Neonatal Neurobehavioral Examination

A New Instrument for Quantitative Analysis of Neonatal

Neurological Status
ANDREW M. MORGAN,
VERA KOCH,
VICKI LEE,
and JEAN ALDAG

A new neonatal neurobehavioral examination (NNE) was designed in response

to the need for a more quantitative assessment of neonatal neurological status.
The NNE consists of 27 items divided into three sections: 1) tone and motor
patterns, 2) primitive reflexes, and 3) behavioral responses. Each section consists
of 9 items scored on a three-point scale. Fifty-four healthy full-term infants were
examined at 2 days of age and demonstrated total NNE scores ranging from 70
to a maximum possible score of 81 ( = 76, s = 1.03). Mean section scores for
these infants ranged from 25.3 to 26.6 (s = .59-1.79). Intertester agreement was
88% by item and 95% by total score in each section. Two hundred ninety-eight
high-risk infants were then examined at 37 to 40 weeks conceptional age
(gestational age plus chronological age) or at discharge from the neonatal
intensive care unit, whichever occurred first. Total NNE mean scores for high-
risk infants fell into discrete clusters by conceptional age at the time of exami-
nation (37-42 weeks, mean score = 66.5; 34-36 weeks, mean score = 60.7; <34
weeks, mean score = 51.1). Similar clustering occurred for the three section
scores. Highly significant differences existed between the three conceptional
age groups for total scores and section scores. No clinically significant score
differences were associated with severity of illness or gestational age at birth.
The results of this study suggest that the NNE easily and reliably assesses
infants' neonatal neurobehavioral status at a given conceptional age. Additional
studies are in progress to determine the value of the NNE in predicting subsequent
developmental disabilities.
Key Words: Child development; Pediatrics, evaluation; Tests and measurements,
functional.

The field of neonatology has changed
dramatically over the past 25 years, con-
tributing to a steady decline in the mor-
tality and morbidity of smaller low
birth-weight infants.1,2 Despite ad-
vanced technology, however, neonatal
neurological deficits still occur.3,4 The
ability to assess neonatal brain function
and, thereby, to predict neurological
A. Morgan, MD, is Chief, Section of Child De-
velopment, and Assistant Professor, Department of
Pediatrics, The University of Illinois College of
Medicine at Peoria, 530 NE Glen Oak Ave, North
Building, Peoria, IL 61637. Address correspondence
to PO Box 1649, The University of Illinois College
of Medicine at Peoria, Peoria, IL 61656 (USA).
V. Koch, MS, is Clinical Associate, Division of
Child Development, Department of Pediatrics, The
University of Illinois College of Medicine at Peoria.
V. Lee, BS, is Clinical Assistant, Division of
Child Development, Department of Pediatrics, The
University of Illinois College of Medicine at Peoria.
J. Aldag, PhD, is Associate Professor of Medi-
cine, Department of Medicine, The University of
Illinois College of Medicine at Peoria.
This article was submitted April 24, 1987; was
with the authors for revision 17 weeks; and was
accepted March 15, 1988. Potential Conflict of In-
terest: 4.
deficits remains rudimentary. Multiple
risk factors associated with neurological
impairment have been identified, but no
method exists to determine whether a
specific perinatal event has actually re-
sulted in irreversible brain damage.5,6
Cranial sonography performed at var-
ious times during the neonatal course
has been shown to demonstrate struc-
tural abnormalities such as periventric-
ular leukomalacia or cystic changes,7
but the predictive significance of these
findings in terms of irreversible injury is
still uncertain.8
Clinical examination remains the
most effective way to assess neonatal
neurological status. The pioneer work
of Thomas et al in the 1960s focused on
a more classical neurological examina-
tion that emphasized active tone, pas-
sive tone, and primitive reflexes.9
Prechtl and Beintema10 and Amiel-
Tison11 subsequently designed neuro-
logical scales using the data of Thomas
et al9 to assess neonatal maturity. With
the introduction of the Brazelton Neo-
natal Behavioral Assessment Scale
(BNBAS) in 1973, however, the focus
shifted to a more behavioral orientation
that emphasized sensory processing and
interactive responses.12 As interest in
early identification of developmental
problems grew, new neonatal assess-
ment scales emerged that combined
both behavioral and neurological ap-
proaches.13,14
Although many neonatal assessment
scales are currently available to the cli-
nician,15 almost all of them provide a
descriptive, qualitative impression of
neurobehavioral function that is de-
pendent on the skill and experience of
the examiner. This "gestalt" approach
can identify areas of concern but is of
limited value in predicting develop-
mental outcome or assessing the success
of treatment alternatives. Some scales
have been modified to allow statistical
interpretation, such as the "a priori clus-
ters" of BNBAS items by Als et al16 or
the "optimality" scoring of Prechtl,17 but
none of the scales offer the concise nu-

