KOSCHI: Assessment of

outcome following Paediatric

Head Injury

Joanna M. Hamilton, Ph.D., C.Psych., C-CAT(MB)

Private Practice

Peterborough, ON

Many thanks to Dr. Carol Hawley, Warwick

Medical School, University of Warwick, UK

for allowing the use of slides and the case

studies in this presentation.

Dr. Hawley is a world renowned expert on

the KOSCHI and has researched, written

and presented on this topic.

Background and development of

the KOSCHI

Early use of the KOSCHI

Research

Data sources for assessment

Scoring strategies

Case examples

Development of KOSCHI

Glasgow Outcome Scale (Jennett & Bond, 1975) was developed to assess

outcome following TBI

Jennett & Bond noted that there were developmental considerations when

assessing children

Marion Crouchman and Lucille Rossiter, Kings College Hospital, London,

UK

Found the GOS for adults did not allow for developmental changes in

children after TBI

Set out to provide a robust, simple description of outcome after

paediatric TBI in the short, medium or long term

A Practical Outcome Scale For Paediatric

Head Injury (Crouchman et al, 2001)

KOSCHI was developed as a specific paediatric adaptation of the original adult Glasgow Outcome Scale (GOS)

Used a checklist to guide outpatient follow-up and, using this information modified the 5 category GOS to produce the KOSCHI

KOSCHI provides increased sensitivity at the milder end of the disability range

GOS ‘persistent vegetative’ was redefined as ‘vegetative’

Good recovery was divided into two categories to acknowledge the long-term importance of relatively minor sequelae in a developing child

1 Death

2 Vegetative Breathes spontaneously. No evidence of verbal or non-verbal communication or response

to commands.

3 Severe disability A Conscious, totally dependent. May be able to communicate. Requires specialised

educational/rehabilitation setting.

Severe disability B Limited self-care abilities and predominantly dependent. May have meaningful

communication. Requires specialised educational/rehabilitation setting.

4 Moderate disability A Mostly independent for daily living, but needs a degree of supervision/help for

physical or behavioural problems. Has overt problems. May be in specialised rehabilitation/educational

setting or in mainstream school requiring special needs assistance. Behavioural problems may have

caused child to be disciplined or excluded from school.

Moderate disability B Age-appropriately independent for daily living, but with neurological sequelae

frequently affecting his daily life, including behavioural and learning difficulties. May also have frequent

headaches. Likely to be in mainstream school with or without special needs assistance.

5 Good recovery A Appears to have made a full functional recovery, but has residual pathology

attributable to head injury. May suffer headaches which do not affect his school or social life, and may

occasionally have some of the problems listed on the head injury checklist.

Good recovery B The information available implies that child has made a complete recovery. No

sequelae identified.

Inter-rater Reliability

As part of the development Dr. Hawley and colleagues

carried out an inter-rater reliability exercise

6 observers with professional interests in child head injury

2 paediatric neurologists

2 clinical nurse specialists

1 psychologist/health economist

1 medical social worker with specialist experience in the

field

Independently assigned KOSCHI categories to 90 child

survivors of head injury using one page clinical discharge

letters

Inter-rater Reliability Results

General agreement between 5/6 observers. One

observer consistently rated children as more disabled

than other observers

Excluded that observer from the final inter-rater

reliability

Best agreement was in categories 2: vegetative

(0.88), 3a: Severe a (0.63) and 5b: Full (intact)

recovery (0.66)

Agreement worst in categories 3b: Severe b (0.33)

and 4a: Moderate a (0.28)

3b or 4a? (Crouchman et al, 2001)

3b: “Implies a continuing high level of dependency,

but the child can assist in daily activities. E.g. can

feed self or walk with assistance or help to place

items of clothing. Child is fully conscious but may

have a degree of post-traumatic amnesia.”

4a: “The child is mostly independent but needs a

degree of supervision/actual help for physical or

behavioural problems. Such a child has overt

problems. E.g. 12 year old with moderate hemiplegia

and dyspraxia insecure on stairs or needing help with

dressing.”

