Emotional and Behavioral Adjustment After Traumatic Brain Injury

Transcription

1 991 Emotional and Behavioral Adjustment After Traumatic Brain Injury Robin A. Hanks, PhD, Nancy Temkin, PhD, Joan Machamer, MA, Sureyya S. Dikmen, PhD ABSTRACT. Hanks RA, Temldn NR, Machamer J, Dikmen SS. Emotional and behavioral adjustment after traumatic brain injury. Arch Phys Med Rehabil 1999;80: Objectives: To examine emotional and behavioral adjustment and recovery over 1 year after traumatic brain injury (TBI), and to determine whether the difficulties, if present, are due to neurologic insult. Design: Longitudinal evaluation of adjustment from 1 month to 1 year after injury. Setting: Level I trauma center at a university hospital. Patients: One hundred fifty-seven consecutively hospitalized adults with TBI and 125 trauma controls with other system injuries evaluated at 1 and 12 months after injury. Main Outcome Measures: Katz Adjustment Scale (KAS). Results: The TBI group at 1 year follow-up demonstrated significant emotional and behavioral maladjustment, but such difficulties did not appear to be mediated by the brain injury, since the KAS scores for the TBI and trauma control groups were not significantly different. Those with moderate TBI reported greater difficulties than those with mild or severe injuries. Changes in adjustment over 1 year were common for both groups. Within the TBI group there was differential recovery: improvement in cognitive clarity, dysphoric mood, and emotional stability, but increased difficulties with anger management, antisocial behaviors, and self-monitoring. Conclusions: These results raise questions about commonly held beliefs that those with mild TBI report greater distress, and clarify some misconceptions regarding change in emotional and behavioral functioning over time by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation A VARIETY OF EMOTIONAL sequelae and adjustment difficulties have been reported after traumatic brain injury (TBI). The TBI literature documents a high incidence of both active emotional disturbance, including anxiety, agitation, irritability, anger, paranoia, impulsivity and emotional lability, as well as passive emotional disturbance such as depression, apathy, and anergia. 16 Such disturbances have been shown to From the Departments of Rehabilitation Medicine (Dr. Hanks, Ms. Machamer, Dr. Dikmen), Neurological Surgery (Drs. Temkin, Dikmen), Biostatistics (Dr. Ternkin), and Psychiatry and Behavioral Sciences (Dr. Dikmen), University of Washington, Seattle. WA. Submitted for publication September 28, Accepted in revised form March 24, Supported by grants from the Agency for Health Care Policy and Research (HS06497), National Institutes of Health (NS19643), and National Institutes of Health-National Center for Medical Rehabilitation Research (HD33677 and HD07424). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Robin Hanks, PhD, Department of Rehabilitation Psychology and Neuropsychology, Suite 555, Rehabilitation Institute of Michigan, 261 Mack Avenue, Detroit, M by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation /99/ /0 have persistent and pervasive effects on rehabilitation, return to work, and social/community integration. 7-1I Although much has been learned about the natural history of cognitive sequelae and recovery over time, the understanding of emotional and behavioral problems after TBI has lagged behind. The literature on emotional and behavioral problems is rich with reports on the difficulties experienced by some patients with TBI. Relatively little information exists, however, about the nature and magnitude of difficulties that occur in representative (ie, consecutively referred) samples, how these problems change over time, and to what factors they might be related. Such information is necessary to understand the reasons for complicated clinical recoveries and for treatment planning. The primary reasons for the lack of information about emotional disturbances include problems with study design (eg, clinical/convenience samples and lack of appropriate controls) and problems with measurement of emotional/behavioral constructs. Emotional and behavioral adjustment are complex and ambiguous constructs that are difficult to measure even in individuals without neurologic insult. In individuals with TBI, however, the challenge is even greater due to the nature and etiology of their emotional/behavioral disturbances. The problem is further exacerbated by the decreased