1352 PHYSICAL THERAPY


merical system necessary for quantita-
tive analysis and true standardization.
We attempted to design and standard-
ize a new assessment scale that would
characterize the various aspects of neu-
robehavioral fitness at a given concep-
tional age (gestational age in weeks and
chronological age from delivery in
weeks) with objective, numerical scores.
A quantitative rather than qualitative
assessment of neonatal neurobehavioral
status would be valuable in the identifi-
cation of infants at risk for develop-
mental disabilities and would also pro-
vide a research tool for evaluating early
treatment protocols.
METHOD
Design of the Neonatal
Neurobehavioral Examination
After extensive review of existing ges-
tational age scales and neonatal exami-
nations, we selected 27 items for use in
a neonatal neurobehavioral examina-
tion (NNE) because of their ability to
reflect the distinct changes in neurobe-
havioral function that occur with in-
creasing maturation. Alterations in arm
recoil or prone suspension, for example,
emerge as the infant's muscle tone grad-
ually increases with gestational age.
Grasp, positive support, and other prim-
itive reflexes, and behavioral responses
such as alertness and consolability also
change in quality and intensity as the
infant approaches full term. Almost all
of the assessment items were taken from
the previous work of Thomas et al,9
Brazelton,12 and Dubowitz and Dubo-
witz.13 Other items, such as slip-through
at the shoulders, were added to include
areas of function not addressed in other
assessment scales. Several traditional as-
sessment items were eliminated because
they were either redundant or inappro-
priate when applied to a premature in-
fant. For example, both heel-to-ear and
popliteal angles are measures of hip and
lower extremity tone, so only popliteal
angle was included on the NNE. Be-
cause all high-risk infants are exposed
to the noxious lights and sounds in the
neonatal intensive care unit and must
habituate to them to some degree, we
believed that the BNBAS response-
decrement items were of questionable
value and did not include them on the
NNE. The 27 assessment items were
organized into three sections represent-
ing different aspects of neurobehavioral
status: 1) tone and motor patterns, 2)
primitive reflexes, and 3) behavioral re-
Volume 68 / Number 9, September 1988
sponses. Each section consisted of nine
assessment items.
A three-point scoring system was then
applied to each item. A four- or five-
point system was rejected because we
believed it would result in more subtle
differences in the performance choices
and produce greater scoring indecision
than a three-point scale. A three-point
system simplified the assessment process
and allowed the examiner to choose be-
tween more obvious differences in the
observed performance of each item. The
longitudinal data of Thomas et al9 dem-
onstrated that distinct changes in active
tone, passive tone, and primitive re-
flexes occur at about 32 weeks gesta-
tional age and again at about 36 weeks
gestational age. The resting posture of
an infant, for example, shows absence
of extremity flexion before 32 weeks
gestational age, leg flexion between 32
and 36 weeks gestational age, and flex-
ion of all extremities after 36 weeks
gestational age. Similarly, grasp is weak
before 32 weeks gestational age, reason-
ably strong between 32 and 36 weeks,
and strong enough to lift the infant off
the bed (traction response) after 36
weeks gestational age. The natural evo-
lution of tone and primitive reflexes,
therefore, coincides nicely with a three-
point scoring system.
In the tone and motor patterns and
primitive reflexes sections, a score of 3
reflected responses expected of a full-
term infant (37-42 weeks gestational
age), a 2 reflected responses expected at
32 to 36 weeks gestational age, and a 1
reflected responses expected at less than
32 weeks gestational age. Exaggerated
responses that are generally considered
to be signs of neurological injury (eg,
shoulder retraction, fisting, or equinus)
were included in a separate column and
were assigned a score of 1. The behav-
ioral responses section was divided into
three subtests—responsiveness, temper-
ament, and equilibration—with three
items in each subtest. The three subtests
represented three distinct aspects of be-
havioral performance. Items in the re-
sponsiveness section reflect the infant's
general ability to process and respond to
external stimuli, items in the tempera-
ment section reflect the level of the in-
fant's threshold to noxious stimuli, and
items in the equilibration section reflect
the ability of the infant to return to an
emotional baseline after the stimulation
threshold has been exceeded. The origi-
nal Brazelton scales12 for the selected
items were modified so that a score of 3
consistently represented optimal per-
RESEARCH
formance, and a score of 1 consistently
represented a deficient response. The
original nine-point scoring system was
condensed into a three-point system to
conform to the design of the other NNE
items and to reduce the likelihood of
scoring indecision.
Scores of the 9 items in each section
were summed to provide section scores
in addition to a total score for all 27
items. The maximum total score possi-
ble was 81, and the minimum total score
possible was 27. In the behavioral re-
sponses section, each subtest was also
given a cluster score. The subtest was
assigned a cluster score of 3 if two of the
three items in the subtest were scored as
3, a score of 1 if two of the three items
were scored as 1, and a score of 2 for all
other combinations. This multivariate
scoring system was used at the outset to
improve the possibility of ultimately
finding a marker or combination of
markers predictive of outcome. A scor-
ing sheet was designed with all instruc-
tions and scoring mechanisms on the
front and back of a single page to sim-
plify administration of the NNE
(Appendix).
Standardization
Full-term infants. We reviewed the
records of all admissions to the newborn
nurseries of two local hospitals from
May 1983 to September 1983. Only in-
fants with completely normal prenatal
and perinatal courses were identified as
potential subjects for the full-term infant
