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9 SOCIAL FUNCTIONING Traumatic brain injury (TBI) can lead to disruptions in higher-level functions of everyday life, including social relationships, independent living, employment, and leisure activities. Social functioning is evaluated by using global outcome scales, such as the Glasgow Outcome Scale (GOS) (Jennett and Bond, 1975) and the GOS-Extended (Wilson et al., 1998); rates of return to work and independent living; or questionnaires that typically include self-reported measures of health-related changes in functioning in everyday life, such as the Sickness Impact Profile (SIP) (Bergner et al., 1976). This chapter first discusses primary studies of military and civilian populations and then secondary studies grouped by outcome, including both military and civilian populations because their findings are generally similar. PRIMARY STUDIES OF MILITARY POPULATIONS Penetrating Head Injury Schwab et al. (1993) evaluated work status in a group of 520 Vietnam War veterans who sustained penetrating head injury in 1967–1970 and were seen for a 15-year followup. Subjects were drawn from the W.F. Caveness Vietnam Head Injury Study registry (see Chapter 5) and compared with 85 controls recruited from the Veterans Administration files of uninjured soldiers who had served in Vietnam during the same years and were in the same age range as the TBI subjects. Of the injured veterans, 56% were working at the 15-year followup, compared with 82% of the uninjured controls (p < 0.0001). Work status was strongly and linearly associated with the number of residual disabilities, including posttraumatic epilepsy, paresis, visual-field loss, verbal-memory and reasoning loss, visual-memory loss, psychologic problems, and self- reported violent behavior. Brain-volume loss and postinjury evaluation of intelligence based on the Armed Forces Qualification Test explained similar amounts of variance in work status, as did the number of residual disabilities (Schwab et al., 1993). Closed Head Injury Ommaya et al. (1996) determined that discharged military personnel who had sustained TBI were more likely to be discharged because of behavior than the total discharge population. They identified 2,226 military personnel who sustained a TBI in 1992 through hospital-discharge records of all military hospitals. Information about discharge from military service was obtained for 2.7 years after injury and compared with the total discharge population of 1,879,724. 301

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302 GULF WAR AND HEALTH Discharge from military service because of behavior (for example, problems with motivation, misconduct, discreditable occurrences, or a series of minor discipline problems), criminal conviction, alcohol or drug abuse, or medical disability were examined by TBI severity as classified with the Abbreviated Injury Scale (AIS) head score. Compared with the total discharge population, discharge due to alcohol or drug abuse was more frequent in those with moderate TBI (odds ratio [OR], 5.4; 95% confidence interval [CI], 1.7–16.9) and those with mild TBI (OR, 2.6; 95% CI, 1.6–4.3) but not in those with severe TBI. Discharge due to behavior was no different in those with moderate or severe TBI and 1.8 times greater in those with mild TBI (95% CI, 1.4–2.2). Discharge due to criminal conviction was 2.7 times higher in those with mild TBI (95% CI, 1.9–3.9) and no different in those with moderate or severe TBI. Discharge due to medical disability was 7.5 times higher in those with mild TBI (95% CI, 6.0–9.3), 25.2 times higher in those with moderate TBI (95% CI, 16.2–39.2), and 40.4 times higher in those with severe TBI (95% CI, 30.0–54.4). The authors note, however, that because the risk of medical discharge is directly related to the severity of the injury, these individuals may be receiving medical discharges rather than other types of discharges (such as behavioral). A limitation of the study is that it did not take into account pre-existing factors, such as aggressive tendencies or preinjury alcohol abuse, which may have played a role in discharge outcome. In a related study, Ommaya (1996) examined 1,617 patients admitted to hospitals for TBI in 1992 and 1993, 4,626 patients admitted for orthopedic or internal injuries, and a random sample of 9,997 active-duty Army subjects to compare rates of discharge from military service based on behavioral criteria. After adjustment for confounders (age, sex, marital status, educational level, pay grade, months in current grade, years of active-duty service, injury severity, and preinjury “adverse action,” disciplinary action recorded in a soldier’s personnel file), head injury was related to an increased risk of behavioral separation (relative rate [RR], 4.01; 95% CI, 3.54–4.94) and criminal conviction (RR, 4.99; 95% CI, 3.62–6.87) compared with the random sample of active-duty Army personnel. Head injury also was related to an increased risk of postinjury adverse action (RR, 1.31; 95% CI, 1.14–1.51). In addition, the risk of medical discharge was lower in the head-injured group than in the orthopedic- or internal-injury group (RR, 0.64; 95% CI, 0.51–0.80). McLeod et al. (2004) examined employment retention in the British Army in a group of 564 British Army personnel who had sustained a TBI in 1994, a group of 368 British Army personnel who had a lower-limb fracture in 1994 (and did not sustain any other injuries), and a group of 25,575 healthy army personnel. All those with TBI were admitted to the hospital or medical center and were selected if they had International Classification of Diseases (ICD) codes indicating TBI and did not have other ICD injury codes. Employment retention in the Army was examined with Kaplan-Meier survival analysis, stratifying for age (16–24, 25–28, 29–33, and >34 years), which roughly paralleled career steps in the Army. The results indicated that in the youngest group (16–24 years old), healthy subjects left the Army earlier than subjects in either injury group: in a median of 1.74 years, compared with 3.91 years for those with TBI and 4.39 years for those with lower-limb fractures. An opposite pattern was observed in the oldest group (34 years old and older): healthy subjects served the longest: a median of 5.55 years, compared with 3.33 years for those with TBI and 3.75 years for those with lower-limb fractures. Subjects 34 years old or older had the lowest employment retention: 69% of them in the TBI group continued in the Army beyond year 1, and 19% were still employed at year 6, compared with 85% of the fracture group employed at year 1 and 26% at year 6 and 80% of the healthy group at year 1 and 48% at year 6 (p < 0.001). The authors discuss the possibility that the greater drop in

