University of Groningen

Neurological development in infancy

Touwen, B.C L

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Touwen, B. C. L. (1975). Neurological development in infancy. [S.l.]: [S.n.].

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 BERT TOUWEN

NEUROLOGICAL DEVELOPMENT

IN INFANCY
 ERRATA

Page 73 footnote: am grateful . . .• read: I am grateful . . .

Page 26 Group IV: A group of Items which did not show . .

read: A group of Items which did show . . .

Page 34 Fifth line from above, table XI and XIII; read: table XII and XIV

Page 35 Third line from below, table XI and XIII; read: table XII and XIV

Page 37 Nlneth line from below, 4 read 3

Page 38 First line above, 2 read 7

S eventh and eighth line from above, table X and XII;
read: table XI and XIII

Page 44 Sixth line from above, 2 and 4, read 7 and 3

Page 49 and 51 Exchange figures 70 and 7 7

Page 49 Seventh line from above, 10, 31 and 21, read 70, 34 and 24

Page 6 7 Heading: Recording: 2. wriggling . . ., read 1. wriggling . . .

Page 78 Table VII: first changes of standing up and of other Items;

read: first changes of standing up and final changes of other Items .. .

Page 88 First line, ... final first changes ... ; read: final and first changes .. .
 RIJKSUNIVERSITEIT TE GRONINGEN

NEUROLOG I CAL DEVELOPMENT IN INFANCY

PROEFSCH RIFT

TER VERKR I JG I N G VAN H ET D O CTO RAAT I N D E

G ENEES K U N D E
AAN D E R IJKS U N IVERSITEIT TE G R O N I NGEN OP G EZAG VAN D E
RECTOR MAG N I FI CUS
D R . M. J . JANSSEN

IN H ET O PENBAAR TE VERD E D I GEN O P

WO ENSDAG 8 O KTO BER 1 975
D ES NAM I D DAGS TE 2.45 UUR PRECI ES.
DOO R
B ERT CHRISTIAAN LOUIS TOUWEN

GEBOREN TE D E N HAAG

D R UKKERIJ G RAS M EIJER & WIJNGAAR D - G R O N I NGEN

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 STELLINGEN

BD de extrapolatie van neurologische verschUnselen en hun

betekenis bD het zich ontwikkelende kind naar de volwassene
en omgekeerd wordt ten onrechte kwalitatieve identiteit
van het kinderiUke en volwassen zenuwstelsel ge"impliceerd.

11 LeeftUdsnormen voor de kinderiUke funktie-ontwikkeling

zUn slechts in beperkte mate bruikbaar voor- de diagnostiek
van hersenaandoeningen.

Ill lnconsistentie gedurende de ontwikkeling van de motoriek

is een karakteristieke eigenschap van het gezonde zenuw­
stelsel.

IV De vraagstelling: ,Veroorzaakt ondervoeding stoornissen in

de ontwikkeling van het centrale zenuwstelsel?" gaat voorbU
aan interacties tussen een toestand van ondervoeding en
direct en indirect daarmee samenhangende andere
omgevingsfaktoren. De vraagstelling dient dan ook te luiden:
,Draagt ondervoeding bU tot het ontstaan van stoornissen
in de ontwikkeling van het centrale zenuwstelsel?"

V Het instellen van fysiotherapeutische behandeling van

motorische stoornissen dient niet te wachten tot een
specifieke diagnose volgens een der klassifikaties van
cerebrale paresen gesteld of uitgesloten is.

VI Gedurende de eerste levensjaren is er geen wezeniUk

verschil tussen fysiotherapie, ergotherapie en logopedie.
De opleidingen van fysiotherapeuten, ergotherapeuten en
logopedisten dient hieraan te zUn aangepast.

VII Zolang er geen deugdeiUke internationale overeenstemming

bestaat over de definitie van hypoglycaemie in de zuigelingen­
periode, is naonderzoek naar de gevolgen van hypogly­
caemie in de eerste levensdagen zinloos.
VIII De door Raine voorgestelde glycine-medicatie bU de
behandeling van een prolinemie type 11 heeft als bezwaar
dat vooral in het pasgeborene-tUdperk de verhoogde
concentratie van glycine in de weefsels een schadeiUke
bUwerking kan hebben.

IX BU het stellen van de indicatie tot partus arte praematurus

dienen intra- en extra-uterine risico's zorgvuldig tegenover
elkaar te warden afgewogen. Vooral de laatste plegen te
warden onderschat.

X Voor de beoordeling van de funktie ontwikkeling van een

prematuur geborene dient diens kalenderleeftUd gecorrigeerd
te warden voor de duur van de zwangerschap.

XI Het verschUnsel dat Nederland aan de top staat van de

Europese landen wat betreft het jaariUks aantal kinder­
slachtoffers van het verkeer, dient o.m. de arts te stimuleren
tot een aktieve houding ten aanzien van de nog steeds toe­
nemende verkeersproblematiek.

XII Aan de omgang met patienten en de stervensbegeleiding

wordt tUdens de opleiding tot arts en tot specialist te
weinig aandacht besteed.

XIII De ambivalentie van vooral de oudere Engelse literatuur­

kritiek ten aanzien van Joseph Conrad is ten dele te
verklaren uit diens positie van Engels schrUvende
niet-Engelsman.

XIV De arts dient zich met polemologie bezig te houden.

XV lronie is de enige mogeiUkheid tot overleven.

Stellingen behorende bU het proefschrift van B. C. L. Touwen.

8 oktober 197 5.
lama is la nature ne no us livrerait ses secrets; elle n' avait pas de secrets;
c' est no us qui inventions des questions, et qui fac;onnions ensuite des
n§ponses: et jamais nous ne decouvrions au fond de nos comues que
nos propres pensees; ces pensees pouvaient au cours des siec/es se
m ultiplier, se comp/iquer, former des systemes de plus en plus vastes et
subtils, jamais el/es ne m' arracheraient a moi-meme.

(Simone de Beauvoir, 1946)

3
CONTENTS

Chapter I : INTRODUCTION 9
p u rpose of the p resent study

C h apter 11 : DESIGN OF THE STUDY 13

p redicti onbands
interrelati o nshi p s

Ch apter I l l : THE CRITERIA FOR THE SELECTION 17

Chapter IV : THE FOLLOW-UP EXAM INATION 21

Chapter V : A S H O RT DESCRIPTION OF THE COURSE

OF THE EXAMINATION 24

Ch apter VI : THE PRESENTATION OF THE RESULTS 26

Ch apter V I I : GROUP 1: ITEMS WHICH DID NOT SHOW

DIFFERENTIATION AMONG THE INFANTS 28
facial i n n ervation 28
pupils 28
optical b l i n k 28
acousti cal b l i n k 28
reacti o n to sound 29
m u scle tone 29
head contro l 30
abdo m i n al ski n refl ex 30
crem asteric refl ex 30
with d rawal reaction 30

Ch apter VI I I : GROUP 11: ITEMS WHICH S H OWED LITTLE

DIFFERENTIATION AND/OR A RAPID
DEVELOPM ENTAL COURSE 32
spontaneous trem o r 32
tremor d u ri n g Mora-reactions 33
conj u gatio n of eyemovem ents 33
fi xati on time 34
visual p u rsuit m ovements 34
co nvergence of the eyes 35
p u p i l l a ry reacti o n to co nvergence 36
corneal refl ex 36
d o l l ' s eye p h enomenon 36

4
 rotati o n test 37
l i p-tap response 37
recoi l of the e l bow 38
b i ceps refl ex 38
ankl e j erk 38
step p i n g m ovem ents 39

C hapter IX G ROUP I l l : ITEMS WHICH S H OWED AN·EVIDENT

D EVELOPMENTAL S EQUENCE 41
Observatio n of posture and motility 43
spontaneo u s posture a n d motil ity of arms a n d l egs 43
sponta neous m oti l ity of the l eg s i n verti cal suspension 48
goal-di rected m oti l ity of a rm s an d h a n d s 50
typ e of vo l untary g ras p i n g 54
coord i n ati o n of the upper extremities 57
posture of head, tru n k a n d a rm s i n p ro n e pos itio n 58
l o com otion i n p ro n e position 61
ro l l i n g over fro m supine i nto p ro n e pos itio n 64
ro l l i n g back from p ro n e i nto s u p i n e position 67
spontaneous hea d l ift i n su p i n e position- 68
sitti n g u p 69
d u rati o n of sitti n g 71
postu re o f t h e tru n k d u ri n g sitti n g 75
stan d i n g u p 77
wal ki n g 79
Reactions and Responses 82
rooti n g refl exes 82
asym m etri c ton i c n eck responses 84
p a l m a r g rasp refl ex 86
reaction to push agai nst the s h o u l d er d uri n g sitti n g 89
fo l l owi n g of an o bj ect with the eyes a n d rotatio n
o f h e a d a n d tru n k when s itti ng 91
opti cal p l aci n g reaction of the h a nds 92
p a rach ute reaction of arms and h a n d s i n p rone
suspension 93
opti cal p l acing reaction of the feet 94
footso l e response 95
acousti cal o rienti n g 99
t h e M o ro reacti o n 1 01

5
Chapter X : GROUP IV: ITEMS WITH SO MANY INCONSISTENT
CHANGES DURING THE FOLLOW-UP PERIOD
THAT A D EFINITE DEVELO PMENTAL
SEQUENCE COULD NOT BE ESTABLISHED 1 09
Observation of p osture a n d motility 1 09
spontaneous posture of th e h ands 1 09
posture of head and tru n k d u ri n g p rone suspension
(Lan dau) 1 10
Reactions and Responses 1 12
reaction to tacti l e sti m u l ati o n of the dorsum
of h a nd and fi n gers 1 12
p a l m omental response 1 13
knee j erk 1 14
a n kl e clonus 1 15
p l antar g rasp 1 15
m agnet response 1 16
crossed extension response 1 16
positive supporting reacti o n 1 17
tacti l e p l ac i n g of the feet 1 18
Schaltenb ran dt- reacti o n 1 19
Bauer-reaction 1 19
G a l ant response 1 20
th reaten- refl ex 1 20

Chapter X I : ANTH ROPOMETRIC AND PSYCHOSOCIAL ITEMS 1 23

b ody wei g ht 1 23
b ody l e ngth 1 23
sku l l ci rcu mference 1 23
fontanels 1 23
vocal izati o n and speech 1 24
sm i l i n g 1 25
reaction to stra ngers 1 25
lacri m ation 1 26

C hapter X I I . : SEX DI FFERENCES 1 27

Chapter XI I I : THE PARAMETERS- INTRA-ITEM RELATIONS H I PS 1 31

Chapter XIV : INTER-ITEM RELATIONS H I PS 1 38

Chapter XV : DISCUSSION AND CONCLUSIONS 1 48

6
 TAB LES
Tab l e I : Some stu d i es of i nfanti l e responses p u b l i s h ed
after 1 950 10
Tab l e 11 : O ccup ati o n or vocati o n a l tra i n i n g of the fathers 18
Tab l e I l l : Item s which d i d not show d ifferenti ati o n a m o n g the
i nfants (group I) 28
Tabl e IV : Items which s howed l ittl e d ifferenti ati o n a nd/o r
a rap i d develop m ental cou rse (group 11) 32
Tabl e V : Items which s howed fai r differenti ati o n a n d a n
evi dent developm ental sequence ( gro u p I l l) 42
Tab l e VI : Co rrel ati on-coeffi cients (p < 0.0 1 ) of rel ati o n s h i ps
b etwee n the fi n a l c h an ges of spontaneous m otil ity
of the l egs and the fi rst changes of some other items 48
Tabl e VI I : Corre l ation-coeffi ci e nts (p < 0.01 ) of rel ati o n s h i ps
b etween the fi rst chan ges of standi n g u p and
th e fi n a l changes of oth er items 78
Tab le VI I I : Items with m any i n con s i sten cies a n d a p rotracted
devel o p me ntal cou rse so that a d efi n ite
develop m ental sequence cou l d not be estab l i s h ed
(g ro u p IV) 1 14
Tabl e IX : Anth ro p o metric items 1 23
Tab l e X : Psychosoci a l items 1 23
Tab l e X I : Item s w h i c h showed s i gn ificant sex d iffere nces
in the favou r of the b oys 1 28
Tabl e X I I : Items w hi ch showed s i g n ificant sex differe nces i n
th e favo u r of t h e g i rl s 1 28
Tabl e XI I I : Means a n d standard devi ati o n s o f the ite ms i n which
t h e b oys were s i g n ifi cantly advanced compared
with the g i rl s 1 29
Tab l e XIV : Means a n d standard devi atio n s of the items in which
t h e g i rl s were s i g n ifi cantly advanced co m p a red
with the b oys 1 30
Tabl e XV : Corre l ation-coeffi ci ents (p < 0.01 ) of i ntra-item
rel ati o n s h i ps of the items of g ro u p I l l ,
i n c l u d i n g sp eech d evelopment 1 36
Tab l e XVI : Items without a ny s i g n ificant rel ati o n s h i p s (p < 0.0 1 )
with other items with reg a rd t o fi rst chan ges 1 4Q
Tab l e XVI I : Items without a ny s i g n ificant rel ati o n s h i ps ( p < 0.01 )
with oth er items with regard to fi na l changes 1 42
Table XVI I I : Item s without any s i g nifi cant relatio n s h i p s ( p < 0.01 )
with oth er items with reg a rd to developm ental ran ges 1 43
Tab l e XIX : The n u m be r of i ncon s i sten cies and the n u mb e r of
i nfants with i n co nsi stencies of the items of g ro u p I l l 1 45

7
APPENDICES

Appen d ix A: Criteria fo r opti m al obstetri cal co nditions.

Appendix B: C riteria for neonata l neuro l o gi ca l o pti m a lity.

Appendix C: Means, standard d evi ations, coeffi ci ents of skewn ess

and kurtosis fo r the items of gro u p I l l , i n cl u d i n g speech
deve l o p ment.

Appen d ix D: Correlation-coeffi ci ents (p < 0.0 1 ) of the rel ati o nshi ps

b etween the fi rst a n d fi n a l chan ges o f the items of gro u p
I l l.

Appendix E: Correl ation-coeffi ci ents (p < 0.01 ) of the interre l ation­

ships of the fi rst changes of the items of gro u p I l l .

Appendix F: Correl ation-coeffi cients (p < 0.01 ) of th e i nterrelati on­

ships of the fi na l chan ges of the items of gro u p I l l .

Appen d ix G : Corre l ation-coeffi ci ents ( p < 0.01 ) o f the i nterre lation­

ships of the developmental ran ges of the items of g ro u p
I l l.

Appendix H: Co rrel atio n-coefficients (p < 0.01 ) of the rel atio n s h i ps

b etween the developm enta l ra n ges and the n u m ber of
i n co nsistencies of the items of g ro u p I l l .

Appendix J: Vari ati o n ra nges of the fi rst a n d fi na l chang es and the

n u m be r of i n co nsi stencies of the i tems of gro u p I l l .

8
Ch a pte r I Introduction

I n the l ast few decades a peri o di cal eva l uation of the co ndition of i nfants
has becom e customa ry. Besides general pediatric s u pervis i o n and advice
con cern i n g feed i n g-qual ity and -sched u l e, a l so the condition of the ner­
vou s system h as g rad u a l ly beco me a focus of i nterest. Th i s has bee n
sti m u l ated by s everal c l i n i ci a ns and p hysioth erapi sts who stated that
early d i agnosis of a devi ant n eu ro l o g i ca l deve l o pment often m i n i m alizes
i nval i dati on at old e r ages, b ecause of t i m ely treatm ent and pa rent­
counsel i ng .
Early d i agnosis p resupposes a n eu ro l o g i ca l e.l(a m i n ation-tec hni qu e ,
wh i ch enab l es the exam i n e r t o p ronounce upon the i ntegrity of the ner­
vous system. As fo r such a tech n i q u e the exa m i ner m ust take i nto
rega rd the s pecific p ro p erties of the i nfanti l e n ervo us system , and the
techn iq u e shou l d b e based o n knowl edge of the neura l mech anisms
u nderlyi n g th e m a n ifestations of n ervo us activity. I n this respect a
d i stinction s h o u l d be m ade b etween the n eo natal period a n d subseq u ent
i nfan cy, b ecause m u ch wo rk has been done to i l l um i n ate the neuro l o gy
of the fo rm er, wh i l e o u r knowl edge of the neu ro l o gy of subsequent i n ­
fan cy i s co n s iderab ly sma l l er.
Among the very fi rst who paid attention to the newborn i nfant from a
n eu ro log ical p o i nt of view was Andn3-Th omas. After a who l e l ifetime
spent on adult neuro l o gy, h e turn ed to the newbo rn i nfant at an age, at
wh ich the m ajo rity of p eo p l e reti re.
Because a l l h i s l ife he h ad wo rked with adult neu ro l o gical pati ents, i t i s
n ot s u rp ri s i n g that h i s app roach t o n ewb o rn i nfants w a s stro n gly affec­
ted by h i s con cepts of the adult nervo u s system . H i s work was of g reat
val ue b ecaus e it stressed the n ecessity of p ayi n g attentio n to the u p
til l t h e n rather negl ected fi e l d o f neonatal n e u ro l o gy (An d re -Tho m as a n d
St. A n n e D a rg assi es, 1 952) .
G radua l ly it beca m e c l ea r that i n deal i n g with an i nfant' s n ervou s system
knowl edge of adult neu ro l o gy was not suffi cient. Thi s i s the reason why
Prechtl b ased his extens ive work o n an onto genetic concept, givi n g
ful l cred it t o t h e specific p rop erties o f t h e i nfant's n e rvo us system (see
eg. Prechtl , 1 956, 1 960; P rechtl and Bei ntem a , 1 964). His work i n du ced
h i m to design a neu ro l o g i cal exa m i n ation tec h n i q u e fo r the fu l lterm
n ewborn i nfant, a n d it sti m u l ated fu rth er research on i nfan cy a n d chi ld­
hood, n ow cal l ed devel o p menta l n e u ro l o gy. Schu lte's approach to n ee­
n atal neuro l o gy o ri gi n ated i n n e u ro-phys i o l o gy, espec ia l ly th at of the
s p i n a l cord, as i s refl ected i n his ch apter o n the n eu ro lo gical develop­
m ent of the neonate i n " Sci entifi c Fou ndati ons of Paedi atrics" (Davis
and Dabbi n g , 1 974) .
Contrary to the extensive knowl edge concern i n g the n ewbo rn i nfant,
m uch l ess is kn own about the neural m echanisms and th ei r developm en­
tal cou rs e throu g hout i nfan cy, altho ug h Pei per (1 961 ) was able to com-

9
TABLE I
Some studies of i nfantile responses publ ished after 1950
Babki n , P. S. (1 960) Foot sole response
Brai n , R . and Wi l kin so n, M . (1 959) Foot sole response
D i etri ch , H. F. (1 957) Foot sole response
Ho lt, K. S . (1 961 ) Foot so l e response
l n g ra m , T. T. S. (1 962) Feed i n g reflexes
Lam ote de G ri gn o n , C. (1 955) Mo ro
Linden, J. (1 969) P l antar g rasp
MacKeith , R . C. (1 964) Step p i n g m ovements
MacKeith , R . C. (1 964) Pl aci n g reactions
M itch el l , R . G. (1 960) Moro
M itchel l , R. G. (1 962) La ndau
Pa ine, R . S . , Brazelton , T. B.,
Donovan , D . E., D ro rbau g h , J . E.,
Hubbell, J . P. and Sears, E. M. (1 964) Po stu ra l reactions
Pa i n e, R . S . (1 963) Postural reactions
Parm elee J r. , A. M. (1 964) Mo ro
Poeck, K. (1 968) Pa l m a r g rasp
Prechtl , H . F. R. (1 958) Feed i n g refl exes
Twitchel l , Th . E. (1 970) Pal m a r g rasp
Vassella, F. , and Karl sso n, B. (1 962) Asym m etri c to n i c neclc refl ex
Wolff, P. H. (1 968) Sucki n g
Zape l l a , M. (1 966) Pl aci ng reactions
Zape l l a , M. (1 967) Pl aci n g reactions and p l a ntar grasp
Zel azo, Ph. R . , Zelazo, N. A.
and Kol b , S. (1 972) Step p i n g movem ents

pound a su bstanti al vo l u m e on the development of the nervo us system

i n i nfancy.
Th i s val uab l e work conta i n s a g enera l su rvey of the litteratu re ti l l about
1 960, b ut it co nsists m a i n ly of an encyclopedic co l l ection of s i n g l e neu­
ro lo gical item s . As the titl e of h i s book shows, ("D i e Eigenart der kind­
l i chen H i rntatigkeit") Pei p er co nsidered the i nfanti l e bra i n tho ro u g h ly
different from the adult b ra i n , but in h i s book he o n ly records a co l l ec­
tion of i nfanti l e reactions and responses.
Th e book l acks a critical evaluation and fo rm u l ation of a methodo logical
co ncept. lt is, therefo re, not surp ri s i n g th at Peiper d i d not bel i eve i n the
possi b i l ity of a c l i n ical neuro l o g i cal assessment of the i nfant (persona l
co m m u n i cation to P rechtl , 1 957). Altho u g h a carefu l report of vario u s
studies is g iven i n h i s b o o k , l ittl e attenti o n i s paid to such issues a s
u n ifo rm ity of defi n ition, and standard i zati o n and operatio n a l i zati o n o f the
m ethods. Th us it is very d iffi cult for the reader to compa re the results of
the variou s stud i es. Fu rtherm o re, co m p ari son with fi n d i n gs of mo re re­
cent stu d i es, such as l i sted i n tab l e I , is co m p l i cated by the differences
in rea ri n g attitudes consequent to differences i n i deas of co nsecutive
generati ons of p arents and exa mi ne rs.

10
S u ch a generati on-effect m ay i nfluence feed i n g- m ethods and -contents,
health-care in general and m odes of tra i n i n g and rea ri n g d u ri n g infancy, r

as i s strik i ngly evi dent i n the case of, fo r i nstance, prematures. The ef­
fect of s u ch d ifferen ces on the m a ni festations of nervous devel opment
i s u n kn own. As for the stu d i es l i sted i n tab l e I, operati o n a l i zati o n , and
stan d ardi zati on of tec h n i q u e and recordi n g , as wel l as cri teri a fo r sam­
p l i n g of the s ubj ects and defi niti o n s of the respo nses, a re d u ly repor­
ted i n the m aj ority of cases. Neverth eless defi n itions and p rocedu res
often vary wi dely, which h ampers co m p ari s o n .
Li ke Pei per, M cG raw (1 943) w a s i nterested i n the development of n er­
vous fu n cti ons, whi ch she ca l l ed " n euro muscu l ar m aturati o n " . Wh i l e
Peiper restri cted h i m self t o col l ecti n g items without b u i l d i n g u p a spe­
cific fra m e of reference, M cG raw started from a d i fferent a n g l e.
She co l l ected l on g itu d i n al d ata on the m aturatio n of a set of m otor item s ,
s u c h as postu re and l o co motion, and responses s u c h as g raspi n g a n d
m o roreactions. S h e t h e n tried t o exp l a i n the vari ous and co nsecutive
p h enomena which she observed, with respect to the th eo retical concept
of " Cerebra l i zati o n " or " Co rti cal i zati o n " . Th i s con cept i s partly b ased
on Cogh i l l's i n divi d u a l ization theo ry (1 929) , partly o n the mo rp h o l o g i ca l
a n d h i stol o gical b ra i n stud ies o f Ti l n ey (1 937 , cited by M cG raw) a n d
Conel (1 939, 1 94 1 , i dem). H er wo rk i s sti l l o utsta n d i n g i n its exqu i s ite
obs ervation and descripti o n of ch anges occurri n g in several m oto r
p henomena d u ri n g d evelopment. McG raw d i d not i ntend to des i g n a
n eu ro l og ical exa m i n ation, or to p o i nt the way to neuro lo gi cal d i agnoses.
She m erely tried to com p rehend the chan g i n g activity of the b ra i n
d u ri n g development i n th e l i ght of the o nto gen etic i deas of her t i m e .

Qui te a d ifferent a p p roach i s to b e observed i n the wo rk of G esel l , who

was i nterested i n the development of overt b eh avi o u r. He defi ned beha­
viour as an exp ression of activity of the nervo us system. H e stated ex­
p l i citly that he stu d i ed the development of behavi o u r i n o rder to arrive
at a diagnosis of the developm ental status of a c h i l d , whi ch in h i s
o p i n i o n reflected th e degree of i ntegrity of t h e ch i l d's n ervou s system .
H e i nterp reted deviant b eh avioural develop ment i n term s of neuro l o g i cai
i m p a i rm ent, i n acco rd ance with h i s theory that behavioura l development
i s b ased on i n n ate m echanisms of m aturati o n of the nervo us system
(Gesel l , 1 954).
Unti l to-day G esel l 's wo rk h as had a g reat i m pact on m any su bsequ ent
wo rkers, such as G riffiths (1 954), l l l i n gwo rth (1 966), B ayley (1 969), Knob­
loch, Pasam anick and S h erard (1 966), Franke nb urg a n d Dodds (1 967)
a n d oth ers.
lt was his g reat m erit that he showed that system ati c a n d accu rate o b­
servation and testin g of i nfants yields i m p o rtant i nfo rm atio n about their
fun cti o n a l developm ent. But h e did not offer an exp l i cit form u l ation of
the ways in wh ich the nervo us system generates b eh aviour. Therefo re
Gesel l ' s tech n iq u e for " developmental diagnosis" (G esel l a n d Arma­
truda, 1 947) i s not a neuro l o g i cal exa m i n ati o n i n the stri ct sense.

11
A recent approach to develop mental testi n g with an i m p l icit evaluati o n of
the nervo us system was fo rwarded by Zdanska-Brincken and Wo lanski
(1 969). They descri b ed a g raph i c method for the eval u ation of m otor
d evelopm ent, which has the m erit of d i sti n g u i s h i n g g ross fu n cti o n a l
areas of develop m ent s u c h as respectively devel o pment i n p ro ne, su­
p i ne and vertical positi o n . However, they l i m ited themselves to a me re
description of fu ncti onal development.
S u m m a rizi n g we m ay con cl u de that the knowl edge of the development
of the nervous system d u ri n g i nfancy is l i m ited to scattered i nform atio n
about s i n g l e items, b ut that a mo re p rofo u n d u ndersta n d i n g o f t h e neu­
ral m echanisms d u ri n g a ch i l d ' s developm ent, especial ly after the new­
born period, is sti l l needed.

Purpose of the p resent study

To form u l ate the p u rpose of the study which is presented here, is as
i m p o rtant as stati n g exp l i citly what it is not meant to be.
Fi rstly this study repo rts a descri ptive a na lysi s of the developme ntal
course of a series of items, such as used i n neuro l o g i cal and d evelop­
m ental assessment i n infancy, especi a l ly d u ri n g the fi rst yea r of l i fe.
Seco n d ly a n an alysi s of th e chan ges occu rri n g i n the functi o n a l organi­
zati on of the neural mechanisms thro u g ho ut devel opm ent wi l l be fo rward­
ed: the developmental chan ges wi l l be considered as the vari ab les
which m ay g ive i n s i g ht i nto the o rganizati o n of neural mecha n i s m s .
For th i s p u rpose a g ro u p of l ow-risk infants has b e e n selected carefu l ly.
Low-risk i nfants were chosen in o rder to m i n i malize a possi b l e i n c l u s i o n
of infants with i m pa i red nervo us system s . I n this gro u p of infants the
developmental co u rse of a set of items is an a lysed, as wel l as the p re­
sence or absence of coherence. The resu lts of this study wi l l be useful
fo r a better u n dersta n d i n g of maturi n g b ra i n mech a n i s m s and, at a l ater
stage, for th e des i g n of a tech n i q u e for neuro l o gi ca l diagnosis and
developmental testi n g p roced u res.
The p resent study does not p reten d to g ive norm s fo r the neuro l ogical
develop m ent i n i nfan cy, as the size and selecti o n of the g ro u p of i nfants
p recludes the use of the resu lts as norm ative data. Neither does it su g­
gest a desi g n for th e neuro l ogica l exa m i n ation. lt me rely p resents a se­
lection of items p otenti al ly rel eva nt for a com p rehensive exam i n ation­
tech n i q u e and it i l l u strates the difficu lties and p robl e m s p resent i n neu �
ro logical and developm ental assessment d u ri n g i n fancy.

12
C h a pte r 1 1 D e s i g n of the study

In a s m a l l and stri ctly sel ected but extensively documented group of

l ow-ri sk i nfants, a l a rg e n u m b er of items of the n e u ro lo gi cal repertory
was assessed l o n gitu d i n a l ly at fou r-weekly i nterva ls.
D eta i l s on the selection-criteria of th e sam p l e wi l l b e given i n chapter
I l l , and on th e exam i n ation-procedure in chapter V. The g ro u p co nsi sted
of 51 i nfants, 28 boys an d 23 g i rl s .

A deci si o n had t o b e m ade concern i n g t h e l e ngth of t h e fol l ow-u p . Al­

tho u g h it seemed attractive to use calendar-age as a cutti n g-poi nt, the
wel l-known i nter- i n d ividual vari ations in fu n cti onal d evelopment m ad e
th is criteri on l ess appro p ri ate. Therefo re it w a s decided u p o n t o fix o n
a d evelop m ental m i l eston e , na mely the age of wal k i n g free fo r a t l east
seven p aces, as the l i m i t of the fo l l ow-u p . Conseq uently the size of the
g roup decreased g radu a l l y after the c h ro n o l o g i ca l age of about one
year.