standardization of the NNE. Infants
were selected who satisfied the following
criteria: 1) gestational age of 38 to 40
weeks as determined by dates and Du-
bowitz scoring system, 2) serial prenatal
care, 3) no maternal problems (eg, tox-
emia, diabetes, medications), 4) spon-
taneous vaginal delivery without com-
plications, 5) 5- and 10-minute Apgar
scores of 9 or 10, 6) no resuscitation
needed, 7) normal newborn examina-
tion results, 8) normal activity and sleep
pattern in the nursery, and 9) no feeding
problems. These infants were examined
with the NNE at 48 hours postgesta-
tional age midway between feedings in
a quiet, dimly lit area adjacent to the
nursery. Informed consent was obtained
from the infants' parents. A subgroup of
subjects was examined separately by two
of the authors (V.K. and V.L.) within
the same hour to determine intertester
agreement.
High-risk infants. The NNE was sub-
sequently standardized on a randomly
1353
selected group of infants in the neonatal
intensive care unit at Saint Francis
Medical Center (Peoria, Ill) who were
considered to be at greatest risk for de-
velopmental disability. The criteria for
inclusion in the standardization process
were 1) birth weight less than 1,500 g,
2) respiratory difficulty requiring me-
chanical ventilation, or 3) any neurolog-
ical complication (eg, intraventricular
hemorrhage, meningitis, seizures, or
prolonged hypotonia). Infants with con-
genital defects were excluded from the
study. Infants selected to participate in
the study were enrolled in a follow-up
program to monitor their develop-
mental outcome.18
Infants eligible for inclusion in the
standardization process were monitored
by the neonatal intensive care staff dur-
ing their hospitalization. The infants
were scheduled for examination by one
of two therapists (V.K. or V.L.) as they
approached conceptional term (37-42
weeks conceptional age) or at discharge,
whichever occurred first. The examina-
tion was performed as part of routine
care, but informed consent was obtained
from the infants' parents whenever pos-
sible. Because the population included
a combination of infants born in the
hospital and infants admitted after birth,
many infants were discharged or trans-
ferred back to referring hospitals before
they reached conceptional term or be-
fore they could be examined. The NNE
was performed at the infants' bedside
midway between feedings with no spe-
cial preparation. The examination was
postponed if the infant was medically
unstable or had recently experienced an
invasive procedure.
Data Analysis
Full-term infants. Means and stand-
ard deviations of the three section scores
and the total score on the NNE were
determined for full-term infants. Inter-
tester agreement was established both
by total score and by individual item.
High-risk infants. Visual inspection
of the mean total scores (Figure) and the
three section scores for high-risk infants
examined at each conceptional age dem-
onstrated three distinct conceptional age
clusters: 1) 33 weeks of age or less, 2) 34
to 36 weeks of age, and 3) 37 weeks of
age or more at the time of examination.
The infants, therefore, were divided into
these three conceptional age groups in
the subsequent data analysis. We also
divided the infants into three groups by
severity of illness according to the
1354
Figure. Mean total scores of high-risk infants on the neonate neurobehavioral examination
by conceptional age (in weeks) at time of examination.
amount of ventilatory support they re-
quired (<2 days, 2-7 days, or >7 days).
To study the NNE score differences
associated with conceptional age and
severity of illness, four two-way analyses
of variance (ANOVAs) were performed
for each measure (tone and motor pat-
terns, primitive reflexes, behavioral re-
sponses, and total score). Post hoc t tests
were planned if a significant interaction
effect occurred to determine the nature
of the mean differences. If no interac-
tion effect existed, the main effects were
tested and post hoc t tests were used to
determine where the group differences
occurred for any significant main effect.
Because four separate primary analyses
were made, an alpha level of .05 with a
Bonferroni correction19 (0.5/4) yielded
an acceptable level of significance of
.013. The SPSS-PCplus ANOVA and t-
test programs were used.20,21
We also determined correlations be-
tween conceptional age, gestational age,
severity of illness, tone and motor pat-
terns, primitive reflexes, behavioral re-
sponses, and total score. Means and
standard deviations were reported by
conceptional age groups for all four
measures. The SPSS-PCplus CORRE-
LATION program was used.20
RESULTS
Full-term Infants
Fifty-four full-term infants satisfied
the study criteria and were available for
examination. The NNE was completed
and scored for each infant within 15
minutes. A scorable response was ob-
tained for each item on each infant.
Mean age of testing was 46 hours (s = 6
hours) postgestational age.
Means, ranges, and standard devia-
tions were calculated for the three sec-
tion scores and the total score (Tab. 1).
Limited variability in scores existed for
these presumably "normal" full-term in-
fants. Eighty percent of the section
scores were between 25 and 27, with
standard deviations ranging from 0.6 to
1.8. Variability in full-term infants' per-
formance, as reflected by the range of
scores and the standard deviation, was
greatest for behavioral responses and al-
most nonexistent for tone and motor
patterns. No section scores were below
20, and no total scores were below 70.
All behavioral subtests were rated 2
or 3.
Intertester agreement was established
based on paired examinations of 20 chil-
dren performed by two examiners (V.K.
and V.L.) within an hour of each other
(Tab. 2). We found an average of 88%
item agreement and 95% section agree-
ment between examiners.
High-risk Infants
Between May 1983 and June 1985,
298 high-risk infants who satisfied the
inclusion criteria were examined with
the NNE. As with the full-term infants,
the NNE was completed and scored on
all high-risk subjects within 15 minutes.
A scorable response was obtained for
each item on each infant examined.
The results of the two-way ANO VAs
PHYSICAL THERAPY

