomes Arch Phys Med Rehabil 2000;81(suppl 2)S30- S45
PubMed Link to Article
Ewing-Cobbs  LBarnes  MFletcher  JMLevin  HSSwank  PRSong  J Modeling of longitudinal academic achievement scores after pediatric traumatic brain injury Dev Neuropsychol 2004;25107- 133
PubMed Link to Article
Schwartz  LTaylor  HGDrotar  DYeates  KOWade  SLStancin  T Long-term behavior problems following pediatric traumatic brain injury: prevalence, predictors and correlates J Pediatr Psychol 2003;28251- 263
PubMed Link to Article
Yeates  KOTaylor  HGWade  SLDrotar  DStancin  TMinich  N A prospective study of short- and long-term neuropsychological outcomes after traumatic brain injury in children Neuropsychology 2002;16514- 523
PubMed Link to Article
Taylor  HGYeates  KOWade  SLDrotar  DKlein  SKStancin  T Influences on first-year recovery from traumatic brain injury in children Neuropsychology 1999;1376- 89
PubMed Link to Article
Broman  SHMichel  ME Traumatic Head Injury in Children  New York, NY Oxford University Press1995;
Fay  GCJaffe  KMPolissar  NLLiao  SRivara  JBMartin  KM Outcome of pediatric traumatic brain injury at three years: a cohort study Arch Phys Med Rehabil 1994;75733- 741
PubMed
Rivara  JBJaffe  KMPolissar  NL  et al.  Family functioning and children's academic performance and behavior problems in the year following traumatic brain injury Arch Phys Med Rehabil 1994;75369- 379
PubMed Link to Article
Greenspan  AIMacKenzie  EJ Functional outcome after pediatric head injury Pediatrics 1994;94425- 432
PubMed
Jaffe  KMFay  GCPolissar  NL  et al.  Severity of pediatric traumatic brain injury and neurobehavioral recovery at one year: a cohort study Arch Phys Med Rehabil 1993;74587- 595
PubMed Link to Article
Kraus  JFFife  DConroy  C Pediatric brain injuries: the nature, clinical course, and early outcomes in a defined United States' population Pediatrics 1987;79501- 507
PubMed
Levin  HSEisenberg  HMWigg  NRKobayashi  K Memory and intellectual ability after head injury in children and adolescents Neurosurgery 1982;11668- 673
PubMed Link to Article
Brink  JDImbus  CWoo-Sam  J Physical recovery after severe closed head trauma in children and adolescents J Pediatr 1980;97721- 727
PubMed Link to Article
Rutter  MChadwick  OShaffer  DBrown  G A prospective study of children with head injuries, I: design and methods Psychol Med 1980;10633- 645
PubMed Link to Article
Levin  HSEisenberg  HM Neuropsychological outcome of closed head injury in children and adolescents Childs Brain 1979;5281- 292
PubMed
Fuld  PAFisher  P Recovery of intellectual ability after closed head-injury Dev Med Child Neurol 1977;19495- 502
PubMed Link to Article
Stancin  TDrotar  DTaylor  HGYeates  KOWade  SLMinich  NM Health-related quality of life of children and adolescents after traumatic brain injury Pediatrics 2002;109E34
PubMed Link to Article
Coster  WJHaley  SBaryza  MJ Functional performance of young children after traumatic brain injury: a 6-month follow-up study Am J Occup Ther 1994;48211- 218
PubMed Link to Article
Taylor  HGYeates  KOWade  SLDrotar  DStancin  TMinich  N A prospective study of short- and long-term outcomes after traumatic brain injury in children: behavior and achievement Neuropsychology 2002;1615- 27
PubMed Link to Article
Jaffe  KMPolissar  NLFay  GCLiao  S Recovery trends over three years following pediatric traumatic brain injury Arch Phys Med Rehabil 1995;7617- 26
PubMed Link to Article
McCarthy  MLMacKenzie  EJDurbin  DR  et al.  The Pediatric Quality of Life Inventory: an evaluation of its reliability and validity for children with traumatic brain injury Arch Phys Med Rehabil 2005;861901- 1909
Link to Article
Association for the Advancement of Automotive Medicine;; Committee on Injury Scaling, The Abbreviated Injury Scale: 1990 Revision.  Des Plaines, Ill Association for the Advancement of Automotive Medicine1990;
