Develop. MeA Child Neurol.
1974, 16, 329-335
A Developmental Study of the Asymmetrical
Tonic Neck Reflex
Carol Parr Donald K . Routh Marcia T . Byrd
Introduction
The purposes of this research were to
determine whether the asymmetrical tonic
neck reflex (ATNR) could be quantitatively
demonstrated in normal children, to study
the developmental course of the reflex from
the ages of three to nine years, and to
compare the reactions of children of
different ages to instructions to inhibit the
reflex.
The ATNR was one of three general static
reactions identified by Magnus (1924) in
decerebrate experimental animals. The
nature of the reflex was as follows: when
the animal’s head was rotated to one side,
the arm and leg on that side of the body
extended, while the arm and leg on the
opposite side flexed, producing a typical
‘fencing’ position which was obligatory in
the decerebrate animal and could be seen
in pure form when the labyrinths were
removed. McCouch et al. (1951) demon-
strated in cats that the receptive field for
the ATNR lies in the ipsilateral neck joints.
Magnus also observed the ATNR as a
pathological phenomenon in adult human
neurological patients with extrapyramidal
tract lesions, and it is not uncommon in
children with cortical CNS pathology.
Demonstration of the almost universal
existence of the ATNR in normal human
Division for Disorders of Development and Learning, Child Development Institute, University of North
Carolina, Chapel Hill, North Carolina 27514.
329
Julia McMillan
infants was first carried out by Gesell
(1938). Gesell and Ames (1950) observed
the reflex in fetal babies of 28 weeks’
gestation and also in normal full-term
newborn infants. They felt that the reflex
reached its peak of influence by two months
of age and then gradually disappeared with
the maturation of over-riding cortical
systems. The belief that the ATNR dis-
appears in infancy except in pathological
cases is still current. Paine and Oppt
(1966), for example, state that ‘a strongly
imposable tonic neck reflex after the age
of 6 months, or a completely obligate one
at any age, may be taken as evidence of a
degree of motor decerebration . . .’. Note,
however, that for these authors the em-
phasis is not upon the mere presence of
the reflex but upon its magnitude, and
particdarly its obligatory nature, as a sign
of CNS pathology. Despite common belief,
a number of studies have now been carried
out which demonstrate the existence of the
ATNR in normal adult humans.
In the usual clinical method of testing
for the reflex, the subject is supine; the
head is rotated to one side and the posture
of the extremities is observed. This method
is clearly not the most sensitive one.
Tokizane et al. (1951) demonstrated the
influence of the ATNR on the electro-
 DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
myographic potentials of normal subjects.
In that study the subject was seated in a
chair and required to rotate his head to
one side and then the other. The EMG
readings indicated more electrical activity
in the muscle groups which would be
involved in the ATNR than in other muscles.
One descriptive study of the movement
patterns of athletes (Fukuda 1961) sug-
gested that the more efficient players (for
example, contestants in a fencing match)
actually used A I N R postures more than did
less competent ones. Probably the most
thorough demonstration of the ATNR i n
normal adults was that of Hellebrandt
ef 01. (1962).
Although the ATNR has been abundantly
demonstrated in normal adults. minimal
research has been done with normal
children beyond infancy. If, as the adult
studies suggest, the ATNR does not dis-
appear with age, what is its developmental
course? And what can be said about the
obligatory nature of the reflex in children?
The present study is concerned with these
questions.
Material and Methods
Eighty-four children participated in the
study, including six boys and six girls at
each year from three to nine years of age.
The participation of the children was ar-
ranged either through day-care centres or
through direct contact with their parents.
All of the children resided in the Chapel
Hill, N.C. area, and the sample would be
described as a relatively intelligent and
socially advantaged group, rather than one
representative of the general population.
On the Peabody Picture Vocabulary Test
(Dunn 1965) the children had a mean IQ of
112, with a standard deviation of 17. On
the eight-point Hollingshead (1957) Occu-
pational Scale, the heads of the households
in which these children lived had a mean
rating in the second-highest group (busi-
ness managers, proprietors of medium
330
1574, 16
businesses, and lesser professionals), with
a standard deviation of 1.65 scale points.
The procedure began with the Peabody
Picture Vocabulary Test, and ;I few
questions were asked of the child to be
certain that he would understand the
instructions to be given later. The child
was first asked to point to his elbow. Then
he was instructed to relax his arm so that
his elbow would bend easily. He was then
asked to keep his arm straight and not let
i t bend. If the child was able to follow
these instructions, he was given some
candy as a reward for his co-operation,
and the formal testing was continued.
The child was asked to get down on his
hands and knees. This posture, first sug-
gested by Brain (1927), was found by
Hellebrandt et al. (1962) to provide one
of the most sensitive methods of measuring
the ATNR in adults. The child's head was
placed in the midline so that his face was
parallel with the floor, and the examiner
made certain that the knees and hips were
flexed as closely as possible to 90". The
child was then blind-folded so that he
would not be affected by visual cues. All
of the children went through the rest of the
procedure twice, once under each of the
two different instructions. The first 27
children seen were randomly assigned to
one of two different sequences of instruc-
tions; some were instructed to relax and
then to keep their arms straight and not
let their elbows bend, the rest of these
children were given the opposite sequence
(i.e. told to keep their arms straight and
then to relax). Statistical analysis of this
preliminary data showed no significant
effect of sequence of instructions, either by
itself or in interaction with other variables.
Therefore the remainder of the children
were examined with a single fixed sequence
of instructions, first to relax and then to
keep their elbows straight.
Measurements of both elbows were made
within each instructional condition, first
 CAROL PARR DONALD K . ROUTH MARCIA T. BYRD JULIA MCMILLAN