awareness that can occur with more severe brain injuries.4 Given the problems of cognitive impairments, lack of awareness, and the nature of the difficulties, the measurement issues include who the reporter should be (self, significant other, clinical raters), what instrument to use (checklists, broad measures of emotional functions), what the difficulty level of the instrument should be for subjects with a broad range of severity and associated cognitive impairments, and what psychometric properties the measures should have. These measurement issues make it difficult to determine the optimal measure of emotional/behavioral function for individuals with TBI. Although some studies have used broad-based well-validated measures such as the MMPI, 12,13 these long and verbally demanding measures are not appropriate for individuals with more severe injuries. Although am absolute gold standard for measuring emotional functioning after TBI is not available, the Katz Adjustment Scale (KAS) has been the most frequently used, perhaps because of its inclusion in the Traumatic Coma Data Bank investigations. This measure is shorter and easier than the MMPI and has demonstrated clinical utility and sensitivity to emotional and behavioral changes following traumatic brain injury. 1,t41s As Jackson and associates a6 suggest, the KAS items are more behaviorally based, which allows for objectivity in reporting and may decrease some of the potential biases resulting from self-report, such as social desirability and lack of awareness. The items are designed so that nonprofessionals can adequately answer them, and they cover a wide range of emotional behaviors clinically relevant to the changes observed after TBI. Previous studies using the KAS have shown significant disturbances in social behavior and emotional control after injury. For example, the KAS has shown an association between TBI and anxiety, depression, confusion, and social

2 992 ADJUSTMENT AFTER TRAUMATIC BRAIN INJURY, Hanks withdrawal at 6 months after TBI. 14 In addition, Klonoff and Costa 19 reported that patients at 1 to 4 years after injury exhibited greater belligerence, verbal expansiveness, negativity, helplessness, suspiciousness, social withdrawal, confusion, and hyperactivity than exhibited by subjects in a normal community sample on this measure. Higher rates of poor adjustment, as measured by the KAS, have been associated with increased severity of injury. 1s,19 While these KAS studies have added useful evidence demonstrating emotional and behavioral dysfunction after TBI, they used clinically referred samples rather than representative, nonselect cases. Many studies did not use an appropriate control group. 14,18 In addition, these studies have used the relative rating version of the KAS (KAS-R), 2 which describes behavioral adjustment from the perspective of others, but ignores the subjective aspects of emotional function. Finally, these studies used cross-sectional rather than longitudinal designs. 14As Although cross-sectional designs may produce clinically useful descriptions of current emotional and social function, longitudinal designs are more appropriate for examining how these problems change over time. The present study used the KAS and attempted to improve upon some of the methodology described above. A large representative sample of persons with TBI and appropriate comparison groups were used. The individuals with TBI were recruited based on consecutive admissions to a Level I trauma center because of brain injury and not based on outcome. A normative sample from the KAS and a general trauma control group were included to determine if problems of psychological adjustment occur after TBI and, if so, whether these problems are related to the brain injury. Finally, a longitudinal, rather than cross-sectional study design was used to more accurately measure recovery. METHODS Participants TBI and trauma control groups. Participants were 157 adults with TBI enrolled in a longitudinal study of TBI outcome. They form a subgroup of a larger sample, the characteristics of which have been described elsewhere. 