Varni  JWSeid  MRode  CA The PedsQL: measurement model for the pediatric quality of life inventory Med Care 1999;37126- 139
PubMed Link to Article
Varni  JWBurwinkle  TMKatz  ERMeeske  KDickinson  P The PedsQL in pediatric cancer: reliability and validity of the pediatric quality of life inventory generic core scales, multidimensional fatigue scale, and cancer module Cancer 2002;942090- 2106
PubMed Link to Article
Bastiaansen  DKoot  HMBongers  ILVarni  JWVerhulst  FC Measuring quality of life in children referred for psychiatric problems: psychometric properties of the PedsQL 4.0 generic core scales Qual Life Res 2004;13489- 495
PubMed Link to Article
Friefeld  SYeboah  OJones  JEdeVeber  G Health-related quality of life and its relationship to neurological outcome in child survivors of stroke CNS Spectr 2004;9465- 475
PubMed
Powers  SWPatton  SRHommel  KAHershey  AD Quality of life in paediatric migraine: characterization of age-related effects using PedsQL 4.0 Cephalalgia 2004;24120- 127
PubMed Link to Article
Varni  JWBurwinkle  TMRapoff  MAKamps  JLOlson  N The PedsQL in pediatric asthma: reliability and validity of the Pediatric Quality of Life Inventory generic core scales and asthma module J Behav Med 2004;27297- 318
PubMed Link to Article
Varni  JWBurwinkle  TMSeid  MSkarr  D The PedsQL 4.0 as a pediatric population health measure: feasibility, reliability, and validity Ambul Pediatr 2003;3329- 341
PubMed Link to Article
Schwimmer  JBBurwinkle  TMVarni  JW Health-related quality of life of severely obese children and adolescents JAMA 2003;2891813- 1819
PubMed Link to Article
Varni  JWBurwinkle  TMJacobs  JRGottschalk  MKaufman  FJones  KL The PedsQL in type 1 and type 2 diabetes: reliability and validity of the pediatric quality of life inventory generic core scales and type 1 diabetes module Diabetes Care 2003;26631- 637
PubMed Link to Article
Varni  JWSeid  MKnight  TSBurwinkle  TMBrown  JSzer  IS The PedsQL in pediatric rheumatology: reliability, validity and responsiveness of the pediatric quality of life inventory generic core scales and rheumatology module Arthritis Rheum 2002;46714- 725
Link to Article
Miller  IWEpstein  NBBishop  DSKeitner  GI The McMaster Family Assessment Device: reliability and validity J Marital Fam Ther 1985;11345- 356
Link to Article
Byles  JByrne  CBoyle  MOfford  D Ontario Child Health Study: reliability and validity of the general functioning subscale of the McMaster Family Assessment Device Fam Process 1988;2797- 104
PubMed Link to Article
Epstein  NBBaldwin  LMBishop  DS The McMaster Family Assessment Device J Marital Fam Ther 1983;9171- 180
Link to Article
MacKenzie  EJ Injury severity scales: overview and directions for future research J Emerg Med 1984;2537- 549
Osler  TBaker  SPLong  W A modification of the injury severity score that both improves accuracy and simplifies scoring J Trauma 1997;43922- 926
PubMed Link to Article
Diggle  PJLiang  KZeger  SL Analysis of Longitudinal Data. 1st ed. New York, NY Oxford University Press1994;
Laffel  LMConnell  AVangess  LGoebel-Fabri  AMansfield  AAnderson  BJ Relationship to patient management and diabetes-specific family conflict Diabetes Care 2003;263067- 3073
PubMed Link to Article
Eiser  CVance  YHHorne  BGlaser  AGalvin  H The value of the PedsQL in assessing quality of life in survivors of childhood cancer Child Care Health Dev 2003;2995- 102
PubMed Link to Article
Wesson  DEWilliams  JISpence  LJFiller  RMArmstrong  PFPearl  RH Functional outcome in pediatric trauma J Trauma 1989;29589- 592
PubMed Link to Article
Hu  XWesson  DELogsetty  SSpence  LJ Functional limitations and recovery in children with severe trauma: a one-year follow-up J Trauma 1994;37209- 213
PubMed Link to Article
Ding  RMcCarthy  MLHouseknecht  E  et al.  The health-related quality of life of children with an extremity fracture: a one year follow-up study J Pediatr Orthop In press