Predi ctio n bands

A p resentation of the actua l percentages of th e g roup cou l d b e con si­
dered as m i s l eading, as a g reater a n d m o re gen eral s i gni fi cance wou l d
b e attached t o s u c h d ata than i s j ustified. Therefo re, i t was decided to
p resent 80 0/o p redicti o n b a nds, which show al l th e poss i b l e sco res ob­
tain ed by at l east 80°/o of the i nfants at the consecutive assessments.
Beside the 80°/o p red i cti o n b a n d , the fu l l ran g e of scores, i.e. scores
obtained by 1 00°/o of the i nfants, wi l l be g iven . The p rediction bands
i l l u strate the general developmental co u rse of the items a n d the i nter­
i n divi d u a l overl ap of scores occu rri n g at comparabl e ages. The cuttin g­
p o i nt of 80o/0 was chosen a rb itrari ly. Fo r the rel atively s m a l l g ro u p of
i n fa nts examined, this l i m i t gave scope for suffi cient d ifferenti ati o n . At
th e same ti m e th e effect of extremely fast o r s l ow d evel o pm ent, as oc­
curri n g i n some i nfants, on the vari ati o n of sco res was m i n i m al i zed. As
for these i n fa nts, a com p l ete variati o n ran g e of the s cores (i.e. 1 00°/0
predi cti on b a n ds) i s added.
It s h o u l d b e stressed that a 80°/o p rediction band m ay not b e i dentifi ed
with th e b an d-wi dth b etween the 1 Oth and 90th centi l es . The p rediction
bands m ai n ly visualize the trend of the developm ent. They p resent the
scores which are o bta i ned by the m aj o rity of the i nfants at consecutive
ages. Th e position of the p rediction b an d o n the time-axis i n d i cates the
t i m e cou rse of the developm ent, its l e ngth refl ects the rate of develop­
m ent, a n d its width descri bes the n u m ber of scores which can b e found
i n th e g rou p of i n fants at one com pa rab l e age.
Fi nally the shape of the p rediction bands i n di cates the developme ntal
course of the item s, by showi n g th e sequence in which i ndentifi ab l e
scores m ay b e obta i ned co nsecutively d u ri n g t h e peri o d of developm ent.

am grateful to Prof. Dr. W. Molenaar for bringing to my attention the potential value of prediction
bands.

13
 Type of voluntary grasping

<J>

�
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

1 1
exam.
1 1 1 r 1 1
0 3 6 9 15 18 21
age,months
Fig. 1 :
Type of vol u n tary gras pi n g : exam ple of prediction bands. Key for f i g . 5-20, 23-44.
Vertical ax i s : scor i n g scale of the res ponse.
Horizontal axi s : n u m ber of follow-u p exa m i nations from the neo natal per i o d
o nwards.
Below the horizontal ax i s the corre s po n d i ng t i m e scale in m onths i s drawn u p .
T h e dark-s haded area re presents t h e 80% predicti o nba n d for this i te m , i .e . the
scores at particular exa m i n ations obtained by at least BO% of the i nfants . The
l i g ht-s· h aded areas o n each side of the dark-s haded o n e represent the scores
obta i n e d by the rest of the i nfan ts , so that the dark-s haded and l i g ht-sh aded
areas together represent the scores obta i ned by the total grou p of i n fants
( i . e . 1 00o/o) .

As an exa m p l e of a p rediction band, in fi g. 1 the development of the type

of vo l u ntary gras p i n g is p resented. The poss i b l e scores d u ri n g the de­
velop mental cou rse are given verti cal ly, i n this i nstance a seven p o i nt
score (th e exact mea n i n g of these sco res is given on page 54 in the
paragra p h on the developm ent of this item) .
On the h o rizontal axi s the number of exa mi nati ons is give n ; as the exa­
m i n ations took p l ace once per fou r weeks, the nu mber of exa mi n ati o n s
rep resent t i m e g raded i n fou r-week interva l s.
A time scale i n m o nths is drawn up so that one may calcu l ate the i n ­
fant' s age. Th e dark-shaded area demonstrates the 80°/0 p rediction ba nd,
wh i ch m eans th at a t t he exa mi nation i n q u esti o n a t l east 80°/0 of the i n­
fants g ot th e sco res i n d i cated b y t he dark shad i n g . The l i g ht-shaded
areas on both sides of the 80o/0 p rediction bands give the fu l l range of
scores obta i ned by the infants at each exam i n ation . Fo r i n stan ce, at the
4th exa m i nati on at l east 80°/0 of the infants obtai ned a sco re 0 o r 1 , as
i n d i cated by the dark shad i n g . As is clear fro m the absence of l i ght
shad i n g , other sco res were not given , which i m p l i es that at this exami­
nation a l l infants o btai ned a sco re 0 or 1 . Yet the n u m ber of infants ob­
tai n i n g a score 0 or a score 1 , respectively, i s not i n d i cated. lt is m erely
stated that at th is exa m i n ation, at the age of about fo ur months, the i n ­
fants m ay obtain a 0 o r a 1 , i . e. de not g rasp vol u ntari ly o r h ave just
started to do so. An analogous situati on ari ses at the 1 2th exa mi na­
tion, when a l l the infants were fou n d to score 3, 4, 5 or 6. At the eighth

14
exa m i n ation (age about 7% mo nths) at l east 80°/0 of the i nfants scored
2 or 3, as i s i n di cated by the dark-shaded area, whi l e the rest of the
i n fants rnay sti l l score 1 o r a l ready score 4, as is i ndi cated by the l i ght­
s h adea a rea.
At the fifteenth exa m i n ation (age about 1 4 m o nths) at least 80% of the
i nfants obta i n ed a sco re 6, i .e. the fi na l sco re as defi ned fo r thi s item
i n this stu dy, wh i l e m axi m a l ly 20% of the i n fants sti l l sco red 3, 4 o r 5.
Fi n al ly, at the 1 8th exa m i n ation (age about 1 7 mo nths) all i nfants were
fou n d to score 6 .

A final rem ark m ust b e m ade concern i n g the p res entatio n of the predic­
tion b a n ds. As the i n fants i n study were fo l l owed-up til l they wal ked
without any support, the size of the g roup depended on th e developmen­
tal rate of this m otor fu n cti o n . Conseq uently from the 1 2th exa m i n ation
onwards, i . e. after about 48 weeks , the total n u mber of i n fants decreased
steadi ly. The 80°/0 p redicti o n bands were cal c u l ated fo r the actual si ze of
the g rou p at the specific exam i n ation ti m e, so that after one year of age
the percentag es were calculated fo r d i fferent n u m bers of i nfants . Con­
sequently the s h ape of the bands at the end of the time sca le i s often
rather i rreg u l ar. N everthe l ess it was decided not to n o rm a l i ze the per­
centages to the size of th e o ri g i na l g ro u p (N = 5 1 ) , as the response of
the items obtai ned at the age of wal k i n g without support co u l d not be
said to b e the fi n a l , stable response in all i n stances (i n the case of e.g.
th e footsol e respon se).
Moreover, the m aj o rity of th e neuro l o g i cal items s howed their develop­
m ental course with i n th e fi rst year of l ife, so that the p redicti o n bands
a re l ocal ized on the time sca l e m a i n ly i n the peri od i n which the size of
th e g rou p had h a rdly changed. The actual n u m ber of i n fants exa mi ne d
i s g iv en i n fi g u re 3.

I nterrelationships
As wi l l be reported l ater the items co u l d be divided i nto fo u r categori es;
the criteria were : the d i fferenti atio n a m o n g the i nfants, and the possibi­
l ity of defi n i n g an evi dent devel o p m ental sequence du rin g i nfan cy. An
evi dent develop m ental sequence was taken to be p resent if the fi rst de­
velop m ental change and the final change (i.e. stabi l i zati on) of th e res­
p onse d u ri n g the period of study cou l d be defi n ed u nequ ivocal ly.
Stab i l i zati on m eans either the defin ite d i sapp earance of a response,
such as the p a l m ar g rasp reflex, or th e p resence of a so-ca l l ed " m ature"
response such as for i nsta nce wa l ki n g without h e l p in the case of l oco­
motion as the end of th e developm ental co u rse.

A fifth category was added which comprised a few items such as body
l en gth, sku l l c i rcumference, sm i l i n g and speaki n g , which co u l d not be
i n c l u ded i n any of the oth er categori es .

15
Fo r the items which differentiated suffi ciently among the infants and
which sh owed a wel l defi ned developm ental sequence, fo u r parameters
were established:
a. th e age of the fi rst change of the response
b . the age of the fi nal ch ange of the response
c. the length of the developm ental cou rse, i . e. the amount of time be­
tween fi rst and final chan ge, measured as the n u m ber of fou r-week
interval s .
d. t h e n u m ber o f i nconsistencies occu rri n g d u ri n g t h e developmental
co u rse of the item. I n consistencies were defi ned as tem porary rel ap­
ses into a form er developmental p h ase, refl ected by scores appro­
pri ate to a yo u n ger age.

For the analysi s of the developm ent of neurolog ical p h enomena d u ri n g

i nfancy, these parameters were chosen because they characteri ze each
s i n g l e item in term s of early versus l ate developm ent, fast or s l ow de­
velopment and consistency of developm ent. They enabl e the exa m i ner
to determ ine wheth er an early o r late fi rst change l eads to an ea rly or
l ate sta b i l i zati on of a response or reaction, which means that the ti m e
needed for t h e d evelopment i s fai rly co nstant, or whether, i rrespective
of the mom ent of the fi rst developm ental change, the moment of fi nal
stab i l izati on i s more or less fixed i n time.
lt is also possi b l e to determ i n e a poss i b l e relation between the l e n gth
of time needed fo r the devel opm ent of an item (exp ressed in the devel­
opmental range) and the occu rrence of i n consistencies d u ri n g develop­
ment (see fu rth er chapter X I I I).

Categorization of the items accord i n g to co mpara b l e i nterrelationships

between thei r parameters and i nterpretation of these interrelationships
m ay serve to i n crease i n s i ght i nto the dyna m i cs of neuro l o g i ca l devel­
opm ent. Beside an analysi s of the i nterrel ati onships between the fo u r
param eters o f each s i n g l e item, t h e i nterrel atio nships between parame­
ters of different items were analysed in order to expl o re the existence
of a coh erent fra m e i n which the m aturati on of the centra l nervo us sys­
tem a n d the functi o n al m otor developm ent fits.
For th is an alysis only the items with an evident developm enta l seq uence
were used and the intercorrelati ons of each of the fo u r pa ram eters
were calculated. In th i s way we tried to fi n d and defi ne cl usters of items
wh ich were compara b l e with respect to time of onset and end of devel­
opment, rate of devel opment and consistency of development. Such
cl usters, if present, m ay yield i nform ati on about the p ro g ram m i n g of the
brain d u ri n g developm ent.

16
C ha pter Ill The criteria for selection

The criteria fo r selectio n of t he i nfants were :

I . Low-risk pregnancy and delivery
Extensive i nform ati o n about p regnancy a n d delivery was o btai n ed
from the m other, an d if necessary th i s i nformati o n was checked with
th e doctor or m i dwife wh o attended h er. Th e i nformati o n was record­
ed on a p receded form . Th e o bstetri cal data, o btained fro m the
moth e r (natural ly data about th e condition of th e p l acenta for i n stan­
ce cou l d o n ly rarely b e gained) were checked with the o pti m al ity
ran ges as defi ned by Prechtl (1 968). An obstetrical optim a l ity-sco re
was then calc u l ated by cou nt i ng the n u mber of o pt i m a l obstetrical
conditi o n s . Th i s m ethod of eva l u ation of th e o bstetri cal h isto ry m akes
it possib l e to q u a ntify the cou rse of p regnancy and del ivery.
As P rechtl ( 1 968) h as p o i nted o ut, it is d iffi cult to d efin e the wei ght
of obstetrical co m p l i cations. lt i s m u c h easier to d efi n e an o ptim a l
ran ge, i . e. the q u a l ity of obstetri cal conditions wh i ch refutes any
doubt about thei r i ntegri ty.

Obstetric score N= 51
p .9

0 __.__

35 33
score
Fig. 2 :

The p recentage d i stri bution o f the obstetrical o ptimal ity scores.

Vertical axis: n u m ber of infants expressed as the percentage of the total g ro u p
(N = 5 1 ).
H o ri zontal axis: n u m b e r of o pt i m a l o bstetrical conditions.

17
 Moreover, Prechtl could show that non-optim a l conditions, i . e. o b ste­
trical conditi o n s outside the o pti m a l range, which h ave cl i n i cal s i g n i ­
ficance on ly ra rely o c c u r as isol ated p h enomena. I n the present
study, in which cases of m ajor o r overt obstetri cal compl i cations
were exc l u ded b efo rehand, the obstetri cal o pti m a l ity-sco re enabl ed
us to scrutin ize the o bstetri cal h i story of the i nfants. I n appendix A
th e opti m a l ity rages, as defi ned by Prechtl (1 968), a re give n.
Fi g . 2 sh ows t h e p ercentage d i stri b uti o n of th e obstetri cal o pti m a l ity­
scores of the g ro u p . As can be seen, al l the infants bel o n g to an ob­
stetri cal l ow- risk g ro u p .
11. The low-risk neonatal neurological examination
The n eon atal neuro l o g i ca l exa m i n ation was carried out accord i n g to
the m ethod descri bed by Prechtl a n d Bei ntema (1 964). The neuro lo­
gical fi n d i n g s were compared with the criteria g iven by these a uthors.
O n the basis of these criteri a an o pti m a l ran g e was defi ned fo r the
respon ses of the exa m i n ation. By cou nti n g the n u m ber of opti m a l
co n ditions, i . e. fi n d i n gs with i n t h e o pti m a l range, a neuro l o g i ca l o pti­
rnal i ty-score was determ i ne d .
�ppendix B shows the criteri a fo r n eo natal neuro l o g i cal opti m a l ity.
Al l 51 infants m et these crite ria. Th u s the infants of the study can b e
co n s idered a s not o n ly b e l o n g i n g t o an o bstetri cal low-ri sk g roup
but a l so to a n eu ro lo g ical ly opti m a l g ro u p with respect to the neona­
tal exa m i n atio n .
I l l . A l l t h e infants were sel ected fro m a ho mo geneous socio-eco n o m i c
cl ass, i n order t o e l i m i nate varian ces i n development d u e t o thi s
issue as m u ch as possi b l e. l t i s genera l ly u n derstood that socio­
eco n o m i c cl ass does not affect the rate of development i n i nfancy, at
l east in Caucasian p o p u l ations, wh i l e it does affect development af­
ter i nfancy. (H i n d l ey, 1 960, 1 96 1 ; Bayl ey, 1 965; Francis-Wi l l i a m s a n d
Yu l e, 1 967). Sti l l d i scussions o n this subject conti n u e (see fo r in­
stance Knobloch a n d Pasa m a n i ck, 1 963). N el i gan and Prudham (1 969)
i n thei r l o n gitudi na l popu l ati o n study in Newcastle upon Tyne fou n d
that there w a s a s i g n ificant rel ati o n s h i p between soci o-econ o m i c
c l a s s a n d t h e m i l esto ne o f wal k i n g without suppo rt.

TABLE 11

Occupation o r vocatio nal tra i n i ng of the fathe rs

Academ i c trai n i n g: doctors, chem i sts, p hysicists, etc. 36
H i gher occupati onal trai n i n g: arch itects , accou ntants, etc. 5
Managers and busi ness peop l e 4
C hief-agents 2
Pu b l i c servants 2
Tech n icians 2
51

18
 I n view of these fi ndi n gs it seemed advisab l e t<P keep the pa ra m eter
of socio-econom i c class con stant. Th e socio-eco n o m i c c l ass chosen
was the u p p er-m i d d l e cl ass, determ i n ed by the father' s occup ati o n
(Tabl e 11). I n this cl ass rep eated assess ments cou l d b e carri ed out
without too m u ch diffi culty and i n H o l l a n d feedi n g- and caretakin g
attitudes cou l d b e exp ected t o b e rather ho mogeneous i n thi s soci o­
econom i c c lass.
IV. lt was n ecessary that the n u m ber of b oys and g i rl s was nearly equal.
Th ere are o n ly few d ata ava i l ab l e about th e exi stence of d ifferences
of develop m ental rate during i nfancy b etween b oys and g i rl s .
I n gen eral these data point t o a h i gher vul n erab i lity of boys com p a red
with g i rl s to different kinds of a dverse co n d itions, whi ch m ay b e re­
fl ected in the deve l o pm ental cou rse. Accord i n g to Zachau-Ch ri stian­
sen ( 1 972), in n o rm a l i nfants b o rn at term th e d i ffere nces in m oto r
development a re very s m a l l at t he age of o n e year. N e l i ga n a n d
P rudham (1 969) reported differences for sp eech d evelo pment o nly.
S m ith 's data, reana lysed by H i nd l ey (1 967) s u g gested that g i rl s wa lk­
ed s i gn ificantly ea rl i e r tha n boys ; these d ata were m a i n l y b ased o n
n o n-caucasean p o p u l ations. Neither B ayley (1 965), nor H i nd l ey e t a l .
( 1 966) , n o r Francis-Wi l l i am s a n d Yu l e (1 967) fou n d substantial sex­
d i fferences b etween b oys a n d g i rl s d u ri n g th ei r d eve lo pment.
In the p resent study a l l the i tems of the exa m i n ati o n were checked
on poss i b l e d ifferences in deve l o p ment due to sex, b efo re the d e­
velopmental course was an a lysed i n the total g ro u p. To serve thi s
p u rpose care was taken that i n the sam p l e boys a n d g i rl s were re­
p resented about e q u al ly.
V. The i nfants were not related to each oth er; a l l of them were D utch
n atives, s o that th e re are no cu ltura l and racial i nfl uences on the de­
vel o p m ent (see a l so Touwen, 1 974).
VI. From a gen era l pediatri c p o i nt of vi ew the i nfants were i nconspicious
at b i rth. In al l the cases a m edical exa m i n atio n was carri ed o ut by
th e fam i ly d o ctor in the fi rst m onth after b i rth . O n l y if the resul ts of
th i s exam i n ation p roved n o rm a l , was the i nfant kept in the g ro u p.
Non e of the i nfants h ad t o b e exc l u ded d u e to abnorm a l fi n di n gs
by th e fam i ly doctor.

19
 N
cf' 28-

24-
-

20 -
-

16 -

12 -
-

8-

4-
-

0
-

I
I
I
I
I I I I,I 11
I 11 I I I I I
I I
I
I I I I
4 I I
8

12

16

9 20

1111 1111 Ill I 1111 1111 Ill I Ill I Ill I Ill I 1111 Ill I Ill I
N 1 2 3 4 5 6 7 8 9 10 11 12
cJ' 28
4Nweek periods
24

20

16

12

12

16

9 20

1111 Ill I Ill I Ill I Ill I Ill I Ill I Ill I Ill 1111 Ill I Ill I
13 14 15 16 17 18 19 20 21 22 23 24
F i g . 3: 4Nweek periods
The frequ ency-distri bution of the assessmentS' du ring the consecutive fou r-week
peri ods.
Vertical axi s , u pper part : n u mber of the boys ; l ower part: n u mher of the g i rl s .
H orizontal axiS': n umber of fou r-week periods, each of which i s g raded i n
fou r s i ng l e wee, k s.
D u ri n g e ach fou r-wee k period each i nfant was assessed o n ce. Ti l l the twel fth
four-week pedod the tota l g ro u p consisted of 28 boyS' a n d 23 girls; from the
twelfth fou r-we e k peri1od o nwa rds the nu mber of b oys a n d g i rls g rad ually
decreased.
Chapter IV The fol low- u p exa m i n ation

The i n fants were exa m i ned at ho me i n their o w n envi ro n m ent wi th fou r­

weekly i n terval s , i n o rder to keep the e nvi ro n mental co n d iti on s i ntra­
i n divi d u a l ly as con stant as possi b l e. T h e i nfants h a d a m p l e tim e to
adjust themselves to the exa m i n er' s p resence. Th e m other was p resent
during t h e exa m i n ation.

l t was n ot possi b l e to exa m i n e a l l th e i nfants at strict fou r week-i nter­

val s. I n t h e m ajority of cases the i n terva l b etween two consecutive exa­
m i n ati o n s was fou r weeks, b ut someti m es the i n terval was three or five
weeks. N evertheless a l l c h i l d ren u nderwent an exami n ation i n a p e ri o d
of fou r weeks.
Fi g . 3 s hows the frequency d i stri b uti o n of the exa m i n ations d u ri n g the
consecutive fou r-week periods. l t can b e observed that boys a n d g i rl s
s h ow a s l i g htly _different d i strib uti o n . T h e m ajority o f t h e g i rl s was exa­
m i ned d u ri n g the secon d a n d thi rd week of the fou r-week peri o d so
that the d i stri b utions a re u n i mo d a l . The h i stograms fo r the boys show
two p eaks from t h e s ixth fou r-week period o nward s : o n e at the seco n d
a n d o n e a t t h e fou rth week o f th e period. T h e b oys b e l o n g i n g t o t h e se­
cond peak g rou p therefo re m ay appear to show a somewhat faster
d evelopment than the othe r b oys and than the m ajo rity of the g i rls, d u e
to the ti m e of exa m i n ation and the m ethod of analysis, which w a s b ased
o n com p l ete peri ods. Th i s h as to b e kept in m i n d when the resu lts with
relatio n to s ex a re d iscussed.

I n o rder to stan dardize the i nfl u ence of endogenous variabl es such as

fati g u e a n d h u n g er, the i n fants were exa m i n ed at a fixed tim e of the day,
i . e. at a ro u n d six o' clock in t he eve n i n g b efo re feedi n g .

I nterval com p l ic ation s, i .e. d i so rd ers d u ri n g t h e p eri o d o f study, i f p re­

s ent, were reco rded a n d coded on a fou r p o i nt sca l e: 0: no i l l n ess o r
disord er; 1 : s l i ght disorders without fever o r evi dent i nfluence o n t h e
i nfant's b e h avi o u r, s u ch as m i l d col d s ; 2 . d i s o rd ers acco m pa ni e d b y
fever u p to 39° centi g rade, l asti n g for o n e d ay a t m ost o r acco mp a n i ed
by feedi n g d i sturb a nces res ulti n g i n vom iti n g a nd/o r d i arrhoea without
wei ght loss; 3: serio u s i l l ness with fever above 39° centi g rade a n d/o r
l asti n g l o n ger than o n e d ay, and/o r feedi n g d iffi culties res u lti n g i n
wei g h t loss.

C o nvu l s i o ns wou l d h ave sco red 3, b ut did n ot o ccur. Fi g . 4 represents

the d i stri bu ti o n of i n terval com p l i cati o n s observed in the i n fants d u ri n g
t h e peri o d o f study.

21
 �
Interval complications
1 • lo
0 2 I . •
� 3 2•
� 4
u 5 "'* 3*
6--r------(
7
8
9
10
11
12
13 0 X
M • *
15 0
16 0
17
18-+-------<
19
20
21
22
23 I •
24
25
26 Cf'
27
2
29-.------�
30
31-r----- 9
32
33
34
35-r-----n
36
37 I •
38
39
40
41
42-+-------(
43
44
45
46
47
48
49
50
51.�-���-���-���--���
2 4 6 8 ID U M ffi m W n M

4-week periods

22
Of the total g rou p of i nfants, 1 6 (about 1 /3) showed 22 i nterval com p l i­
cations. Thi s m eans th at several of the i nfants showed an i nterval com­
p l i catio n m o re tha n o nce. The m ajo rity of these i nterval com p l i catio n s
con s i sted of very m i l d disorders, such as s l i g ht col d s o r m i l d reactions
to vacc i nations (va ri ola, d i p htheri a, tetanus, whoo p i n g cou g h , p o l i o mye­
l itis a cuta anteri o r; the l atter fou r, com p o u nd ed in o n e i njecti o n , a re gi­
ven three times d u ring the fi rst year of l ife) . O n ly 3 of the i nfants, all of
them b oys, suffered fro m m o re seri o us disord ers. O n e boy h ad chi cken­
pox with h i g h fever d u ri n g three d ays, accompanied by exten sive ski n
eruptions, when h e was o n e year of age. Anoth e r o n e was hospitalized
for an asth m ati c attack when he was 1 6 m o nths . The thi rd boy was hos­
p ital i zed for a ski n d i sease witho ut fever when h e was about 1 1j2 year.
N o n e of these i nfants showed s i g n s of reg ression i n the i r n eu ro l o gi ca l
d evelop ment after th e d i sease. Altho u g h i nterval comp l i cati o n s occur­
red m o re frequently a m o n g the boys th an a m o n g the gi rls, this sex
d ifference d i d n ot p rove to b e statisti cal ly si g n ifi cant (chi-sq uare 1 ,8).
=

F i g . 4:
The d i stribution of the i nterval c o m p l ications d u ri n g the period of study.
Vertical axis: case n umbers; no's 1 -28 are the boys, no's 29-5 1 are the g i rl s
of the g ro up.
H o ri zo ntal axis: t i m e scale g raded i n fou r-wee· k periods. C i rcles: m i l d i nterval­
com p l i cations; dots : i n terval com pl i cations of m oderate i n tens, i ty; stars: serio u s·
i nte·rva.l c ompl icat i o n s .

23
C h a pter V A short d escription of the cou rse
of the exa m i n ation

At each session the com p l ete set of items was assessed. The neonatal
exa m i n ation was carri ed out acco rd i n g to the m etho d descri be d by
Prechtl and Bei ntema (1 964). Its resu lts served as one of the criteri a
for the selection of the g roup, as discussed i n Ch apter I l l . Fo r the fo l­
l ow-up exa m i n ati o ns, however, a m ethod had to be developed in which
the expan d i n g repertory of the i nfanti l e nervo us system during devel o p­
m ent was taken i nto account. Conseq uently the n u m ber of items to be
assessed i ncreased, but the strategy rem ained u n ch a n ged, a lso wi th
respect to the sequence of the tests. A p i l ot study of ten i nfa nts, which
were o m itted from the an alysi s subsequently, served to d evelop an
exam i n ation tech n i q u e which wi l l b e descri bed i n th i s chapter.

Sta ndardization of the b eh avi o ura l state d u ri n g the exa m i n atio n , whi ch
i s of extreme i m p o rtan ce fo r the interp retation of the results (Prechtl
and Bei ntema, 1 964 ; P rechtl , 1 972) was app l i ed ri gorous ly.
Al l th e in fants were assessed in the opti m a l cooperative behavi o u ra l
state, i .e. rel axed o r moderately active. A s s o o n as an i nfant started to
cry the assessm ent was put off until the i nfant was happy and rel axed
aga i n . If n ecessary the exa m i n ation was postpo ned to a noth er day.

The exa m i nati o n a lways started with an adapti o n period during which
observation of spontaneous and goal-d i rected m otor beh avi o u r was
carri ed o ut. The d u ratio n of the adaptio n p eri od depended largely o n the
age of the i nfant b ut th e observation lasted at l east th ree m i n utes.
D u ri n g the fi rst 5-6 m o nths m ost i nfants were observed in thei r cribs,
afterwards m a i n ly i n the p l aypen. After the observati o n , the i nfant was
p ut on the d ressi n g tab l e o r o n its m other's lap, dependent o n its age.
Vol u nt ary g rasp i n g was then tested by means of a n ovo i d p l astic object
(two by th ree by th ree cm) p resented in the m i d l i ne. With i ncreas i n g age
the number of objects p resented was augm ented. D u ri n g the p resen­
tation of the object, facial i n nervation and the vi su a l system were exa­
m ined. A s m a l l b aby- be l l was used to assess heari n g and acou sti cal
o rienti n g . Then the q u al ity of the m otor a p paratus was tested, i .e. the
resi stance to passive m ovements, active p ower, a n d the ran ge of m ove­
m ents, fol lowed by the eva l u ation of respon ses and reactions such as
the ten d o n reflexes of arm s a n d l egs, p l a ntar g rasp, footso le respo nse,
pal m a r g rasp etc. D u ri n g th e exa m i n ation of the m oto r apparatus of
tru n k a n d n eck the p resence of the asymm etric ton i c neck reacti o n was
assessed. Sitt in g b eh avio u r, and spontaneous m oti l ity and postu re of
head, tru n k, a rm s and l egs d u ri n g sitti n g were eva l u ated. Depend i n g o n
the age of the in fant, sta n d i n g and wal k i n g were assessed. Then the
exam i n er kept th e i nfa nt i n vertical suspension and observed the post­
u re a n d m otil ity of the l egs. Placin g reactions of the l egs and, i n youn g

24
i n fants, auto m atic stepp i n g m ovements and positive supporti n g reactio n s
were tested. After th e eva l uati o n of the rotatio n test th e i nfant w a s kept
in h orizontal suspension and th e Lan da u a n d Schalte nbra n dt reactions
were assessed.
Subsequently the i nfant was put in p ro n e position o n the d ressin gtabl e
o r o n the floor, and the m otil ity o f h ea d , arms a n d l egs, the q u a l ity of
l ocomoti o n in p ro n e and rol l i ng behavi o ur were eval uated. Thereupon
the Moro reactio n s were tested and the session ended with the eva lu a­
tion of rooti n g and suck i n g behavi o u r a n d of those responses fo r whi ch
the i nfant m ust be J.mdressed , such as th e abdo m i n a l ski n reflex, the
crem asteric reflex and th e G a l ant response.
Length and wei g ht of th e b ody were m easured, as wel l as the sku l l
circum ference (fronto-occip ital m easurement). Voca l i zati o n o r speech
was reco rded as observed d u ri n g the who l e co u rse of the assessment,
a n d i nform ati on about speech was asked from the m other.

Evi dently the n u m ber of items e n l arged i n accord a n ce with the i ncreas­
i n g neuro l o g i cal repertory of th e i nfants. Sti l l i t was possib l e to adhere
to th e genera l course of the p roced u re as d es cri bed above. The d u ratio n
of the assessment, th e adaption p eri o d i n c l u ded, i ncreased specifica l ly
i n i nfants o l der than seven or e i g ht m o nths of age. At that age the m a­
jority of the i nfants often d eveloped rat her stro n g withdrawal reactio ns,
which frequently resulted i n a n expa nsi o n of th e adaptio n perio d, some­
ti m es to m ore th an three q ua rters of an h o u r.

The res u lts were recorded o n a p recoded fo rm d u ri n g the assessment.

I nfo rm ation g iven by the m other was reco rded also, b ut fo r the assess­
m ent of fun cti o n a l deve l o p ment o nl y d i rectly observed p he no men a were
used.

25
C h a pter VI The presentatio n of the resu lts

The items of the assessm ent could b e divided i nto five g ro ups a cco r­
d i n g to their ch aracteristi cs d u ri n g developm ent:

G rou p I
A g roup of items which d i d not show differe nti ati o n among the i nfa nts
and which d i d n ot show any chan ges occu rri n g d u ri n g the peri o d of
stu dy, such as the resi sta nce against passive m ovements, p u p i l lary
reactions and reaction to sound (Ta b l e I l l).

G roup 11
A g rou p of items which showed l i ttle differenti ati o n a m o n g the i nfants,
and/or showed a very rap i d develop mental course, such as spontaneous
tremor, corneal refl ex, stepp i n g m ovements and conju gation of eye mo­
vements (Ta b l e IV).

