Follow-Up Study of Head Wounds in World War II, by a. Earl Walker and Seymour Jablon (1961)

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Chapter VI SOCIAL AND ECONOMIC REHABILITATION In the final analysis, the complete rehabilitation of the head-injured patient is the goal of the therapist. How well this can be accomplished, and the factors modifying its achievement, are the subject of this chapter. It is immediately apparent that the severity of injury plays an important role in certain spheres of rehabilitation (table 170). The rehabilitation of the badly injured men is related to severity of wounding; this factor seems to affect more strongly the readjustment in work and social circles than in economic and home spheres. Unemployment is progressively more frequent as the severity of wounding increases. Similarly, the less severely wounded are more likely to advance in their jobs, whereas those more impaired tend to regress. These observations, coupled with the relatively satisfactory economic and home adjustments, might suggest that the compensation being received goes far to meet the immediate needs of the head-injured so that relatively few have excessive worries. The development of epilepsy, like the severity of injury, may play a role in the work and social rehabilitation, but seems to influence less the home and economic adjustment. Particularly, the occurrence of multiple focal seizures decreases the likelihood of employment and advance in work (table 171). In fact, in all respects, the epileptic is a little worse off than the nonepileptic head-injured man. Moreover, the presence of epilepsy appears to have an influence on rehabilitation, which is independent of the fact that the men with epilepsy were, on the average, more severely wounded than the men without epilepsy (table 172). Even within fixed injury groups, men with epilepsy are more frequently unemployed, have advanced in work less frequently, and have made unsatisfactory home and social adjustments more often (table 173). On the other hand, the electroencephalogram (table 174), which might be considered as indicating an epileptic diathesis, is not well correlated with the work, social, economic, or home status. Only men unemployed or re- gressing in work have significantly different EEC's from other men, in that they are more likely to have focal abnormalities. The intelligence of the head-injured men is an important determinant in the work status (table 175). In the group of men who were unemployed, had odd jobs, or were hospitalized at the time of follow-up, the proportion of deteriorated persons was higher than in the other groups. Of 145 de- teriorated men, 48, or 33.1 percent, had no steady employment, as against 56 of 538, or 10.4 percent, for nondeteriorated men. On the other hand, only a low proportion of men advancing in their jobs were deteriorated or had IQ's of 89 or less. However, the intelligence of the individual, at least as measured by the Wechsler-Bellevue test, seems to be a less important factor in home and social adjustment (table 176). 145

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Table 171.—Relation of Vocational, Social, and Economic Status at Follow-up to Epilepsy Without epilepsy With epilepsy With multiple focal attacks Status Number Percent Number Percent Number Percent Total 532 100.0 207 100.0 65 100.0 Vocational : Unemployed or occa- 64 12.0 46 16 18 16 104 5 2 22.2 21 10 6 2 23 2 1 32.3 15.4 9.2 3.1 35.4 3.1 1.5 Attending school 25 43 71 325 3 1 4.7 8.1 13.3 61. 1 .6 .2 7.7 8.7 7.7 50.2 2.4 1.0 Returned to former job. Advanced at former job . New work Unknown Regression in work 85 16.0 65 31.4 28 43.1 Unsatisfactory adjustment: Home 53 97 10.0 18.2 10.7 30 60 35 14.5 29.0 16.9 11 20 9 16.9 30.8 13.8 Economic 57 The personality seems to play a role in the work adjustment, for un- employed men have a higher proportion of elevated Hs, D, Hy, Pt, and Sc scores than employed men. Similarly, those scores are elevated in a higher percentage of men showing no progress or regressing in their work (table 177) than in men advancing in their jobs. In addition to having a higher proportion of men with high scores in the above categories, men poorly adjusted at home frequently tend to have ele- vated Pd and Ma, while the social misfits exhibit a smaller degree of eleva- tion of thePd score and no significant elevation of the Ma scale. There would, then, seem to be a number of factors other than the neuro- logical deficit which may modify the rehabilitation of the head-injured patient. For this reason the therapy of these patients might profitably be preceded by a series of psychological tests, which may indicate the chances of a successful therapeutic outcome. The individual with an IQ below 90, having evidence of mental deterioration and personality aberrations, has relatively little chance of returning to a useful vocation. On the other hand, time and effort expended on the supernormal individual without personality abnormalities, even if he has a severe neurological handicap, may well result in a successful rehabilitation. 147

Table 172.—Relation of Vocational Status at Follow-up to Epilepsy and R-I Group Status 3 R-I group 4 Number Percent Number Percent No epilepsy Total 247 100.1 35 100.1 Hospitalized 1 33 12 200 1 0.4 13.4 4.9 81.0 0.4 1 8 5 21 2.9 22.9 14.3 60.0 Unemployed or occasional jobs Attending school Employed Other and unknown Regression in work 41 16.6 11 31.4 Epilepsy Total 115 100.0 61 99.9 Hospitalized 2 22 10 80 1 1.7 19.1 8.7 69.6 0.9 3 22 6 29 1 4.9 36.1 9.8 47.5 1.6 Unemployi d or occasional jobs Attending school Employed Other and unknown Regression in work 36 31.3 25 41.0 Multiple focal attacks Total 30 99.9 33 100.1 Hospitalized 2 15 3 13 6.1 45.5 9.1 39.4 Unemployed or occasional jobs 6 20.0 23.3 53.3 3.3 Attending school 7 16 Employed Other and unknown 1 Regression in work 12 40.0 16 48.5

