1034
d NEUROLOGIC OUTCOME SCORES
Neurologic Outcome Score for Infants and Children
Pamela J. Okada, MD, Kelly D. Young, MD, Jill M. Baren, MD,
Soledad S. Raroque, MD, Kenneth R. Huff, MD, Jacqueline B. Wiebe, PhD,
Peter L. Stavinoha, PhD, Roger J. Lewis, MD, PhD
Abstract
Objectives: To develop and validate a practical outcome
instrument applicable to a broad range of neurologic deficits
in children. Methods: Reliability testing of a draft version of
the Neurologic Outcome Scale for Infants and Children
(NOSIC) in 100 children with a wide range of ages and
levels of neurologic function was performed. After review of
the reliability data by a panel of experts, the NOSIC was
revised. Validity and reliability testing of the final NOSIC
was performed in a new population of 157 children, 52 with
cerebral palsy, motor delay, or language delay. Interrater
reliability was assessed using Spearman rank correlation
coefficients of two investigators’ scores. NOSIC scores were
correlated with scores on criterion-standard neuropsycho-
logical tests to assess validity. Results: The median NOSIC
score for normal children was 98, interquartile range 96–100;
Pediatric brain injury is a significant public health
problem in the United States.1,2 Such brain injury may
be traumatic, anoxic (e.g., near-drowning), or in-
fectious. With advances in therapy, many infants
and children who have suffered potentially fatal
insults are now surviving. Although these children
From the Division of Emergency Medicine, Department of
Pediatrics, University of Texas Southwestern Medical Center of
Dallas, Dallas, TX (PJO); Department of Emergency Medicine,
Harbor-UCLA Medical Center, Torrance, CA (KDY, RJL); De-
partment of Pediatrics, Harbor-UCLA Medical Center, Torrance,
CA (KDY, KRH); Harbor-UCLA Research and Education Institute,
Torrance, CA (KDY, KRH, RJL); Department of Emergency
Medicine, University of Pennsylvania School of Medicine, Phila-
delphia, PA (JMB); Department of Pediatrics, Children’s Hospital
Central California, Fresno, CA (SSR); Division of Neurology,
Department of Pediatrics, Harbor-UCLA Medical Center, Torrance,
CA (KRH); Denton Regional Medical Center, Denton, TX (JBW);
Division of Psychology, Department of Psychiatry, Children’s
Medical Center of Dallas, Dallas, TX (PLS); and Division of
Psychology, Department of Psychiatry, University of Texas South-
western Medical Center of Dallas, Dallas, TX (PLS).
Received June 9, 2003; revision received June 9, 2003; accepted June
11, 2003.
Supported by an individual NRSA fellowship grant (5 F32 HS00091)
from the Agency for Health Care Policy and Research (now the
Agency for Healthcare Research and Quality) to Dr. Okada.
Address for correspondence and reprints: Pamela J. Okada, MD,
Department of Pediatrics, Division of Emergency Medicine,
University of Texas Southwestern Medical Center at Dallas, 5323
Harry Hines Boulevard, Dallas, TX 75390-9063. E-mail: pokada@
childmed.dallas.tx.us.
doi:10.1197/S1069-6563(03)00364-6
Okada et al.
the median score for abnormal children was 87, interquartile
range 58–96. Interrater reliability of the NOSIC scores of 84
patients rated by both raters demonstrated excellent re-
liability ( r ¼ 0.77, 95% confidence interval [CI] ¼ 0.62 to
0.88). Correlation of the NOSIC scores of the 127 patients
who had neuropsychological testing with applicable crite-
rion standards was r ¼ 0.63, 95% CI ¼ 0.50 to 0.74.
Conclusions: The NOSIC is a practical, reliable, valid,
instrument applicable to infants and children with a broad
range of neurologic deficits. It should be a useful research
tool when neurologic function is an important outcome
measure. Key words: neurologic outcome; brain injury;
neurologic assessment; child; infant. ACADEMIC EMER-
GENCY MEDICINE 2003; 10:1034–1039.
may survive, the resulting morbidity can be devas-
tating.
Many approaches for improving the neurologic
outcome of children after brain injury are under
investigation, including accurate triage to specialized
centers, medical and surgical therapies, and rehabil-
itation. The efficacy of interventions cannot be
evaluated, however, unless neurologic outcome can
be reliably measured. A recent review of existing
outcome measures for pediatric brain injury identified
a need for versatile, practical, and reliable clinical
instruments for measuring neurologic outcome in
infants and children.3
A number of complex neuropsychological tests to
measure deficits in cognitive or motor function have
been developed and validated.3–8 The need for
specialized expertise on the part of the examiner, the
length and complexity of these instruments, and their
focus on a narrow range of ages or levels of neurologic
function make these instruments largely impractical
for use in clinical pediatric brain injury research. On the
other end of the spectrum, many investigators have
used simple, multilevel scales such as the Glasgow
Outcome Scale (GOS) or the Pediatric Cerebral
Performance Scale (PCPS) to measure neurologic out-
come in children.9–14 These scales are easy to use by the
nonspecialist and cover a broad range of outcomes, but
they do not account for the developmental level of the
child and are often not sensitive enough to detect small,
but important, differences in outcome.
ACAD EMERG MED d October 2003, Vol. 10, No. 10 d www.aemj.org
The purpose of this study was to develop a reliable
and valid neurologic outcome measure for infants and