G ro u p I l l
A grou p of items which showed fa i r d ifferentiation between the i nfants
and which p resented a defi n ite developm ental co u rse, of whi ch a fi rst
change of th e response and a fi na l change (stab le, so-ca l l ed m ature
response, o r disapp earance of the response i n the case of " i nfanti l e
reactions") cou l d b e defi ned. Exa m p l es are items descri b i n g t h e devel­
opment of sitti n g , sta n d i n g , wal ki n g, crawl i n g etc. , the footsole respon­
se, the p al m ar g rasp reflex, the M o ro reactions and the o ptical p laci n g
reactions (Ta b l e V) .

G rou p IV
A g rou p of items which did not show d iffere nti ati o n a m o n g the i nfa nts
b ut, i nteri n d ivi d u al ly as we l l as intrai ndivi d u a l ly, showed so m any i n ­
consi stent chan ges that a defi n ite devel op menta l sequence cou l d not
be establ ished. I n this g roup a l so those items are i n cl uded which d i d
n o t reach thei r fi na l c h a n g e with i n the period of the fo l l ow-u p study.
Examp l es are th e spontaneous posture of head and tru n k d u ri n g p ro n e
suspension, t h e Landau and t h e Schalte nb randt reaction, the knee jerk,
and th e p l antar g rasp refl ex (Tabl e VI I).
The chan ges occu rri n g i n the items d u ri n g the fo l l ow-u p period wi l l be
descri bed, but they are not use d for t he an alysis of interrel atio nshi ps,
as comp arab l e p a rameters w i t h g ro u p I l l were not ava i l ab l e.

Fi n a l ly there is a g ro up of vari a b l es which deal with the i nfants from a n

anthropometric and p ed i atric p o i nt of vi ew, s u c h a s b o d y wei g ht, l en gth,
sku l lc i rcumference (Tab l e VI I I) ; also vari ab les whi ch m ay b e regarded
as h avi n g p sychosocial s i g n ificance such as vocal izati o n , s m i l i n g a n d
reaction towards strangers, i . e. wh ich ca n n ot b e consi dered a s p u rely
n eu ro lo gi ca l items (Tabl e IX).

26
The gro u p s of items wi l l b e discussed i n the fo l lowi n g ch apters. Fo r
reasons of conven ience the items are s u b d ivided i nto two g roups: o n e
co n s i sti n g of items wh i ch can b e observed witho ut specifi c m a n i p u la­
tions being n ecessary ("spontaneous posture a n d motil ity"), the other
co n s i sti n g of " reacti ons and respon ses" , i . e. items fo r which m an i p u l a­
ti on of the i nfant was needed. The develop m ental course of the s i n g l e
items wi l l b e reported, . a n d 80o/0 p rediction bands are p resented i f the
developm ental ran g e and the differe nti ati n g capacity of the exa m i n ation
m ethod m ade t h is worthwh i l e. Attenti o n wi l l b e p a i d to the occurrence
of i nco n s i sten cies, and also sex d ifferen ces wi l l b e dealt with .

For th e items of g ro u p I l l (i .e. items for whi ch fi rst ch ange, fi na l ch an ge,

developm ental ran g e and n u m ber of i n co n s istencies co u l d cl early be
defin ed) the m eans, standard d evi ations and coeffi cients of skewness
and kurtosis of these para meters are p resented in appendix C. As it
m ay b e assu m ed that the di stri b utio n s of the m o me nts of fi rst and fi n a l
change, and a l so of the l e n gth of t h e d evelop mental ran ges are suffi­
ciently symm etri cal (cf. chapter X I I I ) , the m easures p resented i n Appen­
dix C can b e used to describe the p aram eters.
The Pearson Product Mo ment corre l ation tech n i que was used for the
com putation of rel ati o n s h i p s b etween the m o m ents of fi rst a n d fi na l
change a n d the developm ental ran ges (i.e. the l ength of the p erio d be­
tween fi rst and fi n a l change) to b e observed i n s i n g l e items as wel l as
b etween d ifferent items.
Thi s was n ot done when the frequency d i stri b ution of scores was not
fai rly sym m etrical, as was often the case with the n u m b er of i nco nsis­
ten cies. Then Spearm a n Rank Corre l ation Co effi cients were co m p uted.

When the d evelopme ntal cou rs e of the items i s descri b e d , the i n ter­
rel ation s h i p s o ccu rri n g i n the si.n g l e items or with other items wi l l be re­
ported. The corre l ation-coeffi ci ents of corre l ations with p < 0,01 are
s u m m a ri zed i n appen d i ces . Appendix D s u m m arizes the correlation­
coeffi ci ents of the rel ati o nshi p s b etween "fi rst change" a n d "fi n a l
change" of items ; appendix E p resents the corre l atio n-coeffi ci ents of the
i nterrel ati o n s h i p s o f "fi rst chan ges" , a p p e nd i x F a n d G p resent the cor­
rel ation-coeffi cie nts of the " fi n al chan ges" and " d evel o p m ental ran ges"
res pectively.
In the d iscuss i o n of the item s atte ntio n wi l l be p a i d to relevant data ob­
tain ed by other authors. An exten sive d i scussion of the l iteratu re ava i l ­
ab le i s n ot p resented i n the c a s e of al l the items, as the p resent study
does n ot p reten d to b e a com p rehen sive su rvey of the l i teratu re about
i nfant i l e d evelopment.

27
Ch a pter VI I G ro u p 1 : Item s which d i d not s how
d ifferentiation a m o n g the i nfants

I n this ch apter the items wi l l be d i scussed which rema i ned constant

thro ug h o ut the who l e fo l l ow- up p eriod (Ta b l e I l l) .

TABLE I l l

Items which did not show d ifferen t iation among t h e i nfants (group I )
Facial i n n ervati o n
Pup i l s - shape
- reaction to l i ght
Optical b l i n k
Acoustical b l i n k
Reacti o n t o sound
Muscle to n e - res i stan ce agai nst passive m ovements
- active p ower
- ra n g e of m ovements
Head co ntro l
Abdo m i n a l skin reflex
Crem asteric refl ex
With d rawal reaction

Facial i n nervation
All i nfants s howed a symm etrical faci a l muscu l atu re from b i rth o nwards .
Facial expressivity i ncreased after the fi rst weeks, but a standard i zed
descriptio n was not endeavo u red.

Pupils
In all the i nfants the shape of the p u p i l s was rou n d ; this did not change
d u ri n g the peri o d of study. I n al l the i n stances the d i rect a n d i n di rect
reactions to l i g ht were pos itive and d i d not change.

O ptical b l i n k
This response was e l i cited accord i n g to Prechtl a n d Bei ntema (1 964).
I n a l l the i nfants it was p resent a n d d i d not change, p rovi ded that the
l i ght sti m u l u s was of sufficient i ntensity.

Acoustical blink
E l icitation accord i n g to P rechtl and Bei ntema ( 1 964). In the n ewbo rn
peri o d a l l the i nfants had a positive acoustical b l i n k to h a n d c l ap . Pro­
vided they were exa m i n ed in a q u i et envi ron m ent, the response re­
m ained positive d u ri n g the who l e peri o d of study.

28
Reacti o n to sound
For th i s resp onse a s m a l l b a by b e l l was used. Al l the b aby' s reactio ns,
fo r i n stance chan g es in m ot i l ity, chan g es in facial exp ressi o n , gazi n g or
b l i nki n g , were consi dered as a positive reacti o n . A l l the i n fants s h owed
a po s itive response fro m the newborn peri o d o nwards. This i s in accor­
dance with th e repo rt of C h u n , et a l . (1 960) ; sti l l thei r opi n i o n that the
aco u stical b l i n k was h a rdly eve r fou n d after the age of 5 m o nths cou l d
n o t b e confi rm ed .

Muscle ton e
Th ree aspects were assessed accord i n g to the techn i q u e descri bed by
Prechtl a n d B e i ntem a ( 1 964) : resi stance against passive m ovements,
active p ower, ran g e of m ovements.

The resistance against passive movements was assessed excl us ively

in state 3 (fo r the operati o n a l defi n ition of states see Prechtl and B e i n­
tem a (1 964)).
In state 3 the i nfant is awake, com p l etely rel axed, and n ot a ctively m ov­
i n g . When there was n o n oti ceab l e myotat i c refl ex-activity resi sta n ce
agai n st p assive m ovements was com parab l e fo r fl exor and extensor
m-uscles an d d i d n ot d ifferenti ate a m o n g i n fants n o r were evi dent chan­
ges of its q u al ity fou n d at the consecutive exa m i n atio n s .
As the i nfants were awake d u ri n g th e assessment, the h a nd l i n g of their
arms a n d l eg s d i d not fai l to activate them, so that in m any cases state
3 was n ot m a i ntained.
D u ri n g activity the resi stance i n the flexor m uscles of arms and l egs was
fou n d to be h igher than the res i stance in the extensor m u s c l es. Thi s
d ifference b etween flexo rs a n d exten so rs i ncreased during t h e fi rst two
o r three m onth s ; it see med l argely due to resi stance a g ai nst active mo­
vements.
With the tech n i q u e used i t was i m possi b l e to q u antify differences b e­
tween resi stance agai nst p assive a n d agai n st active m ovements. I n the
p resent g ro u p n o evi dent d ifferen ces were fo u n d b etween the consecu­
tive assessments which co u l d b e attrib uted to p rop erti es of m uscle ten ­
s i o n i n state 3. An evi d ent decrease of resistance a t o l de r a g e s seemed
to refl ect the i n fants' cap ab i l ity of vo l untary relaxation d u ri n g state 4.
N o evidence was fou n d for the often repo rted, so-ca l l ed " p hysi o lo gical"
fl exor h yperton i a of early i nfan cy (And re-Tho m as a n d St. A n n e D argas­
s i es, 1 952) o r " e last i c hyperton i a" (Wi l l emse, 1 973), as l o n g as the
behav i o u ra l state of the i nfants was duly contro l l ed. It s h o u l d also be
kept in m i n d that traditi o n al ly the term " hyperton i a " i m p l i es a p ath o l o gi­
cal condition a n d consequently can n ot b e app l i ed in n o rm a l i nfants.

The res i stance against active m ovements, wh i ch refl ects active m uscle
power, i ncreased with age b ut cou l d not adequately be operat i o n a li sed,
due to the rap i d ly i n creasi n g differenti ati o n of m u s c l e activity and m u s­
cle tissue d u ri n g i n fancy. Evi dent decrease or l ack of active m uscle
power was not fou n d i n any of the i nfants.

29
Presumably the difference between flexo r and extensor m u scle-activity
d u ri n g th e fi rst m o nth s of l ife refl ects a d o m i nance of th e neural m e­
chan is m s for flexo r m uscle-activity as wel l as the difference i n b u l k
o f th e flexors and extensors.

The range of movements of the· j o i nts sh owed a certai n degree of va ri a­

tion, intra- as wel l as i nter- i nd ivi d u a l ly; h owever, th is seemed to depend
largely o n the i n d ividual characteri sti cts of the baby.
D u ri n g th e pi lot stu dy measurem ents of a n g l es b etween joi nts were car­
ried out but the res ults ap peared to be i n consistent at con secutive as­
sessm ents, so that th ey were d i sco nti n u ed. The aro u s i n g effect of such
measurements m ay h ave been l a rgely resp o n s i b l e fo r these i n consisten­
cies. Consistent changes in the ran ge of m ovem ents were n ot fou n d .

Head control
Headco ntro l in sitting position was exa m i n ed accord i n g to Prechtl and
Bei ntema (1 964). I n the newborn peri o d a l l the i n fants were able to ba­
lance thei r h eads fo r m o re than 3 seco nd s and th us obta i ned an opti m al
score. Th i s co u l d be observed d u ri n g a l l the co nsecutive exa m i n ati ons.
Adequate h ead contro l d u ri n g sitti n g position c a n be consi dered as evi­
dence for a good i nterp l ay of afferent vesti b u l ar and neck-pro p ri ocep­
tive and efferent m u scle p ower activities. Th e amount of s l i ght swayi n g
movements wh i ch accom p a n i ed th e m ai nten ance o f th e h ead ba l an ce
duri n g th e fi rst m o nths, was not appreci ated .

The abdominal skin reflex

Th i s refl ex was p resent from b i rth o nwards. H owever, the chances of a
p roper eli citati o n varied i n the newbo rn peri o d a n d at subsequent ages.
I n n ewbo rn s e l i citati o n of the refl ex was easi est i n state 3. When the
i nfa nt b ecame active it was often difficult to el icit the res ponse. Fro m
th e seco n d exa m i nati on o nwards also in m oderately active infants the
response cou l d easi ly b e eli cited. Th e fi ndi n g of Ha rlem and Lo n n u m
( 1 957) that i n newborns the . response i s m o re ext e nsive t h a n i n adu lts
was confi rm ed. Th i s. was also the case in o l der i nfants. The m ea n i n g of
th i s p h enomenon is not cl ear. On the one ha nd the i nfant' s s m a l l er vo­
l u m e a l l ows for an i n creased effect of m u scle contractions, on the other
hand th ere i s such vari ab i l ity in ab d o m i n a l skin responses in adu lts as
to m ake concl usions u n re l i ab l e. M o reover, the i nfa nt i n genera l appears
to be m o re "ti ckl ish" than the adu lt.

The cremasteric reflex

A ll the b oys had a wel l developed scrotum a n d descen ded testi cles at
b i rth. In al l of them the crem asteri c refl ex turned out to be p resent from
b i rth o nwards.

The withdrawal reaction

A l l th e in fants reacted to a gentle p i n p rick o n the footso l e wi th a vi go­
ro us with d rawal reaction of the foot and l e g . Th i s reaction did n ot show
any changes fro m b i rth to wal ki n g free.

30
Comment
lt was fou n d that the items of this g ro u p did not s h ow a ny substantial
ch an ges t h ro u g hout the developm ental peri o d as defi n ed i n thi s study.
Th i s i m p l i es that their neura l m echanisms a re ful ly estab l ished at l east
at b i rth . Fro m a develop m ental p o i nt of vi ew these n e u ra l mecha n i s m s
can b e said to b e of p ri m ary i m p o rtance. They form th e basis o n wh i ch
further fu n ctio n a l deve l o p ment rel i es . Th e n ervo u s system m u st b e abl e
t o generate adequate m uscle ten s i o n i n o rder t o m ake a l l kinds o f m otor
behavi o u r poss i b l e. Si m i l arly m ec ha ni sms fo r visual and acoustical m e­
d i ation a re a p rereq u i site fo r the d evel o p m ent of d iffere nti ated visual
a n d acoustical fu n cti o ns, such as fo r i n stan ce visuomoto r abiliti es o r
adeq u ate l o cal i sati o n o f t he so u rces of s o u n d s . Theoreti cal ly it can b e
a rgued th at an i m p a i rm ent o f these m echanisms d estroys o r l a rgely
h a m p ers the p o ssib i l ity of adequate fu n cti o n al deve l o p m ent. Conse­
q u ently it is evi dent that these items a re of g reat s i g nifican ce fo r a
neuro l o g i ca l d iag nosti c p ro cedu re . M o reover, if the n eu ra l m echani s m s
u nderlyi n g these items are of s u c h b a s i c val ue fo r the fun ctio n al d evel­
o p m ent, it m ay b e assumed that i n cases of d i sturb a nces res u lti n g from
i mp a i rm ent of these m echanisms p roper treatment wi l l be rather d iffi cult.

31
Ch a pter VI I I G ro u p 1 1 : lte,m s w h i c h s h owed l ittle
diffe rentiation and/ or a rapid
d eve l o p m ental c o u rse

In th i s ch apter those items wi l l b e d i scussed which showed a very rap i d

developmental co u rse a n d d i s p l ayed h ardly a ny interi n divid u a l differen­
ces. In the p resent study with fou r-weekly exa m i nati ons an item was
estim ated to show a rap i d developmental cou rse if it lasted fo r a period
of o n ly 3-4 fou r-week i nterva l s i n m o re than 80°/0 of the i nfants.
More accu rate i nfo rm ati o n about the developmental cou rse of these
items wou l d req u i re l o n gitu d i n a l exa m i nati ons at shorter interva ls. With
the inter-exa m i n ation-interva l s of fou r weeks appreciable g radients of
score, which woul d show d ifferenti atio n b etween the i nfants c o u ld not
be detected . The items b el o n gi n g to g ro u p 11 are p resented i n Tab l e IV.

TABLE IV
Items which s howed l ittle differentiation and/or rapid developmental
course (group 11)
Spontaneous tremor
Tremor d u ri n g More-reacti o n s
Conju gated eye m ovem ents
Fixation time
Visual p u rsuit m ovements
Co nvergence of the eyes
Pup i l la ry reacti on to convergence
Corneal reflex
D o l l ' s eye phenomenon
Rotation test
Li p-tap reflex
Recoi l of th e elbow
B i ceps reflex
An k le jerk
Stepp i n g m ovem ents

S pontaneous tremor
At the n ewborn exam i n ation ten i nfants showed a s l i ght tremor of h i g h
frequency g 6/sec) a n d low a m p l itude (< 3 cm) d u ri n g spontan eo u s
activity. Th e tremor w a s se e n i n thei r upper l i m bs o n ly. Ei ght of them
were b oys and two were g i rls. Yet from the seco n d exami n ation o nwards
no tremor was observed any m o re, except i n o n e boy who co nsi stently
sh owed a s l i g ht tremor u p to about one yea r. Tremors of l ow frequen cy
a n d h i gh a m p l itude d i d not occu r i n the p resent gro u p (cf. criteria for
n eon atal neurolo g i ca l opti m a l ity) .

32
Tremor d u ri ng M oro-reactions
As wi l l b e reported in ch apter IX the Mo ro reacti o n was e l i cited i n 3 d if­
ferent ways : by the head d ro p , the l ift a n d the h i t o n the s u rface respec­
tively. In the n ewborn period six i nfants (5 b oys and 1 g i rl) showed a
s l i ght tremor of h i gh frequency (> 6 sec.) a n d s m a l l a m p l itude (< 3 cm)
in th e h ead-drop M oro . These six i nfants a l so d i s p l ayed a tremor d u ri n g
spontan eou s actvity. A t t h e secon d a n d th i rd exa m i n ati o n o n l y o n e boy
sti l l s howed a s l i ght tremo r which d isap peared at su bsequent exam i n a­
tions.
D u ri n g the M o ro reaction eli cited by the l ift-m ethod, nine i nfants (4 boys
and 5 g i rl s) showed a h i g h freq uency and l ow a m p l itude tremor d u ri n g
t h e n ewborn exa m i n ation. Th i s n u m be r o f i nfants decreased rap i d l y
d u ri n g the subseq u ent exa m i nati ons, alth o u g h o n e boy persisted i n
showi n g a s l i ght trem o r u nti l the fifth assessm ent. This was the same
boy who showed a trem o r d u ri n g the h eaddrop M o ro at the secon d a n d
the th i rd assessm ent.
D u ri n g the M o ro reacti o n e l i cited by a hit o n the su rface twelve i n fants
s h owed a tremor of h i g h freq u e ncy a n d low a m p l itude d u ri n g the n ew­
bo rn exa m i n ation (5 b oys, 7 g i rl s). At the seco n d exa m i n ation o n ly three
i nfants (al l of them b oys) showed a s l i g ht tremor and from the fou rth
exam i n ation o nwards no tremo r was fou n d .
D u ri n g the l i ft M oro a n d h i t M o ro m o re gi rl s than boys showed a tre­
m o r, but the few i n fants who pers i sted in h avi n g a tremor d u ri n g the fi rst
few fo l l ow-up exa m i nati ons were al l of them boys. Yet the n u mb e r of
i nfants with a tremor is to o s m a l l to a l l ow fo r pertin ent co ncl usi o n s o r
even hypoth eses. O t he r typ es of tremo r were not o bserved.
The eyes
Th e develop m ent of an effi cient visual apparatus showed a rap i d d evel­
opme ntal co u rse d u ri n g the fi rst m o nths of l ife in m o re than 80% of the
i nfants.
a. Conjugation of eye m ovements was eval u ated d u ri n g the whole
cou rs e of the assessm ent. Fo r record i n g a fou r p o i nt s ca l e was
used:
0 . n o n-conju gated eye m ovem ents.
1 . o ccasional ly co njugated eye m ovements.
2. n early conti n u a l ly conju g ated eye m ovements.
3. conti n u a l ly conjugated eye m ovements.
D u ri n g the n ewbo rn exam i n ati o n none of the i nfants obtai ned score
0; 1 6% of them obta i n ed score 1 a n d 80o/0 sco re 2. I n these i nfants
s q u i nti n g occu rred m ai n ly d u ri n g tests which req u i red m uscu l a r
exertion s u ch as the traction-test a n d h ead-balance d u ri n g sitti n g.
O n ly 4% showed conti n u a l ly conju gated eye m ovem ents (score 3).
At the seco n d exa m i n ation, i .e. at about the fifth week of l i fe, one
th i rd of the i nfants showed conti n u a l ly conju g ated eye m ovem ents.
At the th i rd exa m i n ation this was the case with two thi rds of the i n­
fants, wh i l e from the fifth exa m i n ation o nwards, i .e. from about 20

33
 weeks of age, a l l the i nfants sh owed consi stently co nj u g ated eye
movements. Boys were s i g n ificantly l ater than g i rls in showi ng near­
ly conti n u a l ly conj u gated eye movements ( M an n-Whitney U test, p
= 0.01 ), but the d ifference b etween the means of boys and g i rls
was s l i g ht (see Tab l e XI and XI I I and chapter XI I). Th is difference
had disappeared at the ti m e of onset of conti n u a l ly conj u gated eye
movements. The p resent fi n d i n gs are i n agreem ent with Ko upern i k
a n d Dai l ly's view that co m p l ete syn erg i sm between the eyes i s esta­
b l ished b etween 3 and 5 mo nths of age (Ko up ern i k and D a i l ly, 1 968).
b. Fixation time
I n order to assess the fixation-ti m e the exami ner kept a g l itteri n g
si lvery object o f 3 b y 4 cm i n fro nt o f t h e i nfant's eyes and tried out
at wh ich d i stance the i nfant gave the b est response.
The obj ect was kept in movem ent in order to i ntens ify the sti m u l ation.
The response was scored o n a 4 p o i nt scal e .
0. n o fixation.
1 . fixation d u ri n g a few seco nd s o n ly.
2 . fixation d u ri n g 1 5 to 20 seconds.
3. fixation d u ri n g m o re th an 20 seconds.
the test was carried out fo r the fi rst ti m e d u ri n g the seco nd exami­
n ati o n . A l l the i nfants except two sh owed fixati o n d u ri n g a few se­
co nds at least, wh i l e 20°/0 fixated l o n ger than 20 seco nds. At the
th i rd exa m i n ation two th i rds of the i nfants showed fixation d u ri n g
m o re than 2 0 seco nd s; about o n e th i rd fixated during 1 5-20 seconds
a n d on ly two infants fixated d u ri n g a shorter time. From the fou rth
exa m i n ati on o nwa rds, i . e. about 1 6 weeks, mo re than 90o/0 of the
ch i l d ren fixated l o n ger than 20 second s. The boys started to fixate
s l i ghtly earl ier than the g i rl s (Man n-Whitney U test, p. < 0.0 1 ) but
boys and g i rl s reached a fixation period of mo re than 20 seco nds at
about the same t i m e.
There was a low but sign ificant correl ati o n between the fi na l stab i l i­
zati on of fixation an d the o nset of p u rsuit m ovements of the eyes
as defi ned in th i s study (r = .397 p < 0.0 1 ) .
Fixation dep ends l a rgely o n t h e q ua l ity o f the sti m u l us. Therefo re i t
i s h a rdly feas i b l e to compare t h e p resent fi n d i ngs with those o f other
auth ors who often do not descri b e the q u a l ity of the i r sti m u l ation.
c. Visual pursuit movements
The object used i n the test for fixation was also m ade use of i n this
test. lt was moved i n fro nt of the i nfant from one side to the other,
at the distance at wh i ch the i nfant fi xated b est.
The a n g l e over which the i nfant fol l owed the object with the eyes
and h ead was estim ated and scored on a 5-poi nt-sca l e.
0. no p u rs u it movem ents.
1 . p u rsuit m ovem ents over 30 degrees.
2 . p u rsuit m ovements over 45 degrees.
3. p u rs u it m ovem ents over 60 degrees.
4. p u rsuit m ovem ents over 90 degrees o r more.
Th e test was carried out from the seco nd exam i n ation o nwards.

34
 Visual pursuit movements

� I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
-----r---1 T ' I
exam.
-----r ----1 - -,
0 3 6 9 12 15 18 21
age,months
Fig. 5

Fi g u re 5 shows the 80% p red i ction b a n d a n d the fu l l ran g e of the

respons es. Fro m the fifth exa mi n atio n o nwards m o re than 80o/0 of the
chi l d ren s h owed p u rsuit m ovements over m o re than 9 0 degrees. N o
consi stent difference b etween b oys and g i rl s w a s fo u n d . Wolff (1 965)
rep orted visual p u rsuit m ovements i n n ewborns. I n the p resent study
p u rs u it m ovements were l ooked fo r fro m the seco n d assessm ent
onward s ; at that ti m e at l east 80% of t he i nfants s howed visual
fo l lowi n g over 30-60 degrees. l t i s possi b l e that some of these i nfants
wou l d h ave shown visual fo l l owi n g in their n ewbo rn period. The fi n d­
i n g of Barten and R a n ch (1 97 1 ) that there i s no rel atio n s h i p between
n eo n atal visual p u rsuit m ovements and visu a l fo l l owi n g at l ater ages,
s uggests that vario us m ec ha ni sms m ay b e at work.
d. Convergence o f the eyes
The same s i lvery o bject was now m oved towards the i nfant' s face
from a d i stan ce of about 60 cm . A 3-p o i nt scale was used fo r scori n g .
0. n o change o f eye p os itio n o n approach o f t h e o bject.
1 . s l i ght co nvergence of the eyes which soon d i s appeared.
2. evi dent convergence of the eyes which was m ai ntain ed fo r a few
seconds.
Th e test was carri ed out for the fi rst t i m e d u ri n g the seco n d exa mi ­
n ati on . 75°/o of the i nfants showed a n egative response whi l e o n ly
6o/0 showed evi dent co nvergence. From the fifth exa m i n ation o n­
wards, i.e. from about 20 weeks of age, m o re than 80% of the i n ­
fants s howed evi dent convergen ce. I n co nsi sten c i es were observed
in e l even i nfants, but no ne of the i nfants showed m o re than one re­
l ap s e in score.
Boys turn ed out to b e s i g n ificantly l ater than g i rl s in the acq u i sition
of t h is visual m otor activity (Man n-Wh itney U test, p < 0.01 ) . Sti l l
the d ifference of the m ea ns i n the case of b oys a n d g i rl s was s m a l l
(Tab le X I , X I I I) . Co nvergence o f t h e eyes m ay b e regarded a s a m a­
nifestation of devel o p i n g b i nocu l a r vis i o n . The p resent fi n d i n g s are
in ag reem ent with Ko upern i k and D a i l ly' s report (1 968) which says

35
 that there s h o u l d be convergence of the eyes from the end of the
th i rd m onth o nward s. They also co nfi rm White' s fi n d i n g s (1 970) that
visual acco modation to an approach i n g target i s developed between
the seco n d and fo urth mo nth of l ife.

e. Pupillary reaction to convergence

D u ri n g convergence the size of the p u p i l s was i n spected a n d the
p resence o r absence of m i osis of the p u p i l s was recorded wh i ch
can b e co n s i dered to refl ect develop ment of accomodati o n . Altho u g h
a t t h e seco n d exa mi nation 1 0°/0 of t h e i nfants showed evident miosis,
o n ly at the age of 20 weeks i . e. at the fifth exa m i n ati o n , was m i osi s
observed i n m o re than 80°/0 o f th e i nfa nts. Ha rdly a ny i n consisten cies
were fo u n d , but there was a s i m i l a r d ifference between boys and
g i rl s as was fou n d i n the case of convergence, (Man n-Whitney U
test, p < 0.01 ) .
A s i g n ificant rel ati o n s h i p b etween t h e development o f co nvergence
and p u p i l la ry reaction to co nvergence (r = .588) cou l d be ascer­
tai ned.

Corneal reflex
Th i s refl ex, elicited by l i g htly touch i n g th e co rnea with a pi ece of cotto n
woo l , was positive from b i rth o nwards. D u ri ng the newborn exa m i n ation
i n a l l th e in fants, the reacti on was slow, com pa red with the i m m ed i ate
and q u ick reactions occu rri ng from the secon d exa m i n ation o nwards.

Doll's eye-phenomenon
Th i s test was elicited by axi al rotati on of the i nfant when kept i n s u p i n e
suspensi o n . A t the newborn exam i n ation 84°/0 o f the i nfants sh owed a
p ositive response; i . e. evi dent active eye m ovements contrary to the di­
rection of th e axi a l rotation. At the secon d exam i n ati on the response
was n egative i n 25% of the infants, i . e. parti a l eye m ovem ents o r even
an absence of eye m ovem ents contrary to the d i recti o n of the rotati o n .
I n 59% t h e response w a s dubious. From the th i rd exa m i n ati o n o nward s
m o re than 80o/0 of the i nfants showed a negative response. No differen­
ce b etween b oys and g i rl s was fo u n d . The D o l l ' s eye-phenomenon is a
vesti b u la r reactio n . O n e m i ght exp ect the development of fixation to
interfere with th e res ult of the testi ng -p roced u re, and it m i ght be argued
that the p h enomenon wo u l d not d i s appear if no fixati o n-targets were
avai lable. As it was i m possi b l e to exc l u d e fixation-ta rg ets com p l etely,
concl usive evidence o n this issue co u l d not b e obta i n ed. The i nfants could
gaze i nto one d i recti o n o r an other u n system ati cal ly which apparently
was sufficient to i nterfere with the response. I n cidental observations
showed th at i n d rowsy i nfants of different ages a D o l l ' s eye-phenome­
non co u l d sti l l b e obta i ned . Altho ug h these observati ons were not car­
ried out systemati cal ly, it m ay be assu m ed that the Do l l ' s eye-phenome­
non does not d i sappear duri n g developm ent, but becomes l atent d u e to
th e i nterferi n g effect of sca n n i n g movements of the eyes d u ri n g wake­
ful n ess.