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SOCIAL FUNCTIONING 303 employment in the TBI group 34 years old or older reflects the likelihood that older people are typically in positions of greater responsibility in the Army, including leadership and managerial positions. They theorize that the TBI group may have had a disproportionate amount of difficulty in maintaining employment after injury, which led to an increase in medical discharges. PRIMARY STUDIES OF CIVILIAN POPULATIONS Dikmen et al. (1995) examined 466 people with TBI and compared them with 124 trauma controls (people who had sustained bodily injury but not to the head) and with 88 healthy friend controls (people who had not sustained any injury). Subjects were drawn from three prospective longitudinal studies of outcome and were followed from the time of injury until a year after the injury (see Chapter 5). Social functioning was evaluated with the GOS, a rating based on dependence on others for self-care and the ability to participate in normal social life. A structured interview provided information about independent living, school, employment, and income. The SIP, a self-report measure of functioning in 12 activities of living, was also administered. The subjects with TBI were stratified by severity of injury. More severe TBI was related to worse outcome compared to trauma controls on all measures of social functioning except return to school. The absence of a detectable difference in rates of return to school between TBI and trauma controls might reflect the requirement that schools accommodate students with a variety of disabilities. A higher proportion of patients in each of the TBI severity groups, except the most mildly injured, was rated as significantly disabled, according to the GOS, than the trauma controls—for example, percentage with good outcome: trauma controls, 93%; with respect to the TBI group, those with time to follow commands (TFC) 1–6 days, 69%; TFC 7–13 days, 59%; TFC 14–28 days, 31%; TFC over 28 days, 10%; Glasgow Coma Scale (GCS) 9–12, 64%; GCS 6–8, 38%; GCS 3–5, 26% (p < 0.05 by Tukey’s post hoc comparison for each TBI severity group indicated vs trauma controls). Statistically significantly fewer TBI subjects (76%) than trauma controls (93%) returned to living independently at 1 year after injury (p < 0.001). Increasing length of coma was significantly related to decreasing likelihood of returning to independent living at 1 year: those with less than 1 hour of coma, 89%; 1–24 hours, 89%; 1–6 days, 74%; 7– 13 days, 49%; 14–28 days, 55%; and 29 days or longer, 23% (r = 0.49; p < 0.001). Fewer TBI subjects (49%) than trauma controls (63%) were working 1 year after injury (p < 0.05). The more severe the TBI, the less likely the person returned to work: of those with less than 1 hour of coma, 64% had returned to work; 1–24 hours, 50%; 1–6 days, 51%; 7–13 days, 36%; 14–28 days, 18%; and 29 days or longer, 6%. In a subgroup of the same sample, McLean et al. (1993) also found a lower rate of return to work in participants with TBI than in friend controls (p < 0.01). The TBI subjects earned less than trauma controls in the year after injury, and within the TBI group increasing length of coma was associated with decreasing income (Dikmen et al., 1995). TBI subjects reported more dysfunction than trauma controls on the SIP, especially on scales assessing psychosocial, rather than physical, limitations. For example, the TBI subjects (mean, 23) reported significantly more dysfunction than the trauma controls (mean, 14) on the Work Scale (p < 0.001) and on the Psychosocial Summary Scale (mean dysfunction, 11 vs 8, respectively; p < 0.01), indicating difficulties in communication, alertness behavior, emotional behavior, and social interaction. There were no significant differences between TBI patients and trauma controls on the Physical Summary Scale, which evaluates ambulation, mobility, body

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304 GULF WAR AND HEALTH care, and movement. The SIP total mean score for trauma controls showed significantly less difficulty than in TBI subjects with coma length of 1 week or more: trauma controls, total mean score, 6; TBI patients with coma length of 7–13 days, SIP mean, 12 (p < 0.05); 14–28 days, 14 (p < 0.01); 29 days or more, 17 (p < 0.001). There was a significant relationship between TBI severity and reported dysfunction on the SIP on all scales except emotional behavior (p < 0.01) (Dikmen et al., 1995). In a separate analysis of a subgroup of the same population, Dikmen et al. (1994) examined time to return to work in 366 TBI patients and 95 trauma controls who worked before their injury (see Chapter 5). Preinjury workers were followed for 1–2 years after injury to measure the time from injury until the first return to work regardless of the length of that employment. Time to return to work was significantly and systematically related to TBI severity. For the measure of TFC, a measure of coma length, patients with TBI who had milder injuries went back to work more often and earlier than those with more severe injuries: 87% of trauma controls had returned to work by 1 year after injury, 82% returned with TFC of up to 5 hours, 67% with TFC of 6–24 hours, 67% with TFC of 1–6 days, 46% with TFC of 7–13 days, 21% with TFC of 14–28 days, and 6% with TFC of 29 days or longer (p < 0.0001). Similar relationships were found with other TBI-severity indexes, such as the GCS, and with neuropsychologic functioning at 1 month after injury, the latter representing the combined effects of injury severity and premorbid functioning. Doctor et al. (2005) conducted a prospective cohort study to examine the same population as Dikmen et al. (1994) and additional TBI subjects from another prospective investigation. Work rates were examined at 1 year after injury in 418 TBI subjects who were working before their injury and compared with expected unemployment rates from the current population survey (United States Department of Labor, 2002). There was a substantial increase in the risk of unemployment of patients with TBI that increased with severity: 31% of TBI patients with a GCS of 13–15 were unemployed compared with the expected unemployment rate of 8.8% (RR, 3.46; 95% CI, 2.87–4.28), 46.4% of TBI patients with a GCS of 9–12 were unemployed compared with the expected unemployment rate of 9.6% (RR, 4.85; 95% CI, 3.71–6.02), and 62.1% of TBI patients with a GCS of 3–8 were unemployed compared with the expected unemployment rate of 10.4% (RR, 5.98; 95% CI, 4.92–6.96). Edna and Cappelen (1987) followed for 3–5 years after injury a prospective Norwegian cohort of 485 people who sustained closed head injuries in 1979 and 1980 and 89 controls who were admitted to the hospital over the same period with acute appendicitis. Subjects were followed to examine work status and social condition as evaluated with a questionnaire. The majority of the head-injured subjects had mild injuries; 89% had a GCS of 13–15. Unemployment in the head-injured increased from 12% before injury to 27% after injury; unemployment in the controls increased from 5% to 16% (p < 0.01). However, unemployment increased substantially more in head-injured subjects who were 45 years old or older (from 16% to 53%) compared with head-injured subjects who were less than 45 years old (from 11% to 20%). Social outcome was slightly less favorable in the subjects with closed head injuries than in the controls with respect to contact with friends, family life, and income. Oddy et al. (1978) examined 54 people who had closed head injuries and 35 controls with traumatic limb fractures and no head injury, matched on age and socioeconomic status. The head-injured were a consecutive series of patients who had had posttraumatic amnesia (PTA) of more than 24 hours and were followed until 6 months after injury. Work outcome and social