Conceptually, the suggestion that “recovery

after head injury” can be captured in a

unidimensional five (essentially eight) point

scale could be challenged

Difference between 1 (Death) and 2 (Vegetative)

is one of physiological function

Difference between 2 and 3a (Severe Disability)

is a matter of awareness or and response to

stimuli

Difference between 3b and 5a is essentially the

degree of functional independence

KOSCHI can be completed by direct observation or from routine medical records, prospectively or retrospectively

With experience and training children can be allocated to the appropriate KOSCHI category within a matter of minutes

Scale places a high emphasis on concentration, behaviour, and disinhibition

Important to remember, however, that the sequelae of the brain injury be used rather than that of other (e.g., orthopaedic) injuries

When considering children with pre-existing learning and/or behaviour problems, assignment to a category should be based on change in functioning following TBI

First large scale study to use

the KOSCHI (Hawley et al, 2004)

Focus was to identify outcomes among a population of children admitted to one Hospital – North Staffordshire (UK) Hospital NHS Trust

The Head Injury Register contains details of all children admitted to hospital for ≥24 hours with head injury

Children were aged 5-15 years at time of injury and admitted with head injury between November 1992 and December 1998

Identified 986 children admitted – 12 had died as a result of their injury

Postal Survey (Hawley et al, 2004)

974 parents of head injury survivors (age 5-15) were sent a detailed postal questionnaire

48 untraceable

526 parents responded (523 living in the community)

57% overall response rate

63% response rate for those injured within 2 years of the injury

Injured Children : Males = 70% Females = 30%

Mean Age of Child at Time of Injury = 9.8 years

Mean time between injury and Q follow-up = 2.3 years

Mean Age of Child at follow-up = 12 years

(same proportions for responders and non-responders)

Control group of 45 children with no history of head injury or neurological abnormality

Definition of Injury Severity

Mild = GCS 13 - 15 (unconscious less

than 15 mins)

Moderate = GCS 9 - 12 (unconscious

> 15 mins and < 6 hours)

Severe = GCS 3 - 8 (unconscious > 6

hours)

Severity of Injury and Cause of Injury

Not surprisingly, majority of individuals (both

those who responded and who did not) had

sustained mild TBI

80% and 83% respectively

11% had moderate brain injury and 9% of

responders (6% of non-responders) had

severe brain injury

Most common cause of injury was falls and

motor vehicle accident, especially as a

pedestrian

Questionnaire Content

1 Follow-up, therapy, other injuries, information received by parents

2 Changes in child since the injury

3 Current problems/difficulties - incorporating the King’s Head Injury Checklist

4 Return to school

5 Employment since the head injury

6 Effect on parents/family (support required/received)

Outcomes measured using the

KOSCHI

All questionnaires scored by one person

experienced in the KOSCHI and who took

part in the original inter-rater reliability

exercise

Scored using anonymised questionnaires,

without knowledge of injury severity

However, determining between 4a and 4b

could be difficult

Moderate disability 4A

Able to carry out most self-care, but needing support and supervision for these. Likely to have problems with behaviour/learning/communication. Has overt problems. May be in specialised rehabilitation/educational unit or in mainstream school requiring special needs assistance. His behavioural problems may have caused him to be disciplined or excluded from school.

Moderate disability 4B

Age-appropriately independent for daily living, but with neurological sequelae affecting his daily life, including behavioural and learning difficulties. He may also have frequent headaches. Likely to be in mainstream school with or without special needs assistance.

Outcomes (KOSCHI scores) n=526

0

5

10

15

20

25

30

35

40

severe moderate A moderate B good full

0

8

35

21 21

0

26

38

26

10 8

35 35

18

4

percent

mild HI moderate HI severe HI

KOSCHI scores 1 year post injury (n=106)

0 0

17

13

33

42

29

47

25

37

2017

22

0 00

10

20

30

40

50

percent

severe moderate A moderate B good full

mild HI moderate HI severe HI

CLINICAL FOLLOW-UP AFTER DISCHARGE

ACCORDING TO KOSCHI OUTCOMES (N = 526.