2 All individuals were English-speaking patients who were consecutively admitted to Harborview Medical Center in Seattle, Washington, a Level I trauma center. Participants were studied prospectively to 1 year postinjury. The brain injuries sustained by these individuals represented a broad range of severity. Inclusion in the study required: any period of loss of consciousness, posttraumatic amnesia for at least 1 hour or other medical evidence of brain trauma (eg, hematoma), an injury significant enough to require hospitalization, and ability to understand and participate in the assessment at 1 month postinjury. Seventyeight percent of the subjects were classified on the Glasgow Coma Scale (GCS) as having a mild brain injury (GCS score of 13 to 15), 10% had moderate brain injury (GCS score of 9 to 12), and 12% had severe brain injury (GCS score of <-8). Patient consent was required and participants were not excluded for preexisting conditions such as prior neurologic insult (including brain injury), substance abuse history, or psychiatric disorders. One hundred twenty-five general trauma patients also had physical injuries to bodily systems other than the head were enrolled in the study as controls. 2 These people were groupmatched to the TBI group for demographic characteristics such as age and education and for history of preexisting conditions such as neurologic insult, alcohol use, and premorbid psychiatric history. Community Sample from the KAS. The normative group for the KAS 21 consisted of 450 individuals from a community sample that was stratified for age, gender, marital status, and social class. These individuals were drawn from a 3% systematic sample of households in Carroll County, Maryland. This normative sample has been used as a comparison group to determine the relative level of adjustment after moderate and severe TBI. 18 Measures GCS. Severity of brain injury was determined by GCS score, 22 which was obtained in the emergency department immediately after injury. When a component of this measure could not be assessed, usually because of intubation in the field, the score was prorated. 23 Using this criterion, mild head injury was defined as a GCS score of 13 to 15, moderate severity was defined as a score of 9 to 12, and severe brain injury was defined as a GCS score of <-8. KAS. For this study, the KAS was modified from the original version by Katz and Lyerly zl on which a patient's relative rated the patient on 127 items describing behaviors. The modification for this study included rewording of the items to reflect a first-person, rather than third-person, perspective. This modified version was scored according to the original Katz and Lyerly method, 21 which used cluster analysis to derive 13 subtests: anxiety, belligerence, bizarre ideation, confusion, helplessness, hyperactivity, negativism, nervousness, general psychopathology, stability, suspiciousness, verbal expansiveness, and withdrawal and retardation. Data Analysis The data were analyzed to address the following questions. (1) Do patients with traumatic brain injury exhibit increased difficulties in emotional and behavioral adjustment? (2) Are these difficulties due to the brain injury? (3) What is the relationship between severity of brain injury and adjustment? (4) Is there recovery of adjustment from 1 month to 1 year postinjury? All analyses required a significance level of p To evaluate whether TBI is associated with increased difficulties in emotional and behavioral adjustment, z scores for each of the KAS subtests were calculated based on the normative data presented by Hogarty and colleagues. 24 Because the normative group for the KAS was derived to sample the population characteristics of the community, the group was balanced for gender (50% female), age (15 to 86 yrs), marital status (66% single), and social class (53% in the "lower" socioeconomic class). The TBI group was compared with the normative sample only on gender and age. Our TBI sample had more males and more young persons than the community sample. Since the original normative article on the KAS did not report mean scores for groups cross-classified by age and gender, the z scores presented in this study represent subscales scores corrected for age or for gender separately, but did not adjust for them simultaneously. Other variables (social class and marital status) are also likely different. For all but the stability subscale of the KAS, the higher the z score, the more postinjury maladjustment. The stability subscale is scored in an inverse direction, so a higher score reflects greater emotional and social stability and a negative z score indicates less stability. Because of the different methods of test administration on the KAS-- significant other versus self-report--formal statistical tests of difference between patients and the norm group were not done.