children, appropriate over a broad range of ages and
levels of neurologic outcome, which could be applied
in a brief period of time by nonspecialist examiners,
and which would account for developmental differ-
ences in cognitive and motor skills by age.
METHODS
The Neurologic Outcome Scale for Infants and
Children (NOSIC) was developed in 4 steps: 1)
creation of a draft instrument; 2) reliability testing of
the draft instrument using a test population of
children with a wide range of ages and levels of
neurologic function; 3) revision of the draft instru-
ment after expert review of reliability data; and 4)
reliability and validity testing of the revised instru-
ment in a new population of children.
Creation of the Draft Instrument. The following
domains of neurologic function were included:
general level of consciousness, current mental status
relative to age-appropriate norms, motor function
(cranial nerves, truncal tone, ability to sit, gait,
extremity strength), visual attention, speech and
hearing, learning and schooling, task attention, social
disinhibition, activities of daily living, and the care-
takers’ perception of the impact the child’s neurologic
status has on his or her activities.
Test items were weighted according to their
perceived importance, based on input from a pediatric
neurologist (KRH), a neuropsychologist (JBW), and
a child development specialist. Scoring of items on the
NOSIC is adjusted for items that cannot be assessed in
individual children. For example, if a child with head
trauma and a long-bone fracture cannot be assessed
for motor activity in the fractured limb, the maximum
raw NOSIC score possible is reduced accordingly. The
total score is then normalized to a maximum of 100,
taking into account the maximum possible raw score
based on all evaluable items. Thus, a score of 100
represents normal neurologic status (a perfect score
on all evaluable items), even if some components
could not be tested for non-neurologic reasons.
Reliability Testing of the Draft Instrument. The
draft instrument was administered to 100 children
with and without prior neurologic diagnoses re-
cruited from the pediatric emergency department
and pediatric clinics at Harbor-UCLA Medical Center,
an academic county hospital, by one investigator
(PJO). A second investigator (KDY or JMB), masked to
the results of the first examination, also administered
the draft instrument to 86 of the children. Interrater
reliability was evaluated using the Spearman rank
correlation coefficient and descriptive statistics of raw
differences between paired scores.
1035
Instrument Revision. The reliability data were sent
to an expert panel for review along with the NOSIC
instrument and an explanation of the scoring system.
The expert panel evaluated the face validity and
content validity, and identified any test items that
were unclear, developmentally inappropriate, or
needed modification. Based on the input of the expert
panel, a number of modifications were made. Mental
status criteria were separated into narrower age
groups. Criteria for deficits in the areas of vision,
speech and hearing, learning, attention, social disin-
hibition, and activities of daily living were defined
separately according to age group. Finally, definitions
of several key terms were clarified, and the scoring
system was modified slightly.
Validity and Reliability Testing of the Revised
Instrument. The revised instrument was adminis-
tered to 157 additional children with or without prior
neurologic abnormalities recruited from the pediatric
emergency department, pediatric clinics, and the
inpatient wards at Children’s Medical Center of
Dallas, a large academic children’s hospital, by one
investigator (PJO). Fluent translators were used for
children and parents whose primary language was
Spanish. The complete instrument, along with a scor-
ing guide, is available as a Data Supplement (Adobe
Acrobat .pdf format) in the electronic version of this
article (at www.aemj.org). A second investigator
(SSR), masked to the results of the first examination,
applied the revised instrument to 84 of these children.
Trained psychometrists supervised by a neuropsy-
chologist administered age-specific, previously-vali-
dated neuropsychological tests to the children as part
of their usual clinical care. These tests were used as
criterion standards in assessing the validity of the
NOSIC. Different instruments were used depending
on the age and level of neurologic function of the
child (Table 1).
Data Management and Statistical Analysis. All
data were collected on a closed-response data
collection form and entered into an electronic data-
base (Paradox version 3.5 or 7.0, Borland, Scotts
Valley, CA). Data were translated into native SAS
format using a translation program (DBMS/Copy,
Conceptual Software, Inc., Houston, TX) and analyzed
using SAS Version 8.1 (SAS Institute, Inc., Cary, NC).
Descriptive statistics were calculated for patient
demographics, and for results of the NOSIC and the
criterion neuropsychological tests. Results of all crite-
rion standards were transformed so that a score of 100
represented normal neurologic status, with an ex-
pected standard deviation of 15. A composite criterion
score was created by combining the Bayley Scales of
Infant Development–II (BSID-II) motor and mental
scores for infants and toddlers \3 years old,4 the score
on the Wechsler Preschool and Primary Scale of
1036 Okada et al. d NEUROLOGIC OUTCOME SCORES