MacKenzie  EJSiegel  JHShapiro  SMoody  MSmith  RT Functional recovery and medical costs of trauma: an analysis by type and severity of injury J Trauma 1988;28281- 297
PubMed Link to Article
Max  JELansing  AEKoele  SLCastillo  CSBokura  HSchachar  R Attention deficit hyperactivity disorder in children and adolescents following traumatic brain injury Dev Neuropsychol 2004;25159- 177
PubMed Link to Article
Gerring  JPBrady  KDChen  A  et al.  Premorbid prevalence of ADHD and development of secondary ADHD after closed head injury J Am Acad Child Adolesc Psychiatry 1998;37647- 654
PubMed Link to Article
Kirkwood  MJanusz  JYeates  KO  et al.  Prevalence and correlates of depressive symptoms following traumatic brain injuries in children Neuropsychol Dev Cogn C Child Neuropsychol 2000;6195- 208
PubMed
Janusz  JAKirkwood  MWYeates  KOTaylor  HG Social problem-solving skills in children with traumatic brain injury: long-term outcomes and prediction of social competence Neuropsychol Dev Cogn C Child Neuropsychol 2002;8179- 194
PubMed
Roncadin  CGuger  SArchibald  JBarnes  MDennis  M Working memory after mild, moderate, or severe childhood closed head injury Dev Neuropsychol 2004;2521- 36
PubMed Link to Article
Jaffe  KMFay  GCPolissar  NL  et al.  Severity of pediatric traumatic brain injury and neurobehavioral outcome: a cohort study Arch Phys Med Rehabil 1993;74587- 595
Link to Article
Pollak  ANMcCarthy  MLBess  RSAgel  JSwiontkowski  MF Outcomes after treatment of high-energy tibial plafond fractures J Bone Joint Surg Am 2003;85-A1893- 1900
PubMed
McCarthy  MLMacKenzie  EJBosse  MJCopeland  CEHash  CSBurgess  AR Functional status following orthopedic trauma in young women J Trauma 1995;39828- 837
PubMed Link to Article
Yeates  KOTaylor  HGDrotar  D  et al.  Preinjury family environment as a determinant of recovery from traumatic brain injuries in school-age children J Int Neuropsychol Soc 1997;3617- 630
PubMed

Figures

Place holder to copy figure label and caption
Figure 1.

Percentage of subjects with impaired health-related quality of life by traumatic brain injury (TBI) severity at baseline, 3 months after injury, and 12 months after injury. The health-related quality of life is measured by the total Pediatric Quality of Life Inventory score. Severely impaired indicates 2 SDs below the general population norm; impaired, 1 SD below the general population norm.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Mean health-related quality of life (HRQOL) scores among different study samples. The HRQOL is measured by the total Pediatric Quality of Life Inventory score. TBI indicates traumatic brain injury; asterisk, the HRQOL was measured at 12 months after injury.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Adjusted mean cognitive score by traumatic brain injury (TBI) severity. Scores were adjusted for associated injury, mechanism of injury, patient characteristics, and family characteristics.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Percentage Distribution of Patient Characteristics of Subjects by Traumatic Brain Injury Severity
Table Graphic Jump LocationTable 2. Percentage Distribution of Respondent and Family Characteristics of Subjects by Traumatic Brain Injury Severity
Table Graphic Jump LocationTable 3. Percentage Distribution of Injury Characteristics of Subjects by Traumatic Brain Injury Severity
Table Graphic Jump LocationTable 4. Mean Pediatric Quality of Life Inventory Scores by Traumatic Brain Injury Severity*
Table Graphic Jump LocationTable 5. Estimated Change in Health-Related Quality of Life Scores Associated With Each Characteristic*

References

Varni  JWSeid  MKurtin  PS PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations Med Care 2001;39800- 812
PubMed Link to Article