3 ADJUSTMENT AFTER TRAUMATIC BRAIN INJURY, Hanks 993 By chance alone, however, one would expect that even in the smallest group, average z scores would rarely exceed standard deviations. To determine whether the differences in emotional and behavioral adjustment from the KAS normative group resulted specifically from brain injury, we compared the raw scores on the KAS subtests at 1 year postinjury for the TBI and general trauma control groups using a multivariate analysis of variance (MANOVA). A MANOVA was also computed to determine what effect severity of brain injury had on the raw scores from the KAS. Severity groups were defined as mild (GCS score of 13 to 15), moderate (GCS score of 9 to 12), and severe (GCS score of -<8). For all MANOVAs, if an overall effect was significant, then the groups were compared on individual subscales using univariate ANOVAs and post-hoc Tukey Honestly Significant Difference Test (Tukey HSD). 25 Recovery of emotional and behavioral adjustment from 1 to 12 months was measured with three separate repeated-measures MANOVAs. The first MANOVA measured recovery within the TBI group alone, the second MANOVA examined recovery within the TBI group according to severity of injury, and the third MANOVA assessed the difference in recovery between the TBI and trauma control groups. If an overall effect for change over time was indicated, then univariate ANOVAs were computed for each of the individual KAS subtests. RESULTS Demographics The TBI and trauma control groups were similar in age, education, race, and gender. The mean age for the TBI group was 29 years (SD = 12.21), and the mean age for the trauma controls was 31 years (SD = 12.76) (F[1,261] =.86,p =.35). The TBI group included 115 men (73%) and the trauma control group included 73 men (69%), (X~ =.60, p =.44). Both groups had a mean of 12 years of education (SD = 2.4) (F[1, 261] =.017, p =.90). There were no differences in ethnicity between the groups (X 2 = 3.11, p =.54). Approximately 83 % of the total sample was Caucasian, 11% were African American, 3% were Native American, 2% were Asian, and 1% were of another ethnicity. TBI Group Compared With Normative Sample At 1 year postinjury, the TBI group reported considerable problems of adjustment as measured by the KAS when compared with the normative sample. Table 1 lists a sample of highly endorsed items from each of the KAS subscales, exemplifying item content. Note that the endorsements seem to represent the behavioral and perceptual difficulties reported in the TBI literature rather than frank psychopathology (including thought disorder). The labels in parentheses reflect our interpretation of what these subscale items might mean in a TBI sample. With z scores corrected for age (table 2), the majority of participants in the TBI group showed a high level maladjustment (at least one standard deviation above the mean) on the subscales sensitive to anxiety, anger/impulsivity, sensoryperceptual distortions, confusion, cognitive problems, antisocial tendencies, general adjustment problems, suspiciousness, and social/emotional withdrawal. The z scores indicate that the middle group, ages 30 to 49, has the most problems compared with the community sample. When z scores are corrected for gender, TBI participants report more severe problems than the normative sample, an effect that is most evident on the subscales of anxiety, anger management/impulsivity, sensoryperceptual disturbances, confusion, cognitive problems, antiso- Table 1: Highly Endorsed Sample Items From the 13 KAS Subtests 1. Anxiety Talked about people or things that you were really afraid of Felt suddenly frightened for no reason 2. Belligerence (Anger Management and Impulsivity) Gotten angry and broke things Threatened to tell people off 3. Bizarre Ideation (Sensory-Perceptual Difficulties) Thought that strange things were going on inside your body Done strange things without any reason 4. Confusion Lost track of day, month, or year Forgot your address or other places you know well 5. Helplessness (Cognitive Difficulties) Been unable to make decisions Been unable to concentrate on one thing 6. Hyperactivity (Agitation) Done the same thing over and over again without reason Felt restless 7. Negativism (Antisocial Behaviors) Did not care about other people's feelings Got into trouble with the law 8. Nervousness Got nervous easily Felt jittery 9. General Psychopathology (General Adjustment