TABLE 1. Criterion Neuropsychological Tests

Measure
Bayley Scales of Infant Development,
Second Edition (BSID-II)4
Wechsler Preschool and Primary Scale
of Intelligence–Revised (WPPSI-R)7
Wechsler Intelligence Scale for Children, Neuropsychological assessment and 100, 15, 90, or higher 6 years and older
Third Edition (WISC-III)6
Mean, Standard
Deviation, Range Characteristics of
Dimension(s) Measured of ‘‘Normal’’ Patients Tested
Neuropsychological assessment and 100, 15, 85, or higher 1 month to 35 months old
intelligence scales measure mental
and motor development
Neuropsychological assessment and 100, 15, 90, or higher 36 months to 5 years,
intelligence scales with 11 subtests, 11 months old
measures cognitive function
intelligence scales with 11 subtests,
measures cognitive function

Intelligence–Revised (WPPSI-R) for 3- to 5-year-olds,7
and the score on the Wechsler Intelligence Scale for
Children, Third Edition (WISC III) for 6-year-olds and
older.6 This allowed the creation of a single criterion
standard over the full age range in the patient popu-
lation. Interrater reliability and validity were quanti-
fied using the Spearman rank correlation coefficient
and by describing the differences between paired
measurements. Bootstrap methods using 2,500 resam-
ples were used to calculate confidence intervals (CIs)
around the Spearman rank correlation coefficients.15
a pre-existing neurologic diagnosis. The observed in-
terrater reliability for all children was r ¼ 0.87; for
children with a neurologic diagnosis, it was r ¼ 0.93.
Numerical differences between the scores of paired
examinations also were examined, revealing a mean
difference of 0.1 (SD ¼ 4.3). Although no formal
validity assessment was performed, it was noted that
the neurologically normal children had a mean score
of 99 (range, 84 to 100, SD ¼ 2.8), whereas those with
a pre-existing neurologic condition had a mean score
of 79 (range, 30 to 100, SD ¼ 22).