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SOCIAL FUNCTIONING 305 outcome were evaluated with a semistructured interview, the Katz Adjustment Scale (Katz and Lyerly, 1963), a task-distribution checklist, the Wakefield Depression Inventory (Snaith et al., 1971), and a scale for activities of daily living. Close relatives of the head-injured were also interviewed as a secondary source of information. Return to work by 6 months after head injury was significantly associated with injury severity. A higher percentage of TBI participants who had less severe injuries than of those with longer periods of PTA were back at work by 6 months after injury. The percentage of participants who had returned to work by 6 months decreased with increasing length of PTA: 97% of the control group, 81% of the head-injured participants with PTA of 1–7 days, and 50% of those with PTA of over 7 days (r = 0.41; p < 0.003). Leisure activities were impaired in 33% of the head-injured subjects with PTA of 1–7 days (not significant) and 42% of those with PTA of over 7 days (p < 0.01). However, the control group also reported a significant reduction in leisure activities (p < 0.01), so disruption might not have been specific to brain injury. Social interaction was assessed by number of close friends and acquaintances, frequency of visits, social outings, social discomfort, and loneliness. There was no evidence of disruption in social interaction in the head-injured group as a whole, but the most severely injured group (PTA of over 7 days) experienced a significant decrease in number of friends (p < 0.04) and were more dependent on parents than before injury (p < 0.02). Gerberich et al. (1997) examined academic performance before and after TBI in university undergraduate students. Cases were 99 undergraduate students who sustained a brain injury requiring hospitalization during 1980–1984, and there were two comparison groups: 198 uninjured controls with no documented injury that necessitated hospitalization and 121 injured controls who were hospitalized for an injury other than brain injury during the same period. Most (90%) of the brain-injured subjects sustained mild injuries according to the GCS. All participants were followed from the time of university admission through the end of the winter quarter of 1985; this allowed a minimum of 3 quarters of school after entry into the study. No significant differences in academic performance were found between groups. However, female participants with a brain injury had a significant pre- to postinjury decrease in grade-point average compared with both uninjured and injured controls (each p < 0.02). This finding was not observed in male participants. Bond and Godfrey (1997) compared videotaped social interaction sessions in 62 patients with TBI who had PTA exceeding 24 hours and were between 6 months and 3 years postinjury to 25 orthopedic controls from the same hospital. Patients with a history of neurologic, psychiatric, or alcohol-related discords, as well as those with prior moderate to severe TBI were excluded. Both groups were studied via their participation in videotaped social interactions sessions, which were observed and rated by four undergraduate psychology students for impressions and micro-behaviors, including appropriateness, and for deferral, interest, prompt frequency, and turn duration. TBI and control subjects were videotaped in an unstructured 15- minute conversation with female assistant blinded to group status. Impression ratings were made by four raters, blinded to group status, with 12 hours training (rating test subjects and comparing against established ratings until 95% agreement within 2 points between the 4 raters). They rated conversations as “appropriate,” “effortful,” “interesting,” and “rewarding” on a 9-point Likert scales. Micro-behaviors were examined by one rater, blinded to group status, with training until 90% agreement with another rater, rated turn duration and prompt frequency for both subject and assistant (4 measures). A second rater rated 25% random sample, with interclass correlation 0.92–0.99. The TBI subjects’ conversations were rated as significantly less interesting, less appropriate, less rewarding, and more effortful than those of control subjects. They were also

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306 GULF WAR AND HEALTH characterized by differences in the frequency of prompt usage and turn duration. The authors concluded that TBI subjects are beset by problems in their social communication and behavior. Friedland and Dawson (2001) followed 99 people who were in a motor-vehicle accident (MVA); 64 sustained a mild TBI, and 35 did not. The participants were recruited from consecutive admissions over a 20-month period ending in April 1994. Mild TBI was defined as an initial GCS score of at least 13 (after 30 minutes), loss of consciousness (LOC) of no more than 30 minutes, or PTA of no more than 24 hours. Subjects who did not have a mild TBI all had a GCS of 15, no documented LOC or PTA, normal computed tomography (CT) findings (if CT was done), and no documentation regarding brain injury in the medical chart. Both groups had high mean injury-severity scores (ISS) (mild TBI, 21.09; no mild TBI, 18.17). At 6–9 months after injury, participants were assessed with the Reintegration to Normal Living (RNL) Scale, with the SIP, and according to return to work. Posttraumatic stress disorder (PTSD) was also evaluated with the Impact of Event Scale and the General Health Questionnaire. The mild-TBI group reported significantly more dysfunction on the psychosocial summary score of the SIP than those without mild TBI (p = 0.01). There were no other significant differences between the groups on the SIP, nor were there any significant differences between the groups on the RNL Scale or in return to work (44% of the mild-TBI and 41% of the group without mild TBI had returned to work at the time of outcome assessment). The group with mild TBI had a higher risk of PTSD (OR, 1.043; 95% CI, 1.001–1.067). Stulemeijer et al., (2006) assessed 299 mild-TBI subjects admitted to an emergency department (ED) level 1 trauma center in the Netherlands 6 months after injury. They divided the group into the 89 who sustained additional injuries to the body and the 210 who sustained only mild TBI and compared them with 261 control subjects who attended the ED after suffering wrist or ankle distortions 6 months earlier. Mild TBI was defined as an impact to the head with or without LOC of up to 30 minutes, with or without PTA, and a hospital admission GCS of 13– 15. Although all had GCS scores in the range of 13 to 15, subjects with mild TBI and additional injuries suffered significantly more severe TBI using other indices, than those with only TBI, for example, mean Abbreviated Injury Scale (AIS) head score in mild TBI with additional injuries was 2.3 compared with a mean score in isolated mild TBI of 1.9 (p = 0.0001). At 6 months after injury, social functioning was assessed with the SF-36 Physical Functioning and Social Functioning scales, the SF-36 Perceived Health change, and change in work, defined as a loss of work or change in work status—working fewer hours or working in a lower-level occupation because of the injury. Analyses were adjusted for age, sex, and AIS head score. Each SF-36 measure differed significantly between the groups (each p = 0.0001). The subjects with mild TBI and additional injuries showed more dysfunction than the mild-TBI-only subjects, and both showed more than the minor-injury controls (each p < 0.001). Change in work status also differed significantly between the groups (p = 0.0001): 35% of the subjects with mild TBI and additional injuries, 14% of the mild-TBI-only subjects, and 2% of the controls reported change in work status at 6 months after injury. The location and severity (defined as ISS over 15) of the additional injuries were each significantly related to the SF-36 Physical Functioning scale (each p < 0.01), and subjects with multiple injuries or injuries to the extremities or the chest or abdomen reported more problems. There were no differences by severity and location on the other scales.