TABLE 1
Scores of Full-term Infants on the Neonatal Neurobehavioral Examination (N = 54)
Section
Tone and motor patterns
Primitive reflexes
Behavioral responses
Total score
TABLE 2
Intertester Agreement on the Neonatal
Neurobehavioral Examination for Full-
term Infants (N = 54)
Agreement (%)
Section Item Section
by Item Score
Tone and motor patterns 93 97
Primitive reflexes 88 95
Behavioral responses 83 93
are reported in Table 3. No significant
interactions existed for tone and motor
patterns, primitive reflexes, behavioral
responses, or total score. In addition, no
significant differences were associated
with severity of illness. For the concep-
tional age groups, however, highly sig-
nificant differences were found for each
of the four measures. When t tests were
conducted for each measure by concep-
tional age group, significant differences
(p < .001) existed between all three age
groups for each measure. An inspection
of the means by age group demonstrated
that the youngest age group consistently
had lower scores than the older age
groups (Tab. 4).
Consistent with the findings of the
two-way ANOVAs, the Pearson corre-
lation matrix showed that the correla-
tion of conceptional age with each of
the four test measures was significant
(Tab. 5). Similarly, there was no corre-
lation of severity of illness with any of
the four measures. A mild correlation of
gestational age with scores on the tone
and motor patterns section was found.
Although this correlation was not clini-
cally significant, it did reach statistical
significance because of the large sam-
ple size. No other significant correlation
of gestational age with test measures
occurred.
Correlations among the three sec-
tional scores (tone and motor patterns,
primitive reflexes, and behavioral re-
sponses) varied from .498 to .630, indi-
cating a modest amount of overlap be-
tween the scores varying from 24% to
40% (correlation squared) of the vari-
ance. These modest correlations indi-
cate that although some overlap existed
Volume 68 / Number 9, September 1988
s Range
26.6 .59 (25-27)
25.3 1.45 (22-27)
25.5 1.79 (20-27)
76.0 1.03 (70-81)
between the section scores, a reasonable
amount of variance was unique to each
one. Substantial correlations existed be-
tween each section score, with the total
scores varying from .804 to .862. The
variance in total scores was not unex-
pected because the total score is a sum-
mation of the three section scores.
DISCUSSION
The results of the initial phase of
standardization demonstrate that the
NNE provides a quantitative represen-
tation of the multiple aspects of full-
term infants' neurobehavioral status.
The high numerical scores obtained in-
dicate that the actual performance of
the healthy full-term infants coincides
with the theoretical design of the instru-
ment; that is, healthy full-term infants
obtained a score of 3 (the score expected
of a full-term infant) on almost all of
the NNE items. Behavioral responses,
in general, appeared to be more diverse
than the more neurological items. Very
little score variability, nevertheless, was
shown overall.
Analysis of the data on high-risk in-
fants yielded similar encouraging re-
sults. The total means and section
means for all high-risk groups were
lower than those established for full-
term infants. These results are consistent
with growing evidence that even rela-
tively healthy premature infants do not
perform as well when they reach con-
ceptional term as do their full-term
counterparts.19
A very distinct pattern of distribution
for the high-risk scores created three
significantly different conceptional age
clusters (37-42 weeks, 34-36 weeks, and
<34 weeks conceptional age). These