Institutional Review Board Approval. The Institu-
tional Review Boards at the Harbor-UCLA Research
and Education Institute and at the University of Texas
Southwestern School of Medicine approved this
study. Written informed consent, in either English or
Spanish, was obtained from parents or legal guard-
ians before the first examination. Written assent was
obtained from older children at Harbor-UCLA Med-
ical Center, as appropriate.
RESULTS
Results from Reliability Testing of the Draft
Instrument. The 100 children examined had a mean
age of 6 years (range, 1 day to 21 years); 19 were
younger than 1 year of age. Forty-eight were con-
sidered neurologically without deficit, and 52 had
Results from the Revised Instrument. The ages of
the 157 children tested with the revised instrument
ranged from 2 weeks to 20 years, with a mean of 65
months (interquartile range [IQR] 18–109 months).
Forty-six percent of the children were female; pre-
dominant ethnicities were African American (35%),
non-Hispanic white (34%), and Hispanic (28%). Forty-
seven percent (74/157) of the children had a history of
prior developmental delay: 38 carried a diagnosis of
motor delay, 34 had learning disability, 21 had
language delay, 12 had cerebral palsy, and 12 had
attention-deficit disorder.
The NOSIC scores ranged from 32 to 100, with
a median score of 97 and a mean score of 90 (SD ¼ 16).
Descriptive statistics for the NOSIC scores and criterion
standards are given in Table 2. Children with a history
of motor delay, language delay, or cerebral palsy were
considered neurologically abnormal (n ¼ 52).

TABLE 2. Descriptive Statistics for the Neurologic Outcome Scale for Infants and Children (NOSIC) and
Criterion Neuropsychological Test Scores
Total Neurologically Normal Neurologically Abnormal

Test n Median (IQR) n Median (IQR) n Median (IQR)

NOSIC, rater 1 157 97 (92–100) 105 98 (96–100) 52 87 (58–96)
NOSIC, rater 2 84 98 (95–100) 65 100 (96–100) 19 95 (88–98)
BSID-II mental scale 64 58 (50–76) 40 60 (54–79) 24 56 (50–74)
BSID-II motor scale 62 69 (52–81) 40 73 (60–83) 22 53 (50–69)
WPPSI full scale 9 70 (57–83) 4 88 (80–98) 5 57 (48–68)
WISC III full scale 55 84 (70–96) 35 94 (77–106) 20 67 (47–83)
Criterion score 127 77 (60–94) 79 87 (72–100) 48 59 (43–77)
NOSIC ¼ Neurologic Outcome Scale for Infants and Children; BSID-II ¼ Bayley Scales of Infant Development, Second Edition; WPPSI-R
¼ Wechsler Preschool and Primary Scale of Intelligence–Revised; WISC-III ¼ Wechsler Intelligence Scale for Children, Third Edition;
IQR ¼ interquartile range. The criterion score is either the composite BSID-II, WPPSI-R, or WISC III score, depending on patient age.
ACAD EMERG MED d October 2003, Vol. 10, No. 10 d www.aemj.org 1037