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SOCIAL FUNCTIONING 307 Heitger et al. (2007) examined 37 persons with mild closed head injury and 37 normal controls matched to the head-injured on age, sex, and years of education. The mild closed head injured subjects all had their first assessed GCS equal to 13–15, none decreased to below 13 while they were in the hospital, and all had PTA of less than 24 hours. Social functioning was assessed with the Rivermead Head-Injury Follow-up Questionnaire (RHIFQ) and the SF-36 at 6 and 12 months after injury. The results showed no significant differences between the mild closed head injured subjects and controls on the SF-36 at 6 and 12 months after TBI. The RHIFQ was not used in controls, because it measures perceived change in ability as the result of injury. At 6 months after injury, 27% of the mild close head injured subjects reported mild change or worse in perceived ability in one or more activities; this decreased to 23% at 12 months after injury. Finding that work was more tiring was the most common complaint at both times, reported as at least a mild problem by 14% at 6 months and 23% at 12 months. Other activities reported as presenting at least a mild problem by 10% or more of the subjects were maintaining previous workload at both 6 and 12 months and coping with family demands and having a conversation with two or more people at 12 months. In contrast, 49% and 61% at 6 and 12 months, respectively, reported no changes in any activity after injury. It is not possible to determine whether the results of the study are related to the TBI or to other injuries. SECONDARY STUDIES Results of many secondary studies support what has been found in primary studies. Their most common limitation is lack of a control group or small samples. Secondary studies have examined effects of TBI on major activities (work or school), independent living, social relationships, leisure activities, functional status, and quality of life and effects on the primary caregivers of people who have TBI. Major Activities (Work or School) Many secondary studies have reported an association between TBI and low rate of return to work, especially in those with moderate or severe TBI (Dikmen et al., 1993; Kersel et al., 2001; Mazaux et al., 1997; van Zomeren and van Den Burg, 1985; Walker and Erculei, 1969). For example, Dikmen et al. (1993) studied a group of 31 moderately to severely injured adults and compared them with 102 friend controls. They reported that 33% of the preinjury workers were able to return to work at 1 year and 46% at 2 years after injury, whereas 85% of the friend controls were working at 1 year. Kersel et al. (2001) examined a New Zealand sample of 65 people 6 months and 1 year after they sustained a severe TBI. In their sample, 13% of the preinjury workers were back to work at 6 months and a further 20% at 1 year, 38% of the preinjury students had returned to school at 6 months and 54% at 1 year. Van Zomeren and van Den Burg (1985) assessed 57 people with severe TBI 2 years after injury; 58% reported that they had resumed their former work or study without any changes, 13% had resumed their former work but with lower demands (for example, working part-time), 5% had not resumed their former work but were working at a lower level, 7% were working in a socially sheltered environment, and 16% were not working at all. Mazaux et al. (1997) reported that 58% of preinjury workers had returned to work and 74% of preinjury students had returned to school at 5 years after injury in their sample of subjects who had mild to severe TBI. Walker and Erculei

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308 GULF WAR AND HEALTH (1969) followed a group of 343 World War II veterans 14–17 years after they sustained a TBI; 39% were not working or were working only irregularly. There appears to be a strong relationship between rate of return to work and the severity of TBI. Whiteneck et al. (2004) conducted a population-based study of persons hospitalized for TBI in Colorado. They followed 1,591 adult TBI patients to 1 year after injury and found that the severity of the injury made a significant difference (p < 0.01) in rate of return of preinjury workers: 47% of those with severe injuries (defined as a GCS of up to 8) had returned to work, 78% with moderate injuries (GCS, 9–12), and 80% of those with mild injuries (GCS, 13–15). Dikmen et al. (2003) followed 210 people with complicated mild to severe TBI up to 3–5 years after injury. Rate of return to work varied significantly with TBI severity (p < 0.05) as measured with a modified AIS head score: 73% of preinjury workers with a score of 3 were back to work, 66% with a score of 4, and 49% with a score of 5. The lowest rate of return to work occurred in the group with an AIS head score of 5 and both an anatomic lesion and a TFC greater than 24 hours: only 29% of this group had returned to work 3–5 years after injury. Engberg and Teasdale (2004) used a national hospital register to select subjects who had sustained a TBI in 1982, 1987, or 1992 with ICD codes that indicated either a cranial fracture or a cerebral lesion. The followup period was 5, 10, or 15 years after injury. They reported differences in the rate of inability to work between the cranial-fracture group and the more severely injured cerebral-lesion group at each followup period. No one in the cranial-fracture group reported being unable to work at the 10- and 15-year followups, and only 14% said that they were unable to work at the 5-year followup. In the cerebral-lesion group, 23% at the 15-year followup, 29% at the 10-year followup, and 31% at the 5-year followup said that they were unable to work. The authors cautioned that although it is not clear that these findings are due entirely to the TBI, the differences between the two groups suggest that severity of brain injury is a factor. Return to work has also been associated with computed-tomography (CT) findings. Groswasser et al. (2002) examined CT findings on TBI subjects and compared them with vocational outcome in a group of Vietnam War veterans participating in the Vietnam Head Injury Study. A group of 74 subjects with penetrating head injury and 37 with closed head injury were evaluated 12–14 years after injury. The results indicated that total brain-volume loss, third ventricle width, ventricular score, and septum–caudate distance were significantly related (each p < 0.01) to return to work in the cases with penetrating head injury. There is some evidence that work stability after TBI is related to the severity of the injury. Machamer et al. (2005) examined stability of work up to 3–5 years after injury in a group of 165 preinjury workers who had sustained complicated mild to severe TBIs. Severity of injury and associated impairments were related to amount of time worked after injury. Once a worker returned to work, the ability to maintain uninterrupted employment was related to premorbid characteristics, such as being older or having a higher income. Some studies using different groups of subjects compared characteristics of persons with TBI who are employed at followup with those who are not employed (Drake et al., 2000; Cifu et al., 1997; Fraser et al., 1988; Walker and Erculei, 1969). In general, the results of those studies have indicated that subjects who are employed at followup had less severe injuries and do significantly better on neuropsychologic and functional-status measures administered acutely or concurrently than persons with TBI who are not employed at followup. For example, Cifu et al. (1997) compared the employed and unemployed at 1 year after injury in a group of 132 TBI subjects who were participants in the Traumatic Brain Injury Model Systems project. The