with the head in neutral position, next with
the head rotated to the right (chin to right
shoulder) and finally with the head rotated
to the left (chin to left shoulder). In each
case, the examiner positioned the child's
head and then reminded him to keep it in
place while measurements were taken. All
measurements of the degree of elbow
flexion were made with a full-circle metal
goniometer. In between the two instruc-
tional conditions, the child was allowed to
remove the blindford and to have a brief
rest.
Results
Analysis of variance was performed on
the data, with between-subjects factors of
age (each age-group from three to nine
years) and sex, and within-subjects factors
of elbow measured (left or right), head
position (left, midline and right), and
instructions (relax or straight). There was
a significant main effect of age (see Appen-
dix for analysis of variance). The nature of
this age-effect was simply that, averaging
all of the measurements taken for each
There was no significant over-all dif-
ference between boys and girls in degree
of elbow flexion, and all of the interactions
between sex and thz other variables in the
study were non-significant.
The two elbows did not, in general,
differ significantly from each other in
degree of flexion. There was a main effect
of head position, the elbows being in
general more flexed when the head was
turned to the left (mean flexion=13") or to
the right (mean flexion= 12") than when
the head was in the midline (mean flexion
=6"). There was also a significant main
effect of instructions, the elbows being in
general more flexed when the child was
told to relax (mean flexion=13") than
when he was told to keep his arms straight
(mean flexion= 7").
The major findings of the study were in
the interactions of the three variables of
the particular elbow measured, the position
LEFT ELBOW
309 r
= I
0 P

/
X

child, the older children tended to hold y

LL 20'1

their elbows straighter than the younger

ones (Fig. 1). The developmental change
was a regular one up to six or seven years,
and then seemed to level off. Age did not I I

interact significantly with any of the other 90' TO LEFT

MIDLINE ROTATED
9 0 - TO RIGHT
variables in the study. HEAD P O S I T I O N

200-
0
,.
., RIGHT ELBOW
W 30" r
_J 15'-
U
3
0
sw 100-

!5
y 5"-
I: - - - ---a
t i l l , I , , I ,
W
n
'0-
INSTRUCTIONS TO KEEP ELBOW STRAIGHT
3 4 5 6 7 8 9
O" ROTATED MIDLINE ROTATED
AGE IN YEARS 9oD TO L E F T 90' TO RIGHT
HEAD POSITION.
Fig. 1. Degree of elbow flexion in chiIdren of
different ages, averaging the measurements made Fig. 2. Degree of elbow flexion as a function of
on each child over all instructional and head- the elbow measured, position of the child's head,
position conditions. and the instructions given to the child.
331
 D H I L D NEUROLOGY.
DEVELOPMENTAL M E D I C I S E A ~ C 1974, 16