Table 173.—Relation of Home, Social, and Economic Adjustment to Epilepsy and R-I Group Adjustment 3 R-I group 4 Number Percent Number Percent No epilepsy Total 247 100.0 35 100.0 Unsatisfactory: 221 39" 23] 8.9 3 10 3 8.6 28.6 8.6 Social 15.8 9.3 All epilepsy Total 115 100.0 61 100.0 Unsatisfactory: 15 26 20 13.0 22.6 17.4 11 23 11 18.0 37.7 18.0 Social Multiple focal attacks Total 30 100.0 33 100.0 Unsatisfactory: 4 7 3 13.3 23.3 10.0 7 13 6 21.2 39.4 18.2 Social 149

Table 174.—Relation of Vocational, Social, and Economic Status to Electroencephalogram Electroencephalogram Statui Total Generalized abnormality Focal abnormality Number Percent Number Percent Total 595 110 18.5 135 22.7 Vocational: Unemployed or occasional jobs . . Attending school .... 94 35 5 458 3 16 6 2 85 1 17.0 17.1 40.0 18.6 (*) 30 7 2 96 i 31.9 20.0 40.0 21.0 (*) In hospital Employed . . . Unknown Regression in work 121 23 19.0 44 »36.4 Unsatisfactory adjustment: Home 69 138 8 11.6 17.4 15.3 15 35 22 21.7 25.4 30.6 Social 24 11 Economic 72 i Differs significantly from percent in total group (P<.05). 1 Differs significantly from percent in total group (P<.0l). *Not calculated. 150

Table 175.—Relation of W echsler-Bellevue Intelligence Test to Work Status Number of men Wechsler-Bellevue Status Intelligence Scale Abnor- mally de- teriorated <89 90-119 >120 Number j Total 683 88 470 125 145 Hospitalized 4 100 39 537 3 1 37 4 46 3 60 Unemployed or occasional jobs .... Attending school 17 387 3 3 18 104 45 7 90 Employed Unknown Regression in work 135 34 98 3 53 Percent Total 100.0 12.9 68.8 18.3 21.2 Hospitalized . ... 100.0 100.0 100.0 100.0 25.0 37.0 10.3 8.6 75.0 60.0 43.6 72.1 75.0 i 45.0 17.9 16.8 Unemployed or occasional jobs .... Attending school 3.0 46.2 19.4 Employed . Regression in work 100.0 25.2 72.6 2.2 39.3 'Differs significantly from percent in total group (P <.01). 830802—62 11 151

Table 176.—Relation of Wechsler-Bellevue Intelligence Test to Home, Social, and Economic Adjustment Number of men Wechsler-Bellevue Adjustment Intelligence Scale Abnormally deterio- rated <89 90-119 >120 Number Total 683 88 470 125 145 Unsatisfactory: Home 75 138 88 19 22 22 49 98 53 7 18 13 23 39 23 Social Economic Percent Total 100.0 12.9 68.8 18.3 21.2 Unsatisfactory: Home 100.0 100.0 100.0 25.3 15.9 30.8 65.3 71.0 53.8 9.3 13.0 15.4 30.7 28.3 30.8 Social Economic 152

Table 177.—Relation of Adjustment to Minnesota Multiphasic Personality Factors Num- ber of men Scale Status Hs D Hy Pd Mf Pa Pt Sc Ma Percent with abnormally elevated score Total 485 36.9 28.7 31.3 6.6 2.5 1.9 15.5 16.5 4.9 Unemployed or oc- casional jobs Work status 48 31 401 '54.2 29.0 35.4 M7. 9 29.0 26.2 H5. 8 22.6 30.2 6.2 12.9 6.2 6.2 112. 9 1.0 "33. 3 16. 1 13.2 135. 4 22.6 13.7 10.4 School '. Work progress 2.2 3.2 4.5 None 120 69 148. 3 46.4 »39. 2 37.7 36.7 36.2 10.8 1.7 1.4 4.2 '22.5 17.4 125. 0 23.2 5.0 8.7 Regression Advancement, includ- 7.2 287 30.0 22.0 27.5 4.9 2.8 1.4 12.2 11.5 4.2 Depressed, restless, unhaDDv . Home adjustment 37 80 51.4 156. 8 43.2 »32.4 8.1 5.4 132. 4 156. 8 '16.2 Social adjustment Has difficulty "50.0 143.8 '43.8 '12.5 6.3 5.0 128. 8 »33.8 7.5 i Differs significantly from percent in total group (P > .05). 1 Differs significantly from percent in total group (P > .01). 630802—62 12 153