clusters approximated the design of the
three-point scoring system, theoretically
representing performance at greater
than 36 weeks, 32 to 36 weeks, and less
than 32 weeks gestational age. This find-
ing suggests that the NNE as designed
does reflect gestational maturation and
is a quantitative representative of neu-
robehavioral status at a given concep-
tional age.
Additional analysis of the high-risk
RESEARCH
infants' data demonstrated that the
scores appear to depend primarily on
conceptional age at the time of the ex-
amination; gestational age at birth and
severity of illness do not appear to be
major contributing factors to NNE
score. The correlation matrix indicates
a reasonable amount of variance unique
to each section score and supports the
importance of including all three neu-
robehavioral sections on the NNE. No
one developmental area is representa-
tive of neonatal neurological status, and
items assessing these three areas should
be included in any neonatal evaluation
tool.
The NNE, therefore, appears to be an
efficient and accurate assessment of
neurobehavioral status at the time of the
infant's discharge from the nursery. The
NNE is easy to administer to both full-
term and premature infants and has
good intertester agreement. It has an
advantage over previously published
scales in that it offers a numerical rep-
resentation of neurobehavioral status
rather than a gestalt impression. Addi-
tional studies are in progress to deter-
mine the potential clinical applications
of the NNE.
CONCLUSION
The NNE was developed in response
to the need for a more quantitative as-
sessment of neonatal neurobehavioral
status. The 27-item examination meas-
uring tone and motor patterns, primi-
tive reflexes, and behavioral responses
was standardized on a sample of 54
healthy full-term infants and 298 high-
risk infants. The total score and three
section scores varied primarily by con-
ceptional age at examination (gesta-
tional age and chronological age) inde-
pendent of gestational age or severity of
illness. Full-term infants scored higher
on all measures than preterm infants
examined at conceptional term.
Recent federal and state legislation
has mandated that every infant at risk
for possible developmental disabilities
must be identified and referred for ap-
propriate intervention services from the
nursery.22 This identification process
would be enhanced by an examination
capable of assessing neonatal neurobe-
havioral status as a predictor of subse-
quent disabilities. The NNE has been
shown to be an effective and reliable
method of quantifying the neurobehav-
ioral abilities of infants at the time of
examination. Additional studies of the
NNE are needed to establish its predic-
1355
TABLE 3 REFERENCES
Two-way Analysis of Variance by Age Group and Severity of Illness for High-risk Infants 1. Shapiro S, McCormick M, Crawley B, et al:
on the Neonatal Neurobehavioral Examination (N = 298) Changes in infant morbidity associated with
decreases in neonatal mortality. Pediatrics
72:408-415, 1983
P
2. Caron B, Hack M, Rivers A: The very low
df Tone and Primitive Behavioral Total birthweight infant: The broader spectrum of
morbidity during infancy and early childhood. J
Motor Patterns Reflexes Responses Score Dev Behav Pediatr 4:343-349, 1983
Main effect 3. Kitchens W, Keir E, Keith C, et al: Changing
outcome over 13 years of very low birthweight
Age group 2 <.001 <.001 <.001 <.001 infants. Semin Perinatol 6:373-387, 1982
Severity of illness 2 <.153 <.086 <.229 <.098 4. Ross G: Morbidity and mortality in very low
Interaction birthweight infants. Pediatr Ann 12:32-44,
Age group x sever- 1983