36
Rotatio n test
D u ri n g the rotati on test, e l i cited acco rd i n g to Prechtl and Bei ntema
(1 964), i n 96o/0 of the i nfants nystag m o i d m ovem ents of the eyes were
fou n d at the n ewborn exa m i n ati o n . From the seco n d exami n ation on­
wards they were fou n d in 1 00°/o of the i nfants, without the d i recti o n of
the rotation b ei n g of any con seq uence.
l t was n ot c lear wheth er the nysta g mo i d m ovements were of o ptoki neti c
o r of vesti b u l a r o ri g i n . There were m any g ross contrasts between d ark
and l i ght (wi ndows, shadows, l arge p a i ntings of the wal l s etc.) i n the
b ackg ro u n d a g ai n st which the i nfants were rotated. These s u p p l ied suf­
ficient fixation targets fo r the i nfants, which are a p rereq u i site fo r the
optokinetic nystagmus. O n the other h a n d it w a s often fou n d that a
very s l i g ht turn i n g m ovem ent, fo r i n stan ce over an a rc of about 45° ,
was suffi cient t o p rovoke nystag m o i d m ovements with a c learly d i sti­
g u i s h a b l e fast and s l ow compo nent; this m i ght p o i nt to a vestib u l ar
o ri g i n . D u ri n g t h is p roces of sl i ght rotat i o n accel e ratio n is the m a i n sti­
m u l us whi l e p res u m ab ly the contrasts in the visual fi e l d p l ay a m i no r
rol e. W h e n rotation was conti nued, th ere seemed t o b e a decrease o f ny­
stag m oid movements i n som e i nfants, which poi nts to a vestib u la r o ri­
gin, wh i l e i n others the frequency of these m ovem ents seemed to re­
m a i n u n ch an ged, which sug gests an o ptoki netic o ri g i n . lt m u st be con­
c l u ded that o n the basis of the p resent fi n d i n g s no clear d i sti n ctio n can
b e m ade b etween optokinetic and vest i b u l a r o ri g i n . N evertheless i t is
evi dent that in h i s n ewb o rn peri od the i nfant is al ready ab l e to m ake
consecutive s l ow and fast consensual eye m ovements in a n eatly coord i­
n ated way.

Lip-tap response
The resp on se, e l i cited by a b ri s k tap o n the u p p er o r l ower l i p, was
scored o n a fou r p oint scale (state 3).
0: negative res p onse.
1 : a p h as i c contraction of the o rb i c u l ari s o ri s m uscle.
2 : a s h ortlast i n g ton i c p rotru s i o n of the l i ps .
3 : a n evident ton i c p rotrusion of the l i p s, often fo l l owed by s macki n g
m ovements.
At the n ewborn exa m i n ati o n a l l the i nfants s h owed a to n i c response; i n
96o/0 o f the cases this was sco red a s a n evi dent to n i c p rotru s i o n o f the
l ip s . At the s eco n d exa m i nation a ton i c respo nse wa s p resent i n about
two thi rds of the cases, h al f of which sco red 4, b ut i n 20% of the i n­
fants no respo nse was obtained.
At the th i rd exa m i n ation (age about 12 weeks) 1 Oo/0 of the i nfa nts sti l l
s h owed a n evident to n i c p rotrusion o f the l i p s, but the n u m ber o f neg a­
tive responses in c reased (35o/0) a n d o n e fou rth of the i nfants showed
a p h asic contracti o n as a sole response.
At the fo u rth a n d fifth assessments a m i nority of i n fants (about 1 5%)
sti l l showed a s h ortl asti n g ton i c l i p-p rotru s i o n , whi l e in a rapi d ly decreas­
i n g n u m ber of i nfants a p h asic reaction persi sted u nti l the age of

37
about six m onth s. Two i nfants obtai n ed the score 2 u nti l the tenth exa­
m i n ati o n . I n con s isten cies occu rred in 1 7 i nfants, usua l ly o nce. An app re­
ciab l e difference in i n consistencies b etween boys and g i rls was not
fo u n d . Sti l l th e develop mental course lasted s i g n ificantly l on ger i n the
case of the g i rl s (Mann-Whitney U test, p < 0.01 ) , although the differen­
ce b etween gi rls and boys was very s m a l l (about the le ngth of one i nter­
val) a n d less than one sta ndard devi ati o n from the means (Ta b l e X and
XI I).

Recoi l of t h e elbow
At the neonatal exa m i n ation a l l the i nfants sh owed a b risk flexi o n of both
el bows when the two fo rea rm s were p assively extended and then rel eas­
ed. At the secon d exa mi nation half of the i nfants did not show a flexi o n
at the elbows. The percentage of negative respon ses i n creased to 82
and 96 at the thi rd a n d fou rth exa m i n ation respectively. Th ere was no
d ifference b etween b oys and g i rl s . lt can b e co ncl uded that the active
postural fl exo r d o m i n ance which is characteri stic fo r the newbo rn pe­
riod (An d re-Th omas and St. Anne D a rgassies, 1 952 ; l n gra m, 1 959 ;
Prechtl and Bei ntema, 1 964) decreases rapi d ly d u ri n g th e fi rst two
m o nths of i ife.

Biceps reflex
The bi ceps reflex was e l i cited by tap p i n g with o n e i n dex fi n ger on the
other one which was p l aced o n the tendon of the b i ceps m uscle of the
i nfants' sem iflexed arm . There was a b ri sk response i n the majo rity of
i nfants at a l l th e exa m i n ations. D u ri n g the second exa m i n ation two
th i rds of the i nfants showed an exag gerated contracti o n of the b i ceps
m uscle. D u ri n g the th i rd exa m i n ation th i s sti l l happened in about one
th i rd of the i nfants. I nconsi stently the n u m ber of infants in which this
exaggerated contraction was fou n d (6, 4 , 2 i nfants respectively) decreas­
ed rap i d ly. Th e in fants who sh owed exaggerated repo n ses duri n g se­
veral assessments were not i denti cal, as i n specti o n of the i n divi d u a l
scores m ade cl ear; th us a conspicuous numb e r of i ntra-ind ivi dual i ncon­
s i stencies occu rred i n the i ntensity of the response, especi a l ly d u ri n g
th e fi rst m o nth s. There was no difference b etween boys a n d g i rl s .

Ankle jerk
At the n ewborn exa m i n ation the i ntensity of the ankle jerk, eli cited ac­
cord i n g to Prechtl and Bei ntema (1 964) was g raded medium in al l the i n ­
fants. D u ri n g the seco n d a n d th i rd exa m i nati o n six i nfants showed a re­
l ative i n crease of i ntens ity of the an kle j e rk. H owever, these were diffe­
rent infants. Therefo re th e val i d ity of these s i n g l e observati o n s can b e
q uestioned. O n e b oy sh owed an i n creased i ntensity o f t h e a n k l e jerk u p
ti l l the 1 Oth exa m i n ation, i . e. u n t i l t h e age o f 4 0 weeks. This was n o t the
boy who persi stently sh owed a sl i ght tremor during spontaneous m oti l i­
ty as mentioned above.

38
Steppi ng movements
D u ri n g the n eo n atal exa m i n ation step p i n g m ovem ents, e li c ited acco rd­
i n g to Prechtl a n d Bei ntema ( 1 964) were cl early p resent i n 94°/0 of the
in fants ; th ree i nfants (6o/0) s howed a weak respon se. Fo u r weeks l ater
the response was absent in 59o/0 of the i nfants, and at the thi rd exami na­
tion o n ly 6%> ?hawed weak step p i n g m ovem ents, n otwithsta n d i n g the
rei nforcem ent by p assive extension of the head as d escribed by Mac­
Keith (1 964). I n two i nfants (4o/0) a weak response rema i n ed p resent du ­
ri n g the fou rth a n d fifth exam i n ation, i . e. u nti l the age of about 20 weeks.
Th ere was n o difference b etween b oys and g i rl s . M acKeith' s fi n d i n g that
p assive extension of the h ead resu lts i n a p ro l o n ged p resence of step­
p i n g m ovements in a m ajo rity of i nfants, co u l d n ot be confi rmed. Thi s
m i ght b e d u e to the fact that the exam i n er started to apply the p assive
extension of the h ead o n ly at ei g ht weeks, when stepp i n g m ovem ents
without h ead exten s i o n were not p resent anymo re.
Because of the very s m a l l n u m ber of i nfants who s howed persi sti n g
step p i n g m ovements after t h e fi rst assessm ent, a re l atio n s h i p b etween
these m ovements and the o nset of walki n g cou l d not b e ascerta i ned.
Th e i n fants who sti l l showed the respo nse at the t h i rd assessm ent did
n ot wal k rem arkably early. Zel azo' s suggesti o n that a persi stence of
step p i n g m ovem ents wo u l d resu l t in an earl i er o nset of wal ki n g coul d
therefore n ot b e confi rm ed (Zel azo e t a l . 1 972). H owever, t h e n u mber of
i nfants was too s m a l l to a l l ow for defi n ite con c l u s i o n s on thi s issue.

Comment
The items of this g ro up can b e divided i nto two s u b g roups. The fi rst sub­
g roup con tain s those items i n which the m ajo rity of the i n fants behaved
i n a s i m i l a r way. The items m eant are: trem o r duri n g spontaneo u s m oti l i ­
t y a n d m o ra-reactions, t he a n k l e j erk and the rotati o n test. A s fo r the ro­
tati o n test, its d ifferentiation is very s l i gth and b ri ef; the item shows a
very rap i d develop m ental course so that it can be ran ged b etween
g ro up I (chapter V I I ) and g ro u p 11. The other items of this subgroup
(tremor a n d ankle jerk) scored q u a l itatively d ifferently fo r a co n s i der­
ab l e period of t i m e in a very s m a l l m i no rity of th e i nfants, i n contrast
with the l a rg e m ajority of the i nfants. Th u s in one i nfant a spo ntaneous
tremor was fo u n d u p ti l l the age of one year, wh i l e in the case of a few
in fa nts an i n creased i ntensity of the an k l e j erk was observed d u ri n g the
fi rst few m o nths of l ife, i n o n e i nfant even u nt i l the tenth exa m i n ati o n.
l t i s rather diffi c u lt to d raw a ny conc l u si o ns o n the basis o f the se s i n g l e
o b servations. Tremors of h i g h freq uency an d l ow amp l itude a re wel l ­
known p h en om en a i n neonatal n e u ro l o gy, especi a l ly i n i nfants who are
exhausted or u pset. They m ay be seen as osci l l ations occu rri n g d u ri n g
coord i n ated m otil ity. A s they m ai n ly occur i n t i m es o f stress o n t h e ner­
vous system (wh en the i nfants a re exh austed, cryi n g , h u n g ry, u pset etc.)
they s u g g est that the b ra i n o rg a ni sati o n fo r this pa rti cul ar m ovement
control is n ot yet conso l i dated and can easily b e d i sturbed.
C l i n i ca l ly they a re co nsi dered to b e of l ittl e s i g n ifi can ce.

39
Tremors b ein g p resent i n some i nfants fo r a l o n g period of time d u ri n g
development c a n be i nterp reted as an exa m p l e o f t h e vari abi l ity i n the
m atu rati on of the nervo us contro l-systems u n derlyi n g s mooth movem ent.

The secon d s u b g ro u p of g ro up 11 conta i n s those i tems wh ich show a

fai r differentiati o n among the infants, b ut at the sam e time h ave a rap i d
developmental cou rse. Consideri n g t h e frequen cy of assessm ents i n t h e
p resent study, th ei r developm ent c a n b e said t o fi gu re as a stepfu nction .
These items seem to be based on neura l m echanisms com parab le to
those of th e items of g ro up I which sh owed no changes d u ri n g deve l­
opment. lt m ay b e a rgued th at they refl ect an i ncrease of th e scope and
of the differentiati o n of these neura l m echanisms. Th e d i s appearance of
the recoi l of th e elbows, e.g., wo u l d refl ect the decrease of the fl exor
d o m i n ance which i s characteristic fo r the n ewborn baby. Its di sappear­
ance is i n dispensa b l e fo r the fu n cti o n al developm ent n eeded fo r ade­
q u ate use of th e arms. I n a s i m i lar way the items concern i n g the eyes
reflect a refi nem ent and extension of the neu ra l m echanisms i n di spens­
ab l e fo r the development of an app rop ri ate vi sual apparatus. The l atter
is a p rereq u isite fo r adequate fu rther fu n cti onal devel o pment, such as
m echan is m s which ensure conj ugated eye-movements and fixation.
The d i s appea rance of step p i n g movements, wh ich are b ased o n a spi nal
coord i n ati n g m echan i s m , i l l u strates the dom i n ation of these m ovements
by m o re com p lex m ech a n i sm s m a n ifesti n g th emselves in different m oto r
patterns. Th is p rocess fi n a l ly resu lts in the matu rati o n of m echanisms
for wa l k i n g free. Theoretica l ly it can b e a rgued that the rap i d d evelop­
m ental course of al l items of th i s sub g ro u p refl ects the m atu ration of
sti l l rather basic n e u ral mechan isms. Th e i r i m p a i rment m ay eas i ly res u lt
i n a d i sturbed m aturati o n of mo re com p l ex neura l m ec ha ni sms, the vo­
l untary m otor system i n c l uded.
Th i s stresses the s i g n ificance of the items of gro u p 11 for n eu ro lo gi cal
d iagnosis.

40
Ch apter IX G ro u p I l l : Ite m s which s h owed a n evi dent
d eve l o p m e ntal seq u e n ce

The items of t h is g ro u p fu lfi l l ed the fol l owi n g criteri a :

1 . The fi rst ch ange of the response c o ul d u n eq u ivo cal ly be d efi n ed o n
t h e time-scale.
2. Also the fi n a l change co u l d b e defi ned accu rately o n the time-scale.
The defi n iti on of fi rst and fi n a l changes depended o n the sta n d ard i­
zatio n a n d the operati o na l i zation of the scori n g sca l e, which wi l l be
d escribed i n con nection with every s i n g l e item. A fi rst change m ay be
a q u a l itatively different response, as for i n stance with the typ e of vo­
l u ntary g rasp i n g or sp o ntaneous m otor behaviour, or it m ay be a
q u antitatively different resp o nse, e. g . a d ecreas i n g i ntensity of the
resp onse, as i s the case with th e palmar g rasp reflex. As fo r p h eno­
m e n a which m a n ifest themselves i n the cou rse of the d evelopm ent,
the fi rst change was defi n ed as the fi rst appearance of the response.
The optical p l aci n g of hands and feet m ay serve as an examp le.
Th ere a re two types of fi na l change: In the case of responses which
d i sappea r d u ri n g d evelopm ent, s u ch as th e pal m ar g rasp refl ex, the
fi n al change was co nsi dered to h ave taken p l ace when the response
cou l d n o l o n ger b e e l i ci ted . As fo r the responses which m a n ifested
th emselves in the co u rse of developm ent, or which showed evi dent
ch an ges, the assessm ent after which no g ross chan ges in the res­
p o n s e occurred was chosen as the m o m ent of their final change.
o
T h i s was the case with the o ptical p l aci n g reactions of h ands and
feet.
3. A th i rd c riteri on fo r the i nc l usi o n of an item i n g ro u p I l l is that the
d evelopmental ran g e i s a p p recia b l e. This was co n c l u ded to b e the
case when the deve l o pme ntal ran ge, defi ned as the peri o d between
fi rst and fi n a l ch ange, exceeded at l east th ree to fou r exa m i n ation­
i nterva ls . The m aj ority of the items of g ro up 11, such as th e items des­
cri b i n g fu n ctio n s of the visu a l appa ratus, were excl uded from th is
g ro u p as they d i d not fulfi l t h i s criteri o n.

I n tab l e V the it em s of g ro u p Il l are l i sted. They are d ivided i nto two su b­

g roups. Th e fi rst g ro u p consi sts of i t e ms deal i n g with spo ntaneous b e h a­
vio u r which c ou ld b e observed without specifi c m a n i p u l ation of the
i nfant. The s econ d g ro u p i s com po sed of i tems fo r which specifi c e li ci­
tatio n techn i q ues a re needed. The seq u ence i n which the items a re ran­
ked withi n these g roups is d rawn up o nl y for reason s of conveni e n ce
a n d does n ot serve as a d i rective fo r neuro lo gi ca l assessment.

41
TABLE V

Items which showed fair differentiation and an evident developmental

seq uence (group Ill)

Observation of posture and motility

spontaneous postu re of the arm s
spontaneous postu re o f t h e l egs
spontaneous moti l ity of the arm s
spontaneous moti l ity o f t h e l egs
spontaneous m oti l ity of the l egs i n verti cal suspensi o n
goal-d i rected m oti l ity o f a r ms and ha nd s
typ e of vo l u ntary g rasp i n g
coo rd i n ation o f t h e upper extrem iti es
postu re of head, trunk and arm s in p rone positi o n
locomoti on i n p ro n e positi o n
rol l n i g over from s u p i ne into p rone position
ro l l i n g b ack from p ro n e i nto supine position
spontaneous head l i ft i n s u p i n e position
sitting up
durati on of sitti n g
postu re of t h e tru n k d u ri n g sitti n g
sta n d i n g u p
wa l k i n g
Reactions and responses
rooti n g reflexes
asym m etric ton i c n eck response i m posed
asym m etric ton ic neck response spontaneous
palmar g rasp reflex
reaction to push agai nst the shou l der d u ri n g sitti n g
fo l l owing o f an object with t h e eyes, and rotation o f t h e h ead and tru n k,
when sitti n g
optical p l aci n g reacti o n o f the hands
parach ute reacti on of arm s and hands i n p ro n e suspension
optical placing reaction of the feet
foot s ole response
acoustical orient i n g
the M o ro reacti on headdrop
l ift
h i t on the surface

42
The items of g rou p I l l can be consid ered to show a g radual and p rotrac­
ted developm ental course, which refl ects a s l ow m atu rati o n of the n e u ral
m echani sm s on which they a re based. The m ean i n g of this g radual and
p rotracted develop m ent fo r a co rrect u n de rsta n d i n g of the m aturi n g ner­
vous system wi l l be di scussed i n ch apters XI I , XI I I and XIV.

Observation of postu re and moti l ity

S p o ntaneous posture and motility of arms and legs

Procedure: Depen dent o n his age the i nfant was p laced i n his crib or
p l aypen in s u p i n e p ositio n . State 3 (postu re) or 4 (moti l ity).
The spontaneous postu res a n d m oti l ity of a rm s and l egs resp ectively
were observed . Th e i n itial observati o n ti m e was at l east 3 m i n utes. The
observation of postu re and m oti l ity was conti n u ed during the w h o l e p ro­
cedu re of assessm ent. Th e p redo m i nant postu re and moti l ity i . e. the
posture and m oti l ity which cou l d b e observed m ost often , were recorded.

Recording:
The post u re and m otil ity of arms and l egs were reco rded separately.
Observation of the d evelop me ntal chan ges resu lted i n the fol lowi n g
scori n g sca l es :

Spontaneous p osture o f arms a n d legs respectively:

1 . p redo m i n ant fl exi o n
2. p redom i nant sem ifl exion
3. p redo m i n ant extension
4. a rb itrary postu re i . e. posture without a p redo m i na nt p attern .
Sco res 2 and 4 were con s i dered as fi rst and fi nal chan ges respectively
of sponta n eous postu re.

S p o ntaneous m otility of the arms :

1 . n eon atal a ltern ati n g typ e of m ovem ents i . e. altern ati n g flexion/exten­
sion m ovem ents with a rath e r stereotyped tem po and a m p l itude.
2 . p redom i n antly asym m etrical m ovements : asymmetri cal, i rreg u l a r
flexi on/extension m ovements of varyi n g tem po and a m p l itu de, u s u ­
a l l y acco m p a n ied by p ro- a n d supi n ation of the a rms, often o n o n e
s i d e of the b ody.
3. p red o m i nantly sym m etrical m ovem ents : rather i rreg u l a r fl exion/ex­
ten s i o n m ovem ents, o ccu rri ng on b oth si des s i m u ltaneously with va­
ryi n g tem po and a m p l itude. P ro- and supi n ation l ess m arked.
4. sym m etri cal and vo l u ntary m ovements : goal-directed m ovem ents
witho ut a do m i nant flexion/extension pattern were considered as vo­
l u ntary m ovem ents.
5 p redom i n antly vo l untary m ovements.
S co res 2 and 5 were consi dered as first and fi n a l changes respectively.

43
 Spontaneaus motil ity of the legs:
0. neonatal alternating m ovements
1 . predo m i n antly asym m etrical m ovements
2. pred o m i n antly sym m etri cal movem ents
3. p red o m i n antly vo l u ntary m ovements
Scores 2 and 4 were regarded as fi rst and fi nal changes respectively.
The p rediction bands with the fu l l ran ges fo r the spontaneous posture
of the arms and l egs a re p resented i n fi g u res 6 and 7.

Spontaneous posture o f the arms

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.
I I I r I . r I r r -,-.-
0 3 6 9 u B lli n
age,months
Fig. 6

Spontaneous posture of the legs

Vl

Q
(1)
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

I
exam.
I I I I I r r I I r I I I I r I I I I I
0 3 6 9 12 15 18 21
age,months
Fig. 7

The general confu g u ration of the p rediction bands is compara b l e, a l ­

t h o u g h the p rediction band of the postu re o f the legs shows a more p ro­
tracted developmental course. This refl ects the cran io-caudal gradient of
functional developm ent. The interi n d ividual vari ab i l ity of devel opm ent is
i l l u strated by th e occu rrence of d iffe rent sco res at the same exa m i n a­
tion.
In o n ly a few infants extension postu re of the arm s was fo u n d predo­
m i n antly, the m ajority of the i nfants d i s p l ayi n g arb itrary postures of the
a rm s i m m ediately after p redom i nant semiflexi on postu re type.
On the basis of these data one m ay ass u m e that usual ly a flexi on post­
u re of arms and l egs occurs o n ly during the fi rst weeks of l ife as a p re­
dom i n ant posture. Th e period d u ri n g which sem iflexion postures occu r
i s m uch shorter i n th e case of the arms than i n that of the l egs. Arbitrary
postures of arm s a n d legs man ifest th emselves at about the sam e ti m e

44
when goal-di rected m oti l i ty develops. Of cou rse t hi s happens m uch l ater
in the case of the leg s than in that of the arm s . l t reflects the sequence
of th e d ifferentiatio n of m otor p ro g ra m m i n g i n the b ra i n . In the l iteratu re
o n e genera l ly ag rees that the postu re of a rm s a n d l egs fo l lows the de­
vel o pm ental course descri bed ab ove (I n g ram , 1 959 ; Peipe r, 1 96 1 ). I n
t h e case o f the arm s , fl exio n- postu res a re rapi d l y repl aced by vo l u ntary
postu res, whi l e in the l egs an extension postures c an b e clearly d i stin­
g ui s h ed as an i ndependent p hase. This should p ro bab ly be regarded as
p artly b e l o n g i n g to vol u ntary m otor activity b ecause i nvolved in o r p re­
pa ratory to vol u ntary sta n d i n g behavi o u r.
I n the p resent study extension of the l egs was sco red 4 as soon as i t
appeared to b e part of vo l u ntary m otor behavi o u r. Thus l n g ra m ' s seco n d
exten s ion p h ase, w h i c h he l o ca l i zes at t h e end of the fi rst year, c a n b e
co n s idered as t h e begi n n i n g o f a rbitrary l e g postu res.

In the case of t h e arm s the n u m b er of i nconsi stencies, i.e. rel apses to

a p revious score, was m u ch sma l ler than in the case of the l egs. Th i s
m ay b e d u e p a rtly t o the m uch sho rter develop m ental co u rse i n t h e
case of the arm s, wh i ch reflects a faster development of differenti ati o n
of thei r m oto r p ro g ra m m es.
The g reat n u m b e r of i n cons i sten cies with resp ect to spo ntaneous pos­
ture of the l egs a l so i n d i cates the p ro b l em of sta nda rd i zation. N o rm a l
i n fants do n ot d evelop i n accordance with a stri ctly sterotyped course.
Th e sco ri n gsystem i s b ased o n the m ost freq uent occu rrence of the
vari o u s postures wh i ch can b e d isti n gu i sh ed .
l t does n ot accou nt fo r the g reat n u m b er o f co-existi n g p h ases occu r­
rin g i ntra- i n dividual ly. Sco res m ay b e arb itrary to some extent because,
in some cases, of two co-existi n g responses only one was scored.
In such cases the response typ e whi ch occu rred p repo n derantly was
recorded o r, i f i n evitabl e, an arb itrary choice was m ade. I nco nsistencies
p artly resu l t from this p rocedu re ; they refl ect the vari ab i l ity of the (mo­
tor) exp ression of nervo us activity.

As for the age of the fi rst change o r fi na l change, the d evelopm ental
ran g e o r th e n u m ber of i n co nsi stencies, there were no statisti cal ly s i g­
n ificant d ifferen ces b etween b oys a n d gi rl s .

A rel ati o n s h i p b etween t h e fi na l change o f spontan eo u s postu re

of the a rm s (i.e. arbitrary postu re) and the fi rst appeara n ce of vo l u ntary
g rasp i n g (i.e. p a l m a r g rasp type) was fou n d (r .393). The co rre lation
=

coeffi cient i s low, tho u g h s i gn ificant (p < 0.01 ) . A l ow b ut statistica l ly

s i gn ificant correlation was fou n d b etween the fi na l change of spontane­
ous postu re of the arms a n d the fi rst change (i.e. fi rst decrease i n sco re)
of the p a l m ar g rasp refl ex (r = .449, p < 0.01 ) .

Th e fi n a l change o f spontaneus postu re o f the l egs (i.e. arbitrary postu re)

was s i g n ifi cantly rel ated (p < 0.01 ) to the fi rst change of items d escri b­
ing sitti n g behavi o u r a n d b a lance deve l o p ment during s itti n g, i . e. post­
u re of th e tru n k d u ri n g sitti n g , d u ratio n of s itti n g , response to p u s h

45
 agai n st the shoulder d u ri n g sitti n g , and fo l l owi n g an obj ect with eyes,
h ead and trunk d u ri n g sitti n g . The fi rst chan ges of these items are con­
tam i n ated as they were scored o n ly if the i nfant was able to sit free.
The co rrelation-coeffi cients were mo re o r l ess s i m i l a r, ran g i n g fro m
.352 to .393. Th ese rel ati o nshi p s refl ect that arbitrary use of the legs is
a p rereq u isite fo r the develop ment of steady sitti n g .

Spontaneous motility o f the arms

I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

I I
exam.
I I I I I T
0 3 6 9 15 21
age,months
Fig. 8

Spontaneous motility of the legs

"'

8
1-1
(b
I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.
I I I I I
o 3 6 9 u B ffi n
age,months
F'i g . 9

In rl g u res 8 and 9 the p rediction bands are p resented fo r spontaneous

m oti l ity of the arms and of the l egs. There i s a p rotracted developmental
cou rse of the spontaneous moti l ity of the legs compared with that of the
arms. Th i s i s dem onstrated by the conspi cuous difference of the d u ra­
tion of n eon atal alternati n g movem ents in arms and l egs. However, a
co m p arab le sequence of developm ent was fo u n d in arms and legs, the
fi rst change of the neo natal alternati ng type of moti l ity being asymm e­
trical m oti l ity, fol l owed by symm etrical p revi o u s to vo l u ntary moti l ity.
The i nfant started to watch h i s hands and p l ay with them , and grasp fo r
obj ects at about the same time when p red o m i n antly sym m etri cal m oti l ity
of the arms m an ifested itself.
Th ese m oto r activities co nsist of typi cal sym metri cal use of arm s and
hands. They can b e regarded as an exa m p l e of the way i n which a pa r­
ti cular motor pattern becomes i n co rpo rated i n goal-di rected activities
duri n g thei r development. Th i s point is also i l l ustrated by the observa-

46
tion that i n the m ajo rity of i nfants, d u ri n g th e development of arm mo­
ti l ity, there was a developm ental p h ase d u ri n g which the sym m etri cal
typ e of motil ity and vo l u ntary m ovem ents were p resent i n about the
same quantity (score 4) . S uch a p hase was not fo u n d fo r the l egs.
D u ri n g t h is p h ase especi a l ly the i nfants were b u sy p l ayi n g with their
h an ds or g ras pi n g thei r clothes, in al l sorts of ways m a n i p u l ati n g their
envi ro n m ent with b oth hands at the same time. Beside thi s vol u ntary
b eh aviour, they often showed sym m etri cal swayi n g m ovements of the
arm s , such as o n e m i ght see i n i nfa nts who suffer fro m a lack of sti m u­
l ation , o r i n retarded i nfants.
In the l iteratu re the sequence of development of spontaneous m oti l ity
of a rm s a n d l eg s (asym m etri ca l , sym m etri ca l , vo l u ntary) as d escribed
above i s often attri b uted to the i nfl uence of to n i c n eck refl ex-activity
(Koupern i k a n d D a i l ly, 1 968). Asym m etrical ton i c n eck reactions occur
in i n fancy with a peak frequency b etween the ages of two and fo u r
m o nths, whi ch i s about t h e s a m e peri o d when asym m etri cal a rm mo­
ti l ity i s p redo m i n ant.
In the case of the legs the period of asym m etrical m oti l ity l asts l o nger;
it m ay b e a rg u ed that ton i c neck refl ex i nfl uence is evid ent in l eg posture
and motil ity fo r a l o n ger period of ti m e than i n the c ase of the a rms.
Sti l l , t h is observa b l e effect of ton i c n eck reflex activity i s vari a b l e a n d
i n cons istent i n n o rm a l i nfants (Pa i ne , 1 964; a l so M a g n u s a n d de Kleyn
did not co nsider the com p arab l e postu res i n n o rm a l i nfants to be i d enti­
cal with th eir asym m etri c ton i c neck reflex (cited by Vasse l l a and Karls­
son, 1 962)). Th i s wo u l d exp l a i n the l a rg e amount of i nteri ndivi d u a l varia­
b i l ity of the developm ental co u rse of posture and m oti l i ty. I ndeed, it ap­
pears that at al most each assessm ent al l the fo u r scores co u l d b e fou n d .
The s a m s patterns of motil ity were p resent i n th e case o f i nfants whose
heads were centered, so th at asym m etri cal ton i c n eck effects were avoi d­
ed. M o reover, no rel ati o n s h i p was fou n d b etween the fi rst a n d fi na l
chan ges a n d the develo p mental range o f spontaneous posture an d mo ­
ti l ity of th e arm s and the l eg s o n the o n e ha nd and of the asymm etri c
to n i c n eck reactions (spontaneous o r i m posed) on the othe r ha nd. The
develo pmental sequence of patterns of m otil ity as d escribed above can­
n ot b e exp l ain ed exc l usively by the d evelopmental cou rse of toni c n eck
reflex activity; it app ears to b e b ased o n m o re general centra l n ervou s
o rga n i zati on .
I nconsi stenci es i n the deve l o p mental co u rse of the spontaneous m oti l ity
of the a rm s o ccu rred o n ly in a m·i no rity of i nfants ; as fo r the l egs, about
half of the i nfants showed at l east o n e i n co n si stency d u ri n g their d evel­
opmental cou rse. No statistically s i gn ificant differences were fo u n d be­
tween boys a n d g i rl s , contra ry to Sta m b ak's o p i nion cited by Ko u perni k
a n d D ai l ly (1 968) that i n g i rl s t h e asym m etri cal m oti l ity o f t h e arms
wo u l d d i sappear earl i er than in b oys.