Difficulties) Acted as ifyou had no control over your emotions Preferred to be alone 10. Stability Been pleasant Gotten along well with other people 11. Suspiciousness (Mistrust and Misinterpretation of Social Cues) Acted as if you were suspicious of people Thought people were talking about you 12. Verbal Expansiveness (Poor Self-Monitoring) Shouted or yelled for no reason Talked too much 13, Withdrawal and Retardation Just sat Would stay in one position for a long period of time cial tendencies, general adjustment difficulties, and mistrust. The scores indicate a trend toward greater levels of emotional problems among men with brain injury than among women with brain injury on the majority of subscales when nonspecific gender effects are taken into account. In summary, results indicate that individuals with TBI appear to have difficulties 1 year after injury compared with a community sample. Impact of Severity of Brain Injury on Psychosocial Adjustment A severity effect (table 3) was evident at the 1-year point for raw scores on the KAS (F[26, 195] = 1.66, p =.03), although the effect size was modest (eta 2 =.11). Analysis of variance (ANOVA) and post-hoc Tukey HSD tests indicated that the moderate TBI group (GCS score of 9 to 12) reported more anger/impulsivity, more mistrust, poorer self-monitoring of behaviors, and more sensory-perceptual distortions than the individuals with mild or severe brain injury. TBI Group Compared With General Trauma Controls Based on the comparisons of their raw scores (rather than z scores), the TBI subjects and trauma controls did not differ in their performances on the KAS at 1 year postinjury (MANOVA

4 994 ADJUSTMENT AFTER TRAUMATIC BRAIN INJURY, Hanks Table 2: KAS Subscale ZScores Adjusted for Age and Gender for the TBI Group at I Year Postinjury Age (yrs) Gender Male Female Katz Subscales (n = 126) (n = 65) (n = 11) (n = 149) (n = 53) Anxiety 1.44 (2.28) 2.39 (3.50) Belligerence (Anger and Impulsivity) 1.21 (1.85) 1.41 (2.20) Bizarre Ideation (Sensory-Perceptual Distortions) 1.69 (2.61) 2.99 (4.81) Confusion 1.56 (2.81) 2.52 (4.13) Helplessness (Cognitive Difficulties) 1.38 (2.11) 1.87 (2.16) Hyperactivity (Agitation).27 (1.48).69 (1.74) Negativity (Antisocial Behaviors) 1.01 (1.02) 1.63 (1.40) Nervousness.56 (1.39).51 (1.28) General Psychopathology (General Adjustment Difficulties) 1.73 (1.89) 1.83 (1.91) Stability -.67 (.86) (1.10) Suspiciousness (Mistrust and Misinterpretation of Social Cues) 2.12 (2,31) 2.84 (3.16) Verbal Expansiveness (Poor Self-Monitoring).96 (1.55).63 (1.30) Withdrawal 1.20 (1.45) 1.31 (1.27) -.18 (.48) 3.16 (4.78) 1.36 (2,00),49 (1.27) 1.38 (1.92) 1.66 (2.45).24 (.79) 2.55 (3,67) 1.35 (2.53) 2.18 (3.55) 2.19 (3.64) 1.58 (2.90),71 (1.54) 2.22 (2.73) 1,70 (2.09) -,21 (.85).36 (1.40).52 (1.64),23 (,64) 1.18 (1.10) 1.33 (1.21) -.21 (.78).54 (1.28).64 (1.30).58 (.99) 1.86 (2.02) 1.64 (1,81) -.92 (.76) (.94) -.95 (.81) 1.37 (2.57) 2.59 (2.70) 1.99 (2.51) -.08 (.80) 1.02 (1.49).64 (1.70).47 (.96).72 (1.03) 1.03 (1,38) Results reported as mean (SD). F[13,304] = 1.10, p =.36). The individual subscale scores are presented in table 4. Recovery of Adjustment To assess the change in adjustment from 1 month to 1 year postinjury, three repeated-measures MANOVAs were computed. The first analysis attempted to assess recovery over time in the TBI group. Results indicated that significant change in adjustment occurred over one year in the TBI group (F[13, 157] = 3.65, p =.0005, eta 2 =.25). The direction of change over time was variable in the TBI group depending on the Table 3: KAS Raw Scores by Injury Severity Group at 1 Year Postinjury Katz Subscale Mild Brain Moderate Severe Injury Brain Injury Brain Injury Group Group Group (n = 138) (n = 23) (n = 34) Anxiety 8.28 (2.82) 8.96 (3.69) 8.33 (3.09) Belligerence (Anger and Impulsivity) 5.92 (1,81) 6.83*** (2.26) 5.22 (1.27) Bizarre Ideation (Sensory- Perceptual Distortions) 6.54 (1.93) 7.70* (3.15) 6.50 (2.04) Confusion 3.97 (1.47) 4.63 (2.22) 4.08 (1.36) Helplessness (Cognitive Difficulties) 6.48 (2.26) 7.17 (3,07) 6,76 (2.76) Hyperactivity (Agitation) 4.69 (1.81) 5.25 (2.11) 4.20 (1.47) Negativity (Antisocial Behavior) (2.72) (3.25) (2.93) Nervousness 7.47 (2.59) 7.42(2.19) 7.06(2.32) General Psychopathology (Overall Adjustment Difficulties) (9.00) 43.67* (10.89) (9.54) Stability (4.00) 25,38 (5.45) (3.62) Suspiciousness (Mistrust and Misinterpretation of Social Cues) 6.37 (2.27) 8,21"* (2.27) 6.40 (2.33) Verbal Expansiveness (Poor Self-Monitoring) 7.18 (2.05) 8,13"* (2.58) 6.57 (1.79) Withdrawal (2.39) 10,92 (3.30) (2.99) Results reported as mean (SD). MANOVA: Overall F [26, 195] = 1.66, Wilks Lambda =.798, p <.03, eta 2 =.11. * p <.05. ** p <.01. *** p <.005, subscale. Improvement occurred on KAS subscales that were sensitive to confusion (F[1,157] = 7.37, p =.007, eta 2 =.05), cognitive difficulties (F[1, 157] = 5.25, p =.02, eta 2 =.03), stability (F[I, 157] = 7.98, p =.005, eta 2 =.05), and withdrawal (F[1,157] = 12.29,p =.001, eta 2 =.07). However, the TBI group reported slightly worse scores at 1 year compared to 1 month postinjury in subscales reflecting anger and impulsivity (F[1, 157] = 3.96, p =.04, eta 2 =.03), antisocial tendencies (F[1, 157] = 4.94, p =.03, eta 2 =.03), and self-monitoring (F[1,157] = 5.71,p =.02, eta 2 =.04). To look at the effects of severity on recovery, we computed another repeated-measures MANOVA. Although moderate levels of severity appeared to be associated with greater maladjustment at 1 year postinjury, there was no main effect of overall severity on change of adjustment from 1 month to 1 year (F[13, 157] = 1.22, p =.21). There was, however, a significant interaction effect, demonstrated by the differences in KAS subscale scores among severity levels (F[26, 157] = 1.53, p =.05). Univariate tests indicated that this significant interaction was evident on the subscale tapping emotional stability. The moderately severe group showed the greatest gain in recovery (2.13 points), but the severely impaired group decreased an average of 1.72 points on this subscale. Finally, results of the repeated-measures MANOVA for the TBI and trauma control participants indicated that these two groups were not significantly different in their recovery from 1 month to 1 year (F[13, 262] = 1.13, p =.338). As with the brain-injured subjects alone, tests indicated change over time within subjects (F[13,262] = 4.81,p <.0005). The interaction of group membership and change over time approached significance (p =.06), and this trend most likely resulted from the TBI group's improvement on the subscale sensitive to confusion (p =.007). DISCUSSION The results of this study indicate that persons with TBI experience significant difficulties 1 year after injury compared with a community sample. The role of brain injury in emotional/ behavioral adjustment, however, is not clear; both the TBI and trauma control participants demonstrated equal levels of difficulties in emotional and behavioral adjustment. When looking more closely at the TBI group, the severity of brain injury seems to affect emotional and behavioral adjustment 1 year after injury. Within the TBI group, change is manifested as improvement in cognitive clarity, dysphoric mood, and emo-

5 ADJUSTMENT AFTER TRAUMATIC BRAIN INJURY, Hanks 995 Table 4: Raw Scores KAS Scores for TBI and Trauma Control Groups Showing Change from 1 Month to 1 Year TBI Trauma Control Katz Subscale 1Mo 12Mo 1Mo 12Mo Anxiety Belligerence (Anger and Impulsivity) Bizarre Ideation (Sensory-Perceptual Distortions) Confusion Helplessness (Cognitive Difficulties) Hyperactivity (Agitation) Negativity (Antisocial Behaviors) Nervousness (Agitation) General Psychopathology (Overall Adjustment Difficulties) Stability Suspiciousness (Mistrust and Misinterpretation of Social Cues) Verbal Expansiveness (Poor Self-Monitoring) Withdrawal 8.66 (3.46) 8.28 (2.93) 8.41 (3.02) 7.63 (2.47) 6.59 (2.14) 5.92 (1.93) 5.80 (1.91) 5,94 (1.95) 6.80 (2.32) 6.74 (2.25) 6.66 (2.17) 6.48 (1.89) 4.40 (1.80) 4.04 (1.55) 3.76 (1.15) 3.91 (1.37) 7.00 (2.39) 6.60 (2.39) 6.68 (2.14) 5.87 (1.72) 4.69 (1.84) 4.70 (1.89) 4.67 (1.61) 4.35 (1.55) (2.91) (2.73) (2.51) (2.53) 7.69 (2.83) 7.39 (2.50) 7.65 (2.44) 6.96 (2.19) (10.48) 39,63 (9.73) (8.39) (8.53) (4.33) (4.26) (4.06) (4.08) 6.22 (2.57) 6.84 (2.09) 6.02 (2.11) 5.97 (2.13) 6.84 (2.09) 7.26 (2.17) 6.97 (1.78) 6.85 (1.71) (2.76) (2.57) (2.63) (2.25) tional stability and as deterioration in anger management/ impulsivity, social behaviors, and self-monitoring. It is difficult to know whether this deterioration represents return to preinjury levels, head injury-related impairments, or exacerbation of preinjury tendencies. The generalizability of these results is favorable given the selection of consecutive trauma admissions, the prospective nature of this study, and the large sample size, The