5. Siegal L, Saigal S, Rosenbaum P: Correlates
ity of illness 4 <.419 <.535 <.264 <.462 and predictors of cognitive and language de-
velopment of low birthweight infants. J Pediatr
Psychol 7:135-148, 1982
6. Nelson K, Ellenberg J: Neonatal signs as pre-
TABLE 4 dictors of cerebral palsy. Pediatrics 64:225-
High-risk Infants' Mean Scores and Standard Deviations by Conceptional Age Group for 231,1979
7. Weindling A, Rochefort M, Calvert S, et al:
Each Neonatal Neurobehavioral Examination Section (N = 298)
Development of cerebral palsy after ultraso-
nographic detection of periventricular cysts in
Conceptional Age (wk) at Time of
the newborn. Dev Med Child Neurol 27:800-
Examination 806,1985
Section 8. Graziani L, Pasto M, Stanley C, et al: Neonatal
<34 34-36 >36 neurosonographic correlates of cerebral palsy
(n = 21) (n = 138) (n = 139) in the preterm infant. Pediatrics 78:88-94,
1986
Tone and motor patterns 9. Thomas A, Chesni Y, St. Anne Dargassies S:
17.43 20.51 22.57 The Neurological Examination of the Infant.
s 3.25 2.98 2.90 London, United Kingdom, Spastics Interna-
tional Medical Publications, 1960
Primitive reflexes
10. Prechtl H, Beintema D: The Neurological Ex-
17.38 20.28 22.01 amination of the Full Term Newborn Infant, ed
s 3.53 3.06 3.10 2. Philadelphia, PA, J B Lippincott Co, 1984
Behavioral responses 11. Amiel-Tison C: Neurological evaluation of the
maturity of newborn infants. Arch Dis Child
16.33 20.09 21.84
43:89-93,1968
s 3.94 3.82 3.31 12. Brazelton TB: Neonatal Behavioral Assess-
Total score ment Scale. Philadelphia, PA, J B Lippincott
51.14 60.65 66.45 Co, 1984
13. Dubowitz L, Dubowitz V: Assessment of the
s 9.49 8.00 7.45
Preterm and Full Term Infant. Philadelphia, PA,
J B Lippincott Co, 1981
14. Kurtzberg D, Vaughn H, Daum C, et al: Neu-
robehavioral performance of low birthweight
TABLE 5 infants at 40 weeks post-conceptional age:
Correlation of Conceptional Age with Neonatal Neurobehavioral Examination Section Comparison with normal full term infants. Dev
(N = 298) Med Child Neurol 21:590-607, 1979
15. Gorski P, Lewkowicz D, Huntington L: Ad-
CA GA TMP PR BEH TS SI vances in neonatal and infant behavioral as-
sessment: Toward a comprehensive evaluation
Conceptional age (CA) 1.000 .427a .413a .337a .291 a .412a .243b of early patterns of development. J Dev Behav
Gestational age (GA) 1.000 .161b .038 .137 .139 -.222 a Pediatr 8:39-53, 1986
16. Als H, Tronick E, Lester B, et al: The Brazelton
Tone and motor patterns Neonatal Behavioral Assessment Scale
(TMP) 1.000 .573a .498a .804a .020 (BNBAS). Abnormal Child Psychology 5:215-
Primitive reflexes (PR) 1.000 .630a .862a .061 231,1977
Behavioral responses 17. Prechtl H: Assessment methods for the new-
born infant: A critical review. In Stratton P (ed):
(BEH) 1.000 .847a -.029 Psychobiology of the Human Newborn. New
Total score (TS) 1.000 .007 York, NY, John Wiley & Sons Inc, 1982, pp
Severity of illness (SI) 1.000 21-52
18. Cohen H, Morgan A: Neonatal follow-up: A
a
p < .001. regional program. IMJ 170:23-26, 1986
b 19. Godfrey K: Comparing the means of several
p < .01.
groups. N Engl J Med 313:1450-1456, 1985
20. SPSS Incorporated Staff, Norusis MJ: SPSS-
PCplus. Chicago, IL, SPSS Inc, 1985
tive value and ability to measure change correlation of the NNE with develop- 21. SPSS Incorporated Staff, Norusis MJ: SPSS-
in response to intervention protocols. mental outcome to determine the clini- PCplus Advanced Statistics. Chicago, IL,
SPSS Inc, 1985
We currently are conducting a detailed cal value of the NNE in the follow-up 22. Nondiscrimination on the basis of a handicap.
item-by-item analysis of the NNE and a of high-risk infants. Federal Register March 48:9630, 1983

