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OUTCOMES AFTER MINOR HEAD INJURY IN CHILDREN

Tools for the Measurement of Outcome after Minor Head Injury in Children: Summary from the Ambulatory Pediatric Association/EMSC Outcomes Research Conference* Susan Fuchs, MD, Roger J. Lewis, MD, PhD Abstract This article summarizes discussions held during a conference on outcomes research in emergency medical services for children. It provides detailed information on existing outcome measures for pediatric minor head injury. Benefits and/or limitations in their applicability for use in pediatric

emergency medicine and pediatric minor head injury research are highlighted. Key words: pediatrics; outcomes; minor/mild head injury. ACADEMIC EMERGENCY MEDICINE 2003; 10:368–375.

A conference entitled ‘‘Improving Emergency Medical Services for Children (EMSC) through Outcomes Research: An Interdisciplinary Approach’’ was held in March 2001 in Reston, Virginia. This conference was supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, EMSC program, and the Ambulatory Pediatric Association (APA). The goals of the conference were to educate researchers in pediatric emergency medicine (PEM) about the importance of outcomes research, review existing outcomes measures, explore the applicability of these measures to PEM research, and promote a dialogue between health service researchers and PEM investigators. The participants in the conference included investigators in PEM, emergency

medicine, health services researchers, and representatives of federal agencies. As part of this conference, several workgroups were convened to focus on research topic areas and their associated outcome measures. These included: asthma, head injury, pain management, and trauma. In the workgroup focusing on the measurement of outcomes after pediatric head injury, the participants discussed available outcome measures and their usefulness for pediatric patients, designated priority areas where additional outcomes tools are needed, and formulated recommendations for priority research areas. This article summarizes these deliberations. Head trauma continues to be a leading cause of death and disability in children. Every year there are more than 400,000 emergency department (ED) visits related to brain injury.1 Almost 50% of these injuries result from falls, and this mechanism is particularly common for young children (0–2 years).1 Although the majority of head injuries are classified as mild, approximately 10–15% of children sustain a severe head injury. This latter group often develops the most serious long-term disabilities.2 The workgroup members focused on the measurement of outcomes relevant after minor head injury. Minor head injury was defined by a Glasgow Coma Scale (GCS)/Children’s Coma Scale (CCS) score of 13– 15.2 Within this definition, some participants believed that patients with a GCS of 13 are substantially different from patients with a GCS of 15 (more likely to have a clinically important intracranial injury [ICI]), and that there are additional characteristics that indicated more severe injury, such as a loss of consciousness [1 minute.3 Consideration of this heterogeneity even within the population of children with apparently mild head injury is important during the design, selection, or testing of an outcome measure.

From the Department of Pediatrics, The Feinberg School of Medicine, Northwestern University, Division of Pediatric Emergency Medicine, Children’s Memorial Hospital, Chicago, IL (SF); and the Department of Emergency Medicine, The David Geffen School of Medicine at UCLA, Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (RJL). Received August 19, 2002; accepted October 24, 2002. Address for correspondence and reprints: Susan Fuchs, MD, Associate Director, Division of Pediatric Emergency Medicine, Children’s Memorial Hospital, 2300 Children’s Plaza, Box 62, Chicago, IL 60614. Fax: 773-880-8267; e-mail: s-fuchs@northwestern. edu. *The conference entitled ‘‘Improving Emergency Medical Services for Children through Outcomes Research: An Interdisciplinary Approach’’ was held March 30–April 1, 2001, in Reston, VA. It was presented by the Ambulatory Pediatric Association in collaboration with the Emergency Medical Services for Children Program, Health and Human Services Administration, Maternal and Child Health Bureau. Workgroup participants: Sheryl E. Allen, Shireen Atabaki, Peter Baker, Jonathan Bennett, David S. Greenes, James F. Holmes, Pamela Okada, Vidya Sharma, Wendy J. Pomerantz, and Linda Quan.

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ISSUES REGARDING CURRENT OUTCOME MEASURES During the discussion of each outcome measure, the group sought to answer the following key questions regarding the available measures: 1.