As was the case with the fi na l change of the spontaneo u s postu re of the
a rm s , the fi n al change of th e spontaneous m oti l i ty of th e a rm s (i.e. p re­
domi n antly vo l u ntary m ovements) app eared to be rel ated to the fi rst

47
chan ges of type of vo l u ntary g ras p i n g and the p a l m a r g rasp reflex (r =

.445 a n d .376 resp ectively, p < 0.01 ) .

The fi n al change of the spontaneo u s moti l ity of the l egs (i.e. p redomi­
n antly vo l u ntary m ovements) was s i g n ificantly rel ated to the fi rst change
of items descri b i n g fu n cti onal motor b eh avi o u r such as sitti n g , sta n d i n g
and wa l k i n g and with the fi rst c h a n g e o f the o ptical p l a c i n g reacti o n of
the feet.
Tab l e V I li sts these rel ati o n s h i ps, which are se lf-evident.

TABLE VI
Correlation-coefficients (p < 0.01) of relationshi ps between the fi nal
changes of s pontaneous moti lity of the legs and the first changes of
some other items (Pearson Prod uct-Moment correl ations)
Postu re of the tru n k d u ri n g sitti n g : .4 1 3
D u ration of sitti n g .43 1
Response t o push agai nst shoulder d u ri n g sitti ng .420
Fol l owing an object with eyes, head and tru nk, sitti ng .4 1 3
Sta n d i n g u p . 659
Wa l k i n g .598
Opti cal p l aci n g of t h e feet . 505

They suggest that b efo re these moto r a b i l ities can beco me m a nifest,
th e central nervo us system m ust h ave m atured suffi ciently to a l l ow fo r
vo l untary spontaneo u s m oti lity.
Spontaneous moti l ity of the legs in vertical susp.e nsion
Procedure: The exa m i n er held the i nfant suspended in vertical posi­
tion, supporting hi m u n der the shou l ders. Th e spontaneous m oti l ity of
the legs was observed, and the typ e of m otil ity appare nt m ost frequently
was reco rded. State 4.
Recording: The seq uence of the development h as been scored in the
fo l l owi n g way:
1 . N eon ata l , alternati n g typ e of m ovem ents.
2. Pred o m i nantly fl exi o n m ovem ents of hip and knee j o i nts.
3. P redomi nantly extension m ovements of hip and knee j o i nts.
4. Pred o m i n a ntly asym m etrical m oti l ity, d u ri n g which the legs showed
i rreg u l ar asym m etrical flexion/extension m ovements of varyi n g tem po
and a m p l itude.
5. Predo m i n antly sym m etri cal motil ity co ns isti n g of flexion/extension
m ovem ents of th e hips and kn ees of both l egs, of varyi n g tem po and
a m p l itude.
6. Pred o m i n a ntly arbitrary movem ents.
Scores 2 and 6 were co nsi dered as fi rst and fi na l chan ges respectively.

48
 Goal directed movements of arms and hands

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.
1 1 1 1 1 1 r 1 - 1 -� 1 1 .-----. 1 1 1 1 1 1 1 1
0 3 6 9 12 15 18 21
age,months
F i g. 1 0

The p rediction b an d i s p resented i n fig u re 1 0. The developmental co u rse

of the spontaneous m otil ity of the l egs i n vertical suspension appears to
be m u ch p rotracted. Th e same overa l l p attern of devel o p m ent was fou n d
as i n spontaneous motil ity of a m s a n d l e g s i n s u p i n e position.
H owever, i n verti cal suspens i o n , after the fi rst phase of neonatal alter­
n atin g type of m ovements about o n e thi rd of the i n fants showed fl exion
a n d/o r extension m ovements of h ips a n d kn ees p red o m i n antly b efo re
asym m etri cal motil ity a ppeared.
Yet this was not the rul e. Wh i l e 1 0- 1 5% of the i nfants persisted in ex­
ten s i o n m ovem ents u nti l the 1 3th exami nati o n , i .e. u nti l the age of about
o n e year, 35 percent of the i nfants showed asym m etrical m ot i lity at the
th i rd assessment al ready; this percentage reached its peak (69o/0) at the
sixth assessm ent, i.e. at the age of about 24 weeks.
From the fifth assessment o nwards m o re th an ten percent of the i n ­
fants sh owed symm et ri cal m otil ity o f the l egs, whi ch type o f m oti l ity
reached its peak at the 1 1 th assessm ent (about 44 weeks of a ge) .
Arbitrary l eg m oti l ity was observed i n o n e i nfant as early as at the
n i neth assessment (36 weeks). From the tenth assessm ent onwards a
rap i dly i ncreasi n g n u m ber of i nfants showed this typ e of m oti tity p re­
d o m i nantly; the 50th centil e was exceeded at the age of about 64 weeks
(1 4th assessm ent). Th e flexion an d/o r extension m ovements of h i p s a n d
k nees occurri n g i m mediately after n eonatal altern ati n g leg m ovem ents,
m ay poss i b ly b e consi dered to refl ect symm etri cal vestib u l a r infl u en ces
on the m oti l ity of the l egs i n vertical suspension. There was no relation­
ship with the occu rrence of th e positive supporti n g reaction.

Compa ri son of fi g . 1 0, 3 1 and 2 1 (spontaneous motil ity of the l egs i n ver­

tical suspension, optical p l ac i n g reactions of the feet a n d sta n d i n g up),
shows that the opti cal p l aci n g reacti o n of the feet a n d standi n g u p begin
to m a nifest themselves at the tim e when the sym m etrical m ovement typ e
reaches its peak-freq uency and begins to m erge i nto vol u ntary m ove­
m ents of te legs (at about 44 weeks). From this o n e m ig ht co n c l u d e that
the p h ase of sym m etrical m ovem ent type of m otor activity of the legs

49
reflects p reparatory central nervo us o rganizati o n fo r the developm ent
of th e m otor ab i l ity of sta n d i n g o n both l egs.
Actua l ly the fi n a l change of the item spo ntaneous moti l ity of the legs
i n vertical s u s p ensi o n w a s fou n d t o b e cl osely related to the fi rst chan­
ges of the optical p l a c i ng reaction of the feet, sta n d i n g u p and walki n g
(r' s ran g i n g from . 7 1 5 t o . 798) . Th e co rrel ati o n-co effi ci ents o f its rel a­
tionship with the fi rst change in items descri b i n g sitti n g beh avi o u r (pos­
ture of the tru nk, d u rati o n , reaction to push against the shoulder and fo l­
l owi n g an object with eyes, h ead and tru n k) ran ged from r = .474 to
.501 (p < 0.01 ). This m eans that the mo ment when the development of
effective b a lance d u ri n g sitti ng sets in is (moderately) predictive of the
m o ment at which i n vertical suspensi on the i nfant is abl e to m ove h i s
l egs a rb itrari ly. T h e fi na l chan ges o f t h e developm ent o f sitti n g behavi­
our and motil ity i n verti cal suspension a re rel ated a lso (r's ran gi n g from
.464-.580, p < 0.01 ). If Ko rn hu ber's (1 973) theo ry about the ro le of the
cerebel lar n u clei i n the moto r o rganizati o n i s co rrect, the m atu rati o n of
the cerebel la r nuclei i s of g reat i m po rtance fo r th e develop m ent of the
a b i lity to m a i ntai n adequate postu res of parts of the body (e. g . arms
a n d l egs) d u ri n g vo l u ntary m otor beh avi o ur. lt i s evi dent that this a b i l ity
is n eeded d u ri n g sitti n g behavi o u r. Arbitrary, i . e. vo l u ntary use of the
l egs is i m po rtant fo r sta n d i n g and wal k i ng , i n which o bvi ously cerebel la r
m echan is m s are also i nvo lved . I n Korn h u ber' s o p i n i o n the cereb e l l a r cor­
tex i s respo n s i b l e fo r the reg u l ation of fast m ovements, whi l e the cere­
b e l l a r n u clei u n dertake the reg u l ation of the postu res between the m ove­
m ents. Both typ es of reg u l ation are i mportant fo r a smooth contro l of
vo l unta ry m ovements. Th e rel ati o nshi p s between the fi na l chan ges of
sitti n g b eh avi o u r and of moti l ity i n vertical suspension refl ect the ro le
of the m aturation of cereb e l l a r m echanisms i n the developm ent o f these
two motor pattern s.
Nearly a l l the i nfants showed one o r m o re i nconsistencies i n the scores
d u ri n g the developmental co u rse of this item. Th e i n co nsisten cies were
d i strib uted over the developmental co u rse at rando m. They refl ect the
degree of i ntra-in d ividual va ri a b i l ity which can be regarded as charac­
teristi c of a n o rm a l ly developi n g nervo us system , b ut they a lso i l l u strate
th e p roblems of op erationalizati o n of the seve ral p hases. There was no
s i g n ificant rel ation b etween the developme ntal range a n d the n u m ber of
i n con s i sten cies. Stati sti cal ly s i g n ifi cant differences between boys and
g i rl s were n ot fou n d .

Goal-di rected motility o f arms a n d hands

Procedure:
Positio n of the i nfa nt: S u p i n e pos iti o n, duri n g the fi rst five mo nths, sit­
ti n g on h i s m other' s l a p su bseque ntly (state 3 or 4) . D u ri n g the obser­
vation p eriod it was observed whether the i nfant showed m a n i p u l ative
m anua l activity. Then the i nfant was p resented with a s m a l l ovo i d o bject
(2 . by 3 by 3 cm) which he was verb ally encouraged to grasp. If he was
a b l e to h o l d the object in his ha nd , he was p resented with a seco n d o n e,
a n d if h e cou l d h o l d the two o bjects h e was p resented with a thi rd one.

50
Recording: Observation of the data resulted in defi n i n g the fo l l owi n g
sequence:
0. No goal di rected m oti l ity of a rm s a n d h ands.
1 . Lookin g at a n d p layi n g with the h a n d s : the i nfant m oved o n e or
both hands i n front of h i s eyes a n d watch ed them i ntently. M utua l
touchi n g and/o r gras p i n g o f t h e hands were a l s o scored 1 .
2. G rasp i n g objects. The i nfant approached the obj ect p resented with
one o r both hands and touched it with or without actu a l ly getti n g
h o l d o f i t . Altho ugh both asymm etrical an d sym m etri cal arm/h and
moti l ity cou l d res u lt i n a score 1 o r 2 , dependent on the fin a l resu l t
of the m ovem ent, it w a s fou n d that p l ayi n g with the hands a n d this
type of grasp i n g obj ects m ai n ly i nvolved symm etrical a rm/h a n d ac­
tivity.
3. P layi n g with th e feet. The i nfant touched or g rasped one or both
feet, with one o r both hands. This behavio u r was scored separately
because of bei n g so sp ectacula r, even though thi s score was obtain­
ed by o n ly a m i n o rity of the i nfants a n d usual ly occurred in con­
j u n ction with score 2 or with one of the fol l owin g scores.
4. H o l d i n g one object. Th e i nfant was ab l e to g rasp and h o l d one ob­
j ect with one h a n d .
5. H o l d i n g an object i n e a c h h a n d . After g ras p i n g th e fi rst object the
i nfant was p resented with a seco n d one; h e m a n aged to grasp and
h o l d th i s seco n d obj ect without d roppi n g the fi rst o ne.
6. H o l d i n g two objects in o n e hand. Whi l e h o l d i n g a n object i n each
hand, the i n fant was ab l e to g rasp a thi rd object p resented to h i m
without d ro p p i n g o n e o f t h e others. I n t h e m ajority o f cases t h e i nfant
s h i fted one of the objects from one h a n d to the other and g rasped
the thi rd o n e with the free h a n d . Some of th e i n fa nts s h i fted the ob­
j ect to the u l n ar s i d e of the p a l m , h e l d it with p a l m a n d fi n gers a nd
g rasped the thi rd obj ect with the t h u m b a n d i n dex fin ger of this
hand.
A score 1 was consid ered as the fi rst ch ange, a score 6 as
the fi nal change.
Th e p rediction band fo r goal-di rected m oti l ity of a rm s a n d h ands i s p re­
sented i n fi g u re 1 1 . Looki n g at a n d p l ayi n g with the hands occu rred i n
Spontaneous motility of the legs in vertical suspension

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.
I I I I -1 I T I I I I
0 3 6 � 12 15 18
age,mon
21 ths

Fig. 1 1 51
 m o re than 80o/0 of the infants from the t h i rd exa m i n ation o nwards, i . e.
from about the age of 1 2 weeks . Th i s behavi o ur occu rred earl i er in o n ly
six percent of the i nfa nts.
A score 2, i . e. g rasp i n g o bjects, was obtai ned m a i n ly d u ri n g the fou rth
and fifth exa m i n ation. At the sixth exa mi nati o n m o re than 80°/0 of the i n ·
fants had exceeded this phase. A t a b o u t the same ti me the i ntens ity
of the p a l m a r grasp reflex decreased. Actual ly the palmar grasp
refl ex m ay p l ay an i m po rtant ro l e in reach i n g score 1 or 2 . As the i n­
fant' s o n e h an d approaches an obj ect or h i s other ha nd and touches it
acci dentally with h i s pal m , this may resu l t i n a palmar grasp reflex, re­
sem b l i n g vo luntary gras p i n g .
Th us the scores 1 and 2 do not o n ly exp ress g rasp i n g behavi o u r b ut a l ­
so the i ntenti on o f grasp i n g .
I n the period i n which scores 2 and 3 are obta i ned by the m ajority
of i nfants, observation of the spontaneous moti l ity of arms a n d hands
revea ls p redomi nantly sym m etri cal motil ity. Yet the i nfant' s ab i l ity to di­
rect h i s. arm towa rds a specifi c goal shows that vol u ntary arm and hand
motil ity are devel o p i n g . Score 4, i . e. h o l d i n g an object, can b e con­
sidered as wel l-develo ped vo l u ntary motor b ehavi o u r; at this ti m e the
palmar g rasp refl ex has decreased i n i ntensity and the observati o n of
spontaneous motil ity of arms and hands reveals vo l u ntary m ovement
pattern s. Scores 5 and 6 refl ect the differentiati o n of m a n ua l m a n i p u l a­
tive cap aciti es. Score 5 m eans that the open i n g of the free h a n d i n
order to g rasp an o bj ect i s no l o n ger acco m p an i ed by open i n g of the
other hand which holds an object. lt refl ects the disappearance of asso­
ci ated m ovements as a res ult of matu rati o n of the nervo us system . A
score 6 m ay be co nsi dered to refl ect fu l ly differentiated m a n u al ab i l ity.
The ti m e cou rse of the different p h ases as shown in the predictio n ba nd
i s i n accordance w i t h the fi n d i n gs o f B runer ( 1 970) and Wh ite (1 970) .

Fi g u re 1 1 shows that the d u rati o n o f t h e various phases i nc reases when

the sco res beco m e h i g h er. Wh i l e m o re than 80°/0 of the i nfants obta i n
a sco re one duri n g two exam i n ations, it takes seven exa m i n ations be­
fore the fi n al sco re 6 is reached by mo re than 80% of the i nfants.

Nearly half of th e infants showed a relapse in sco re once. There were

n o stati sti cal ly s i g n ificant differences between boys a n d g i rls, neither
with regard to the m om ent of the fi rst change nor with regard to the
fi n al change, developmental range o r n u m ber of i n co nsi stencies.
The l e n gth of develop mental ra nge was rel ated to the ti m e of o n set of
the fi n a l change with a h i g h co rre l ation co efficient (r = .97 1 ) . Th ere was
no rel ati o n s h i p b etween the o n set of the fi rst change and the le ngth of
the developmenta l ra ng e. The fi rst app earance of goal di rected motil ity
of the arm s and hands has a m u ch s m a l l er vari atio n range than the
mom ent of sta b i l izati o n (i .e. the fi nal ch an ge). Th i s exp l a i n s the close
rel ati o n s h i p b etween develop mental ran g e and fi na l change, which re­
fl ects the i nteri ndivi dual d ifferenti a l m aturati o n of b rai n mecha n i s m s

52
n eeded for goal d i rected abi l ities. l t is evi dent t hat when the fi rst go al
di rected m oti l ity of a rm s and hands m ani fests itself no p redictio n can
b e m ad e con cern i n g the d u rati o n of the devel o pme ntal ran g e of this
typ e of m a nj p u l ative b eh avi o u r.

The fi n al change of goal d i rected motil ity of the arms and h a n d s (i .e.
h o l d i n g two objects i n one ha nd) sh owed a stati sti cal ly s i g n ificant rela­
ti o n s h i p with the fi rst change i n items deal i n g with the develo pment of
steaqy sitti n g , co m p arab l e to the rel ati o n s h i p s fou n d i n the case of
spontaneou s motil ity of the arms (r' s ran g i n g from .401 to .440, p < 0.01 ) .
Sti l l , t h e fi n al change of g o al d i rected ab i l i ty of the arms and h ands oc­
cu rred co n s i dera b ly l ater than that of the spo ntaneous motility of the
arm s (cf. fi g. 8 a n d 1 1 ) . l t m ay b e ass u m ed that steady s itti n g , i .e. esta­
b l i sh ed tru n k-balance, advances i n dependent and differenti ated u se of
the arms.
There was no rel ati o n s h i p with the development of typ e of vol u ntary
g raspi n g , neither with regard to the fi rst change, n o r to the fin a l change
or th e d evelopm ental ran ge. Th i s m i ght i m p ly t h at the d eve lo pmental
cou rse of goal d i rected motil ity of t h e arm s and hands differs from that
of fi n e differe nti atio n of fi n ger-use (wh ich i s i m p l i ed i n typ e of vo l untary
g ras pi n g) ; th ere was no rel ation i n ti m e ; a n d app arently they are b ased
on d ifferent b ra i n m echan i s m s.
Keepi n g i n m i n d Korn h uber' s (1 973) theory about the ro l e p l ayed by t h e
cerebra l co rtex i n the m otor o rganizati o n , o n e m i ght con s ider the fi n a l
typ e of g ras p i n g as a typ i c al m ote-cortical fu ncti o n (see a l so Wiesen­
danger (1 969) , Lawrence and H o pki ns (1 972) wh ere as the goal d i rect­
ed moti l ity of arms and hands wo u l d be medi ated by n o n-cortical struc­
tures, i.e. the basal gan g l i a, b ra i n stem an d cereb e l l u m .
T h e rel ati o n s h i p b etween g o a l d i rected arm/hand m oti l ity and the d evel­
o p m en t of steady sitti n g m ay b e co n si dered to support this hypothesis.
The m e d i ati o n of a steady and well b a l a n ced sitti n g posture m u st cer­
tai n ly b e l o o ked fo r i n non-cortical stru ct ures.

Comp arison of the n u m ber of i ncon s i stencies in the d evel o p m ental

co u rse of spo ntaneous p ostu re and m oti l i ty of the arms o n the o n e
h an d and of goal d i rected m oti l ity o n the other, shows that i n the form er
developmental cou rse there a re l ess relapses to a p revi o u s phase tha n
i n the l atter. Th e developmental ran ges vari ed i n l en gth, b ut there was
no s i gn ificant rel ati o n b etween the developme ntal ran g es and the oc­
curren ce of i n co n s i stenc i es . I n the case of the devel o p ment of goal di­
rected m oti l ity the i nconsi stenci es m a i n ly occu rred during the seco n d
h alf o f the developmental cou rse, i . e. d u ri n g the p hases w h e n differen­
tiati on of vol u ntary m a n u a l activity i ncreased. T hi s differe ntiati o n is a re­
s u l t of the i nc rea s i n g com p l exity of the u n d erlyi n g b ra i n m echa n i s m s ;
o n e m i gh t conten d t hat the occu rre nce o f i nco nsi stencies refl ects o cca­
s ion a l l apses of a com p l ex m echanism d u ri n g its m atu rat i o n .
Th e d evelopmen t of the ab i l ity to store a n o bject b efore graspi n g al)d
h a n d l i n g another o n e, as described by B ru ner (1 973), co i n c i des with

53
the devel o p m ent of the ab i l ity to h o l d m o re than o n e o bj ect i n one hand,
as descri b ed ab ove. Actu ally th e act of sh ifti n g an object to th e ul na r
side of the h a n d i n o rder t o g et h o l d o f a seco n d object without losi n g
the fi rst, c a n b e seen a s a ki n d o f sto ri ng , m ade poss i b l e b y a neuro lo­
gically determ i n ed differenti ati o n of m a n u a l a b i l ities.
Typ e of vol u ntary g rasping
Procedure: D u ri n g the assessment of goal-directed m oti l ity of arms
a n d h a n ds, th e m ode of g rasp i n g of both hands was observed consecu­
tively. An ovo i d o bj ect of 2 x 3 x 3 cm was used. State 4.

Recording:
0. No g ras p i n g of the obj ect.
1 . Pal m a r g rasp : When g rasp i n g the i nfant used the who l e p a l m a r su r­
face of h an d and fi n g ers.
2. Radial p a l m a r g rasp : the i nfant used the rad i a l half of h i s h a n d p a l m ,
i n c l u d i n g th u m b and i ndexfi n ger, p red o m i n a ntly.
3. Scissor g ras p : the i nfant g rasped the o bject between the vo l a r s u r­
faces of h i s extended th u m b a n d i n dexfi n ger.
4. I nferio r p i ncer g rap : the i nfant g rasped the object between the tip of
h i s i n dexfi n ger and the vo l a r si d e of h i s th u m b .
5 . Po inti n g : the i nfant app eared u n a b l e t o g rasp, h e po i nted and even­
tual ly touched th e object with an extended i ndexfi n ger ("tip p i n g " ) .
Sometimes t h i s poi nti n g w a s fol l owed by an i nferi o r p i n cer g rasp o r
a p i n cer g rasp .
6. Pi ncer g ras p : the i nfant g rasped the o bject neatly between the ti ps
of i ndexfi n ger and thumb.

The p h ase of p o i nti n g was observed i n a very sm a l l m i nori ty of i nfants

(at m ost 1 Oo/0) . Yet on cl osely i nterviewi n g the mothers, it appeared that
the maj ority of the i nfants h ad shown this phase d u ri n g a short period
of time (often not m o re than one day), at a time when they could h an d l e
obj ects adeq u ately. W h e n poi nti n g w a s observed d u ri n g t h e assess­
m ent, it always occu rred b etween the p h ases of the i nferio r p i n cer grasp
a n d the p i n cer g rasp. D u ri n g the phase of p o i nti n g the i nfants were
easi ly u pset. Th i s was confi rmed by the m others, who observed the
same b eh avi o u r i n thei r babi es. As th i s p hase seemed to b e stri k i n g i n
a t l east some o f th e i nfants, i t was i n cl uded a s a separate score. Scores
1 an d 6 were' co n s idered as fi rst a n d fi n a l changes respectively (fi g . 1 2).

Wh i l e at the th i rd assessment a l a rg e m ajo rity of the i nfants (96°/0) did

n ot m an ifest any g rasp i n g at all, d u ri n g the fo u rth assessment half of
the in fants showed the palmar type of g rasp i n g, wh i l e fo u r weeks l ater
this was the case in 88o/0 of th e i nfants.
D u ri n g developm ent an i ncreased d ifferenti atio n of the developmental
rate b ecame apparent, which i s refl ected i n the shape of the p rediction
bands. Especi a l ly d u ri n g the l ast peri o d of devel o pment i.e. the peri o d
i n w h i c h th e sci ssor a n d the i nferi o r p i ncer grasp were p reponde ra nt,
m uch overlap of sco res was fou n d . One th i rd of the i nfants d i s p l ayed a

54
 Type of voluntary grasping

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

1 1 r-'- 1 1
exam.
�1 1 1· � --r 1 --,--r 1 �� 1
0 3 6 9 12 15 18 21
age,months
Fig. 1 2

n eat p incer g rasp at the 1 2th assessment (about 1 1 m onths), wh i l e near­

ly h alf of them reached t hi s p h ase at the age of o n e year. M o re than
80% were a b l e to use the p i n cer typ e of g rasp i n g d u ri n g m a n i p u l ative
b eh avi o u r at the age of 1 4 m o nths (1 5th assessm ent) .

There w a s n o stati sti c a l ly si g n ificant difference b etween boys a n d g i rl s

with reg ard t o the m o m ents o f onset o f fi rst change o r fi n a l change. I n
the b oys there were th ree t i m es a s m any i ncon s i stencies a s i n the
gi rl s ; t h is d ifference was stati sti cal ly s i g n ifi cant (Mann-Whitney U test,
p < 0.01 ). There was a negative rel ati o n s h i p b etween the o nset of the
first change a n d the l e n gth of the d evelopm ental ran g e (r -.554), =

whi l e the l atter showed a close and positive rel ati o n s h i p with the fi n a l
c h a n g e (r = .94 1 ) . T hi s combi n ati o n of rel atio n s h i ps suggests that t h e
m om ent o f fi n a l stab i l i zati o n of the type of vol u ntary g rasp i n g , as defined
in th is study, i s m o re o r less fixed ; i t i s i n dependent of the m o m ent of
th e fi rst exp ression of g rasp i n g .
As reported elsewhere (To uwen, 1 97 1 ) there w a s no c l o s e rel ati o n s h i p
b etween the develop m ental cou rse of the p a l m a r g rasp refl ex and t h e
typ e of vol u ntary g rasp i n g .
A statisti cally s i g nifi cant rel ati o n s h i p with a l ow corre lation coeffi cient
(r = .273, p < 0.05) was o n ly fou n d b etween the fi rst change of the pal­
mar g rasp refl ex and the fi rst ap peara n ce of vo l untary g raspi n g (p a l m ar
g rasp typ e) . Alth ou g h the p a l m a r g rasp refl ex m ay b e pa rtly respon si b l e
for t h e su cces o f t h e fi rst attem pt o f g raspi n g, t h i s g ras p i n g cannot b e
regarded a s b e i n g sol ely b ased o n refl ex mechani s m s ; i t p roves that a
differentiati o n of vo l u ntary m a n i p u l ation h a s set i n . Neither can thi s l ow
rel atio n s h i p b e consi dered as a stro n g support fo r the vi ew that a de­
crease of the p a l m a r g rasp refl ex is a p rereq u i s ite fo r the devel o p m ent
of vo l u ntary g ras p in g.

Th e d evelo p ment of vo l u ntary g raspi n g has been described extensively

by H al verson (1 931 , 1 940) , who d i sti n gu i shed 1 0 p hases in the develo p-

55
ment of p reh en s io n, reach i n g and differenti al m a n i p u l ative beh avi o u r i n­
cl uded. He also concl uded th at there was a p roxim o-d i stal co u rse of
developm ent, such as is apparent i n the descri bed developm ental se­
q uence. lt stands to reaso n that the typ e of vo l u ntary grasp i n g i s an
i m porta nt va riab le i n develop mental tests. Yet i n these tests m eans o r 50
centi l es are usua l ly g iven without ra ng es (a n excepti o n is the Denver
Developm ental Scree n i n g Test (Franken b u rg and Dodds, 1 967), which
gives 3-95 centi l es i n addition to i nterq u a rti l e ran ges) and the devel op­
m ental sequence i s often not taken i nto con s i derati on, o r it is p resented
o n ly with key-ages. M o reover, the standa rd i zati on of the tech n i qu es of­
ten vari es wi dely. Th i s h a m pers co mp a ri son with th e fi n d i n gs of the pre­
sent stu dy. The p h enomenon of the vari ati on ran ges ten d i n g to i n crease
with i n creas i n g differenti ati o n of typ e of g ras p i n g i l l u strates the i m p o r­
tance of knowl edge about the va ri ati o n-ran ges of the developm ental
p h ases.
From a neuro lo g i ca l p o i nt of view the develop ment of th e typ e of vo l u n­
tary g raspi n g reflects the maturati o n of th e mote-co rtical a n d corti co­
s p i n a l mech an i s m s . As Wiesendanger (1 969) , in h i s extensive revi ew of
th e fu n cti on of the pyra m i dal tract, and Korn h uber (1 973) h ave poi nted
o ut, the somato-sensory regu l ati o n of h i g h ly differentiated m ovem ents
such as fi ne fi n ger m ovem ents i s a specifi c p ro perty of the motor cortex.
The fi n d i n gs of Lawrence a n d Hopkins (1 972) in the i nfa nt rhesus mo n­
key su g gest th at th e appearance of d i fferenti ated use of th e fi ngers i s
rel ated t o t h e m aturati o n o f corti co s p i n a l co nn ecti ons. If thi s m ay be
tran sferred t o h u ma ns, t he ti m e sched u l e as p resented i n the p redicti on
band of th e developm ent of typ e of vo l u ntary gras p i n g, m ay refl ect the
time course of the estab l i s h m ent of co rti cosp i n a l co n necti ons in the h u­
m a n i nfant. lt wou l d be attractive to hypoth esize that the p h ase of " p o i nt­
i n g " m a rks the transition b etween " n o n-cortica l " a n d " co rti cal " grasp­
ing m ech a n i s m s .
L o w b ut statisti cal l y s i g n ificant rel ationsh i ps were fo u nd, with r' s ran g­
i n g from .370 - .449 (p < 0.01 ) b etween the first change of vo l u ntary
g rasp i n g and th e final change of spontaneous posture a n d m oti lity of
th e a rm s , as rep o rted i n the p arag raph on spontaneous posture a n d
motil ity of arm s a n d legs.