1356 PHYSICAL THERAPY

 RESEARCH
APPENDIX
Neonatal Neurobehavioral Examination Scoring Sheet

Name STATES
1. Deep sleep, no movement, regular breathing
Date of Birth Gestational Age 2. Light sleep, eyes shut, some movement
3. Dozing, eyes opening and closing
Date of Exam Chronological Age 4. Awake, eyes open, minimal movement
5. Wide awake, vigorous movement
Timing of Exam Corrected Age 6. Crying

1 (<32 wk.) 2 (32-36 wk.) 3 (>36 wk.) A (Abnormal)

A. TONE AND MOTOR PATTERNS

POSTURE
(Predominant) opisthotonus
tonic extension
LE flexed, UE
total extension extended total flexion
ARM RECOIL
Infant supine; take difficult to extend
arms and extend jerky flexion
parallel to the body; partial flexion at arms flex at elbow to
hold several secs no flexion within 5 elbow >100° within 4- <100° within 2-3
and release. sec. 5 sec. sec.

Behavioral Responses
SCARF

Responsiveness
Infant supine. Head tonic flexion

Temperament
in midline. Bring arm shoulder retraction

Equilibration
across chest until limited resistance
resistance is met. no resistance past midline at or before midline
POPLITEAL
ANGLE
Infant supine.