participants were recruited on the basis of their brain injury, rather than their outcome (eg, attendance at a clinic), reducing the risk of overestimating morbidity. The inclusion of a trauma control group also permitted us to compare adjustment after brain injury, while controlling for demographic and trauma factors, including non-central nervous system injuries sustained in the same accident. Another strength of this study is its longitudinal design, which facilitates for examination of recovery. The results indicate that when the TBI group's age- and gender-corrected z scores were compared to the normative group, emotional and behavioral difficulties were evident on the KAS in the TBI group at 1 year postinjury. The TBI participants displayed greater difficulties than the community sample with respect to anxiety, anger and impulsivity, sensory-perceptual distortions, confusion, cognitive difficulties, antisocial tendencies, and mistrust. Elevations on these scales, based on inspection of their item content (table 1), appear to reflect perceptual, behavioral, and cognitive difficulties often reported in patients with TBI rather than frank psychopathology, including thought disorders, as the labels of some of the scales imply. Thus, one is well advised to stay at the level of item content of the scales when interpreting the results of the KAS for people with TBI. This is why we have used more descriptive titles when referring to the KAS subscales. The results of both the TBI group and general trauma controls indicate that traumatically injured patients do present a host of emotional and behavioral difficulties. Some of those problems probably reflect the characteristics of the injured or an exacerbation of those tendencies (eg, impulsivity, antisocial behaviors), while others probably reflect the results of, or reaction to, the traumatic event and injury-related losses. Comparison of the TBI group with the community sample provides information about injury-related effects as well as the preinjury characteristics of the injured person. Comparisons with the trauma controls provides information about brain injury effects, controlling for both demographics and injury effects other than those related to the brain. The latter comparison does not indicate specific brain injury-related effects. In addition to true lack of effect, we need to consider lack of power of the study, which results from the poor sensitivity of the KAS and from a sample consisting primarily of people with mild TBI, particularly in light of the finding related to differences as a function of brain injury severity. In the present study, persons with mild or severe brain injuries reported less extensive problems than those with moderate injuries. While lack of awareness in those with severe injuries is a relatively well-accepted phenomenon, the low problem endorsement rates in the mild group are contrary to some reports in the literature. 26-2~ This might be due to differences in the samples studied. Studies reporting higher endorsement rates among mild injury patients than among those with severe injuries were based on clinical/convenience samples of persons who sought treatment for their difficulties. In contrast, the present study was based on a representative sample of consecutive, nonselect patients who were recruited and followed based on the occurrence of their injuries. Clinically, the reasons those with mild injuries seek treatment are likely to be different than the reasons of those with more severe injuries. Patients with severe injuries tend to be seen for medical and rehabilitation issues, while those with mild injuries tend to be seen for issues related to postconcussive syndrome, pain, depression, and litigation. What is seen clinically, then, might simply reflect the reasons the patient seeks treatment, rather than the natural history of emotional and behavioral problems following TBI. This potential misunderstanding is another example of differences in results created by using clinical convenience rather than representative samples, as well as differences in conclusions regarding presence and magnitude of morbidity in TBI. 29,3 Results of this study also indicate that there is change in adjustment over time after head injury regardless of severity level, a finding with the largest effect size (eta 2 =.25) of all of the analyses reported in this study. Over a period of i year, the TBI group