of the child’s head, and instructions (Fig.
2). The effects of head position varied sig-
nificantly, depending on whether the left
or right elbow was measured, and the
effects of the different head positions
varied with instructions. The three-way
interaction of the variables of elbow
measured, head position, and instructions
was also significant. However, as already
mentioned, none of these three variables
interacted significantly with either age or
sex.
The upper part of Figure 2 shows the
flexion of the left elbow under various
conditions. When the head was rotated to
the right, the left elbow flexed significantly
compared with the head-in-midline posi-
tion. whether instructions had been to relax
or to keep the arms straight. The left elbow
was more flexed when the head was ro-
tated to the right than when rotated to the
left, whether instructions were to relax or
to keep the arms straight. Unexpectedly,
the left arm also flexed slightly when the
head was rotated to the left, and this was
significant both when instructions were to
relax and when instructions were to keep
the arms straight.
The lower part of Figure 2 shows the
results of flexion of the right elbow under
various conditions. The results for the
right elbow were parallel to those for the
left, with the minor exception noted below.
When the head was rotated to the left, the
right elbow flexed significantly compared
with the head-in-midline position, both
when instructions were to relax and when
instructions were to keep the arms straight.
The right elbow was more flexed when the
head was rotated to the left than when
rotated to the right, whether instructions
were to relax or to keep the arms straight.
When the head was rotated to the right, the
right elbow flexed significantly only when
the instructions were to keep the arms
straight.
Discussion
One of the purposes of this study was a
quantitative demonstration of the ATNR in
children. This was achieved, in that when
the child’s head was turned in either direc-
tion, the contralateral elbow flexed more
than the ipsilateral one. However, the find-
ing that the ipsilateral elbow also flexed
was unexpected and not in accordance
with the typical ATNR pattern found, for
example, by Hellebrandt et al. (1962).
Their adult subjects, also examined in a
quadruped position, were found to extend
the arm ipsilateral to the direction of head-
rotation rather than the slight flexion seen
in the children in the present study. Future
research must examine the effects of pro-

TABLE I
Quantitative standards for the examination of the ATNR in children

,411iounrof change f r o m head-in-midline

Position of hmri Elbopi IneoTiired Weiin Standurd detiatron 98th percentile
___ ________ --___ -_
Inrtriictronc to rdu\
Right Right 1 7’ 14”
Left 17 14’ 45’
Left Right 18 15 49”
Left 3 10’ 23
Instructionc to Xeep elbow struighi
Right Right 1 4” 10‘
Left 6 9” 25‘
Left Right 7 9 25“
Left -
1 5” I1

332
 CAROL PARR DONALD K. ROUTH MARCIA T. BYRD JULIA MCMILLAN

cedural and subject differences between the
two studies in order to discover what is
responsible for this divergent finding.
Possibly the flexion of the elbow contra-
lateral to head movement was a bio-
mechanical reaction, in that the head was
turned so far that the opposite elbow was
pulled into flexion. This is also a possible
criticism of the study by Hellebrandt et al.
(1962), since in photographs included in
the report the heads of the subjects seem
to be rotated rather more than 90". In the
present study, however, every attempt was
made to have the child's head turned only
90"; in addition, the measurement was
made while the child was holding his head
in this position, not while his head was
being passively turned.
The pattern of response of the child to
head rotation did not differ quantitatively
between the ages of three and nine years.
The only significant developmental finding
was that the older children in general held
their elbows straighter than did younger
children. One implication of this finding is
that the reflex changes in the elbow should
be measured as difference scores relative
to the position of the elbow when the head
is in the midline, rather than as an absolute
amount of flexion. The latter would intro-
duce a spurious set of age differences into
the amount of reflex change recorded for
children.
The inhibitory instructions were found
to have a general effect, but not greater for
the older children than for the younger
ones. In general, the children were able to
resist the reflex movement somewhat when
asked to do so but could not completely
overcome it. Thus, even in normal children
it seems that a slight degree of influence by
the ATNR is 'obligatory' and that the
presence of such obligatory movement
should not be regarded as evidence of any
'motor decerebration'.
The major contribution of studies such
as the present one may be to introduce
quantitative standards into the physical
examination of children's reflexes. Table I
provides some tentative norms which might
be used in the examination of the ATNR in
children from between three and nine
years of age. Using this information, one
might amend the statement of Paine and
Oppt (1966) to suggest that in children of
this age an ATNR of over 49", or an obli-
gatory one over 25", may be regarded as
suggestive of some abnormality. It is hoped
that future work may show the usefulness
of such standards in the examination of
children with subtle CNS pathology.
Acknowledgements: This research was supported
by U.S. Public Health Service, Maternal and Child
Health Service Project No. 916 and by Grant
HD-03110 from the National Institute of Child
Health and Human Development. Computer funds
were provided by the Department of Psychology
of the University of North Carolina at Chapel Hill.
Data from the initial 27 children examined in this
study formed the basis of a paper in Physical
Theropy submitted to the University of North
Carolina at Chapel Hill by Marcia T. Byrd.