2. 3.

4. 5. 6. 7. 8. 9.

10.

11.

Was the outcome measure developed and tested in a patient population similar to the one we hoped to use it in? Was the distribution of severity of illness or level of disability similar to our study populations? Were the settings in which the outcome measure was developed and tested similar to the settings in which we intend to use it? Does the outcome measure have adequate sensitivity and specificity? Is the outcome measure free from significant bias? Does the measure have sufficient precision? Does it have adequate inter-rater reliability? Is the outcome measure valid? What is the respondent burden—the time, energy, and other demands required to complete the outcome instrument? What is the administrative burden—the time and required qualifications of those who administer the outcome instrument? Did the tool require face-to-face contact, only a telephone interview, or could it be based on a chart review?

While we could not answer all of the questions for each measure/instrument discussed, we developed a table of relevant outcome measures, which would assist the workgroup in selecting outcome measures for future studies. The table also helps define specific age groups or populations for which adequate outcome measures/instruments do not exist.

AVAILABLE OUTCOME MEASURES When the available outcomes measure were discussed, parameters of interest included the appropriate age range, the domains tested, who needed to perform the test (administrative burden), the amount of time required (respondent burden), and other issues. Table 1 organizes answers to some of these issues. [Since the conference, several other outcome measures have become available, and are being utilized. These measures are noted in the table by an asterisk (*).]

ADDITIONAL COMMENTS ON SPECIFIC MEASURES Child Health Questionnaire (CHQ). Domains tested by this tool include physical function, social/ emotional role, social/behavioral role, bodily pain, general behavior, mental health, self-esteem, general

369 health perception, change in health, parental impact– time, parental impact–emotional, family limitation in activities, and family cohesion. It can be administered by a parent or child, is scored by a computerized algorithm, using scannable forms, and is useful to track changes in the individual and population status over time. There are long (50, 87, 90 items) and short (28 items) versions, and a toddler version is under development. The 98-, 50-, and 28- item versions are based on parent report, and the 87-item version is based on child report (for children $10 years). It can be self-administered or interviewer-administered.7 –9 Some limitations include no published studies of use in children with traumatic brain injury, and limited data about sensitivity to change over time.6 Functional Independence Measure (FIM). This tool is an 18-item ordinal scale used for children aged [8 years, to monitor progress in an inpatient rehabilitation. It is useful to assess individuals’ ability to perform daily activities such as self-care, sphincter control, transfers, locomotion, communication, and social cognition.12–16 Functional Independence Measure for Children (WeeFIM). This tool was designed to measure independence in self-care, sphincter control, transfers, locomotion, communication, and social cognitive tasks. It is useful for measuring developmental strengths and limitations across health at home, in school, and in the community. It is an 18-item, sevenlevel ordinal scale with levels of independence (score 7 ¼ no helper, to score 1 ¼ total assistance). It has been tested in non-disabled children aged 6 months to 8 years, children with developmental disabilities aged 6 months to 12 years, and for individuals of all ages with developmental disability and a mental age \7 years.9,17,18 Glasgow Outcome Scale (GOS). Only five levels of outcome are defined: death, persistent vegetative state, severe disability, moderate disability, and good recovery. Because we were interested in those with good recovery only, this tool would be too insensitive to detect subtle differences in outcome in the population with minor head injury. It has been used successfully in a number of adult studies of more severe injury.10–12,19,20 Halstead Impairment Indexes (HII) and HalsteadReitan Neuropsychological Test Battery. The HII is based upon the patient’s five core tests that make up the test battery. It includes the Halstead Category test, a measure of abstract reasoning and concept formation; a tactile performance test, which is a form-board with slots in which the blindfolded patient must place appropriately shaped blocks; the seashore rhythm test, where the patient differentiates between 30 pairs