A stati sti cal ly s i g n i ficant rel ati o n s h i p was fou n d between the final chan­
ge of vo l u ntary g rasp i n g and the first changes of stand i n g u p and wal k­
i n g (r= .495 a n d .452 respectively, p < 0.01 ) . Th i s m ay o n ly mean that
th e tim e of on set of th e developm ent of stand i n g and wa l k i n g behavi o u r
i s rel ated t o th e occu rrence o f fi ne d ifferenti ated use o f h ands and
'fi n gers. Yet one m i ght argue that there i s a seq uenti a l o rgan izatio n be­
cause th i s rel atio n s h i p suggests the p ri o rity of m anu a l differenti ation to
moto r development i n verti cal positi o n . Teleo l o g i ca l ly th i s is a p lausi b l e
sequence o f developm ent: t h e i nfant m u st b e ab l e t o u s e h i s h ands and
fi n gers p roperly when he starts to pull h i m self i nto a kneel i n g position
(first change of sta n d i n g up) o r sta rts to wal k using both h a n d s fo r sup­
port (fi rst change of wa l k i n g) .

56
 Coord i n ation of the upper extremities
Procedure: The sm ooth ness an d adequ acy of m a n i p u l ation and p l ayi n g
behaviou r was observed d u ri n g the whole co u rse o f t h e assessm ent; at
the end an overal l semi-quantitative score was g iven .
Recording:
0. Badly d i rected swayi n g m ovements, t he i ntended go al b ei n g m issed
rep eated ly.
1 . We ll- d irected m ovements, alth o u g h overshootin g occurred repe ated­
ly. The goal was m i ssed n ea rly h a l f of th e time, a n d when the
i ntended m ovement succeeded, the q u a l ity of the m ovement was
ab rupt a n d hesitati n g as a resu l t of b adly contro l l ed a rm- and h an d­
m otility.
2. Wel l-di rected arm and ha nd m ovem ents without overshooti n g , of
s m ooth and adequate q ua l ity. Th e i ntend ed movement succeeded
m ost of the ti m e.
A score 1 a n d a score 2 were reg a rded as the fi rst a n d the fi n al change
respectively.

Coordination of the upper extremities

"'

g
(l
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

1-----r-- r
exam.
1 1 1 1 1 1 1 1 T 1
0 3 6 9 12 15 18 21
age,months
Fig. 1 3

Th e p rediction b a n d for the coo rd i n ati o n of the upper extrem ities i s

shown i n fi g u re 1 3. lt i s c l ear that smooth a n d wel l-d i rected motil ity of
the upper extremities is_ shown by m o re than 80°/o of the i nfants at the
end of the fi rst year. Th ere were no co n s i stent differences between
boys and g i rls , alth o u g h the n u m ber of i ncon s i stencies was som ewh at
l a rger i n the b oys. Th ere was a negative rel atio n s h i p , with a l ow co rre­
l ation coeffi cient, b etwee n the time of o nset of the fi rst change a n d
the d u rati o n of the developmenta l ra n g e (r -.449, p < 0 . 0 1 ) . An early
=

o ns et of the development of goal-di rected m ovements does not p redict

a rap i d developmental course, i . e. an early esta b l i s h ment of good a n d
sta b l e coord i n ation.
G esel l j u d ged the developm ent of coo rd i n ati o n o n the basi s of specifi c
perfo rm ance, such as b a n g i n g with toys, shaking, transfer fro m h a n d to
h an d , m atch i n g two o bj ects, a n d so o n (G esell and Arm atruda, 1 947):
In h i s view coord i n ation was a derivative from specific m oto r p atterns.
l t s eem s m o re adeq uate, h owever, to co n si der coo rd i n ation as a fu n c­
tion of a p roper b ra i n m echanism servi n g m otor perfo rm ances. l t i s pos­
s i b l e that the n e u ra l m echan i s m s fo r coo rd i n ati o n and those fo r vo l u n­
tary m otor perfo rm ances develop rather i n dependently. Vol untary m otor

57
activity is based on corti co-sp i na l mech anisms, wh i l e coord i n ation-me­
chanisms (i.e. cereb e l l a r mech a n i s m s) serve as a contro l system fo r
carryi n g out the vo l u ntary m ovement adequately and effici ently. An awk­
ward a n d badly coo rd i n ated moto r b eh avi o ur m ay be the result of i m­
p a i rm ent of the mecha ni sms for coord i n ation, without the mecha n i s m s
for vo l u nta ry m otor activity b ei n g i m p a i red. Th i s i s t h e c a s e i n fo r i n ­
sta nce ataxia.
Th i s view, i . e. the devel o p ment of coord i n ation and vo l u ntary moto r be­
haviou r are based o n the m aturati o n of d ifferent b ra i n m echanisms, i s
supported b y the fa ct, observed i n the p resent study, that the devel­
opment of the coord i n ation of the upper extremities was not s i g n ifi cantly
rel ated to the developm ent of specifi c perfo rm ances of hands and arms
(e. g . g raspi n g types o r goal d i rected motil ity of the arm s and ha nds).

A low, but stati sti ca l ly si g nificant rel ati o nshi p (r = .370, p < 0.01 ) was
fou n d b etween th e fi rst change of the coo rd i n ation of the arm s (i .e. onset
of develop m ent) and the fi nal change (i.e. d i sapp earance) of the spon­
taneously occu rri n g asym m etri c ton i c neck reaction . This m i ght i m p ly
that the l atte r wou l d h ave a cou nteracti n g effect on the developm ent of
the form er. Th i s wo u l d be contrary to the o p i n i on of G esel l , who co nsi­
dered the p resence of the asymm etric ton i s neck response an i m po rtant
p romoti n g p h enomenon fo r coord i n ated p rehension (Gesel l and Ama­
truda, 1 947). The corre l ation coeffi cient is appreci ab ly l ow, however.
A rel atively low though s i g n ificant relati o n s h i p (r = .371 , p < 0.01 ) was
fou n d b etween th e fi n a l change (i.e. stabi l i zati on) of the coo rd i n ation of
th e arm s and the fi rst change of stan d i n g up (i.e. kneel i n g), which su g­
gests that the i nfa nt needs an adeq u ate coord i n ation of the arms i n
order t o b e ab l e t o p u l l h i m self u p i nto a knee l i n g positi o n .

Posture o f h ead, tru n k a n d arms i n prone position

Procedure: Th e i nfa nt was put o n a flat surface in p ro n e positi o n . H i s
h ea d was centered . Th e posture o f h ead, trunk and a rms w a s described.
State 4.

Recording:
1 . Th e i nfant lifted h i s head and kept it l ifted fo r some seconds, witho ut
u s i n g elb ows or hands. Th e upper part of the tho rax was either s l i ght­
ly l i fted or n ot l i fted at a l l . Absence of h ea d l i ft in p ro n e positi o n d i d
n ot occu r a m o n g t h e i nfants o f t h e study d u e t o t h e selectio n criteri a
for n eu ro logical o pti m a l ity.
2. Th e i nfant l i fted the h ead and the upper p a rt of the tho rax, suppor­
ti n g h i m self o n h i s elbows apparently. Sti l l h e di d not top p l e over
when this elb ow support was p u l l ed away.
3. The i nfant lifted h i s head and upper p a rt of the tho rax, part of the
ti m e supporti n g h i m self o n his elbows, part of the ti m e witho ut sup­
porti n g h i m self. I n the l atter case h e extend ed and spread his arms
i n a p l an e l i ke fashi o n (l l l i n gworth, 1 966, ca l l s this latter position
" swi m m i n g").

58
4. The i nfant l ifted h i s head and upper part of the thorax without sup­
porti n g h i m self on elbows or hands ("p l a ne" or ,swi m m i n g" posi­
ti on).
5. The i nfant l i fted h ead and tho rax, part of the time without any su p­
port, p a rt of the ti m e supporti n g h i mself o n h i s (open ed) hands and
extended a rm s . I ntermi ttently h e supported h i m self o n h i s elbows,
which s eem ed to b e a tra nsition to support o n extended a rm s . He
top p l ed over if this support was p u l l ed away.
6. The i nfant supported h i m self on h i s hands and extended a rm s al­
m ost excl us ively. D u ri n g t hi s p hase h e m i g ht be gi n to d raw his
knees u nder h i s abdomen .
7. The i nfant supported h i m self on exten ded a rm s and flexed knees.
Scores 2 and 7 were co nsidered as fi rst an d fi na l chan ges respectively.

Posture in prone position

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.
-- I I I I I I I I I I I I I
0� 1 3I 1 1�6 9 12 15 18 21
age ' months
Fig. 1 4

The p redictio n b a n d fe r t hi s item i s p resented i n fi g u re 1 4.

Beside th e i ntra- i n d ividual overl ap of the several co nsecutive p h ases,
rep resented by sco res 3 and 5, i nteri ndividual overlap of scores i s clear­
ly evi dent.

At the s econd assessment six i nfants were well a b l e to l i ft head an d u p­

per p art of t h e thorax from the s u rface on which they were lyi n g. About
half of the i nfants showed this typ e of m otor b eh avio u r at the th i rd as­
s essm ent, and two th i rds of them at the fou rth assessm ent (about 1 6
weeks) . At that time twenty two percent d i sp l ayed " p l ane- l ike" o r " swi m­
m i ng " postures.

Support o n the h an d s was observed in some i nfants fro m the s ixth as­
sessment onwards (24 weeks). D u r i n g the n ext twenty weeks there was
a l a rg e overl ap of p h ases . At the 1 4th assessm ent (about 1 3 m onths)
m o re than 80o/0 of the i nfants assu med t he al l-fo u rs positi o n , but a m i ­
no rity of i nfants persi sted i n an abdo m i n al positi o n u nti l the 1 8th as­
sessment (about 1 5 m onth s) .

59
One o r two i n co ns i sten cies were fou n d i n 40 i nfants, with out any diffe­
rence b etween boys and g i rl s . Neither was there a consistent difference
b etween boys and g i rl s as for the time of onset of the fi rst change, the
fi n a l change or the l e ngth of develop mental ran ge. There was no re l a­
tionsh i p between th e ti m e of onset of the fi rst change and the le ngth of
develop mental ra nge, neither b etween the l e ngth of the developm ental
ran ge and the occu rrence of i nconsi stencies.

The fi n al change of the postu re in p ro n e positi o n (i.e. al l fou rs position)

was s i g n ifi cantly related to the onset of the develop ment of items deal­
i n g with motor behavi o u r duri n g sitti ng (r' s ran g i n g from .364 to .383,
p < 0.01 ) and sta n d i n g, wa l k i n g and optical p l a c i n g of the feet (r's ran g­
i n g from .690 to .461 , p < 0.01 ). Appendix C shows the co i n ci dence i n
tim e o f these p a rameters. One m ay contend that the developm ent of ba­
l ance, as req u i red fo r th e al l -fo u rs position i s a p rereq u i site for the d e­
vel o pment of adequate sitti n g . The a b i l ity to achi eve an al l-fo u rs position
refl ects a l so an adequate use of m oto r contro l needed fo r an effi cient
development of verti cal posture.

The variatio n-wi dth of ti m e of the fi na l change of posture in p ro n e positi o n

appeared t o b e m u ch l a rger th an that o f t h e fi rst change. Th e le ngth­
eni n g of th e vari atio n-wi dth i s m a i n ly caused by a sma l l n u m ber of i n­
fants (less than 20o/0) i n whom the fi na l change was reta rded. Th i s p h e­
nomenon of skewn ess of the d i stri buti o n i s fou n d i n the case of other
item s a l so. Its mean i n g was recogn i zed by severa l auth o rs, e.g., H i n d­
l ey (1 966, 1 968), Franke nb u rg and Dodds (1 967), Ne li gan a n d Prudham
(1 969a, b) by wh o m it was used to detect abnorm a l ly retarded c h i l d ren.
As i s clea r from the fact that th i s p h enomenon occurs in a group of
low risk i nfants, such d i a g nostic co nclusions b ased o n ti m e-scales are
h azardous. Alth o u g h it i s l i kely that i n random gro ups retarded i nfants
m ay b e l a rgely respo n s i b l e fo r th i s skewi n g , this argu mentati o n cannot
b e i nverted, espec i a l ly if an i nfant sh ows a l ate development i n o n ly
one or two item s. As Nel i gan a n d Prudh am stated, a combi n ati o n of
vari ous items sh owi n g l ate development may h ave a greater p red i ctive
val u e with regard to (menta l) development than the iso lated fi n d i n g that
an i nfant s its, wa lks or speaks l ate (Nel i gan and Pru dha m, 1 969b).

l l l i n gworth (1 966) states that generally the newbo rn is not ab l e to l ift h i s

head from t h e couch a n d that h e i s ha rd ly ab l e t o do s o , fo r a few se­
conds, at the age of fou r weeks (l l l i n gwo rth , 1 966). I n thi s gro u p of l ow
risk i nfants al l of them cou l d lift thei r heads fo r at l east fo u r seconds
i n the n ewborn peri o d ; they were a b l e to support themse lves o n the i r
el bows fo r a t l east t e n seco nds a t a b o u t five weeks o f age. These fi nd­
i n gs m ay be due . to the sel ecti o n criteri a of the g ro u p.
B e i ntem a (1 968) a l so fo und th at th e ab i l ity to l ift th e h ead wa s con­
s i stently p resent d u ri n g the fi rst ei ght d ays of l ife from the seco n d day
onwards , i n about half of the i nfa nts he exa m i ned. They belon ged to a
random hospital g roup.

60
In the present study the phase of " support on the elbows" was found
to p recede the "swimming" o r "plane" phase, wh ile l l l i n gworth sug­
gests an i nverse sequence. Differences of operational ization m ay be
responsible for this difference. This is very l i kely as on the whole the
results with respect to the schedule of the "swim m ing" phase and the
subsequent phases, in the present study, are in accordance with l l l i ng­
worth's data.

Locomotion i n prone position

Procedure: When in prone position, the i nfant was stimulated to move

forwards, verbally and by an i nteresting toy held in front of him. Neona­
tal crawling movements and rol l i n g were not considered.
State 4.

Recording:
0. No unequ ivocal change of spatial position.
2. Wriggling or pivoting movements, without specific use of arms and/
or legs, resulting in spatial displacement. Movi ng backwards was
also scored 2.
2. Abdominal progression using the arms only.
3. Abdominal progression using the arms and legs.
4. Progresion by way of abdominal creeping and creepi ng on all fours,
cf. on hands and knees.
5. Creeping on all fours exclusively.
Scores 1 and 5 were regarded as first and final chan ges respectively.

Locomotion in prone

I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.

0 3 6 9 12 15 18 21
age,months
Fig. 1 5

The prediction band of locomotion in prone is presented in figure 1 5.

The i nteri ndividual overlap is evident. Score 4 represents a spectacular
i ntrai ndividual overlap of developmental phases.
In the present group there were no i nfants who did not show any

61
creeping behaviour. The phase of pivoti ng and wriggling movements
arose at about the same time when the i nfant showed a "plane-li ke"
posture in prone position. At about the time when the majority of in­
fants could progress using their arms, in prone position they supported
themselves on extended arms. Yet, for crawl ing purposes they made
mainly use of thei r elbows. Only for creeping on all fours an extended
arm posture was used.

About half of the infants showed i nconsistencies, alike i n boys and

girls. The boys of this group showed the first ch ange of locomotion in
prone earlier than the girls; this difference, though small, was stati sti­
cally significant (p = < 0.01 , Mann-Whitney U test). Sti l l boys and girls
did not differ significantly as for the time of onset of the fi nal change
or the duration of the developmental range. Th is means that the girls
caught up with the boys during development. There was a statistically
significant relationship between the times of onset of the first and
final changes (r = .544, p < 0.0 1 ). So the moment of the first change
has a moderate predi ctive value with respect to the moment of the fi nal
change.

As reported elsewhere there is a close relati onship between the ma­

ture phase of locomotion in prone and wal king unsupported, while the
relationship between the first appearance of pivoti ng movements and
walking unsupported, is sl ight (r = .650 and .277 respectively; Touwen,
1 97 1 ).
There were also low but statistically significant relationships between
the m ature phase of l ocomotion in prone and the first change of the
development of steady sitti ng behaviour (e.g. duration and trunk post­
ure during sitting, response to push and fol lowing an object with head
and trunk) with r's ranging from .381 to .426 (p < 0,0 1 ), while the cor­
relation coefficients of the relation with the onset of development of
standing and walking were appreciably h igher (r = .651 and .620 res­
pectively). Moreover, a significant relationship (r =.558, p < 0.0 1 ) was
found with the first appearance of the optical placing reaction of the
feet.
The relationships between the development of locomoti on in prone on
the one hand and the development of standing and walki ng on the other
hand reflect the development of vol untary motor behaviour based on
the maturation of brain mechanisms, in which the basal ganglia may
play an important role (Kornhuber, 1 973), and the development of the
connections between the brain and the spinal cord. In the spinal cord
a well establ ished motor organ ization for coordin ated leg-motility is
present at birth, as is shown by the so-cal l ed spontaneous crawling
movements and stepping movements. However, at birth the mecha­
nisms needed for mai ntai ning balance during crawl ing o r standing, a l­
though present, cannot express themselves because appropriate in­
strumentation (e.g. muscle power) is stil l lacking.

62
During development these so-call ed automatisms disappear, presuma­
bly due to i nfl uences from differentiati ng brai n-stem structures. An inhi­
bition of the automatisms is unlikely, as flexion and extension of the
legs remains unimpaired, only the a lternati ng rhythm disappears, though
temporarily. lt reappears i n another form when the i nfant starts wal­
king. Increasing m uscle power and differentiation and organization of
the cooperating vesti bular and cerebel lar mechanisms which result in
the improvement of the maintenance of trunk and limb posture, are
needed for the brain to generate effici ent movement patterns. This is re­
flected by the relationships between the first change in the develop­
ment of sitti ng posture and sitting balance, and creeping on all fours
- as far as locomotion in prone is concerned - and by the relation­
ships between the development of standing and of wal king, whi ch will
be discussed later on. Thus an infant must be able to organize the
postu re of his trunk and limbs sufficiently, before he i s able to creep
on all fours, and he m ust be able to stand before he can start to walk.
The increasing integration of the various brain areas (cerebel lum, brain
stem, basal ganglia, sensorimotor cerebral areas) during development
i s also i l l ustrated by the relationship of the mature phase of l ocomotion
i n prone with the development of the optical placing reaction of the
feet, i n which corti cal mediation (especially for di rected and guided
visual placing reactions as Hei n and Held (1 967) showed for kitten5t) is
known to exist (Rademaker, 1 93 1 ).

During the newborn period all the i nfants displayed neonatal crawl ing
movements. These movements are supposed to disappear at the end of
the fi rst month of l ife. In the present study spontaneous neonatal crawl­
ing movements had disappeared indeed at the ti me of the second exa­
m ination, i .e. at the age of about five to six weeks. At th at time none of
the i nfants yet showed pivoting movements as a first developmental
appearance of locomotion in prone as defi ned in thi s study.

The sequence of abdominal crawl ing to creepi n g on all fours is well

known. Sti l l some i nfants never reach the phase of creeping on all
fours, some i nfants never progress i n prone at all and some i nfants pro­
gress only in a sitti ng position ("shuffling"). Neither of these pheno­
mena occurred in the present study. According to Robson (1 973) ab­
dom inal crawl ing (in his termino logy: creeping, i.e. using the l i mbs for
propulsion and sliding on the abdomen; scores 2 and 3 in the present
study) is rarely observed in normal English infants, who generally start
to p rogress on hands and knees much earl ier than the i nfants of the
present study appeared to do. I n his opinion abdominal crawl ing is often
observed in hypotonic i nfants, as a recognizable phase i n thei r retard­
ed development. I n the present study from which hypotonic i nfants
were excluded (cf. chapter I l l) all the i nfants showed abdominal crawl­
i n g for an appreciable length of time. Th is apparent difference between
English and Dutch i nfants emphasizes the necessity of taking popu l a­
tion differences into account.

63
The developmental course of prone progression i s rather lengthy, as is
exposed brilliantly by McGraw (1 943), who disti ngui shed nine phases,
seven of which are concerned with abdominal progression per se. She
demonstrated both an inter- and intra-individual overlap of the conse­
cutive phases, wh ile in her material abdominal crawling took place as
an appreciable developmental phase before creeping on all fours de­
veloped. In the present study i ntraindividual overlap is reflected only by
score 4. In the m ajority of the items scores are based on the prepon­
derance of a certain distinct motor behaviour, but in most cases various
developmental phases coincided. This may account for at l east part of
the inconsistencies i .e. fluctuations found during the developmental
courses. The global time schedule as established in this study is in ac­
cordance with McGraw' s fi ndings. A comparison with Gesell's scales is
hardly feasible, as he only gives a mean key age of 40 weeks with a
time range of four weeks to both sides without explaining the exact
meaning of the variation range (Gesell and Amatruda, 1 947).
Vojta (1 968, 1 974) has described " reflex-crawling" as a crawling pat­
tern which can be el icited in normal infants by specific stimuli (forced
movements of the arms and legs) until the age of onset of the first
phase of locomotion in prone. In his opinion this " reflex-crawling" i s
o f purely reflectory origin a n d never spontaneously displayed b y the
norm al infant. Still he suggests that it's presence is a criterion for the
normal development of (or preparation for the development of) locomo­
tion i n prone. This reflex-crawling may be comparable to the sponta­
neous movements of the newborn (wh ich can be provoked and reinfor­
ced by p ressure on the footsoles: Bauer-reaction), which result from
spinal mechanisms. If appropriate stimuli are appl ied, it may be possible
to provoke th is motil ity in infants, but this does not imply that the move­
ments elicited can be consi dered as reflexes. They m erely indicate
a latent capacity (latent after the fi rst few weeks of life) of the infant's
nervous system. They can be elicited by specific stimuli, but they
would not man ifest themselves spontaneously. This l atent capacity
achieves expression again, when crawl ing sets in during the develop­
ment of voluntary locomotion in prone. According to Vojta the fi rst ap­
pearance of locomotion in prone may take place in the fourth to sixth
months of l ife, wh ile creeping on a l l fours would be present in the thi rd
trimester of the fi rst year. His data concerning the on set of the devel­
opment of locomotion in prone are in accordance with the findi ngs of
this study. However, in the Dutch i nfants mature crawling, as defined
in this study, occurred much later.

Rolling over from supine into prone position

Procedure: The infant was put on a flat surface in supine position; he
was encouraged to turn over, for instance by the presentation of an
i nteresting toy. The qual ity of his rolling behaviour was recorded.
State 4.

64
Recording:
0. No rolling behaviour. The i nfant rem ained in supine position.
1 . The infant turned from supine i nto prone position by way of axial
rolling, i nitiated by head rotation, but without evident hip rotation.
2. The i nfant used rotation of the body on the pelvi s during rolling be­
haviour.
Scores 1 and 2 were considered as fi rst and final changes respectively.

Turning over into prone position

I 2 3 4 5 6 7 8 9 10 1 1 12 13 14 15 16 17 18 19 20 21 22 23 24

6 15 18 21
age,months
Fig. 1 6

The p rediction band for rolling over from supine i nto prone position i s
presented i n figure 1 6. I n more than 80% of t h e i nfants the developmen­
tal course of the abil ity to turn into prone was brief, irrespective of the
q uality of the rol ling behaviour. At the fifth assessment eight of the in­
fants were able to turn i nto prone, whi le at the eighth assessment 92%
of the i nfants could roll into prone position easily and smoothly. Trunk
rotation during rolling showed a more protracted developmental course.
While at the eighth assessment more than 80% of the i nfants displayed
smooth rolling, only half of them showed trunk rotation. Trunk rotation
had developed after 36 weeks in more than 80% of the i nfants. A close
relationship was found between the moment of the final change and the
length of the developmental range (r .743) and also between the mo­
=

ments of the first and the final change (r .673). This suggests th at
=

the moment of the final stabilization is more or l ess preprogrammed i n

ti me. The boys of t h i s group started t o turn i nto prone earlier than the
girls; this difference was no longer evident at the moment of the final
change, so that apparently the girls caught up with the boys during de­
velopment.
The first change in the development of rolling over from supine into
prone position (i .e. the first appearance of rolling) was significantly re­
lated to the mature phase of development of steady sitting, standing
and walking, spontaneous posture of the legs i n verti cal suspension
and the optical placing reaction of the feet, though with low correlation
coefficients (r's ranging from .368 to .424, p < 0.0 1 ) . lt i s not easy to i n­
terpret these relationships, unl ess in terms of general trends of devel­
opment of motor phenomena displayed by a healthy organism. The cor­
relation coefficients themselves are so low as to have little predictive
value in i ndividual i nfants.

65
The final change of rolling over from supine i nto prone position, re­
flecting differentiated use of trunk and leg m usculature, showed sig­
n ificant relationships with the fi rst chan ges of the items describing the
development of steady sitting, standi ng, wal king and optical placing re­
actions of the feet, with r's ranging from .423 to .543 (p < 0.01 ). These
relationships can be interpreted along similar l ines as the relati onships
of locomotion i n prone and posture during prone position.

Kouperni k and Dailly (1 968) cite Stambak, who stated that turning
from supine into prone starts at about fou r to five months, and also re­
ported a sexdifference, boys showing more variations i n this behav­
iour than girls. McGraw (1 943) described the development of rol l i n g over
and distinguished automatic from deliberate rol l i n g behaviour. Automa­
tic rolling is characterized by extension movements of the spine and
the extremities, and may be comp ared with axi al rol l ing as defined in
the p resent study.
She observed the transition of the automatic i nto the deliberate phase
at about the end of the first year of l i fe, which is in accordance with the
findings of the present study, in which transition of axial rolling into
turning over by way of evident trunk rotation was found at about the
same time.
Vojta (1 970) considers rol l i n g from supine into p rone position and back
as "an inherited coordination complex of human moti lity during the
earlier state of ontogenetic locomotion, presumably of spinal and lower
b rain-stem ori g i n". Before rolli n � occurs spontaneously it can be eli­
cited; then it is called "reflex-roll i ng" by Vojta. He suggests that in the
case of a pathological development this " reflex-ro l li ng" persists and
blocks the developm ent of spontaneous rol l i n�. As i n the case of " re­
flex-crawling", commented on in the paragraph concerning l ocomotion
i n prone, this use of the term " reflex" i s confusing; it may suggest that
the nervous system of the very young infant consists merely of a bund­
le of reflexes which gradually develop into "voluntary" motor behaviour.
According to this concept the normal i nfant would be considered as
functioning as a " reflex-being" at some period during his development,
which evidently he does not. From b i rth onwards the i nfant is very well
able to cope with his i nfantile needs, in a far more differentiated and
variable way than would ever be consistent with the notion of a , reflex­
being". Instead of being considered as a bundle of reflexes, the infant­
i l e nervous system must be seen as a complex i nformation processing
apparatus. Its latent capacities may sometimes manifest themselves i n
t h e shape o f reflexes, provided th at t h e adequate stimuli are given.
The fact that specific stimuli may result in reflex-responses definitely
does not imply that the total apparatus is composed of reflexes.
Moreover, Votja makes the usual mi stake and considers reflex-roll i n g
i n brain-dam aged infants as being identical with imposed rol l ing behav­
iour in healthy infants. In the case of a damage of the brain the ner­
vous system is no longer homologous with an i ntact nervous system

66
of the same age. Reactions and responses obtained from b rain-damag­
ed i nfants must be i nterpreted differently from those observed in healthy
i nfants.
Rolling back from prone i nto supine position
Procedure: After the i nfant had turned over i nto prone position it was
observed whether he was able to return i nto supine position. The exa­
mi ner encouraged him to do so by showing an interesting toy and en­
couraging him to grasp it. When an i nfant was able to get into sittin g
position, he usually d i d not return from prone position i nto supine posi­
tion, but started to sit up. The quality of rolling back i nto supine was
recorded.
Recording:
0. The i nfant was not able to return into supine position.
1 . The i nfant rolled back into supine axi ally.
2. The i nfant could turn from prone i nto supine position, sometimes by
rotation of the trunk on the pelvis.
3. The i nfant returned i nto supine position exclusively by means of
trunk rotation. If the i nfant did not return into supine, but got i nto
sitting posture i nstead, as usually happened as soon as the i nfant
was able to sit up independently, this was also scored 3 as trunk
rotation is evidently i nvolved in this process.
Scores 1 and 3 were considered as fi rst and final changes respectively.

Turning back from prone into supine position

I 2 3 4 .'i 6 8 9 10 1 1 12 13 14 15 16 17 18 1 9 20 2 1 22 23 24

0 3 6 9 12 15 18 21
age,months
Fig. 1 7

The prediction band for this behavi our is presented i n figure 1 7. The
time of onset of the fi rst change is about the same i n the case of rol­
ling i nto prone and rolling back i nto supine position. Trunkrotatio n dur­
i n g rolling back from prone i nto supine position started to occur about
four weeks earlier than in the case of rolling over from supine i nto
prone position. it occurred at about the time that in prone position the
i nfant started to support himself on extended arms. lt seems to be
easier for an infant to push himself up on extended arms and then
rotate the upper half of the body on the pelvis i n order to turn on his
back, than i n supine position to l ift head and shoulders and rotate them
on the pelvis in order to turn over i nto prone.

67
More than 80% of the i nfants started to sit up from prone position at
the 1 2th assessment, instead of return ing i nto supine position.
Evidently trunkrotati on is needed for this motor behaviour. I n the case
of rolling over i nto prone, at the n inth assessment trunk rotation was
found in more than 80% of the infants while more than half of the
group showed trunk rotation during turning back into supine at the
eighth assessment. Perhaps the former process requi res more complex
cerebral programming than the latter.

During rolling back from prone i nto supine position there were more
inconsistencies than in rol l i n g from supine i nto prone position. There
was no difference between boys and girls. In ro lling back from prone
into supine position boys were significantly earlier i n displ aying trunk
rotation than girls (Mann-Wh itney U test, p < 0.01 ) . A relationship with
a negative correlation coefficient was found between the time of onset
of the first change and the len gth of the developmental range (r =

-.398), wh ile there was a close positive relationship between the mo­
ment of the final change and the developmental range (r .788). This =

means that the l en gth of the developmental range cannot be predicted

by the moment of onset of this behaviour. The relationships between
the final change of rolling back i nto supine position and the first chan­
ges of other items were comparable with those of the final change of
rolling over from supine i nto prone position. Other relationships were
not found.