SUMMARY
The asymmetrical tonic neck reflex (ATNR) was elicited in 84 normal children aged bet-
ween three and nine years. The children were positioned on all-fours and the head was
placed first in the mid-line, then rotated to the right and finally to the left; the positions
of the ipsilateral and contralateral elbows were then measured with a goniometer. The
ATNR was demonstrated in all the children and showed no systematic change with increasing
age. When instructed to do so, the children in all age-groups were able to lessen the amount
of reflex movement, but not to eliminate it completely. Some tentative norms for the physical
examination of the ATNR in children are provided.
333
 DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY. 1974, 16

RESUME
Etude du dfveloppenierit de la rkponse torrique asyme‘trique du cou
I,e reflexe tonique asymdtrique du cou (ATNR) a ttC sollicit6 chez 84 enfants normaux de
trois h neuf ans. Les enfants etaient A quatre pattes, la t&te placCe dans la ligne moyenne
puis tournee vers la droite et finalement vers la gauche. Les ouvertures des coudes ipsila-
tdraux et contra-latdraux etaient alors mesurdes a I’aide d’un goniomktre. L‘ATNRetait
present chez tous les enfants de tous les groupes sans changement avec I’rige. Quand on le
leur demandait, les enfants de tous les groupes pouvaient diminuer I’irnportance du
mouvement rCflexe sans le supprimer complktement. Quelques indications de normes
pour la recherche clinique de I’ATNR chez l’enfant sont indiqudes.

ZUSAMMENFASSUNG
Eine Entwicklungsstudie iiber den asynzmetrisclt tonischen HalsreJex
Der asymmetrisch tonische Halsreflex (ATNR) wurde bei 84 normalen Kindern im Alter
zwischen drei und neun Jahren ausgelost. Die Kinder wurden in VierfuDerstellung gebracht
und der Kopf aus Mittelposition erst nach rechts dann nach links gedreht: die Positionen
der ipsi- und kontralateralen Ellenbogen wurde mit einem Goniometer gemessen. Der
ATXR konnte bei allen Kindern ausgelost werden und zeigte mit zunehmendem Alter keine
Veranderung. Alle Kinder waren in der Lage, auf Anweisung die Starke der Reflexbewegung
herabzusetzen, jedoch nicht vollstandig auszuschalten. Es werden einige empirische Normen
fur die physikaliche Untersuchung des ATNR bei Kindern gegeben.

RESUMEN
Un estudio del desarrollo del rejlejo tdnico del cuello asimktrico
Se estudi6 el reflejo tonico del cuello asimktrico en 84 niiios normales de edad entre
3 y 9 aiios. Fueron colocados a 4 patas y la cabeza primer0 en la linea media, y despues
girada hacia la derecha y finalmente hacia la izquierda, midiendose con un gonibmetro el
angulo del cod0 homolateral y contralateral. El reflejo se demostro en todos nifios de 10s
4 grupos de edad y no mostro ningun cambio sistematico a1 sumentar la edad. Cuando se
les ensefi6 a hacerlo 10s niiios de todos 10s grupos eran capaces de disminuir la cantidad
de movimiento reflejo, pero sin eliminarlo completamente. Se dan algunas normas para el
examen fisico del citado reflejo en niiios.