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of tones; the speech sounds perception test, consisting of 60 nonsense words the patient hears on tape and then selects from choices on an answer sheet; and the finger oscillation test, which is a measure of finger tapping speed. The HII is a summary value based on seven scores derived from these five tests.21 Neurologic Outcome Scale for Infants and Children (NOSIC). The NOSIC is intended to allow nonspecialists to obtain a valid measure of the overall neurologic functioning of infants and children. It requires a face-to-face interview and a brief neurologic examination, yielding a numerical score in the range of 3–100 (or 3–80 or 3–90, depending on the age of the child). It can assess neurologic outcome over a wide range of functional levels, but is insensitive to subtle neurologic or cognitive deficits. It has been validated with Bayley infant scales and with standardized intelligence tests.22,23 Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category Scale (POPC). These tools were developed to quantify short-term cognitive impairments and functional morbidity. The POPC scale is dependent on the PCPC scale, as the PCPC status is included in POPC. Scores range from 1 to 6 for both scales with 1 ¼ good, 2 ¼ mild disability, and 6 ¼ brain death. The scales are good for pediatric intensive care unit (PICU) patients, and correlate with PICU length of stay and PRISM (Pediatric Risk of Mortality Score). Studies of patients with scores of 1–4 at PICU discharge, hospital discharge, and one- and six-month follow-up show association with the Stanford Binet Intelligence Quotient, Bayley scales, and Vineland Adaptive Behavior Scale.4,7,24,25 Pediatric Evaluation of Disability (PEDI). This tool assesses functional skills, caregiver assistance, and modification of environment for self-care (15 domains), mobility (13 domains), and social function (13 domains) for children aged 6 months to 7.5 years in a pediatric rehabilitation setting. There are 197 questions, 20 caregiver assistance items, and 20 environmental modification items.9,18 A new version is in development that is designed to be completed by parents or providers, is designed for children 1 to 18 years, and focuses more on community and school participation than did the original version.6 Pediatric Quality of Life Inventory (Peds QL). This tool is useful for measuring quality-of-life measures in healthy children and adolescents (aged 2–18 years) with both acute and chronic problems. It consists of a 23-item modular core with eight physical functioning items, five emotional functioning, five social functioning, and five school functioning items. A seven-item cognitive functioning module can be

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added. It can be done by children aged [5 years, or by the parent for all age groups, and takes less than 4 minutes to complete. It has been tested for reliability and validity, and is responsive to change over time. There are 30 disease-specific modules, such as asthma, diabetes, cancer, and cardiac conditions. It does not measure family function or family impact.9,26 RAND Health Insurance Study (RAND HIS){part of the Health Insurance Experiment–HIE}. This tool looks at functional limitations in physical activity, role activity, self-care activity, and total functional limitations (ages 0–4 years); and mobility, physical activity, role activity, self-care activity and total functional limitations for ages 5–17 years. Other aspects include social functioning, behavior, general health, impact on parent, mental health, and general health perceptions. It can be self- or parent-administered and encompasses 154 questions (0–4 years) and 122 questions (5–17 years).9,27 RAND-36. This tool is a generic health status measurement designed to measure a patient’s quality of life. It measures health from eight domains: physical functioning, social functioning, role limitations due to physical or emotional problems, mental health, vitality, bodily pain, general health perception, and health change. It can be performed by selfadministration (via mail) for those aged $14 years, or by telephone or in person by a trained interviewer. It does not correlate with degree of physical or cognitive impairment.16,27 Vineland Adaptive Behavior Scale (VABS). This tool measures communication, daily living, socialization, and motor skills for children from birth to 18 years. For children under 8 years, it consists of a total of 261 items, which includes 47 communication items, 57 daily living skill items, 38 socialization items, and 36 motor items. The optional maladaptive behavior section has 36 items and is for children aged 5–18 years. The interview is semistructured and takes 30– 60 minutes.4,14,18,19,29 Wechsler Intelligence Scale for Children–Revised (WISC-R). This test consists of 11 subtests: information, similarities, arithmetic, vocabulary, comprehension, digit span, picture completion, picture arrangement, block design, object assembly, and coding (digit symbol). The first six make up the verbal subtests, and the later five comprise the performance subtests. The intelligence quotient (IQ) is derived from these two subtests scores, plus a full scale (all subtests), and is comparable to an overall IQ score. In addition, some research has determined that three separate factors underlie the test: verbal comprehension (information, similarities, vocabulary, and comprehension), perceptual organization (picture completion, picture arrangement, block design, object