Spontaneous head l i ft in supine position

Procedure: The i nfant was put on a flat surface in supine position. The
examiner encouraged the i nfant to rise from supine into sitting posi­
tion by stretching out his hands towards him without actually touch i n g
him. State 3 or 4.

Recording:
0. The i nfant was not able to l ift his head.
1 . The infant was able to lift his head for one or two seconds on ly.
2. The infant was able to lift head for at least five seconds.
Scores 1 and 2 were regarded as first and fi nal changes of the respon­
se respectively.
Head lift in supine position

1 2 3 4 5 6 8 9 10 11 12 13 14 l'i 16 17 18 HI 20 21 22 23 24
exam.

0 3 6 12 15 18 21
age,months
Fig. 1 8

68
The prediction band is presented in fi gure 1 8. In the majority of i nfants
the abi l ity to l ift the head in supine position developed between the fifth
and tenth assessment, i .e., between 20 and 40 weeks. The develop­
mental course was rather rapid as is reflected by the slope of the pre­
diction band. I nconsistencies occurred in a minority of i nfants and
there was no difference between boys and girls. This was also not
the case with regard to the time of onset of the first change and the
final change and the length of the developmental range. The ti mes of
o nset of the first change and of the final ch ange were closely related
(r = .751 ). One i nfant in this group did not l ift his head unti l the 1 8th
assessment.

The notion is plausible that the abi l ity to l ift the head in supine position
plays a role i n the development of the abi lity to sit up from supi ne. A
compari son with the prediction band of sitti ng up (fig. 1 9) shows that
a well-developed headl ift in supine position is concurrent with a ra­
ther well-developed abi lity to sit up. Yet no relationship was found be­
tween the first and final changes of headl ift i n supine and sitti ng up
respectively. lllingworth (1 966) also described the spontaneous head
l ift in supine position as a complemental phenomenon occurring duri n g
a later stage o f t h e development o f sitti ng, a n d reported that it takes
place at about 28 weeks. The present fmdrngs are in agreement with
these data.
The abi lity to lift the head in supine position reflects the differentiation
of vestibular brain mechanisms, which enable the i nfant to orient his
head in sp ace. Evidently increase of muscle power also plays a role.
The notion of the signifi cance of differentiati ng vestibular mechanisms
for this motor behaviour is supported by the fact that the i nfant's
ability to control his head position at various anglel:f when lying in prone
increases at about the same time. I n this instance the influence of ves­
tibular mechanisms is evident; the i nfant had been able to l ift his head
from bi rth onwards, which means that i n prone position the m uscle
strength was great enough for this purpose.
The final change of the headlift in supine position was significantly
related with the onset of the development of walking (r = .460,
p < 0.01 ); the correlation coefficient of the relatronship with the onset
of standing up did not reach this level of sign ificance.

Sitting up

Procedure: The infant was put on a flat surface i n supine position.

The examiner grasped the i nfant's wrists and encouraged him to sit up,
helping him, if necessary, by pulling at his hands.
Every kind of active flexion of the i nfant's elbows was regarded as a
manifestation of active sitti ng-up behaviour, and recorded. The reflex­
flexion of the elbows during the traction-test in the newborn was not re­
garded as active flexion and consequently as a part of voluntary sit­
ting-up behaviour. State 3 or 4.

69
Recording:
0. No active flexion of the elbows and/or retraction of the shoulders
during pulling i nto sitting position. The head rem ained in one line
with the trunk.
1 . Slight active flexion of. the el bows and/or retraction of the shoul­
ders, with evident flexion of the head. The i nfant was not able to
reach a sitting position without the exami ner's help.
2. Evident active flexion of the elbows and retraction of the shoulders.
The i nfant stil l needed the examiner's help during the last part of
the movement. Evident head and trunk flexion.
3. The i nfant was able to sit up without any active help of the exam iner.
Scores 1 and 3 were regarded as indicators of fi rst and final changes
respectively.
Sitting up

I 2 3 -1 5 6 7 8 9 10 11 12 13 1-1 l.'i 16 l i IX 19 20 21 22 23 2-1

3 6 12 15 1H 21
age,months
Fig. 1 9

The prediction band for sitting up is presented i n figure 1 9. The varia­

tion range for the different phases is considerable. Although a small
m i nority of the i nfants was able to sit up independently at the age of
about 32 weeks, about 50% of the i nfants could not do so until the end
of the fi rst year of life. At the age of about 14 months more than 80%
of the infants m anaged to sit up i ndependently. I n this group of l ow
risk i nfants the ful l range for sitti ng-up i ndependently lasted 36 weeks;
some infants were able to sit up without help as early as at about 32
weeks of age, wh ile some others managed to do so at about 65 weeks.

About half of the i nfants showed inconsistencies during the develop­

mental course of sitting up. There were no differences between boys
and girls. Compared with the boys, the girls of this group showed the
first appearance of sitti ng up behaviour significantly later (p < 0.01 ,
Mann-Whitney U test). I n the girls also the final change took p lace
somewhat l ater than i n the boys; this difference was only significant
at a 5% level (Mann-Whitney U test). The mean developmental ranges
did not vary significantly as for boys and girls. The moment of onset
of the fi rst change was weakly related to the length of the developmen­
tal range (r -.382, p < 0.01 ). Thus the length of the developmental
=

range can only be p redicted from the age at whi ch the fi rst change oc­
curs to a l i m ited degree. There was no relationship between the num­
ber of i nconsistencies and the length of the developmental range.

70
There was a close relationship between the final change of sitti ng up,
(i.e.: sitti ng up without help) and the o nset of the development of stand­
ing up and walking (r = .805 and .81 2 respectively). Hardly any re­
l ationship was found between the final change of sitti ng up and the de­
velopment of the response to push against the shoulder duri n g sittin g
o r following an object with the eyes a n d rotation of the head a n d trunk
during sitting. lt is evident that balance i s developed before an i nfant is
able to sit up independently. This notion is supported by the relation­
ship between the duration of sitting and the onset of the development
of the response to push agai nst the shoulder, whi l e at the same time
the duratio n of sitti ng and sitti ng up are not related (see next para­
graph.

The neonatal flexion of the elbows occurri ng during the tractiontest

persisted in at least half of the i nfants until about ten to twelve
weeks. This reflex-flexion gradually merged into active flexion or was
replaced by extension of the arms without any active attempt to sit up.
I n more than half of the i nfants during some period of their development
extension of the arms was found during pulling i nto sitting position,
before active flexion occurred as the fi rst appearance of vol untary sit­
ting up. The selection criteria for the present group p recluded the oc­
currence of head lag resultin g from hypoto n i a durin g the traction test.
The head lag occasionally found in normal i nfants during the first
months when they are pu lled i nto sitting position (McGraw, 1 943;
lllingworth, 1 966) , was not observed either. I n h er descripti o n of the de­
velopmental course McGraw included sitti ng up by way of turning o n
t h e side i n p rone position. This would occur after t h e phase of evident
active elbow flexion (score 2), although she emphasi zed the consider­
able overlap between phases. In the present study the standardization
may account for the protraction of ph ase 3, which i n McGraw's study is
replaced by turni ng and roll i n g patterns. There i s no discord between
McGraw·s fi ndings with respect to the abi lity to sit up independently
and those mentioned in the present study.

Duration of sitting

Procedure: The duration of sitting unsupported on a flat surface was

counted in seconds, i rrespective of the way in which the infant reached
sitting position. State 3 or 4.

Recording:
0. The i nfant was not able to sit without support.
1 . The i nfant was able to sit free for some seconds.
2. The i nfant was able to sit free for about 30 seconds.
3. The i nfant was able to sit free for about one minute.
4. The i nfant was able to sit free longer than at least one m inute.
Scores 1 and 4 were considered as the fi rst change and the final change
of sittin g unsupported respectively.

71
 Duration of sitting

I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 li 18 19 20 21 22 23 24
exam.

() 3 6 9 12 15 1R 21
age, months
Fig. 20

The prediction band of sitting unsupported is presented in figure 20. At

the ei ghth assessment about one th i rd of the i nfants was able to sit
unsupported for at least some seconds, i.e. at about the age of 32
weeks. Some i nfants were already able to sit up i ndependently at the
same age. Sti l l generally the abil ity to sit up without help developed
several months later. This confirms the common fi nding that manu in­
fants are able to sit unsupported before being able to get into sitti ng
position without help. The prediction band m akes clear that i n the ma­
jority of the i nfants the duration of sitti ng unsupported i ncreased rapid­
ly. Sti l l the vari ation-width was considerable. The scores 2, 3 and 4
showed m uch overlap, so that o ne may conclude that the ability to sit
free for about half a minute indicates a fu l ly developed abil ity to sit un­
supported. A comparison of the prediction bands of figures 19 and 20
shows an overlap also whi ch implies that an i nfant who is able to sit
unsupported for longer than half a mi nute, very soon will be able to
sit up independently as wel l . I nconsistencies in the duration of sitti ng
occurred i n a small minority of the infants.
There were no consistent differences between the boys and the girls
of this group. A close statistical relationship (r .695) was found be­ =

tween the times of onset of the first change and of the fi nal change.
This means that to some extent the moment of the first change is pre­
dictive of the moment of the final chan ge, i .e. stable sitting. At the same
time a negative relationship (r -.479 p < 0.0 1 ) was found between
=

the fi rst change and the developmental range, which seems to be con­
tradictory. Presumably two different subgroups of i nfants should be dis­
tinguished: one subgroup of i nfants in whom the development of the
ability to sit free for a certai n amount of time has a rather fixed devel­
opmental range as the fi rst appearance of this ability predicts the mo­
ment of stabilization, and another subgroup of i nfants in whom this is
not the case. Actually, plotti ng "first change" agai nst "final change"
and "developmental range" respectively displays these two subgroups
(fig. 21 and 22).

72
I n the boys a positive relationship was found between the fi rst changes
of the ability to sit up and the duration of sitting (r .696). There was
=

no such relationship in the subgroup of the girls. The l ast changes of

sitti ng up and duration of sitting showed a statisti cally significant rela­
tionship i n the case of both boys and girls, though to a greater extent
in the case of the boys (r = .805, r .470, recpectively). lt is not sur­
=

prising that these relationships are found as comparable brain mecha­

nisms for balance control are needed i n the cas'e of sitti ng up i ndepen­
dently and sitting free. Sti ll the abi lity to sit up as defined in this study,

Duration of sitting r=.70 N=SO

�
� 13 22
19
5

�
33
� 12

25 27 17 44 12
11 36 38
41 42

49 13 15 20
10 21 2628

48 7 24 16 9 29 32
9 50 52

8 1 23 2 10 14 30 37 11 31
8 4 46 45 40
6 51

34 18 35 3
7

43
6

9 10 11 12 13 14 15 16

Fig. 21 :
Final change
The relation between the first changes and the final changes· of duration of
sitting (N = 50).
Vertical axis: assessments during which the first changes occurred.
Horizontal axis : assessments during which the final changes occurred.
Case numbers are plotted in order to be able to identify the i nfants.
lt a ppears that case-number 9, 29, 32, 30, 37, 1 1 , 40, 31 and 3 are localized
somewhat bes·ide the cloud of the rest of the case-numbers.

73
 Duration ofsitting r=-.48 N=so
�
� 14
--8
� 22 19 5
U:: 13

33
12

25 36 17 44 12
11 27 38
41 42
15 13 20 21
10 49 26 28

48 7 24 16 9 29 32
9
50 52

8 1 23 3 10 14 30 37 11 40 31
8 4 46
6 51 45

34 18 35 3
7

43
6

1 2 3 4 5 6 7
Developmental range
Fig. 22:

The relation between the first changes and the developmental ranges of
duration of sitting (N = 50).
Vertical axis: ass·essments during which the first changes occurred.
Horizontal axis: length of the developmental ranges expressed as the number
of four-week periods between the first and the final change.
Case numbers are plotted i n order to be able to identify the infants.
The cases 9, 29, 32, 30, 37, 1 1 , 40, 31 and 3 appear to be responsible for the
statistical significance of the computed Correlation-Coefficient.

74
is based mainly on active power, whi l e sitting unsupported for a few
seconds also requires a development of balance.
As stated above the boys started to sit up with help earlier than the
girls. Yet as far as the duration of sitti ng i s concerned there was no
difference between boys and girls. This m ay imply that there is more
active power in the boys, but that in the girls the development of balance
is similar or even faster. Gesell , and after him l l l i n gworth, state that mo­
mentarily the " normal" i nfant sits without the examiner's help at 28
weeks, whi l e he i s able to sit free for a long period of time at 40 weeks
(Gesell and Armatruda, 1 947; l l l ingworth, 1 966). These dates are m uch
earl ier than those presented in the present study.
When the age of the final change, i .e. sitti ng free for longer than one
minute, in the present study i s compared with the centiles of Neligan
and Prudham {1 969) a substantial d ifference also appears whi ch for
the medians amounts to about one month and a half. As the defin itions
of sittin g free do not vary, this difference i s suggestive of population
differences, although different modes of data collection and analysis
may also be partly responsible (Touwen, 1 97 1 ).

Posture of the trunk during sitting

Procedure: The posture of the i nfanfs trunk during sitting without
support was described, i rrespective of the way in which the i nfant
reached sitting position.

Recording:
0. The i nfant was not able to sit without support.
1 . The i nfant sat with rounded back and supported h imself on his arms.
2. The i nfant sat with rounded back without supportin g h imself on h i s
arms.
3. The i nfant sat with strai ght back without evident lumbar kyphosis
or l o rdosis.
4. The i nfant sat upright with evident lumbar lordosis.
Scores 1 and 4 were considered to reflect the moments of the fi rst and
final changes respecively.

Posture of the trunk during sitting

I 2 3 4 5 6 7 8 9 10 11 12 13 14 l!i 16 17 lli 19 20 21 22 23 24

() 3 6 9 15 1H 21
age,months
Fig. 23

75
The prediction band of trunk postu re during sitti ng is presented in fi­
gure 23. The prediction bands of the durat1on of sitti ng and the posture
of the trunk during sitti ng are comparable with regard to both shape
and l ocalization on the time axis. This impl ies that parallel to the i ncrea­
se of the duration of sitti ng, the posture of the trunk during sitti ng de­
velops rapidly. One may argue th at the development of erect posture
during sitting reflects the development of bal ance which in its turn re­
sults in an i ncrease of the duration of sitti ng. In about one fifth of the
infants an i nconsistency was found during the developmental course
of postu re during sitti n g ; there were no differences between boys and
girls.
There was a statistically significant rel ationship between the time of
onset of the first change and the final change (r = .509, p < 0.0 1 ) , while
the relationship between the time of onset of the first change and the
length of developmental range was negative (r = -.492, p < 0.01 ). This
may be accounted for in the same way as was done in the case of du­
ration of sitting.
I n the majority of the infants the abi lity to use one or two hands vo lun­
tarily during sitti ng developed in the period of time when the infant was
able to sit longer than half a mi nute with a straight back. I n the majority
of the i nfants the postu re of the legs during sitti ng showed a specific
developmental course: the infants started to sit with flexed legs, while
subsequent extension of the legs coincided with the abil ity to sit longer
than half a mi nute with a straight back. In the m ajority of infants an ar·
bitrary posture of the legs, i.e. a posture of the legs without a specific
flexion or extension pattern, occurred only if the i nfant was able to sit
unsupported for more than one mi nute with a neatly hol low back.
The moment of onset of the first change of the items "duration of sit­
ting" and "posture of the trunk during sitti ng" were significantly related
to the final change (the stabilization) of balance development during
sitting ("response to push against the shoulder" and "fol lowing an ob­
ject with the eyes and rotation of the head and tru nk"), with correlation
coefficients ranging from .587 to .652 (p < 0.0 1 ). The two items mention­
ed were closely i nterrelated. Low but sti ll significant relationships were
found with standing free and walking unsupported and with an arbitrary
posture of the legs during vertical suspension and evident optical plac­
i n g of the feet (r's ranging from .368 to .499, p < 0.0 1 ) .
The relationships with the fi nal changes o f prone position, locomotion
in prone and the postu re and spontaneous motil ity of the legs have al­
ready been mentioned. Higher correlation coefficients, ranging from
.480 to .762 (p < 0.01 ) (see appendix D), were shown by reverse rela­
tionships, i .e. those between on the one hand the fi nal ch anges of "du­
ration of sitting" and " posture of the trunk during sitti ng" and the first
changes of the other items on the other hand.
lt i s evident that the age of steady sitting during more than half a mi­
nute is predictive of the development of standing up and walking. Ac­
tual ly all the relationships mentioned reflect the more or less closely

76
related development of a set of functions in which pri marily postural
mechanisms of head, trunk and legs are i nvolved.
The actual time schedule (appendix C) together with the relationships
between the fi rst and final chan ges of the various items points at a
schematic developmental course, in which standing and walking are
preceded by steady sitting, whi l e the development of balance, reflected
by sitting behaviour, should at least have started before the al l-fours
position and creeping on al l-fours canbe achieved.

Standing up
Procedure: The way i n which the infant tried to get i nto standing po­
sition was observed and described. If necessary he was verbally en­
couraged but not touched. State 4.

Recording:
0. The infant was not able to stand up.
1 . The i nfant was able to get i nto a kneeling position , whi l e supporting
hi mself with one or both h ands.
2. The i nfant was able to get into a standing position whi l e supporting
himself during standing, He was not able to sit down without help.
3. The i nfant was able to get into a standing position while supporting
hi mself during standing; he was able to sit down without help.
4. The i nfant was able to stand free.
Scores 1 and 4 were consi dered to reflect the first and final changes
respectively.

Standing up

I 2 3 4 'i 6 7 ll 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

0 3 6 9 12 15 18 21
agc,months
Fig. 24

The p rediction band for standing up is presented i n fig. 24. lt shows a

wide overlap of the different phases. The first appearance of standing
with support showed a variation range from about 36 to about 72 weeks.
Although one i nfant could stand free at about 44 weeks, 80% of the in­
fants had reached this developmental phase at about one and a half
year of age. The median for standing free was found at the age of about
65 weeks (c. 1 5 months). The median for standing with support was
found at about one year.

77
 Andre-Thomas describes the period during which the infant is not yet
able to stand free without losi ng balance, as a period of physiological
astasia and abasi a, implying motor and postural i ncom petence. He stat­
ed that this is perfectly normal in i nfancy and mentions ultimate time
l imits of 1 5- 1 8 months of age (Andre-Thomas and St. Anne Dargassies,
1 952). However, the use of terminology with a specifically pathological
mean i n g belonging to (adult) neurology should not be appl ied to the
normal motor behaviour of i nfancy. Moreover terms like astasia and
abasia are disproportionately "heavy" for a description of relative imba­
lance occurri ng during the development of balance and trunk-coordi­
nation in standing position.
The girls started and reached the final change later than the boys,
while their developmental range was also more protracted; these diffe­
rences did not reach statistical significance (Mann-Whitney U test).
There were hardly any inconsistencies in the development of this mo­
tor behaviour. A statistical relationship was found between the moments
of onset of the fi rst change and the final change (r = .563, p < 0.01 )
and also between the moment of the final change and the l ength of the
developmental range (.765). lt seems as if standi ng up (reflected by the
relationship between the fi rst and final changes) develops in accordan­
ce with a kind of time-tally; as soon as development sets in a rather
fixed amount of time is available for reach i n g the final change. At the
same time environmental conditions may effect the developmental cour­
se (as reflected by the close relationship between the fi nal change and
the developmental range).

The relationships between standing up and other items describing

functional motor development, such as sitting, rol l i n g and l ocomotion
i n prone, have been discussed already. Both the first chan ge and the
fi nal change were closely related to the first and fi nal changes of walk­
ing (r's rangi ng from .794 to .820). There were also relationships with

TABLE VII

Correlation coefficients (p < 0.0 1 ) of relationships between the first

changes of standing up and of other items (Pearson-Product-Moment
correlations)
response to push against shoulder during sitti ng .724
fol lowing an object with eyes, head and trunk during sitti ng .703
optical placing of the feet .697
type of voluntary grasping .495
palmar grasp reflex .456
parachute reaction of arms and hands .438
footsole response .400
coordination of upper extrem ities .371

78
some reactions (table VII). Kneel ing, defined as the fi rst change of the
development of standing up, was related with wel l developed balance
reactions in sitting position and with adequate optical placi ng of the
feet. lt is not surprising that these relationships were found as i n all
these i nstances wel l gui ded motor control of trunk and legs is required,
implying a differentiated integration of brain mechanisms promoting
th is motor control, i.e. cerebellum , brain stem and basal ganglia. The
relationshi ps with the fi nal change of type of vol untary grasping (i.e.
pincer grasp), palmar grasp reflex (i.e. complete dissolution), parachute
reaction of the arm s and coordination of the upper extrem ities suggest
that a differentiated use of the hands is important for the development
of voluntary rising i nto standing position ; they reflect the importance of
the development of corticospinal connections i n this context. The rela­
tionship with the final change of the footsole response can be consider­
ed as evidence of an i ncrease of suprasegmental influence on spi nal
mechanisms, due to the maturation of cerebrospinal i ntegration, as a re­
sult of which the dom i nance of extensor activity in the motil ity of the
toes is shifted to the flexor side (Kugelberg, Eklund, G rimby, 1 960 ;
G ri mby, 1 963 a + b ; Gassel , 1 970).

The fi nding that standing free is related to the onset of the development
of balance during sitting and optical placi n g of the feet (r' s ranging
from .360 to .522, p < 0.0 1 ) poi nts at the i ntri cate relationships between
the b rain mechanisms i nvolved in the development of motor patterns
which n ivolve active m uscle power, balance and vol untary use of mus­
cular activity.

Walking

Procedure: The i nfant's trials to progress on his feet were observed

and recorded. If the i nfant was not able to walk without support, his
mother was asked to help h i m . State 4.

Recording:
0. The i nfant was unable to walk.
1 . The i nfant could wal k if his mother held him by both hands.
2. The infant could walk if his mother held him by one hand.
3. The i nfant walked free for a few paces.
4. The i nfant walked free for at least seven paces consecutively.
Scores 1 and 4 were regarded to reflect fi rst and final changes res­
pectively.

The surface on whi ch the infant walked was standardized as m uch as

possible, dependent on the home environment. For the majority of in­
fants a soft surface was avai lable.

79
 Walking

I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.

I I I I I I I I I
0 3 6 9 12 15 18 21
age,months

Fig. 25

The prediction band for walking is presented in fi gure 25.

The width of the last part of prediction band is not rel iable, as walk­
ing for seven paces consecutively was the criterion for the finishing
of the follow-up study and the prediction bands were not corrected for
51 i nfants.
In this group of low-risk i nfants the width of the variation-range is con­
spicuous. The median for walking with the support of both hands was
found at the age of about one year while the 50th centi le for walking
free was found at about 64 weeks (16 months).
There were hardly any i nconsistencies during the development of this
motor behaviour. I n the girls the fi rst change occurred later than i n the
boys; this difference did not reach a 1 % l evel of confidence (Mann­
Whitney U test). Walking free was achieved sign ificantly earlier by the
boys than by the girls (Mann-Whitney U test, p. < 0.01 ). In the girls the
duration of the developmental range was more protracted than i n the
boys ; this difference was not stati stically significant. In the girls there
was a close relationship between the time of onset of the first change
and the fi nal change (r .877) ; this relationship was also found i n the
=

boys, though with a lower correlation coefficient (r .678). Moreover, =

in the boys there was a low negative relationship between the time of
onset of the fi rst change and the lenght of developmental range (r =

- .347, p < 0.0 1 ) , which was not found in the girl s (r .055). =

it is difficult to account for this difference in relationships between boys

and girls. Several factors may play a role. Possibly the genetic differen­
ces, based on endocrine i nfluences, are partly responsible, and result
in greater muscular strength in the case of the boys. Also the harmonic
constell ation may i nfluence b rain maturation differential ly. Various cul­
turally conditioned expectancy patterns with regard to male and fem ale
behaviour may affect ch ild reari n g patterns, the result of which may ma­
nifest itself al ready i n i nfancy.

In the total group (i.e. boys and girls taken together) the hei ght of the
correlation coefficients of the relati onships between the first and final
changes (r .794) differed from those of the developmental range and
=

final change (r .493). This implies that the time needed for the devel­
=

opment of walking free, is more or less fixed, and that the moment at

80
which the fi rst m a n ifestation of wal k i n g occu rs p redicts the age at
wh i ch wal k i n g free is ach i eved to a reasonab l e extent.
A close rel ati o n s h i p was fou n d b etween the development of wal k i n g
a n d o f stand i n g u p . Th i s rel ati o n s h i p refl ects the d ifferenti ati o n a n d i n ­
tegration of b ra i n m echanisms n eeded fo r t h e developm ent of motility
i n a vertical positi o n , i n which p ro cess cereb el l ar, b ra i n stem , b asaJ
g a n g l i a a n d corti cos p i n a l m ec ha ni sms a re i nvolved. Th e m aturatio n of
p ostu ral (i n cl u d i n g equ i l i b ri u m ) m echanisms m ust take p l ace b efo re th e
abi l i ty of b ipede p ro g ress i o n i n space can b e ach i eved. A com p ari so n
o f th e characteri stic featu res o f sta n d i n g a n d wal ki n g i n d i cates t h e d i f­
ferenti ati on of m otor o rganizatio n as reflected i n th e l atte r fun ctio n .
T h e rel atio n s h i p s b etween wal k i n g and othe r items resemb l e those
menti o n ed in co n n ecti o n with the deve l o p ment of standi n g up; th ey
can b e i n terpreted a n a l o gi c a l l y.
A com p a rison of the p resent d ata with rep o rts fou n d i n the l iteratu re
con cern i n g the age of wal ki n g free reveals con s iderabl e d i fferences.
Whi l e for this abi l ity G esel l and B O h l er give a ran ge from 1 5- 1 8 m o nths
(BO h l er a n d H etzer, 1 932 ; G esel l a n d Armatruda, 1 947), l l l i n gworth
mentions 1 3 m onth s , the D enver D evelopm ental S creeni n g Test gives
1 2. 1 m onths as a median, an d Bayley in her crosssecti o n a l sam p l e even
1 1 .8 m onths ( l l li n gworth, 1 966; Fra n ken b u rg a n d Dodds, 1 967; B ayley,
1 969). N e l i gan, u s i n g the sam e operati o n a l i zatio n as i s a p p l i e d i n the
p resent study, mentions 1 2. 8 m onths as a m ed i a n (Neli g a n a n d P ru d­
h am , 1 969).
The eventua l ity of p o p u l ation d i fferences has to b e taken i nto regard
apart from m eth o do logical differe nces i n th e col lectio n of data a n d i n
th e mode o f an alys i s . H i n d l ey emphasi zed t hi s point i n h i s compa ri s o n
of five E u ropean l o n g it ud i na l samp l es ; h e d rew attention t o the fi n d i n g
that no s i g n ificant sex d ifferen ces (o r even tendencies) fo r wal k i n g
free co u l d b e fou n d i n these samp l es (H i n d l ey e t a l , 1 966).
Thi s i s contrary to th e p resent fi n d i n gs , wh i ch show s l ight but s i gn ifi­
cant d i fferences b etween b oys and g i rl s .

A l s o a com p a rison o f th e ful l ran ges of walki n g without suppo rt revea ls

differences : the Denver D evelopm ental Screen i n g Test mentio n s a
ran g e from 9.8 - 1 4.3 m o nth s (5 - 95%), Zdanska-Brin cken a n d Wol a nski
( 1 969) give about 1 0 - 1 4. 5 m o nths (1 0 - 90 0/o) , N el i gan 9.7 - 1 5. 8 (5 -
90°/o) wh i l e i n the p resent stu dy a ran ge of 1 3. 5 - 1 8 m o nths was fou n d
( 1 0 - 90°/o). S am p l e com position (cf. N e l i gan's con c l u s i o n that l ower
class i nfants wal k earl i e r than u pper cl ass i nfants), stan dardization a n d
operatio n a l i zati on (observation versus m other' s repo rt ; e nvi ron m ent a n d
tim e of the day) m ay account fo r part of these d i ffere nces.

Attention m ust also b e paid to Nel i gan's rem ark that there i s a p rotract­
ed cou rs e to be observed in th at part of the centi l e c u rve whi ch spe­
cifical ly rep resents the i nfants whose ab i l ity to wal k free was retarded.
In a p o p ulation study t hi s p rotracted course o f t he centi l e curve m ay
b e attrib uted to " late walkers " , recru i ted from devi ant i nfants. However,

81
 a s i m i l ar phenomenon was fo und i n the p resent study from which devi­
ant i nfants were ca refu lly excl uded.
In the case of five i nfants the rou n d i n g off of thei r fo l l ow-u p had to be
postponed for 16 weeks due t o a l ate ach i evem ent of walki n g free.
These in fants are respon s i b l e fo r the i n crease of the variati on-wi dth of
wal k i n g free on the ri ght ha nd si d e. Yet th ey were q u ite i n conspicuous
from a neuro lo g i cal and behavi o u ral p o i nt of view. Therefo re it i s doubt­
ful whether m ed i ans and centl ies a re of g reat val u e for the assessm ent
of m otor retardati o n in term s of neu ro l o g i cal i ntegrity. Also d u ri n g thei r
l ater developm ent (wh en this book was written the yo u n gest ch i l d was
about 6 years o l d) no ne of them showed any neuro lo g i ca l or m ental
d i sturb a n ces, which wo u l d point at a cause for a retardati o n of m otor
developm ent. Th us it can be conten ded that the q u a l ity of the deve lop­
mental cours e rather th an a stri ctly del i n eated time sched u l e has to be
con s idered i n order to eva l u ate the i ntegrity of the nervo us system .
Reactions a n d responses
In this section a n u mber of reacti ons and respon ses wi l l be di scussed
wh ich fu lfi l th e criteria for g ro u p I l l . They are arran ged in Tab l e V, in
subgroups co m posed fo r reasons of conven i ence (Pag. 42).
Rooting reflexes
Procedure: Rooting was e l i cited accord i n g to the m ethod descri bed
by Prechtl a n d Bei ntema (1 964) . D u ri n g the fi rst 4 o r 5 mo nths of l ife,
the i nfant was usual ly in s u p i n e positi o n , subsequently it was seated
on the m oth er' s lap. State 3 or 4.
Al l the in fants were exa mi ned about half a n hour befo re feed i n g ; in this
way the differenti a l effect of the feed i n g condition was e l i m i n ated as
m uch as poss i b l e.
Recording:
0. No turn i n g of the h ead in the d i recti o n of the sti m u l ated area.
1 . S l i ght reaction to l atera l sti m u l ation, no reacti o n to sti m u l ation of
u pper or l ower l i p .
2. S l i ght reaction to sti m u l ation of a l l fou r a reas.
3. Evi dent reaction to l ateral sti m u l ati o n , but s l i g ht reaction to sti m u l a­
tion of upper and l ower l i p .
4. Evi dent tu rn i n g of the head towards th e sti m u l ated si de both i n
h o ri zonta l a n d verti cal d i recti o n.
Rooting

VJ

� 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

I
exam.
I I I I I I I I I I I I I I I I I I I I
0 3 6 9 12 15 18 21
age,months
Fig. 26
Th e p rediction b an d for rooti n g is p resented i n fi g u re 26. An evi dent
rooti n g response was observed i n m o re than 80% of the i nfants u nt i l
th e seventh assessm ent. M o re th an 80°/o o f th e i nfants sh owed a nega­
tive response o n ly after about half a year. The vari ati o n ran g e was
l arge and m any i nconsi sten cies occu rred (see appendix J) without evi­
dent sex differences. The re were no differen ces b etween boys and
g i rl s with regard to the m o m ent of the fi rst change, the fi n a l change o r
the l e n gth of t he developm ental ran ge.
A negative rel ati on s h i p with a l ow corre l ation coefficient (r = -.438,
p < 0.01 ) , was fou n d b etween the m o m ent of the fi rst change and the
l e n gth of the developm ental ran ge. Th i s m eans that in i nfants who sh ow­
ed an early fi rst chan g e, a p rotracted developmenta l ran g e cou l d sti l l
b e fou n d . The close rel ati o n s h i p b etween t h e fi na l ch a n ge a n d the d e­
vel opmental ran g e (r = . 824) su g g ests also a p repro g ra m m i n g of the
d i ssol ution of the respo nse. The n u m be r of i n consi stencies was rel at­
ed to th e l en gth of the developmental ran g e (r = . 557, p < 0.01 ) .