Daltroy  LHLiang  MHFossel  AHGoldberg  MJPediatric Outcomes Instrument Development Group, The POSNA pediatric musculoskeletal functional health questionnaire: report on reliability, validity, and sensitivity to change J Pediatr Orthop 1998;18561- 571
PubMed Link to Article
Landgraf  JMAbetz  LAWare  JE The CHQ User's Manual 1st ed. Boston, Mass Health Institute, New England Medical Center1996;
Torrance  GWFeeny  DHFurlong  WJBarr  RDZhang  YWang  Q Multiattribute utility function for a comprehensive health status classification system: Health Utilities Index Mark 2 Med Care 1996;34702- 722
PubMed Link to Article
Msall  MEDiGaudio  KRogers  BT  et al.  The Functional Independence Measure for Children (WeeFIM): conceptual basis and pilot use in children with developmental disabilities Clin Pediatr (Phila) 1994;33421- 430
PubMed Link to Article
Starfield  BBergner  MEnsminger  M  et al.  Adolescent health status measurement: development of the Child and Health Illness Profile Pediatrics 1993;91430- 435
PubMed
Haley  SMCoster  WJLudlow  LHHaltiwanger  JTAndrellos  PJ Pediatric Evaluation and Disability Inventory (PEDI): Development, Standardization and Administration Manual 1st ed. Boston, Mass New England Medical Center Hospitals Inc, PEDI Research Group1992;
Stein  REJessop  DJ Functional status II(R): a measure of child health status Med Care 1990;281041- 1055
PubMed Link to Article
Kaplan  RMAnderson  JPWu  AWMathews  WCKozin  FOrenstein  D The Quality of Well-being Scale: applications in AIDS, cystic fibrosis, and arthritis Med Care 1989;27S27- S43
PubMed Link to Article
Ware  JE Conceptualization and measurement of health-related quality of life: comments on an evolving field Arch Phys Med Rehabil 2003;84(suppl 2)S43- S51
PubMed Link to Article
Andresen  EMMeyers  AR Health-related quality of life outcomes Arch Phys Med Rehabil 2000;81(suppl 2)S30- S45
PubMed Link to Article
Ewing-Cobbs  LBarnes  MFletcher  JMLevin  HSSwank  PRSong  J Modeling of longitudinal academic achievement scores after pediatric traumatic brain injury Dev Neuropsychol 2004;25107- 133
PubMed Link to Article
Schwartz  LTaylor  HGDrotar  DYeates  KOWade  SLStancin  T Long-term behavior problems following pediatric traumatic brain injury: prevalence, predictors and correlates J Pediatr Psychol 2003;28251- 263
PubMed Link to Article
Yeates  KOTaylor  HGWade  SLDrotar  DStancin  TMinich  N A prospective study of short- and long-term neuropsychological outcomes after traumatic brain injury in children Neuropsychology 2002;16514- 523
PubMed Link to Article
Taylor  HGYeates  KOWade  SLDrotar  DKlein  SKStancin  T Influences on first-year recovery from traumatic brain injury in children Neuropsychology 1999;1376- 89
PubMed Link to Article
Broman  SHMichel  ME Traumatic Head Injury in Children  New York, NY Oxford University Press1995;
Fay  GCJaffe  KMPolissar  NLLiao  SRivara  JBMartin  KM Outcome of pediatric traumatic brain injury at three years: a cohort study Arch Phys Med Rehabil 1994;75733- 741
PubMed
Rivara  JBJaffe  KMPolissar  NL  et al.  Family functioning and children's academic performance and behavior problems in the year following traumatic brain injury Arch Phys Med Rehabil 1994;75369- 379
PubMed Link to Article
Greenspan  AIMacKenzie  EJ Functional outcome after pediatric head injury Pediatrics 1994;94425- 432
PubMed
Jaffe  KMFay  GCPolissar  NL  et al.  Severity of pediatric traumatic brain injury and neurobehavioral recovery at one year: a cohort study Arch Phys Med Rehabil 1993;74587- 595
PubMed Link to Article
Kraus  JFFife  DConroy  C Pediatric brain injuries: the nature, clinical course, and early outcomes in a defined United States' population Pediatrics 1987;79501- 507
PubMed
Levin  HSEisenberg  HMWigg  NRKobayashi  K Memory and intellectual ability after head injury in children and adolescents Neurosurgery 1982;11668- 673