Outcome Measure

Age Range

Domains Tested

Characteristics of Tester

Time Required

Comments

References

Infant

Neuropsychological assessment and intelligence scales: mental (Mental Development Index) and motor (Psychomotor Developmental Index)

Tester with specialized training

1 hr

More a measure of developmental status; does correlate modestly with later IQ scores

4

Behavior Rating Inventory of Executive Function (BRIEF)*

2.5–5 yr

Self-administered by parent Self-administered by parent and teacher Self-administered by patient

10 min

More specific than some other measures; sensitive to stimulant medications

5,6

11–22 yr

Assesses functioning such as self-monitoring, organizational control, individual planning; each form has 86 items

Child Health Questionnaire (CHQ)

5–18 yr

14 domains (see text)

Parent/child selfadministered via telephone or in person

Depends upon version

Four versions (28, 50, 87, 98 items); does not include cognitive function; toddler version (\5 yr) in development

7–9

Disability Rating Scale

Older juveniles and adults

Impairment, disability in feeding, grooming, toileting, handicap, employability

Self-administered, 6 medical record review

15 min

Tracks individual from coma to community, low sensitivity for mild traumatic brain injury

10–12

Functional Independence Measure (FIM)

[8 yr

Functional independence and daily activities

In person, or via telephone by trained interviewer

15–20 min

18-item, 7-level ordinal scale; proprietary measure

12–16

Functional Independence Measure for Children (WeeFIM)

6 mo–18 yr (age limits based on population characteristics)

Functional independence in 5 domains

In person, via telephone, non-specialist

15–20 min

18-item, 7-level ordinal scale, measures disability, most useful for 2–5 yr

9,17,18

Glasgow Outcome Scale (GOS)

All ages, but school/ work factors are evaluated

Functional level

In person, via telephone, no specific training

\5 min

5 levels, insensitive, inadequate to distinguish levels of minor traumatic brain injury

10–12, 19,20

Halstead-Reitan Neuropsychologic Test Battery

[18 yr

Abstract reasoning and concept, tactile performance, speech sounds, seashore rhythm, finger oscillation


3–8 hr

WISC-R is often performed with this test battery

21

Neurologic Outcome Scale for Infants and Children (NOSIC)

Birth–21 yr

Mental status, abilities and disabilities, neurologic exam, activities of daily living

Face to face, non-specialist

10–15 min

Not sensitive to minimal or subtle deficits, wide range of outcomes, associated with Bayley infant scales and intelligence tests

10 min 10 min

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Bayley Scales of Infant Development

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TABLE 1. Outcome Measures for Pediatric Head Injury

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22,23

continued

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TABLE 1. Outcome Measures for Pediatric Head Injury (cont.) Outcome Measure

Age Range

Domains Tested

Characteristics of Tester

Time Required

Comments

References 4,24,25

Pediatric Cerebral Performance Category (PCPC)

Birth–21 yr

Short-term cognitive disability after critical illness or injury

Nurse, physician

\5 min

Definitions subject to interpretation; wide range of outcomes (normal to brain death); correlation with length of stay in pediatric intensive care unit (PICU), Pediatric Risk of Mortality Score (PRISM); association with Stanford-Binet Intelligence Quotient, and Bayley (Mental index only)

Pediatric Evaluation of Disability (PEDI)

6 mo–7.5 yr

41 items: 5 domains

Trained professional

45–60 min

Useful in pediatric rehabilitation settings

Pediatric Overall Performance Category (POPC)

Birth–21 yr

Short-term physical disability after critical illness or injury

Nurse, physician

\5 min

Excellent inter-rater reliability, correlation with length of stay in PICU, and PRISM; association with Bayley Infant scales (mental motor) and Vineland (VABS)

Pediatric Quality of Life (Peds QL)