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SOCIAL FUNCTIONING 309 severity of the injury was significantly different between the groups: the employed group had significantly milder initial GCS scores, shorter comas, and shorter periods of PTA (each p < 0.05) than the unemployed group. Functional status was assessed with the Functional Independence Measure (FIM) (Forer and Granger, 1987) and the Disability Rating Scale (DRS) (Rappaport et al., 1982) at rehabilitation admission and discharge. Unemployed persons were functioning at a significantly lower level than the employed at rehabilitation admission on the FIM (p < 0.01) and the DRS (p < 0 .001) and at rehabilitation discharge on the DRS (p < 0.01). The unemployed group also scored significantly lower than the employed on a memory-delay test (p < 0.05). Fraser et al. (1988) found poorer neuropsychologic test scores at 1 month and 1 year after injury and more dysfunction on the SIP physical scales at 1 month after injury in those who failed to return to work by 1 year after injury than in those who had returned. Studies of vocational outcome after mild TBI have had mixed results: some have found good rates of return to work or at least rates no different from those in a control group (Dikmen et al., 1986; Boake et al., 2005), and others have suggested that mild TBI has a lingering effect (Vanderploeg et al., 2003, 2007). Dikmen et al. (1986) studied a group of 19 persons with mild TBI. At 1 year after injury, 15 (79%) had returned to their major role activities (such as work, school, or homemaking) without limitations. Boake et al. (2005) examined time to return to work in 210 people with mild or moderate TBI and 122 trauma controls. All the TBI subjects had closed head injuries, and 90% had mild injuries. The rate of return to work was similar in TBI subjects (61%) and trauma controls (62%) 6 months after injury. Most of the mild-TBI subjects and nonhospitalized trauma controls were back to work by 3 months after injury, but most of the moderate-TBI subjects had not returned to work at 6 months after injury. In contrast, Vanderploeg et al. (2003, 2007) conducted a series of studies of the role of self-reported mild TBI not requiring hospitalization in long-term outcome and factors that could predict outcome. They used the Vietnam Experience Study cohort of Army veterans about 16 years after military discharge and collected information on health-related events that may have occurred from military discharge to the time of the study. A sample of veterans was categorized into three groups according to their responses on a questionnaire: 3,214 veterans with no MVA and no TBI (normal controls), 539 veterans who were injured in an MVA but had no TBI (MVA controls), and 254 veterans who had self-reported TBI with altered consciousness but no hospitalization (mild TBI). ORs were adjusted to control for differences between the groups on demographics, prior or current medical conditions, and preinjury psychiatric conditions. The mild TBI group had increased odds of being employed less than full-time (adjusted OR, 1.89; 95% CI, 1.36–2.64), an annual income less than $10,000 (adjusted OR, 1.88; 95% CI, 1.29– 2.74), and self-reported disability (adjusted OR, 2.90; 95% CI, 1.63–5.15) (Vanderploeg et al., 2007). Vanderploeg et al. (2003) used the same sample but divided it into two groups: 626 veterans who had mild TBI (373 with no LOC and 253 with LOC) and 3,896 veterans who had no TBI (normal controls). Using logistic regression, they examined factors predictive of work status in each group. Demographic, medical, and psychiatric factors accounted for about 23% of the variance in the mild TBI group and about 13% of the variance in the normal controls. The authors conclude that the findings indicate that those factors have a greater influence on work outcome in those with self-reported mild TBI than in those without. It is not clear whether the self-reporting method of ascertaining mild TBI since military discharge (a period of about 16 years) influenced the findings.

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310 GULF WAR AND HEALTH Independent Living A few secondary studies examined living situations after TBI (Dikmen et al., 1993; Kersel et al., 2001; Engberg and Teasdale, 2004). The results have indicated that at least for the first few years after injury, the predominant change is that many people who lived independently before the injury lived with parents after the injury. Dikmen et al. (1993) reported on a group of 22 of a sample of 31 moderately to severely injured subjects who were living independently before injury and were followed up to 2 years after injury. At 1 year after injury, 50% were living independently, 45% were living with parents, and 1 person (5%) was in a nursing home. By 2 years after injury, 68% were living independently, 27% were with parents, and 5% were in a nursing home. In comparison, only 6% of friend controls who lived independently 1 year before were living with parents. Kersel et al. (2001) reported similar findings in a group of severe-TBI patients at 6 months and 1 year after injury with the pattern showing a decrease in living alone or in flats from before to after injury and an increase in living with parents after injury. Engberg and Teasdale (2004) compared living situation before injury with living situation 5, 10, or 15 years after injury in a group of TBI patients who sustained cranial fractures and a group who suffered cerebral lesions. They found that the most frequent change in both groups was that most of those who had lived with parents before injury were living alone or with partners. The results from the Dikmen et al. (1993) and Kersel et al. (2001) studies on independent living are consistent with those reported in the primary studies, except for the study by Engberg and Teasdale (2004) which may have been due to a number of factors including milder injuries in the sample, or people living in nursing homes or other sheltered environments not responding to the recruitment efforts. Social Relationships None of the secondary studies was devoted primarily to this topic, but some papers included information on social integration after TBI (Dikmen et al., 1993, 2003; Engberg and Teasdale, 2004; Kersel et al., 2001; Vanderploeg et al., 2007; Walker and Eruclei, 1969; Whiteneck et al., 2004). Most studies have found that social relationships suffer after TBI, although this finding has not been entirely consistent (Walker and Erculei, 1969; Vanderploeg et al., 2007). For example, Kersel et al. (2001) described social contacts before and 6 months and 1 year after injury of 65 people who sustained severe TBI. Although 95% of the sample reported that they had visits from friends before injury, the percentage had dropped to 62% at 6 months after injury and to 59% at 1 year after injury. Likewise, visits to friends went from 100% before injury to 76% and 75% at 6 months and 1 year after injury, respectively. Visits to family also decreased from 94% to 70% and 68%. The measure that showed the least decline was maintenance of good family relationships: 98% before injury and 94% and 90% after. Engberg and Teasdale (2004) examined social interaction in subjects with TBI who sustained cranial fractures and a group that suffered cerebral lesions 5–15 years earlier. They report that 18% of the cranial-fracture group and 48% of the cerebral-lesion group said that life with cohabitants had changed from before injury, and 12% and 37% said that they were seeing other family or friends somewhat or much less than before. Dikmen et al. (1993) examined 31 moderately to severely injured adults 1 and 2 years after injury and compared them with 102 friend controls. They found the mean percentage dysfunction on the SIP (Bergner et al., 1976) Social Interaction