REFERENCES
Brain. W. R. (1927) ‘On the significance of the flexor posture of the upper limb in hemiplegia, with an
account of a quadrupedal extensor reflex.’ Brain, 50, 113.
Dunn, L. M. ( 1965) Espcmried Mnr2ual: Peabody Pictirr-e Vocabularjs Test. Minneapolis : American Guidance
Service.
Fukuda, T. (1961) ‘Studies on human dynamic postures from the viewpoint of postural reflexes.’ Actn
Oto-lnrjngologica, Suppl. 16 1 ,
Gesell, A. (1938) ‘The tonic neck reflex in the human infant.’ Joirrnnl of Pediatrics, 13, 455.
Ames, L. B. (1 950) ‘Tonic-neck-reflex and svmmetro-tonic behavior: developmental and clinical
aspects.’ Journal ofPediatrics, 36, 165.
Hellebrandt, F. A., Schade, M . , Carns, M. L. (1962) ‘Methods of evoking the tonic neck reflexes in normal
human subjects.’ .4tnc~ricanJoirrnnl of Pli~~siral
Medicine, 41, 90.
Hollingshead, A . B. (1957) Two-Factor Index of Social Position. New Haven, Conn.: Author.
334
 CAROL PARR DONALD K . ROUTH MARCIA T. BYRD JULIA MCMILLAN

Magnus, R. (1924) Korperstellung. Berlin : Julius Springer.

McCouch, G . P., Deering, I. D., Ling, T. H. (1951) ‘Location of receptors for tonic neck reflexes.’Journal
of Neurophysiology, 14, 191.
Paine, R. S., Oppt, T. E. (1966) Neurological Examination of Children. Clinics in Developmental Medicine,
No. 20/21. London: Spastics Society with Heinemann Medical, p. 192.
Tokizane, R., Murao, M., Ogata, T., Kondo, T. (1951) ‘Electromyographic studies on tonic neck, lumbar
and labyrinthine reflexes in normal persons.’ Japanese Journal of Physiology, 2, 130.

APPENDIX
Over-all analysis of variance table

Source of variation Sum of squares df Mean square F

-

Elbow measured (A) 238.19 1 238.19 1.88

Head position (B) 10,406.93 2 5.203.47 69.69t
Instruction (C) 8,645.14 1 81645.14 115.80t
Sex (D) 350.04 1 350.04 1.27
Age (El 17,701.98 6 2,950.33 10.74t
A x B 18,994.73 2 9,497.36 131.78t
A x C 0.06 1 0.06 0.00
BXC 2,024.05 2 1,012.03 19.02t
A x B x C 5,119.12 2 2.559.56 39.98t
A x D 15.75 1 15.75 0.12
B x D 26.73 2 13.37 0.18
A x B x D 101.51 2 50.75 0.70
C x D 276.57 1 276.57 3.70
A x C x D 4.06 1 4.06 0.11
B x C x D 50.20 2 25.10 0.47
A x B x C x D 68.48 2 34.24 0.53
A X E 587.51 6 97.92 0.77
B x E 1,088.21 12 90.68 1.21
A x B x E 1,258.44 12 104.87 1.46
C x E 606.23 6 101.04 1.35
A x C x E 101.37 6 16.90 0.44
B x C x E 489.86 12 40.82 0.77
A x B x C x E 909.32 12 75.78 1.18
D x E ~ 2,890.28 6 481.71 1.75
A x D x E 175.96 6 29.33 0.23
B x D x E 460.32 12 38.36 0.51
A x B x D x E 557.74 12 46.48 0.64
C x D x E 339.08 6 56.51 0.76
A x C x D x E 222.98 6 37.16 0.98
B x C x D x E 348.86 12 29.07 0.55
A x B x C x D x E 231.94 12 19.33 0.30
Error (between Ss) 19,237.86 70
Error (A) 8,874.75 70
Error (B) 10,452.64 140
Error (C) 5.225.8 1 70
Error (A x B) 10;089.42 140
Error (A x C) 2,659.69 70
Error (B x C) 7,450.19 140
Error (A x B x C) 8.963.97 140
Total 147;246.00 1007

335