2–18 yr

23 items-specific modules; cognition can be added

Parent/child report forms

\5 min

No family function or impact; good for acute and chronic health conditions

9,26

RAND HIE

Birth–4 yr, 5–13 yr

10 domains (see text)

Parent, self-administered

Depends on age

0–4, 154 questions; 5–13, 122 questions

9,27

RAND SF-36

$14 yr

Patient quality of life in 8 domains

Patient response (mail), via telephone, or in person

36 questions

16,27

Scales of Independent Behavior—Revised (SIB-R)*

Birth–80þ yr

Long form 259 items; short form 40 items; good for early childhood (0–5 yr)

Structured interview or parent checklist

Long form 45–60 min; Short form 15–20 min

Global index of independence based on adaptive (motor, communication, personal living, and community living skills) and maladaptive (internalized, asocial, and externalized) behaviors

6,28,29

Splaingard

Birth–12 yr

Locomotion, self-care, communication

Chart review or via telephone by nurse or physician

\5 min

Four levels: normal to dependent; does not measure cognitive deficits, good for children with orthopedic problems (can use aid or wheelchair)

20,30

4,7,24, 25

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5–105 min

9,18

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assembly), and freedom from distractibility (arithmetic and digit span).32,33

1 hr

Short attention span, motor or visual impairment may alter performance, non-Englishspeaking patients perform poorly

Although the workgroup was able to delineate and discuss the measures listed in Table 1, several key clinical questions require further research and/or the development of new outcome measures. These include:

6–16 yr

3–7 yr

Wechsler Intelligence Scale for Children— Revised (WISC-R)

Wechsler Preschool and Primary Scale of Intelligence (WPPSI)

*Recent outcome measures not discussed at the 2001 meeting.

Neuropsychological assessment and intelligence scales; 11 subtests

Birth–18 yr, 11 mo Vineland Adaptive Behavior Scale (VABS)

Neuropsychological assessment and intelligence scales; 11 subtest measures

Communication, daily living skills, socialization, motor skills; optional maladaptive behavior domain

Infants to adolescents


Short attention span, motor or visual impairment may alter performance, non-Englishspeaking patients perform poorly 1–1.5 hr

Modified version for children \8 yr 30–60 min Interviewer trained in administration and scoring

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DISCUSSION


Requires specialized training to administer and experience to interpret 3–4 hr

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Standardized neuropsychologic tests (various)

Intelligence, language, visuospatial/motor, attention/ memory, academic achievement, social/ adaptive behavior

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Special testing: neuropsychologist, occupational therapist, physical therapist, speech therapist

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1. The development of additional tests for the evaluation of children with minor head injury. Some of the measures listed above may be sensitive enough for the evaluation of these children, but may not be practical. The need for sensitivity to detect small changes is often achieved at the expense of a long battery of tests, which may be difficult to administer in some children. 2. The value of imaging in minor head injury needs further clarification. The American Academy of Pediatrics (AAP) practice parameter on minor head trauma provides for some practitioner variability in the decision to obtain diagnostic imaging, and which diagnostic modality to utilize.35 This practice parameter was developed for use in children aged 2 through 20 years with isolated minor head injury, who were previously neurologically normal. The parameter addresses two patient populations: a) those with minor closed head injury (no abnormal findings on neurological examination, no evidence of skull fracture on physical examination) and no loss of consciousness, and b) those with minor closed head injury with a brief loss of consciousness (\1 minute), a seizure immediately after the trauma, vomiting, or symptoms such as lethargy and headache. The imaging options include none (observation alone), computed tomography (CT) scan/magnetic resonance imaging (MRI), or skull radiographs. The imaging decision is based upon the availability of adequate observation time and personnel (physician office, ED, home), discussions of the health care practitioner with the patient or parents, and imaging modality available (CT scan vs skull radiographs).35 A recent consensus document on the evaluation and management of children younger than 2 years old with minor head trauma tried to help clarify imaging guidelines for the group not covered by the AAP practice parameter.3 For these guidelines, patients were categorized into four groups: a) high risk for intracranial injury, b) intermediate risk with potential risk factors or clinical indicators of brain injury, c) intermediate risk with concerning or unknown mechanism, or findings on physical examination that may indicate an underlying skull fracture, and d) low risk. CT scan was the imaging modality of choice for the high-risk group; observation (4–6 hours) or CT scan for intermediate-risk group b; observation, CT, or