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SOCIAL FUNCTIONING 311 Scale was 10% at 1 and 2 years after injury, significantly higher than reported by the controls (p < 0.0001). In another study, Dikmen et al. (2003) used the Social Integration Subscale of the Functional Status Examination (Dikmen et al., 2001) 3–5 years after injury with 210 patients who had complicated mild to severely injured TBI. About 10% said that they were socially isolated, with social interactions limited to parents, immediate family, or other residents; about 25% reported having partially limited social interactions (fewer friends, less contact with friends or family, or less ability to make new friends) or greater reliance on others to maintain social interactions; about 10% said that social interactions were not more limited but it was more difficult to get along with friends and family; and the remaining 55% said that social interactions were the same as they were before the injury. Whiteneck et al. (2004) conducted a population- based study of 1,591 adult TBI patients in Colorado and followed them to 1 year after injury. They reported that 22% of their sample showed handicap on the Social Integration Subscale of the Craig Handicap Assessment and Reporting Technique Short Form (CHART-SF) (Whiteneck et al., 1992). The percentage of subjects showing handicap on this scale varied significantly by TBI severity (34% of severely, 32% of moderately, and 20% of mildly; p < 0.01) and by age (10% showed handicap at the ages of 16–24 years, 21% at 25–44 years, 26% at 45–64 years, and 43% at 65 years or over; p < 0.01). In contrast, Walker and Erculei (1969) reported that 87% of the 343 World War II veterans seen 14–17 years after TBI rated their social adjustment as normal and only 5% rated themselves as asocial. It is not clear whether more dysfunction would have been reported if questioning had been more detailed. Vanderploeg et al. (2007) examined satisfaction with social support and availability of social support in three groups of subjects from the Vietnam Experience Study that evaluated Army veterans about 16 years after military discharge: 3,214 subjects who said that they had not experienced an MVA or TBI since discharge, 539 subjects who said that they had been injured in an MVA but had not sustained a TBI, and 254 subjects who said that they had experienced a TBI with altered consciousness but were not hospitalized. The authors were unable to find any significant differences among the three groups on being very or somewhat dissatisfied with social support or having a decrease in the availability of social support. However, they did find that the mild-TBI group had significantly higher odds of not being married than the other groups (adjusted OR, 2.01; 95% CI, 1.57–2.75). Leisure Activities A number of secondary studies examined leisure and recreational activities after TBI (Dikmen et al., 1986, 1993, 2003; Engberg and Teasdale, 2004; Kersel et al., 2001). The results indicate that, with the possible exception of people with mild TBI, leisure and recreational activities appear to have been disrupted after injury and the disruption continued to be a problem many years after injury. For example, Kersel et al. (2001) reported that in their sample of 65 patients with severe TBI the percentage who were participating in leisure activities decreased from 95% before injury to 62% at 6 months and 70% at 1 year after injury. Engberg and Teasdale (2004) examined the effect of the injury on leisure activities in a group of subjects with TBI who had sustained cranial fractures and a group who had suffered cerebral lesions 5–15 years earlier. They found that 21% of the cranial-fracture group and 51% of the cerebral-lesion group reported some or marked disruption in leisure activities. Dikmen et al. (1986) examined resumption of leisure and recreational activities in 19 persons with mild TBI. At 1 year after injury, 12 had resumed the activities with no limitations, and six with limitations; 1 person did

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322 Health Outcomes Study Comments or or Outcome Reference Design Population Type of TBI Measures Results Adjustments Limitations 65% reported poor memory or loss of temper or fatigue; number of symptoms had weak association with PTA (r, 0.30; p < 0.02) and time to return to work (r, 0.27; p < 0.04) Controls: 58% 0 symptoms, 20% >3 symptoms Edna and Prospective 485 closed-head None No information Closed head injury Questionnaire on Employment: Cappelen, cohort injured admitted in on demographic with LOC, skull social, working Overall head injured: 1987 1979–1980 to 3 comparison of fracture, or outcome 3–5 years unemployed 12% before, 27% general-surgery closed head intracranial after injury; 85% after department and 1 injured, controls hematoma; 89% response rate in Controls: 5% before, 16% neurosurgery GCS 13–15 closed head injured, after department in controls Unemployment rate increased Trondelag, Norway; more (p < 0.01) in closed- 15–64 years old at head injured than in controls injury More unemployment in those 89 controls admitted >45 years old (16% before, with acute 53% after) than those <45 appendicitis in 1979– years old (11% before, 20% 1980 after) Social condition: Compared with before injury, rated as worse, same, or better than before, more controls than closed-head injured report contact with friends, family life, income better than before (each p < 0.05); more closed-head injured than controls report income same as before (p < 0.05); poor social outcome significantly related to unemployment (X2,