TABLE 3. Reliability and Validity Correlation Coefficients

Spearman Rank
Correlation
Variables Correlated Subgroups n Coefficient 95% CI
Interrater reliability
Rater 1 NOSIC and rater 2 NOSIC 84 0.77 0.62,0.88
Rater 1 NOSIC and rater 2 NOSIC 0–6 months 9 0.74 *
Rater 1 NOSIC and rater 2 NOSIC 7–11 months 4 1.00 *
Rater 1 NOSIC and rater 2 NOSIC 12–47 months 29 0.61 0.26,0.84y
Rater 1 NOSIC and rater 2 NOSIC 48 monthsþ 42 0.88 0.72,0.95y
Rater 1 NOSIC and rater 2 NOSIC No neurologic abnormality 65 0.73 0.52,0.86
Rater 1 NOSIC and rater 2 NOSIC Neurologic abnormality 19 0.81 0.37,0.96y
Validity
Composite BSID-II and rater 1 NOSIC 63 0.68 0.48,0.81
Composite WPPSI-R or WISC III and rater 1 NOSIC 64 0.66 0.47,0.79
Criterion score and rater 1 NOSIC 127 0.63 0.50,0.74
Criterion score and rater 1 NOSIC No neurologic abnormality 79 0.44 0.22,0.60
Criterion score and rater 1 NOSIC Neurologic abnormality 48 0.72 0.58,0.82
NOSIC ¼ Neurologic Outcome Scale for Infants and Children; BSID-II ¼ Bayley Scales of Infant Development, Second Edition; WPPSI-R
¼ Wechsler Preschool and Primary Scale of Intelligence–Revised; WISC-III ¼ Wechsler Intelligence Scale for Children, Third Edition.
*Sample size insufficient to obtain bootstrapped estimates of the 95% confidence interval (95% CI).
yBecause of sample-size constraints, bootstrapped estimates of the 95% CIs should be interpreted with caution.

Interrater reliability assessed by the Spearman rank
correlation of the paired NOSIC scores in the 84
patients rated by both raters demonstrated excellent
reliability ( r ¼ 0.77, 95% CI ¼ 0.62 to 0.88). Correlation
coefficients for subgroups of patients are shown in
Table 3. The mean difference between the two raters’
scores was 0.02 (SD ¼ 2.57, range
5.6 to 11.1), and the
median difference was 0.
Despite the lack of a common criterion standard
across the range of ages and domains covered by the
NOSIC, validity was assessed by Spearman rank
correlation of the NOSIC scores of 127 patients rated
by PJO, who also had neuropsychological testing with
one of the criterion standards (Table 3). Overall, the
correlation between the NOSIC and criterion stand-
ards was r ¼ 0.63, 95% CI ¼ 0.50 to 0.74 (Table 3,
Figure 1). Besides correlation with criterion standards,
another indication of the validity of the NOSIC is its
ability to differentiate neurologically normal and
abnormal children. The interquartile range (IQR) of
the first rater’s NOSIC scores for neurologically
normal children did not overlap with the IQR for
abnormal children (Table 2).