Significant difference: p = 0.006) 100

0

36

64

24

76

0

10

20

30

40

50

60

70

80

90

100

PERCENT

SEVERE DIS MODERATE DIS GOOD

RECOVERY

FOLLOW-UP NO FOLLOW UP

Deprivation and Outcome

Deprivation was measured using the Townsend material deprivation score using postcodes

The range is approximately +10 to -10, where the higher positive = more deprived and lower negative = more prosperous

There was a significant association between deprivation and KOSCHI outcomes

The more social deprivation, the worse the outcome

Comments Most respondents were living in the community,

most were functionally independent, few had physical problems

Classification of “moderate disability” applied to children with learning, behavioural or neurological sequelae

Children with severe behavioural problems or learning difficulties requiring supervision or help were placed in Category 4A, even if otherwise independent

43% of children with mild head injury had moderate disability

Relatively minor residual deficits are potentially more destructive to children than to adults

Conclusions and Recommendations

There was no evidence to suggest a threshold of injury severity below which the risk of late morbidity could be discounted.

The KOSCHI is a simple measure and with training it is easy to use.

KOSCHI outcome scores can be obtained from a detailed mail questionnaire.

Cost effective means of identifying children who are likely to benefit from clinical follow-up after hospital discharge.

Further Research on the

KOSCHI Calvert et al. (2008); Gabbe et al. (2011); Shashikiran et al.

(2012)

Correlates with severity of head injury

Variable relationship with various medical interventions

Variable relationship with some cognitive, health status

and quality of life outcomes early following brain injury

Paget et al. (2012); Casselden et al. (2014)

Moderate to good inter-rater reliability

Younger than 8 years old at time of injury: scores

worsened over time in 23%

KOSCHI – better inter-rater reliability than GOS-E

(Peds)

Use Of KOSCHI To Determine Catastrophic

Injury In Youth With Brain Injury Aged <18

Years

Application for determination of catastrophic

impairment (OCF-19) in young persons with TBI aged

<18 years

Automatically qualify if received for in-patient

treatment (qualifying facility) with positive CT or MRI,

Or in-patient treatment for neurological rehabilitation

in qualifying facility

If above not met KOSCHI will be used

A child would meet the definition for

“catastrophic” if:

One month or more after the accident, the insured person’s level of neurological function does not exceed category 2 (Vegetative) on the King’s Outcome Scale for Childhood Head Injury;

Six months or more after the accident, the insured person’s level of neurological function does not exceed category 3 (Severe disability) on the King’s Outcome Scale for Childhood Head Injury;

Nine months or more after the accident, the insured person’s level of function remains seriously impaired such that the insured person is not age-appropriately independent and requires in-person supervision or assistance for physical, cognitive or behavioural impairments for the majority of the insured person’s waking day.

KOSCHI not specified here, but sounds like 4a or lower.

Data Sources for Assessment

Use as much information as is available

Use a range of sources:

Interview with child

Interview with parent

Interview with teachers

Interview with rehabilitation team

Use other assessments where available

Neuropsychological assessments

Physio assessments

OT assessments

But, can also score KOSCHI from clinical discharge letters or

mail questionnaire incorporating key questions

Scoring the KOSCHI

Original KOSCHI incorporated a functional scoring system using seven categories to measure dependence

Minimum score of 7 (K2) Max score 20 (K5)

By totalling the scores you get a KOSCHI rating

Dependence must be age related

Good recovery (5a or 5b) can only be allocated to children scoring 20

Not only physical disability and

dependency

A severely behaviourally or cognitively disordered child may be

categorised as severely disabled even in the absence of physical

sequalae

KOSCHI Scoring Algorithm

Case Examples

Sarah

Age 9 (STK1041)

Severe TBI 10 months ago (GCS 4) Pedestrian v car

Living at home with full time carers

No speech, but has limited non-verbal communication

Dependent on others for self-care and mobility

Has decreased cognitive function

Cheerful mood but personality change

Receiving specialised education outside the home

Unable to carry out neuropsychological assessments

3a, 3b or 4a? (Crouchman et al, 1998 criteria)

3a: Severe disability

Conscious, totally dependent. May be able to communicate. Requires specialised education/rehabilitation setting.

3b: Severe disability

Limited self-care abilities and predominantly dependent. May have meaningful communication. Requires specialised educational/rehabilitation setting.

4a: Moderate disability

Able to carry out most self-care, but needing support and supervision for these. Likely to have problems with behaviour/learning/communication. May be in a specialised rehabilitation/educational unit or in mainstream school with special needs assistance.