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Health Outcomes Study Comments or or Outcome Reference Design Population Type of TBI Measures Results Adjustments Limitations 39.81; p, 5 * 10-8), number of new postconcussion complaints (X2, 73.19; p, 1 * 10-10) Gerberich et Case–control 99 undergraduate Females with Defined as any Mean total credits No differences when total Uninjured al., 1997 students at University injury above C-1 attempted per brain injury who groups (males, females) controls, TBI of Minnesota returned to that resulted in quarter; mean GPA compared; significant before- matched at 2:1 hospitalized with school had lower LOC and/or loss of credits attempted injury to after-injury decrease ratio to cases brain injury in GPA, attempted awareness and/or per quarter; in GPA in female cases by age (+1 year), sex, 1980–1984, 17–27 fewer classes functional percentage of compared with uninjured academic years old than academic impairment; attempted credits academic controls (p < 0.02) progress 198 matched and injured included completed; GPA Comparison of female brain- classified as Uninjured controls controls penetrating and Return to school injured cases and academic 90 with no documented blunt forces Failure of controls on nonattendance total course injury requiring females to return resulting in after injury: OR, 4.47 (1.21– credits hospitalization during concussion, to school 17.13) Injured study period associated with contusion, Comparison of female brain- controls not 121 injured controls hemorrhage, or injury but not injured cases and injured matched to hospitalized in same laceration of brain specific to brain controls on nonattendance cases trauma centers as injury or brain stem; after injury: OR, 1.14 (0.32– cases for injury other 90% with mild 4.09) than brain injury TBI based on Brain-injury cases: neurologic during same study GCS; based on deficits at discharge among period AIS head: 77% total brain-injured cases, mild (AIS 1 or 2), relation to post injury 12% moderate nonattendance, OR, 7.43 (AIS 3), 11% (1.22–48.37); upper-limb severe (AIS 4 or 5) motor deficits associated with post injury nonattendance, OR, 11.29 (1.55–68.65) Stulemeijer Retrospective 299 mild TBI 18–60 Mild TBI defined 6 mo after injury: Change in work: 35% mild Analyses 52% of mild- years old admitted to as impact to head Rivermead Post- TBI with additional injuries, adjusted for TBI sample, et al., 2006 cohort Concussion 14% isolated mild TBI, 2% of age, sex, AIS 61% of control ED level 1 trauma with or without center in Netherlands; LOC <30 min, Questionnaire; SF- controls report change in work head score sample with or without 36 physical (p = 0.0001) completed 89 sustained 323 PTA, hospital functioning, social SF-36: all 3 scales questionnaires additional injuries

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324 Health Outcomes Study Comments or or Outcome Reference Design Population Type of TBI Measures Results Adjustments Limitations defined as AIS >2 in 1 admission GCS, functioning; GOSE; significantly different between or more other AIS– 13–15 SF-36 perceived groups (each p = 0.0001); post ISS body areas; mean Mild TBI with health change, hoc tests show mild TBI with age, 36.12 years; 75% additional injuries change in work additional injuries have more male had more severe (defined as loss of dysfunction than isolated 261 controls went to TBI than those work or change in mild-TBI cases, both have ED for ankle or wrist with isolated work status to fewer more than minor-injury distortion; mean age, injuries (for hours or other controls (each post hoc p < 33.2 years; 45% male example, more lower-level job due 0.001) Mild TBI significantly report PTA (78% to accident) Location of additional injuries older (p < 0.01), more vs 64%; p < 0.05), significantly related to SF-36 were male (p = RA (47% vs 27%; physical functioning (p < 0.0001) than controls p < 0.01), more 0.01); those with multiple frequent brain CT injuries, injuries to abnormalities extremities, or injuries to (24% vs 14%; p < chest or abdomen report more problems; more dysfunction in 0.05), worse AIS severe injuries (ISS > 15) on head score (mean, physical functioning (p < 2.3 vs 1.9; p = 0.01) but no difference on 0.0001) other outcomes Heitger et Prospective 37 mild closed head Mild closed head RHIFQ, SF-36 at 6, SF-36: no significant Controls al., 2007 cohort injured; mean age, injury based on 12 mo after injury differences between mild matched to 29.1 years; mean first assessed GCS closed-head injured, controls mild closed education, 13.6 years; of 13–15 without on SF-36 at 6, 12 mo head injured all employed or in decreasing below RHIFQ: not administered to on age, sex, school, none involved 13 at any time in controls; 27% mild closed years of with litigation; hospital; PTA <24 head injured report mild or education excluded Ss if any h in all cases worse change on one or more evidence of alcohol or activities at 6 mo, 23% report drugs at time of injury mild or worse change at 12 or regular use of mo; 49% at 6 mo, 61% at 12 psychoactive drugs or mo report no changes history of drug abuse compared with before injury or if had pre-existing on any activity neurologic or

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Health Outcomes Study Comments or or Outcome Reference Design Population Type of TBI Measures Results Adjustments Limitations psychiatric problems or history of prior head injury with persisting symptoms 37 controls selected from volunteer database, matched to closed head injured on age, sex, education; some recruited from relatives and friends of closed head injured if match in database could not be found; same exclusion criteria as in closed head injured group Bond and Cohort 62 blunt trauma Subjects: blunt Measure of Conversations with TBI One way Excluded from Godfrey, (consecutive subjects (55 men and trauma associated pragmatic speech patients were rated as analyses of participation in 1997 hospital 11 female) with PTA Conversations significantly less interesting, variance subjects and admissions) Consecutive hospital exceeding 24 assessed between 6 less appropriate, less (ANOVAs) controls: admissions to hours; mean months and 3 years rewarding and more effortful indicated that premorbid Neurological unit of duration of PTA postinjury than the orthopedic controls. the mean history of Dunedin Pubic was 14.98 days Further the TBI patients’ scores of the psychiatric hospital between with a range of 1- conversations were different disorder; January 1985 and 61 days. characterized by differences in groups were neurologic December 1988 32% of cases had a the frequency of prompt usage not disease; alcohol All patients were duration of PTA of and turn duration significantly dependency; or discharged in a 1-7 days; TBI subjects were perceived different previous conscious state. 56% PTA 8-28 to be less socially rewarding Matched on moderate to 25 Orthopedic days; as a result of changes in their age; sex; mean severe head controls (20 men and 12% PTA >28 social behavior premorbid IQ injury. 7 females) days. Also excluded hospitalized for less 58% GCS >9 on were subjects than 1 week with admission; younger than 15 325 injuries typically 39% GCS 6-8; 3% or older than 65.