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skull radiographs for intermediate-risk group c; and no imaging for group d.3 3. Cost analysis methods need to be used appropriately. When a cost-effective analysis is performed, many costs must be included. From the standpoint of health care resources: the cost of the ED visit, imaging costs, the cost of observation unit vs admission to an impatient unit, the cost of missed injury, the cost of false-positive tests, and the costs of repeat visits must be included. Non-health care costs include loss of productivity, school problems, caregiver time costs, lost wages (parent), parental anxiety, and patient time.

CONCLUSIONS From the workgroup discussion, several priority areas of research emerged: 1.

Defining strategies for baseline assessment or for adjusting for pre-injury level of functions, when conducting outcome measurements on children who did not have formal testing pre-injury. 2. Development and validation of a standardized assessment battery for use after minor head injury. 3. Development and testing of a grading system for CT scans. 4. Defining the optimal follow-up period for children who have sustained minor head injury (1 month, 1 year, 5 years). 5. Defining clinical predictors of sequelae after minor head injury. 6. Defining a cost structure for decision analysis after head injury. References 1. Weiss HB, Mathers LJ, Forjuoh SN, Kinnane JM. Child andAdolescent Emergency Department Visit Databook. Pittsburgh, PA: Center for Violence and Injury Control, Allegheny University of the Health Sciences, 1997. 2. Gedeit R. Head injury. Pediatr Rev. 2001; 22:118–23. 3. Schutzman SA, Barnes P, Duhaime AC, et al. Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediatrics. 2001; 107:983–93. 4. Fiser DH, Long N, Roberson PK, Hefley G, Zolten K, BrodieFowler M. Relationship of pediatric overall performance category and pediatric cerebral performance category scores at pediatric intensive care unit discharge with outcomes measures collected at hospital discharge and 1- and 6-month follow-up assessments. Crit Care Med. 2000; 28:2616–20. 5. Gioia GA, Isquith PK, Guy SC, Kenworthy L. BRIEF—Behavior Rating Inventory of Executive Function. Odessa, FL: Psychological Assessment Resources, Inc., 2000. 6. Langlois JA (ed). Traumatic Brain Injury in the United States: Assessing Outcomes in Children. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2001. 7. Aitken ME. Morbidity measurement. Proceedings from the National Congress on Childhood Emergencies. Baltimore, MD: Maternal Child Health Bureau/EMSC, Mar 2000. 8. Landgraf JM, Abetz LN, Ware JE. The CHQ User’s Manual, 1st ed. Boston, MA: The Health Institute, New England Medical Center, 1996.