changed in a variety of areas. They demonstrated decreases in confusion, helplessness, and social withdrawal while they improved in emotional stability over the 1-year period. Not all changes in adjustment from 1 month to 1 year were positive, however; the TBI group reported more anger/ impulsivity, more antisocial behaviors, and poorer selfmonitoring. Elevations on these subscales can be thought of as endorsement of "acting-out" behaviors reflective of disinhibition and poor self-monitoring. The mixture of both positive and negative changes in emotional adjustment over time may help clarify the mixed results in the TBI literature; some studies 14,31"33 have reported increases in emotional difficulties after TBI over time, whereas others 34 have reported decreases.

6 996 ADJUSTMENT AFTER TRAUMATIC BRAIN INJURY, Hanks Despite its weaknesses, the KAS may have captured the complex picture of recovery, such that there was a pairing of a resolution of cognitive/emotional confusion, along with an emergence of behaviors that are consistent with disinhibition and poor self-monitoring. What is difficult to determine from the results of the present study is whether negative behaviors (belligerence, negativity, verbal expansiveness) reported in the TBI group were returning to baseline levels that may have initially put these persons at risk for traumatic injuries, or if these were new behaviors, or if they were exacerbations of preexisting behavioral tendencies due to the injury. It is important to add that similar changes were observed in those with general trauma. It should be noted, however, that the KAS may not be the best clinical measure of difficulties in emotional and psychosocial adjustment after brain injury. The only available KAS norms are those based on significant others' reports, and the meaning of the results beyond item content (eg, scale or profile) with respect to adjustment are not known. The question, then, is whether the KAS is worth the effort to develop normative data for use in persons with TBI. Therefore, although the items on the KAS may be sensitive to difficulties in emotional and social functioning after injury, its clinical utility on a case-by-case basis is yet to be determined. A major limitation of this study is its use of z score corrections based on the normative sample, which was based on the original (relative rating) KAS, to score the self-report version of the KAS used in this study. The big question in interpreting the TBI group's results compared with the community sample is the degree to which self-report of our responders is similar to KAS reports made by a relative or significant other. The literature on the consistency between patient versus proxy reports is not entirely helpful in resolving this question. Although the literature suggests that TBI patients underreport problems, this finding is based on those with more severe injury. 35 The consistency in reports in less severe injuries is not known. Our conclusions of increased emotional and behavioral problems would be valid if we assumed that our TBI patients were similar to their significant others or underreported compared to their significant others. Such a conclusion would be erroneous if our brain-injured and trauma controls, which are a nonselect and representative series, grossly overreport problems compared to their significant others. Although such a possibility exists, its likelihood is reduced by behaviorally based, objective descriptions of the items. Furthermore, our findings indicate that the KAS may be an effective instrument to measure adjustment in persons with TBI because the items leading to elevations of the scales reflect what is known about the sequelae of TBI, severity of injury is taken into account, and the KAS reveals the pattern of change over time. Additionally, our cases were younger and included more males than the community sample. To the extent females and older people report more problems, our findings would tend to underestimate true difficulties. CONCLUSION Emotional and behavioral difficulties are evident at 1 year postinjury. Clinically, it is important to recognize the presence and pervasiveness of these difficulties in both brain injured and general medical trauma patients, because these difficulties may have substantial impact on rehabilitation, vocational reentry, and community reintegration. 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