PubMed Link to Article
Brink  JDImbus  CWoo-Sam  J Physical recovery after severe closed head trauma in children and adolescents J Pediatr 1980;97721- 727
PubMed Link to Article
Rutter  MChadwick  OShaffer  DBrown  G A prospective study of children with head injuries, I: design and methods Psychol Med 1980;10633- 645
PubMed Link to Article
Levin  HSEisenberg  HM Neuropsychological outcome of closed head injury in children and adolescents Childs Brain 1979;5281- 292
PubMed
Fuld  PAFisher  P Recovery of intellectual ability after closed head-injury Dev Med Child Neurol 1977;19495- 502
PubMed Link to Article
Stancin  TDrotar  DTaylor  HGYeates  KOWade  SLMinich  NM Health-related quality of life of children and adolescents after traumatic brain injury Pediatrics 2002;109E34
PubMed Link to Article
Coster  WJHaley  SBaryza  MJ Functional performance of young children after traumatic brain injury: a 6-month follow-up study Am J Occup Ther 1994;48211- 218
PubMed Link to Article
Taylor  HGYeates  KOWade  SLDrotar  DStancin  TMinich  N A prospective study of short- and long-term outcomes after traumatic brain injury in children: behavior and achievement Neuropsychology 2002;1615- 27
PubMed Link to Article
Jaffe  KMPolissar  NLFay  GCLiao  S Recovery trends over three years following pediatric traumatic brain injury Arch Phys Med Rehabil 1995;7617- 26
PubMed Link to Article
McCarthy  MLMacKenzie  EJDurbin  DR  et al.  The Pediatric Quality of Life Inventory: an evaluation of its reliability and validity for children with traumatic brain injury Arch Phys Med Rehabil 2005;861901- 1909
Link to Article
Association for the Advancement of Automotive Medicine;; Committee on Injury Scaling, The Abbreviated Injury Scale: 1990 Revision.  Des Plaines, Ill Association for the Advancement of Automotive Medicine1990;
Varni  JWSeid  MRode  CA The PedsQL: measurement model for the pediatric quality of life inventory Med Care 1999;37126- 139
PubMed Link to Article
Varni  JWBurwinkle  TMKatz  ERMeeske  KDickinson  P The PedsQL in pediatric cancer: reliability and validity of the pediatric quality of life inventory generic core scales, multidimensional fatigue scale, and cancer module Cancer 2002;942090- 2106
PubMed Link to Article
Bastiaansen  DKoot  HMBongers  ILVarni  JWVerhulst  FC Measuring quality of life in children referred for psychiatric problems: psychometric properties of the PedsQL 4.0 generic core scales Qual Life Res 2004;13489- 495
PubMed Link to Article
Friefeld  SYeboah  OJones  JEdeVeber  G Health-related quality of life and its relationship to neurological outcome in child survivors of stroke CNS Spectr 2004;9465- 475
PubMed
Powers  SWPatton  SRHommel  KAHershey  AD Quality of life in paediatric migraine: characterization of age-related effects using PedsQL 4.0 Cephalalgia 2004;24120- 127
PubMed Link to Article
Varni  JWBurwinkle  TMRapoff  MAKamps  JLOlson  N The PedsQL in pediatric asthma: reliability and validity of the Pediatric Quality of Life Inventory generic core scales and asthma module J Behav Med 2004;27297- 318
PubMed Link to Article
Varni  JWBurwinkle  TMSeid  MSkarr  D The PedsQL 4.0 as a pediatric population health measure: feasibility, reliability, and validity Ambul Pediatr 2003;3329- 341
PubMed Link to Article
Schwimmer  JBBurwinkle  TMVarni  JW Health-related quality of life of severely obese children and adolescents JAMA 2003;2891813- 1819
PubMed Link to Article
Varni  JWBurwinkle  TMJacobs  JRGottschalk  MKaufman  FJones  KL The PedsQL in type 1 and type 2 diabetes: reliability and validity of the pediatric quality of life inventory generic core scales and type 1 diabetes module Diabetes Care 2003;26631- 637
PubMed Link to Article
Varni  JWSeid  MKnight  TSBurwinkle  TMBrown  JSzer  IS The PedsQL in pediatric rheumatology: reliability, validity and responsiveness of the pediatric quality of life inventory generic core scales and rheumatology module Arthritis Rheum 2002;46714- 725