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9. McCarthy ML, MacKenzie EJ, Durbin DR. Children’s health status instruments: their potential application in the emergency department. Amb Pediatr. 2002; 2:337–44. 10. Choi SC, Marmarou A, Bullock R, Nichols JS, Wei X, Pitts LH. Primary end points in phase III clinical trials of severe head trauma: DRS versus GOS. J Neurotrauma. 1998; 15:771–6. 11. Hall K, Cope N, Rappaport M. Glasgow Outcome Scale and Disability Rating Scale: comparative usefulness in following recovery in traumatic head injury. Arch Phys Med Rehabil. 1985; 66:35–73. 12. Wright J, Bushnik T, O’Hare P. The Center for Outcome Measurement in Brain Injury (COMBI): an Internet resource you should know about. J Head Trauma Rehabil. 2000; 15:734–8. 13. COMBI Scales at: http://www.tbims.org/combi/list.html (accessed March 2001 and May 2002). 14. DiScala C, Grant CC, Brooke MM, Gans BM. Functional outcome in children with traumatic brain injury. Am J Phys Med Rehabil. 1992; 71:145–8. 15. Hamilton BB, Laughlin JA, Fiedler RC, Granger CV. Interrater reliability of the 7-level Functional Independence Measure (FIM). Scand J Rehabil Med. 1994; 26:115–9. 16. van der Sluis CK, Kingma J, Eisma WH ten Duis HJ. Pediatric polytrauma: short-term and long-term outcomes. J Trauma. 1997; 43:501–6. 17. Msall ME, DiGaudio K, Rogers BT, et al. The functional independence measure for children (WeeFIM): conceptual basis and pilot use in children with developmental disabilities. Clin Pediatr. 1994; 33:421–30. 18. Msall ME, DiGaudio K, Duffy LC, LaForest S, Braun S, Granger CV. WeeFIM: normative sample of an instrument for tracking functional independence of children. Clin Pediatr. 1994; 33: 431–8. 19. Levin HS, Mendelsohn D, Lilly MA, et al. Magnetic resonance imaging in relation to functional outcome of pediatric closed head injury: a test of the Ommaya-Gennarelli model. Neurosurgery. 1997; 40:432–40. 20. Thakker JC, Splaingard M, Zhu J, Babel K, Bresnahan J, Havens PL. Survival and functional outcome of children requiring endotracheal intubation during therapy for severe traumatic brain injury. Crit Care Med. 1997; 25:1396–401. 21. Gensemer IB, Smith JL, Walker JC, McMurry F, Indeck M, Brotman S. Psychological consequences of blunt head trauma and relation to other indices of severity. Ann Emerg Med. 1989; 18:9–12. 22. Okada PJ, Baren JM, Young KD, Huff KR, Lewis RJ. A reliable and practical instrument for the measurement of neurologic outcome in infants and children [abstract]. Arch Pediatr Adolesc Health. 1995; 149:65. 23. Okada PJ, Raroque SS, Young KD, et al. A validated instrument for the measurement of neurologic outcome [abstract]. Amb Child Health. 1997; 3:205. 24. Fiser DH. Assessing the outcome of pediatric intensive care. J Pediatr. 1992; 121:68–74. 25. Fiser DH, Tilford JM, Roberson PK. Relationship of illness severity and length of stay to functional outcomes in the pediatric intensive care unit: a multi-institutional study. Crit Care Med. 2000; 28:1173–9. 26. Varni JW, Seid M, Kurtin PS. The PedsQL 4.0: Measurement Model for the Pediatric Quality of Life Inventory Version 4.0. San Diego, CA: Center for Child Health Outcomes/Children’s Hospital and Health Center, 1998. 27. RAND at: http://www.rand.org (accessed April 2001 and May 2002). 28. Bruinicks RH, Woodcock RW, Weatherman RF, Hill BK. Scales of Independent Behavior-Revised (SIB-R). Itasca, IL: Riverside Publishing Company, 2002. 29. Hill B. Adaptive and Maladaptive Behavior Scales at: www.isd.net/bhill/compare.htm (accessed April 2001 May 2002).

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33. Donders J. Factor structure of the WISC-R in children with traumatic brain injury. J Clin Psychol. 1993; 49:255–60. 34. Wechsler D. Manual for the Wechsler Preschool and Primary Scale of Intelligence. New York: Psychological Corporation, 1967. 35. American Academy of Pediatrics, Committee on Quality Improvement, American Academy of Family Physicians, Commission on Clinical Policies and Research. The management of minor closed head injury in children. Pediatrics. 1999; 104:1407–15.

30. Splaingard MD, Gaebler D, Havens P, Kalichman M. Brain injury: functional outcomes in children with tracheostomies and gastrostomies. Arch Phys Med Rehabil. 1989; 70: 318–21. 31. Amling JK, Thompson NM, Miner ME. Neuropsychological outcome in children with gunshot wounds to the brain. J Neurosci Nurs. 1990; 22:13–8. 32. Eichelberger MR, Ball JW. EMSC: assessment battery for the brain injured child. Washington, DC: Children’s National Medical Center, 1990.

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