Figure 1. Each point in the scatterplot represents a patient’s
Neurologic Outcome Scale for Infants and Children (NOSIC)
score by the first or second rater, and the patient’s criterion
score. The intended ceiling effect of the NOSIC, by which all
neurologically normal children are intended to score in the 95–
100 range, is evident. The criterion standards used include
intelligence tests, which differentiate children of average
intelligence from those of above-average intelligence. The
NOSIC is not designed to differentiate these two groups of
children, but to incorporate multiple domains (cognitive,
motor, behavioral, and activities of daily living functioning)
into an overall outcome score.
DISCUSSION
The development of a practical, reliable, valid neuro-
logic outcome instrument is an important step in
forwarding research to improve the outcomes of
children with brain injury. Previous research studies
have used a variety of instruments ranging from
complex neuropsychological tests to simple outcome
scales with a few levels.8,12,16–20 Simple measures are
easy to apply and are applicable to children with
a wide range of ages and neurologic diagnoses, but
provide only broad categories of outcomes. Several
commonly used measures from the psychological
literature offer finer gradations of outcome.3 These
measures, however, are often time-consuming, com-
plex, and specially trained personnel are required to
administer them. Also, they are often only applicable
to children from a narrow range of ages or with
a narrow range of neurologic function and address
only one or a few of the domains of neurologic out-
come: cognitive, motor, behavioral, and function in
activities of daily living. There has been a need for
a neurologic outcome instrument that is easy to use,
1038
can be administered by nonexperts, offers finer
gradations of outcome, is applicable to the entire
population of brain-injured children, and addresses
all the domains of neurologic outcome. The NOSIC
was developed to fill this gap.
Our results show that the NOSIC is a reliable and
valid instrument. Interrater reliability coefficients for
both the draft and final instrument demonstrated
good correlation. Spearman rank correlation coeffi-
cients between the NOSIC and the criterion standards
also showed good correlation. Use of correlation alone
to assess validity likely underestimates the validity of
the NOSIC; however, the NOSIC has an intended
ceiling in that all children without significant neuro-
logic abnormalities should score in the 95–100 range.
Criterion standards that are intelligence tests, such
as the WPPSI-R and the WISC III, are meant to
differentiate groups of children who have both lower-
and higher-than-normal intelligence. Figure 1 dem-
onstrates this ceiling effect, by which children with
normal to higher-than-normal scores on the criterion
standards all scored in the 95–100 range on the
NOSIC. Spearman rank correlation depends on rank
ordering of the 2 groups. Whereas the criterion tests
can order normal to high-normal children well, the
NOSIC, by design, cannot.
The fact that no existing instrument addresses the
needs of the research community in providing an
outcome measure applicable to a wide range of
children and measuring all the domains of neurologic
outcome made it difficult for us to identify a criterion
standard to use for validity testing. We were forced to
use different tests for different age groups, and could
not find tests that adequately addressed all the domains
of neurologic function. Whereas the BSID-II assesses
motor and mental function, the WPPSI-R and the WISC
III assess only the cognitive domain.4,6,7 A criterion
standard that tests all the domains of neurologic
outcome, as the NOSIC does, would have to be created
by combining results of several different tests. This
would create a new level of complexity because of the
need to combine tests with different expected means
and standard deviations and to appropriately weight
the results of various tests, making interpretation of the
validity data even more difficult.
Aside from being reliable and valid, the NOSIC is
also easy to use and can be administered by researchers
without specialized training. Our study has validated
it for a wide range of ages, from infancy to 20 years, and
in children with a wide range of neurologic disabilities.
The NOSIC uses data both from parental report and
from neurologic examination, and assesses all the
domains of neurologic outcome: cognitive, motor,
behavioral, and functioning in activities of daily living.
The NOSIC is nonproprietary, and the full instrument,
along with a scoring guide, is available as a Data
Supplement in the electronic version of this article (at
www.aemj.org), or from the first author.
Okada et al. d NEUROLOGIC OUTCOME SCORES
LIMITATIONS
There are some limitations to the NOSIC, and further
experience with its use may be needed. Reliability and
validity testing was performed in a convenience sam-
ple, and normative data are not yet available. Some of
the authors have used the NOSIC in a study of head-
injured children (Young KD, Okada PJ, Sokolove PE, et
al., unpublished data, 1997), and its use in additional
studies could provide more psychometric data. The
NOSIC also lacks sensitivity to mild deficits, although it
performs as well or better than the neurologic outcome
instruments typically used in studies of pediatric head
injury. Finally, the NOSIC requires a face-to-face evalu-
ation; it cannot be administered by mail or by telephone.
CONCLUSIONS
The NOSIC is a practical, reliable, valid, nonpropri-
etary instrument applicable to children with a broad
range of ages and neurologic diagnoses. It should be
a useful tool for research in pediatric brain injury,
cardiopulmonary arrest, and other disorders in which
it is important to measure neurologic outcome.
The authors thank the members of the expert panel for review of
reliability data of the draft instrument: Katherine Gilbright, PhD,
Kenneth R. Huff, MD, Maureen McMorrow, MD, Steven Roach,
MD, Jacqueline B. Wiebe, PhD, and Jordan Witt, PhD. The authors
also thank Jason Haukoos, MD, for statistical expertise in obtaining
bootstrapped estimates of 95% confidence intervals.
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