Sarah KOSCHI using functional

scoring system

Mobility = 1 (dependent)

Communication = 2 (coping mechanism)

Mood/behaviour/personality change = 1 (occasional

problems)

Disinhibition = 2 (not present)

Danger awareness = 1 (unaware)

Self-care = 1 (dependent)

Cognitive/memory/concentration = 2 (decreased)

Total score = 10 = 3a

Andrew

Age 11 (STK1555)

Severe TBI 9 months ago, GCS 4, RTA pedestrian

Independent for ADLs but needs prompts for some aspects of self-care

Severe behavioural problems

Poor memory and concentration

Falling behind and having difficulty learning

In mainstream school, teachers complain he is aggressive, moody and disruptive

Poor danger awareness ‘fearless’

Andrew KOSCHI using functional

scoring system

Mobility = 3 (normal)

Communication = 4 (normal)

Mood/behaviour/personality change = 1 (constant

problems)

Disinhibition = 1 (present)

Danger awareness = 1 (unaware)

Self-care = 3 (needs prompts)

Cognitive/memory/concentration = 2 (decreased)

Total score = 15 = 4a

Scott

Age 7

Severe TBI one year ago, GCS 8. RTA

Living at home with parents and carers

Delayed language development due to TBI

Receiving rehabilitation within the home (SLT, Physio)

Unable to walk and uses wheelchair, dependent on others for mobility

Can feed self with prompts and supervision, but mostly dependent

Receiving limited educational input from specialist teachers

Difficulty with concentration and memory

Occasionally moody and temper tantrums

Poor awareness of danger, needs supervision for safety

Scott KOSCHI using functional

scoring system

Mobility = 1 (dependent)

Communication = 3 (delayed language development)

Mood/behaviour/personality change = 1 (occasional

problems)

Disinhibition = 2 (not present)

Danger awareness = 1 (unaware)

Self-care = 2 (predominantly dependent)

Cognitive/memory/concentration = 2 (decreased)

Total score = 12 = 3b

Fine line between 3a & 3b and

4a Some subjectivity

Good days and bad days?

When is assessment done?

Who should do the assessment?

Child should be assessed on several occasions, taking evidence from different sources and using a range of measures

Caution – are these behaviours or problems due to the TBI?

Summary

KOSCHI is a useful tool for assessing disability after paediatric TBI

Was intended to provide a simple, robust description of outcome in the short, medium or long term

Intended use was to enable clinicians to describe the rate and extent of recovery

Not intended to be used to determine financial compensation

Any health professional experienced in TBI can score, but training needed for consistency of scoring.

Can be difficult to score ‘borderline’ cases. Dependency is key. Must be age related. If in doubt between two scores take the lower

References Calvert, S., Miller, H.E., Curran, A., et al. (2008). The King’s Outcome Scale for Childhood

Head Injury and injury severity and outcome measures in children with traumatic brain injury.

Developmental Medicine and Child Neurology, 50, 426-431.

Casselden, E., Kirkham, F.J., Durnford, A.J. (2014). Inter-rater reliability of two outcome

scoring tools in paediatric head injury [abstract]. Archives of Disease in Childhood, 99 (suppl

1), A191.

Crouchman M., Rossiter L., Colaco T., & Forsyth, R. (2001). A practical outcome scale for

paediatric head injury. Archives of Diseases in Childhood, 84, 120-124.

Gabbe, B.J., Simpson, P.M., Sutherland, A.M., Palmer, C.S., Williamson, O.D., Butt, W.,

Bevan, C., & Cameron, P.A. (2011). Functional and health-related quality of life outcomes after

pediatric trauma. Journal of Trauma: Injury, Infection, and Critical Care, 70, 1532-1538.

Hawley, C.A., Ward, A.B.,Magnay, A.R., & Long, J. (2004). Outcomes following childhood head

injury: a population study. Journal of Neurology, Neurosurgery, and Psychiatry, 75, 737-742.

Paget., S.P., Beath, A.W.J, Barnes, E.H., & Waugh, M.C. (2012). Use of the King’s Outcome

Scale for Childhood Head Injury in the Evaluation of Outcome in Childhood Traumatic Brain

Injury. Developmental Neurorehabilitation, 15(3), 171-177.

Shashikiran, S., Maduri, R., Williamson, S., Sabherwal, S., & Margo, E. (2012). King’s

Outcome Scale for Childhood Head Injury score in severe traumatic brain injury and its relation

to injury severity and medical intervention [abstract]. Brain Injury, 26 (4-5), 715.