C.
Approximate knee

Tone & Motor Patterns

and thigh to
abdomen; extend

Abnormal Patterns

Abnormal Patterns
Primitive Reflexes
leg by gentle
pressure with index
finger behind ankle. 180-135° 90-135° 90-60° <60°

ANKLE
DORSIFLEXION
Infant supine. Flex
foot against shin until

A.

B.
resistance is met. limited 60-90° partial 30-60° complete <30° equinus >90°

PRONE
SUSPENSION

behavioral subtest scored 2, if neither of the above criteria are met

Hold infant in ventral
suspension;
observe curvature of
back and relation of
behavioral subtest scored 1, if 2 of three items are scored 1
behavioral subtest scored 3, if 2 of three items are scored 3
total responses to the 9 items in each area; A scored as 1

head to trunk. complete partial near horizontal tonic extension

SLIP-THROUGH
Hold infant in vertical
suspension under
axillae. Observe
amount of support
required to prevent
score number of abnormal patterns

infant from "slipping." complete partial none shoulder retraction

PULL-TO-SIT
Pull infant toward tonic extension
sitting posture by shoulder retraction
traction on both occasional
arms. complete head lag partial flexion alignment

HEAD RIGHTING
SCORING

Place infant in sitting

position; allow head unsuccessful
to fall forward; wait no attempt to raise attempt to raise head occasional head cannot be
2.
3.
1.

5.
4.

30 sec. head upright alignment flexed forward

Volume 68 / Number 9, September 1988 1357

 APPENDIX
Neonatal Neurobehavioral Examination Scoring Sheet (Continued)
1 (<32 wk.) 2 (32-36 wk.) 3 (>36 wk.) A (Abnormal)

B. PRIMITIVE REFLEXES

ROOT absent mouth opening, full head turning with tongue thrust
partial head turning mouth opening

SUCK weak inconsistent, strong regular clenching-tonic bite

irregular sucking in bursts of 5
or more movements

GRASP absent sustained flexion traction thumb adduction

POSITIVE astasia inconsistent, partial full extension equinus

SUPPORT

WALKING no response some effort but not at least two steps scissoring
continuous with both
legs

CROSSED no response withdrawal and flexion & extension tonic extension

EXTENSOR flexion

MORO no response abduction only abduction & tremor only

adduction

TONIC NECK no response legs only arms & legs respond obligate

CRY absent whimpering sustained cry high-pitched

C. BEHAVIORAL RESPONSES

RESPONSIVENESS 1 2 3

ALERTNESS inattentive or brief moderately sustained and

responsiveness (4 or sustained alertness, continuous
less) may use stimulation attentiveness (7-9)
to come to alert state
(5,6)

ORIENTATION does not focus or inconsistent or jerky sustained smooth

to face & voice follow stimulus, brief following horizontal following 60°
following (4 or less) 30° (5,6) horizontally and
occasionally vertically
(7-9)

DEFENSIVE no response: rooting, head turning swipes with arms

REACTION nonspecific activity
to cloth over face with long latency

TEMPERAMENT 1 - flat 1 - labile 2 3

IRRITABILITY no cry cries to 6 stimuli cries to 4 or 5 stimuli cries to 1-3 stimuli

PEAK OF low level of arousal insulated crying in predominantly state predominantly state
EXCITEMENT never > state 3 response to stimuli 4, may reach state 5 5, reaches state 6
with stimulation with stimulation

CUDDLINESS no molding resists, arches molds with molds and nestles

movement and spontaneously
handling

EQUILIBRATION 1 2 3

SELF-QUIETING cannot self-quiet occasional success, quiets on two or

no sustained crying more occasions
CONSOLABILITY unconsolable consoles with consoles with
holding and rocking; talking or handling
consoling not in crib
COMMENTS:

needed

TREMORS tremors in all states tremors occasionally no tremors or

with aversive stimuli tremors only with
crying

1358 PHYSICAL THERAPY