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326 Health Outcomes Study Comments or or Outcome Reference Design Population Type of TBI Measures Results Adjustments Limitations associated with rapid GCS 4-5. Five subjects recovery 80% of cases had who had PTA > injury caused by 10 weeks were road accident; 14% excluded injury from a fall; 3% assaults; 3% blows from moving objects Friedland Prospective 64 TBI from MVA SIP, Reintegration SIP: mild TBI: overall mean, Mild TBI; initial Controlled for Average ISS in and Dawson, cohort GCS >13 (after 30 19–58 years old, to Normal Living 20.80; psychosocial summary Time 1 (within both groups 2001 admitted to tertiary- min); LOC <30 Scale, return to score, 21.14; physical 1 mo of implies both min or PTA < 24 h care center in work 6–9 mo after summary score, 15.0; no mild injury) scores groups suffered Toronto, Canada; injury; also TBI: overall mean, 15.09; on PTSD for from serious 61% male; average examined PTSD psychosocial summary score, followup other-system ISS, 21; average LOS, with Impact of 10.86; physical summary injuries, which 19 days; English- Event Scale and score, 12.66; psychosocial may have speaking General Health summary score significantly influenced 35 with no TBI but in Questionnaire different between groups (p = findings MVA (defined as 0.01); no other significant Counting GCS of 15, no differences students and documented LOC or homemakers as PTA, normal CT, if Return to normal living: mild independent done, no TBI mean, 69.23; no mild TBI occupations may documentation in mean, 73.91; not significantly have influenced chart regarding brain different results because it injury); age 19–58 may be easier years; 64% male; Return to work: 44% mild for these Ssthan average ISS, 18; TBI returned, workers to average LOS, 22.71 41% no mild TBI returned; return to their days; English- not significantly different; major activity speaking return to work examined by after TBI Excluded anyone with type of occupation grouped as severe disfigurement, independence and decision- amputation, spinal- making (including student, cord injury homemaker, professional or semiprofessional,

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Health Outcomes Study Comments or or Outcome Reference Design Population Type of TBI Measures Results Adjustments Limitations management), not independent (including clerical, sales, manual labor, skilled crafts, trade); mild TBI had significantly higher rate of return if job involved independence and decision- making (p = 0.004); no difference in rate of return by type of occupation in no mild TBI group PTSD: mild TBI had higher risk (p = 0.04; OR, 1.034; CI, 1.001-1.067); grouped Ss into definite PTSD (had qualifying scores on both measures of PTSD), possible (had qualifying scores on only 1 measure), none (did not qualify on either measure); percentage of mild TBI cases in expected direction, but no significant differences between mild TBI and no mild TBI Note: AFQT= Armed Forces Qualification Test, AIS = Abbreviated Injury Score, CDC = Centers for Disease Control and Prevention, CI = confidence interval, DVA = Department of Veterans Affairs, ED = emergency department, EDH = epidural hematoma, FC = friend controls, FIM = Functional Independence Measure, FSE = Functional Status Examination, GCS = Glasgow Coma Scale, GOS = Glasgow Outcome Scale, GPA = grade-point average, ICD = International Classification of Diseases, ISS = Injury Severity Score, LOC = loss of consciousness, LOS= length of stay, MCS = Mental Component Summary, MVA = motor-vehicle accident, NP = neuropsychologic, OR = odds ratio, PTA = posttraumatic amnesia, PTSD = posttraumatic stress disorder, RA = retrograde amnesia, RHIFQ = Rivermead Head Injury Follow-up Questionnaire, RR = relative risk, SIP = Sickness Impact Profile, SO = significant other, TBI = traumatic brain injury, TC = trauma controls, TFC = time to follow commands, WRAMC = Walter Reed Army Medical Center. 327

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328 GULF WAR AND HEALTH REFERENCES Bergner, M., R. A. Bobbitt, W. E. Pollard, D. P. Martin, and B. S. Gilson. 1976. The sickness impact profile: Validation of a health status measure. Medical Care 14(1):57–67. Boake, C., S. R. McCauley, C. Pedroza, H. S. Levin, S. A. Brown, and S. I. Brundage. 2005. Lost productive work time after mild to moderate traumatic brain injury with and without hospitalization. Neurosurgery 56(5):994–1003. Bond, F., and H. P. Godfrey. 1997. Conversation with traumatically brain-injured individuals: A controlled study of behavioural changes and their impact. Brain Injury 11(5):319–329. Cifu, D. X., L. Keyser-Marcus, E. Lopez, P. Wehman, J. S. Kreutzer, J. Englander, and W. High. 1997. Acute predictors of successful return to work 1 year after traumatic brain injury: A multicenter analysis. Archives of Physical Medicine and Rehabilitation 78(2):125–131. Colantonio, A., D. R. Dawson, and B. A. McLellan. 1998. Head injury in young adults: Long- term outcome. Archives of Physical Medicine and Rehabilitation 79(5):550–558. Corrigan, J. D., J. A. Bogner, W. J. Mysiw, D. Clinchot, and L. Fugate. 2001. Life satisfaction after traumatic brain injury. Journal of Head Trauma Rehabilitation 16(6):543–555. Dikmen, S., J. Machamer, and N. Temkin. 1993. Psychosocial outcome in patients with moderate to severe head injury: 2-year follow-up. Brain Injury 7(2):113–124. ———. 2001. Mild head injury: Facts and artifacts. Journal of Clinical and Experimental Neuropsychology: Official Journal of the International Neuropsychological Society 23(6):729–738. Dikmen, S., A. McLean, and N. Temkin. 1986. Neuropsychological and psychosocial consequences of minor head injury. Journal of Neurology, Neurosurgery and Psychiatry 49(11):1227–1232. Dikmen, S. S., J. E. Machamer, J. M. Powell, and N. R. Temkin. 2003. Outcome 3 to 5 years after moderate to severe traumatic brain injury. Archives of Physical Medicine and Rehabilitation 84(10):1449–1457. Dikmen, S. S., B. L. Ross, J. E. Machamer, and N. R. Temkin. 1995. One year psychosocial outcome in head injury. Journal of the International Neuropsychological Society 1(1):67–77. Dikmen, S. S., N. R. Temkin, J. E. Machamer, A. L. Holubkov, R. T. Fraser, and H. R. Winn. 1994. Employment following traumatic head injuries. Archives of Neurology 51(2):177–186. Doctor, J. N., J. Castro, N. R. Temkin, R. T. Fraser, J. E. Machamer, and S. S. Dikmen. 2005. Workers' risk of unemployment after traumatic brain injury: A normed comparison. Journal of the International Neuropsychological Society 11(6):747–752. Drake, A. I., N. Gray, S. Yoder, M. Pramuka, and M. Llewellyn. 2000. Factors predicting return to work following mild traumatic brain injury: A discriminant analysis. Journal of Head Trauma Rehabilitation 15(5):1103–1112. Edna, T. H., and J. Cappelen. 1987. Return to work and social adjustment after traumatic head injury. Acta Neurochirurgica 85(1-2):40–43. Engberg, A., and T. Teasdale. 2004. Psychosocial outcome following traumatic brain injury in adults: A long-term population-based follow-up. Brain Injury 18(6):533–545.

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