Link to Article
Miller  IWEpstein  NBBishop  DSKeitner  GI The McMaster Family Assessment Device: reliability and validity J Marital Fam Ther 1985;11345- 356
Link to Article
Byles  JByrne  CBoyle  MOfford  D Ontario Child Health Study: reliability and validity of the general functioning subscale of the McMaster Family Assessment Device Fam Process 1988;2797- 104
PubMed Link to Article
Epstein  NBBaldwin  LMBishop  DS The McMaster Family Assessment Device J Marital Fam Ther 1983;9171- 180
Link to Article
MacKenzie  EJ Injury severity scales: overview and directions for future research J Emerg Med 1984;2537- 549
Osler  TBaker  SPLong  W A modification of the injury severity score that both improves accuracy and simplifies scoring J Trauma 1997;43922- 926
PubMed Link to Article
Diggle  PJLiang  KZeger  SL Analysis of Longitudinal Data. 1st ed. New York, NY Oxford University Press1994;
Laffel  LMConnell  AVangess  LGoebel-Fabri  AMansfield  AAnderson  BJ Relationship to patient management and diabetes-specific family conflict Diabetes Care 2003;263067- 3073
PubMed Link to Article
Eiser  CVance  YHHorne  BGlaser  AGalvin  H The value of the PedsQL in assessing quality of life in survivors of childhood cancer Child Care Health Dev 2003;2995- 102
PubMed Link to Article
Wesson  DEWilliams  JISpence  LJFiller  RMArmstrong  PFPearl  RH Functional outcome in pediatric trauma J Trauma 1989;29589- 592
PubMed Link to Article
Hu  XWesson  DELogsetty  SSpence  LJ Functional limitations and recovery in children with severe trauma: a one-year follow-up J Trauma 1994;37209- 213
PubMed Link to Article
Ding  RMcCarthy  MLHouseknecht  E  et al.  The health-related quality of life of children with an extremity fracture: a one year follow-up study J Pediatr Orthop In press
MacKenzie  EJSiegel  JHShapiro  SMoody  MSmith  RT Functional recovery and medical costs of trauma: an analysis by type and severity of injury J Trauma 1988;28281- 297
PubMed Link to Article
Max  JELansing  AEKoele  SLCastillo  CSBokura  HSchachar  R Attention deficit hyperactivity disorder in children and adolescents following traumatic brain injury Dev Neuropsychol 2004;25159- 177
PubMed Link to Article
Gerring  JPBrady  KDChen  A  et al.  Premorbid prevalence of ADHD and development of secondary ADHD after closed head injury J Am Acad Child Adolesc Psychiatry 1998;37647- 654
PubMed Link to Article
Kirkwood  MJanusz  JYeates  KO  et al.  Prevalence and correlates of depressive symptoms following traumatic brain injuries in children Neuropsychol Dev Cogn C Child Neuropsychol 2000;6195- 208
PubMed
Janusz  JAKirkwood  MWYeates  KOTaylor  HG Social problem-solving skills in children with traumatic brain injury: long-term outcomes and prediction of social competence Neuropsychol Dev Cogn C Child Neuropsychol 2002;8179- 194
PubMed
Roncadin  CGuger  SArchibald  JBarnes  MDennis  M Working memory after mild, moderate, or severe childhood closed head injury Dev Neuropsychol 2004;2521- 36
PubMed Link to Article
Jaffe  KMFay  GCPolissar  NL  et al.  Severity of pediatric traumatic brain injury and neurobehavioral outcome: a cohort study Arch Phys Med Rehabil 1993;74587- 595
Link to Article
Pollak  ANMcCarthy  MLBess  RSAgel  JSwiontkowski  MF Outcomes after treatment of high-energy tibial plafond fractures J Bone Joint Surg Am 2003;85-A1893- 1900
PubMed
McCarthy  MLMacKenzie  EJBosse  MJCopeland  CEHash  CSBurgess  AR Functional status following orthopedic trauma in young women J Trauma 1995;39828- 837
PubMed Link to Article
Yeates  KOTaylor  HGDrotar  D  et al.  Preinjury family environment as a determinant of recovery from traumatic brain injuries in school-age children J Int Neuropsychol Soc 1997;3617- 630
PubMed

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