The la rg e n u m ber of i n co n si stencies i s i n accordance with l n gra m ' s

o p i n i o n that i n healthy i nfants both inter- a n d i ntra- i n d ivid u a l ly a g reat
vari ati o n is fo u n d with reg a rd to th e feedi n g refl exes (l n g ra m, 1 962) .
Thi s was a l ready observed by P rechtl ( 1 958) i n h i s study o n the head
turn i n g response of the human b aby a n d i n terp reted as dependent on
the i ntern a l state of the i n fa nt. G eneral m oti l i ty, m etabo l i c rate (hu n ger
o r satiation), d rowsi n ess, s l eep, defaecation o r m i cturiti o n etc. m ay
l a rgely i nfluence the response. H e descri bed habituation after repetitive
sti m u l ation and a reap p ea rance of the response due to a " central reset"
when the sti m u l ation is conti n ued. Th i s m ay be app lied to other refl exes
a n d respo nses as wel l ; it l eads to the vari a b i l ity which c an be consi der­
ed as a ch aracteri sti c p roperty of the h ealthy n ervou s system.
Re lationships with para meters of other items were vi rtu a l l y absent.
The s pectacular d ifference with Paine' s (1 960) o p i n i o n th at u nt i l three
or fou r m o nths after b i rth the rooti n g response can o n ly be obta i n ed i n
the i nfant when awake m ay b e expl ai n ed b y th e fact th at i n the p re­
sent study the rooti n g response was e l icited sh o rtly b efo re feedi n g
tim e, whi l e P a i n e does not g i ve a n y i nfo rm atio n about h i s standard iza­
tion.
I n the p resent study the respo nse was e l icited by gently stroki n g the
transiti o n a l a rea b etween l i p m ucosa a n d s u rro u n d i n g skin, a n d the
ski n of l i p s a n d cheek j u st a s i de of the lip m ucosa. A co n s i stent diffe­
ren ce b etween the res ults of those two m odes of e l i ci tatio n was not ob­
served . D u r i n g the fi rst assessm ent i n the n ewbo rn period m ost i n fa nts
reacted to b oth sti m u l ations with rap i d and often overshooti n g turn i n g
m ovements o f th e h ead i nto th e d i rection o f th e sti m u l ation, wh i l e d u r­
i n g subseq u ent exa m i n ations o n both types of sti m u l ation the h ea d
m ovements were fou n d t o b e slower a n d m o re adeq u ate.
As Prechtl (1 958) has show, two typ es of reacti o n s c an be d isti n gu i sh­
ed i n thi s co n n ectio n ; the " s i d e to side m ovem ents", o cc u rri n g i n res­
ponse to tacti l e sti m u l ation near the m o uth, i . e. on the ski n of the

83
cheek or l i p s (a lso at a l a rger d i stance) and even occu rri n g spo ntan e­
o u s ly without sti m u l atio n , and the " d i rected head turn i n g response"
wh i ch develops d u ri n g the fi rst few weeks after b i rth and which only
can b e eli cited from the i m mediate adjacent area of the l i ps. Accord i n g
t o Prechtl t h e " rhyth m i cal sea rch i n g " , man ifesti n g itself i n s i d e t o side
m ovem ents, d i sap pears and is rep l aced by the " d i rected head turn i n g
response".

S u cki n g respon ses were not an alysed, as th e reactions to i n serti o n of a

sti m u l ati n g fi n ger or n i p p l e were too vari a b l e and hetero geneous. M any
i nfants bit or su cked i nconsisten ly. Especi a l ly during the teeth i n g-pe­
ri od, which was very variab l e in occu rre nce, sucki n g responses c o u ld
h ard ly b e obtai n ed i n a stand ard ized way. lt i s posi b l e that the exa m i n a­
ti o n time j u i st b efo re feed i n g , when the i nfants were h u n g ry, was parti­
cularly u nfavo u ra b l e fo r the exami n ation of sucki n g respon ses.

Asymmetric tonic neck responses

Procedure: Th e i nfant was put on a fl at surface in s u p i n e positi o n .
t h e exa m i n e r rotated the i nfant' s head t o o n e side and kept it i n th i s
·p osition for about 1 5 seconds. Th e type o f m ovement a n d t h e resulti n g
b ostu re o f th e arms a n d l egs were observed. Extension o f t h e a r m a n d/
o r l eg on th e s ide towards which the face was turned was consi dered
as a p ositive respon se.

In th e connotati o n of this study this response was cal l ed the imposed

asymmetric tonic neck reaction. Comp ara b l e respon ses res u lti n g from
a spontaneou s turn i n g of the head to one si d e or the other, were cal­
l ed spontaneous asymmetric tonic neck reactions and reco rded sepa­
rately.

Recording:
0. No co nsistent m ovement pattern of arm and/o r leg on rotation of
the head.
1 . S low and vari a b l e respon se, consistently repl i cab l e.
2. I m mediate and consistent respon se, p resent in arm and l eg, tho u g h
easi ly cou nteracted by sponta neous moti lity.
The assessment d u ri n g which a positive response was o btained fo r the
fi rst time, was regarded as the mo m ent of onset of the fi rst change.
This cou l d b e a score 1 o r a score 2 . The fi na l change was regarded to
h ave taken p l ace when the response had d isappeared, i . e. a score 0
was obtai ned.

The p redicti o n bands fo r the asym metri c ton i c neck reacti o n, i m posed
and observed d u ri n g spontaneous moti l ity, are p resented i n figures 27
and 28 resp ectively. M o re than 80o/0 of the i nfants did not show any
asym m etric ton i c neck reaction d u ri n g the fi rst assessment. D u ri n g the
second assessment, m o re than 80o/0 of the i nfants showed a positive

84
 Asymetric tonic neck response (imposed)

(J)

� 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

I
exam.
I I I I I I I I I I I I I I I I I I I I I I
0 3 6 9 u 15 18 21
age,months
F i g. 27

Asymmetric tonic neck response (spontaneous)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.
T� ----. -r -� I I I
o 3 6 9 u � ffi n
age,months
Fig. 28

reacti o n . As fo r the spontaneous asymm etri c ton i c neck reaction, t h i s

was the c a s e u nti l the sixth assessment O nl y 1 0°/0 of th e i nfants d i d
not s h ow a ny sponta neo u s asym m etric to n i c n ec k response d u ri n g
d evelopment Abo ut half o f t h e i nfants o btai ned a score 2 a t s o m e mo­
ment d u ri n g the fi rst m o nths of l ife.

The resu lts of the i m p osed asymm etric ton i c n eck reacti o n were l argely
d ependent on the i nfant's a mo unt of activity. O n ly at the secon d a n d
th i rd asses s m ent a positive reaction cou l d b e obtai ned i n m o re t h a n
80o/0 of the i nfants. The d ecrease of this percentage co u l d b e ascribed
to th e i nfant's i n creas i n g active resi stance to m a n i p u l ation when g row­
i n g o l d er; this m ay also exp l a i n the l a rge vari ab i l ity of the scores fro m
the fo u rth assessment o nwards. I n a s m a l l m i n o rity of e asy g o i n g i n­
fants a positive response cou l d be o btained unti l the ei ghth assessment,
i .e. u ntil about 32 weeks of age. Spontaneous asymm etric ton i c n eck
p attern s occurred d u ri n g a m uch l o n ger p eri o d of ti m e.
O n e th i rd of the i nfants showed i nco n si stencies d u ri n g th e e l icitatio n of
the asym m etric ton i c n eck reaction. l t is not s u rp ri s i n g that i nconsi sten­
cies occu rred m o re frequently in the asym m etri c to n i c n eck reactions
observed d u ri n g s p o ntaneous m oti l i ty. There were n o d iffere nces b e­
tween b oys and g i rl s . Fo r the i mposed and the spontaneous asymm e­
tric ton i c n eck reaction a s i gn i fi cant rel ati o n s h i p with a n egative cor­
rel ation coeffi cient was fou n d b etween the m o m ent of the fi rst change
and th e len gth of the deve l o p mental ran g e (r -.520 and r -.51 0, = =

p < 0.01 , respectively) .

85
The rel ati o n s h i p b etween the dissol uti o n of the spontaneous asym m e­
tric ton i c n eck response and the onset of developm ent of coord i n ation
of the upper extremities h as been d i scussed above (page 58).
At fi rst g l a nce there seems to be a resemb l ance between the asymm e­
tri c to n i c n eck reacti o n observed i n i nfants a n d the asymm etri c ton i c
n eck refl ex as descri bed i n neuro l o gical patients a n d as known from
a n i m a l exp eri m ents. N evertheless Magnus and De Kleyn d i d not con­
sider the i nfanti l e reacti o n as an equ ival ent of the path o l o g i ca l reaction
(cited by Vassel l a and Karl sson, 1 962) . Vassel l a a n d Karl sson stud i ed
the response i n the newborn peri o d ; taki n g i nto accou nt the criteria for
th e specificity of the m otor pattern a n d its co n s i stent occu rrence, they
con cl u ded that a true asym m etric ton i c neck reflex such as descri bed by
Magnus and D e Kleyn occu rred o n ly i n about 8°/0 of newborns. G e­
s ell rep o rted th at the response is freq uently fou n d between the second
and fou rth m onth of l ife, but h e did not repo rt his m ethods of standar­
di zati on and operati onal ization (Gese l l a n d Amatru da (1 947)). Pai n e
(1 964) p a i d attenti o n t o the vari ab i l ity o f the response; i n h i s o p i n i o n
th e response occurs i nconsistently i n t h e newborn period and reaches
its peak frequency d u ri n g the seco n d , th i rd and fo u rth m onths of l ife .
Yet it is not cl ear wh i ch typ e of asym m etric neck reaction he h a d i n
m in d . A s h e ta l ked about spontaneous p ostures i n t h e cri b , it m ay b e
ass u m ed that h e m eant t h e spontaneous asym m etri c tonic neck res­
ponse on ly.
In the p resent g ro up of l ow ri sk i nfants a stereotyped response which
can n ot b e cou nteracted by spontaneous moti l iy and such as i s observ­
ed in path o log ical con d itions, was not fou n d . The asym m etric to n i c
n�ck reaction fou n d i n these i nfants, w a s characteri zed b y a la rge vari­
abi l ity of the pattern and by an interference by spontaneous motil ity.
Th i s i l l ustrates again the fact that vari a b i l ity a n d stereotypy can be con­
sidered as th e characteri stics which d eterm i n e the si gn ificance of a
response.
Palmar g rasp reflex
Procedure: Th e i nfant was i n s u p i n e positi o n with h i s head centered.
The exam iner i n s erted his i n dex fi n ger i nto the palm of the i nfant, start­
i n g from th e u l n a r side of the hand. The response con s i sted of a to n i c
flexi on of the fi n gers a ro u n d the sti m u l ati n g fi n ge r (see a lso P rechtl
and Bei ntema, 1 964) . State 3 o r 4.
Recording:
.0 No i m mediate synchronous ton i c flexi o n of the i nfant' s fin gers
aro u n d the sti m u l ating fi n ger. Exp l o ratory m ovem ents of ha nd a n d
fi n gers around the sti m ul u s eventually resulti n g i n g rasp i n g were
a lso scored u n der thi s head i n g.
1 . A weak, often not l o n g susta i ned , ton i c flexion of the i nfant' s fi n gers
aro u n d the sti m u l ati n g fi n ger. Repeated flexion/extension m ove­
ments of th e i nfant' s fi ngers aro und the sti m u l ati n g fi n ger were a l so
scored.
2. Evident, s u stai ne d ton i c flexion of the i nfant's fi n g ers aro u n d the
sti m u lu s .
86
The p a l m a r g rasp refl ex consi sts of a tacti l e and a p ro p ri oceptive affe­
rent p art. lt m ay be assu m ed that i n sco res 1 a n d 2 both afferent p ath­
ways a re in fu l l operation . lt i s l i kely th at in sco re 0 the p ro p rioceptive
part is operative to a l esser degree. I ncreased p ressure on the i nfant' s
p a l m , for i n stance d u ri n g tracti o n , d i d not i nten sify the response as
h appened in the case of sco res 1 and 2. O n the contrary m ere tacti l e
sti m u l ati on w a s often fol l owed b y som e vari a b l e flexio n o f the fin gers
a nd/o r exp l oratory flexion/extensi o n m ovements of the fi n gers or eve n
with d rawal . lt was co n cl uded that tacti l e sti m u l ation d i d not re_s ult i n a
p a l m ar g rasp reflex but i n vo l untary b e h avi o u r. Fo r t h i s reason score
0 was co nsidered to refl ect absence of the refl ex fo r both typ es of af­
ferent i n p ut.

A score 1 was regarded as refi E?cti n g the fi rst change of the respo nse,
wh i l e a sco re 0 den otates t he di ssol uti o n of the pal m a r g rasp refl ex
(fi n al change).

Palmar grasp

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

J----r- 15
exam.
I I I I I I I �� I 12
I I I I I I I I I I
0 3 6 9 18 21
age ,months
F i g . 29

The p rediction b a n d of the devel o p mental cou rse of the pa l m ar grasp

refl ex i s p resented in fi g u re 29. In 80o/0 of the i n fants the d eve lo p­
m ental range was fo u n d b etween 1 6 and 40 weeks of age. At the sixth
assessm ent, i . e. at about 24 weeks of age 24o/0 of the i nfants sti l l ob-:
tained a score 2. From the seventh assessment o nwards the n u mber 9f ·

negative scores i n creased rap i d ly.

I n co n s i sten cies were fou n d i n 24o/0 of the i nfants, without differences
b etween b oys a n d g i rl s . Boys and g i rl s d i d not differ with resp ect to
the ti m e of on set of the fi rst chan ge, the fi n a l chan ge, o r the l e n gth of
th e d evelop mental range.
A negative rel ati o n s h i p was fou n d , though with a l ow correl ation coef­
ficient (r .436,p < 0.0 1 ) b etween the fi rst change a n d the d evelop­
= -

m ental ran ge. At the same ti m e a rel ati o n s h i p b etween the fi rst and the
fi n a l change was observed , a lso with a l ow co rrel ation coeffcient (r =

.375, p < 0.01 ) . Th ere was a closer rel ati o nshi p between the develop­
m ental ran g e a n d the fi n a l change of the p a l m a r g rasp refl ex (r .665, =

p < 0.01 ) . lt is n ot easy to exp l a i n this p attern of rel atio nships. In s o m e

i n fants the m o m ent of the com p l ete d i ssol uti o n of the refl ex s e e m s t o
b e m o re or l es s fixed, i rresp ective of t he m om ent of the fi rst appeara n ce
of th e d evelopment; this i s reflected by t he rel ati o n s h i p s b etween the

87
developmental ra nge a n d the fi na l fi rst chan ges resp ectively. I n oth er
in fants the time needed fo r the dissol ution of the refl ex seem s to be
p repro g ra m m ed , as i l l u strated by the rel ati o n s h i p b etween the fi rst and
fi n a l changes. Th i s co m b i n ati o n of rel ati o n s h i p s i l l ustrates the p ro b l em s
o f operati onal izati o n of t h e fi na l c h a n g e o f t h e respon se, i n particular.
As was i m p l i ed in the description of the scores, with i ncreas i n g age
and development it b ecomes i ncreasi n g ly diffi cult to d i sti n gu i sh the res­
ponse fro m vo l u ntary g rasp i n g b eh avi o u r. Th u s the amount of active
vol untary behavio u r, whi ch varies i ntra- and i nter-i n d ivi d u a l ly m ay affect
the developmental course of the respo nse differenti al ly.

In the p a ra g ra p h dea l i n g with the developm ental course of vo l u ntary

g ras p i n g, its rel ati o n s h i p with the p a l m a r g rasp reflex has been discus­
sed. Also the rel ationsh i p s with wal ki n g and sta n d i n g h ave been men­
tioned b efore.

The p a l m a r g rasp refl ex i l l u strates th e confusion which m ay arise if de­

fi n itions and op erati o na l i zati o n s are not co n g ruent.
H alverson (1 940) d i sti ng u i shed two asp ects of the refl ex, which was
confi rm ed by An d re-Thom as and St. A n n e D argassies (1 952) who men­
tioned a n exteroceptive and a to n i c p roprioceptive refl ex as two sepa­
rate m otor p h enomena. The exteroceptive refl ex wou l d d i sappear d u ri n g
t h e fi rst m onths o f l i fe, wh i l e t h e p ro p ri oceptive refl ex woul d pers i st u n­
ti l the end of the fi rst year. Koupern i k and D ai l ly are of the same o p i n i o n
(Kou pern i k a n d D a i l ly, 1 968). Poeck (1 968) stated that t h e p a l m a r grasp
reflex can b e regarded as co m p arable to the grasp i n g refl ex fo u n d i n
adult b rai ndam aged p atients. H i s a rgum e ntatio n i s based o n the fi nd­
ing that th e sti m u l us q u a l ity i s rather u n specifi c as in the c ase of
a d u lt patients ; h e observed m erely differences i n l atency ti m e i n con­
n ecti on with vario u s types of sti m u l ations. Twitchel l ( 1 970) descri bed
the develop ment of gras p i n g and the palmar g rasp refl ex com p l etely
in term s derived from adult patho l o gy. In h i s vi ew the i nfant' s g ras p i n g
behavio u r consists o f a co m b i n ation of refl exes w h i c h c a n be e li cited
fro m variou s a reas of the hands and fi n gers. To accou nt fo r these re­
fl exes he d raws upon Den ny-Brown's work which deals with neurologi­
cal ly i m p a i red adu lts and laboratory experi m ents with (adu lt) m o n keys
(Seyffarth and Den ny-B rown (1 948)). I n Twitchel l ' s descri ption of what
h e cal l s th e " p a l m a r g rasp reflex" one does not recog n ize the palmar
g rasp refl ex as shown i n Prechtl ' s fi l m (1 953) and descri bed by P rechtl
and Bei ntem a (1 964). Here the p a l m a r g rasp reflex i s a m oto r p h eno­
menon in which the who l e ha nd and arm participate and which i s evi­
dently b ased on a com p l ex i ntegration of b ra i n m echanisms (i ncludi n g
postural m ech a n i s m s and state o rganization), t o a l a rger degree than
wo u l d b e con g ruous with m ere ha nd- and fi n ger-reflexes. Twitchel l ' s
d i scussi o n o f th e devel o p ment o f g raspi n g a n d graspi n g refl exes i s a n
exam p l e o f th e d ifficulties w h i c h arise if o n e does not consider the
specific p roperties of the i nfant' s nervo u s system , which i s fun damen­
tal ly different from the nervo u s system of the (b rai n i nj u red) adu lt.

88
 When the p a l m ar g rasp refl ex i s see n as an i nfanti l e p h enomenon, it i s
extremely d iffi cult t o m ake a cl ear d i sti n ction b etween the vari o u s cau­
sal mech a n i sm s ; one m ust confi n e o n eself to the app reciati o n of the c l i ­
n ical response as such. D u ri n g developm ent, t he b ra i n m ec ha ni sms
wh i ch a re resp o n s i b l e for th e rea cti o n g rad u a l ly be c o me i n co rp o rated
i n qualitatively different m echanisms, which in thei r turn a re refl ected
by the d evelopm ent of the i nfants' ab i l ities . A d i stinction of mech a n i s m s
m ad e on the basis of a n i m al experi m ents and fi n d i n gs i n a du l t p atients
is artifi cial and even fal l acious. In these i n stan ces q u a l i tatively different
m ech a n is m s a re operative, on the o n e h a n d due to the d ifferent degree
of m atu ratio n of the b ra i n , and on the othe r h a n d to the damage. A
h ea lthy i nfant is n ever compa ra b l e with a b rai n-damaged adu lt.
In the p resent study a p ragmat i c operati onal i zati o n of the p a l m a r g rasp
reflex was app l i ed and a specific d evelop mental co u rs e co u l d b e de­
fi ned which perm its a cl i n i ca l a p p reci ati o n of d evi atio ns.

Reacti o n to push against the s h o u l d e r during sitting

Procedure: Th i s test assesses b a l ance d u ri n g sittin g position. The
exa m i ner gave a gentl e si d eward push against the i nfant' s shoulder
wh i l e h e was s itti n g free. The ab i l ity of the i nfant to rem a i n i n s itti n g
position was reco rded. State 3 o r 4 .

Recording:
0. Th e i nfant was n ot a b l e to s it unsupported.
1 . The i nfant fel l aside if p us h ed agai nst the s h o u l der.
2 . Th e i nfant p l aced h i s a rm s si dewards i n o rder to suppo rt h i m self b ut
h e d i d not s u cceed a n d top p l ed over.
3. The i nfant rem ained s ittin g when p ushed against the s h o u l de r, ef­
fectively u s i n g h i s a rm for support.
Scores 1 a n d 3 were reg a rded to refl ect th e fi rst change a n d the fi n a l
c h a n g e respectively.

Reaction to push against shoulder durip.g sitting

Cll

g
('1)
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.
I I I I I I I I I �-, r--r I
12
I I I I I ,----, -, 1
0 3 6 9 15 18 21
age,months
fi'Q,. 30

89
The p rediction b an d fo r thi s b a l a nce behavi o u r is presented i n fi gu re 30.
A score 3 can b e regarded as refl ecti n g wel l develo ped b a l ance duri n g
sitti n g . Th i s score was o bta i ned b y about h a l f o f t h e i nfants a t about 45
weeks of age; m o re than 80o/0 of the i nfants sh owed a good balance
o nly at the age of one year. One i nfa nt d i d n ot show any supporti n g
reaction o f t h e arm when fa l l i n g sidewards b efo re t h e 1 6th assessment,
i . e . at the age of about 64 weeks. There were o n ly a few i n co nsi sten­
cies in the respon ses of th is test. D ifferen ces between boys and g i rl s
with respect t o t h e m o m ents o f the fi rst changes, t h e fi na l changes, the
le n gths of the developmental ra ng es and the number of i nconsistenci es
were n ot fou n d . A rel ati o n s h i p was fou n d between the m oment of the
fi nal change and the l e ngth of the developm ental range (r . 628,
=

p < 0.01 ); a n egative rel ati o n s h i p was fou n d b etween the m om ent of
th e fi rst change and the l e n gth of the developme ntal ran g e (r = .53 1 ,
-

p < 0.01 ). Th i s s u ggests that the m o m ent of stab i l izatio n is mo re o r l ess

fixed i n time. lt refl ects the ti m e course d u ri n g wh i ch the i ntegratio n of
b ra i n m echan is m s , needed fo r th i s m otor fu n ction (cerebe l l a r and b ra i n
stem d ifferenti ati on and integration) takes p l ace. Andre-Tho mas consid­
ered the response m a i n ly as an acq u i red reaction achi eved after rep eat­
edly fal l i n g sidewards a n d resulting from the frequent use of the arms
for support i n other positi ons as we l l (An d re-Th omas and St. Anne D a r­
gassies, 1 952).
As the response to p u s h against the s h o u l der was tested o n ly when
the i nfants were able to sit free for some seconds, it cannot b e consi­
dered as i dentical wi th th e l ateral supporti n g reacti o n . The l atter i s de­
fi ned as a supporti n g extension of the arm and a sideward p l aci n g of
the o utstretched h a nd when the i nfant is p ushed sidewards, i rrespective
of h i s abi l ity to sit, and va rious auth o rs rep ort it as occurri n g earl ier
th an th e test descri b ed i n thi s s ection.
Compari son of the p rediction bands for the d u ratio n of sitti n g and the
response to push against the s h o u l der (fi g . 20 a n d 30) shows a consi de­
rab l e co nform ity of s h ap e and l e ngth. I n deed m ost of the i nfants who
had ach i eved th e a b i l i ty to sit for just a few seconds, tended to topp l e
over without u s i n g hands o r arm s fo r support when pu shed agai nst the
s h ou l der, wh i l e para l l el to the i n crease of d u rati o n of sitti n g the res­
ponse to p u sh against the shoulder i m p roved . Th us o n e m i ght say that
the p resent test i n di cates the q u al ity of sitti n g i n term s of ba la nce, ra­
ther th an dea l i n g with a l atera l supporti n g reaction which m i ght p recede
th e a b i l ity to sit unsupported, and wh i ch can b e regarded as refl ecti n g
o n ly o n e co n stituent part o f sitti n g bal ance.

The rel ation s h ip s b etween · th i s b a l ance reaction and the developm ent
of observed or i n d uced m otor activity such as sitti n g , ro l l i n g , stand i n g ,
wal k i n g a n d behavi o ur i n p rone positi o n , h ave al ready b e e n di scussed .
There was a close rel ati o n s h i p with the oth er bal ance reaction d u ri n g
sitti n g , i . e. t h e a b i l ity t o fol l ow a n o bject with eyes, hea d a n d tru n k (r' s
ra n g i n g from .577 to . 628, p < 0.01 ) .

90
 Following of an object with the eyes and. rotatio n of the h ead and
tru n k when sitting
Procedure: The exa m i ner m oved a n i n terestin g toy aro u n d the sitti l') g
i nfant, encou ra g i n g h i m t o l o o k a t it. T h e a n g l e over which t h e i nfant
cou l d rotate without - losi n g balance was reco rded.
State 3 or 4.
Recording:
0. The i nfant was not a b l e to sit witho ut support.
1 . The i nfant was not a b l e to watch the obj ect without l osi n g b a l ance.
2 . The i nfant was ab l e to watch the object over c. 3 0 degrees to b oth
s i des.
3. The i nfant was a b l e to watch the obj ect over c. 60 degrees to b oth
sides.
4 . The i nfant was able to watch the object over c. 90 degrees to b oth
s i des.
Scores 2 a n d 4 were con si dered to refl ect the m o m ents of the fi rst a n d
fin a l chan ges respectively.
Visual following ofan object with head and trunk, sitting

Cl>

� 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19· 20 21 22 23 24
exam.
I I I I I I I I 1- I -I I I , - I I ---.- -.:--1--.-----1'
o 3 6 9 u B ffi n
age months
,

Fig. 3 1

The p rediction b a n d fo r t h i s a b i l ity i s p resented i n fi g u re 31 . l t i s evi­

dent that the a b i lity to rotate without l oosi n g b a l ance develops rap idly.
O n e i nfant was not ab l e to watch the obj ect without l o s i n g b a la n ce unti l
the s ixteenth assessm ent, i .e. until about 64 weeks of a ge. Thi s
s a m e i nfant was also not ab l e t o keep h i s b alance after bei n g p ushed
against the s h o u lder. Obvio u s ly th e d evelopment of b a l ance was retard­
ed i n this i n fant. A good b a l an ce d u r i n g s itti n g was fou n d i n m o re
than 80o/0 of the i nfants at the age of o n e year. Th i s corrobo rates the
fi n d i n g that i n the m aj ority of the i nfants of the p resent g ro u p stab l e
a n d m ature sitti n g had d evel oped a t about o n e year of age. Sti l l the va­
riati o n ran g e was l arge and a m o u nted to about six m o nths .
I nco n s i sten cies were observed i n a m i n o rity of the i nfants, i n the g i rl s
s l i ghtly m o re often than i n the boys. Th i s d ifference was not statisti­
cal ly s i g n i fi cant (Man n-Whitney U Test), n ei th e r were there s i g n i fi cant
d iffere nces between boys a n d g i rl s as for the m oment of the first
change, the fi n a l ch an ge or the l en gth of the developm ental ran ge.

91
 There was a negative rel ati o n s h i p betwee n the mom e nt of the fi rst
change and the l ength of the develop mental ran g e (r -. 565, =

p < 0.01 ) , as was the case with the i tem response to p u s h against the
s h o u l der. There was a s i g n ificant relati o n s h i p between the m o m ents
of th e fi rst and fi nal chan ges (r .591 , p < 0.01 ) wh ich was not fou n d
=

i n t h e case o f item response t o push against t h e sho u lder. Thi s

m e a n s that t o a certai n degree t h e a mo u nt o f time needed fo r the de­
velop m ent of this motor ab i l ity i s fixed. The rel atio nshi ps with other
items h ave been d i scussed before.
O ptical placing reactio n of the h ands
Procedure: Th e i nfant was kept i n p ro n e suspension and suddenly
lowered toward s a flat surface. Th e m ovements of arms a n d hands
were recorded. State 3 o r 4.
The response co nsisted of a fo rward extension of the arm s and open i n g
and dors iflexion o f the h a n d s o n approach i n g t h e su rface.
Recording:
0. No forward extension of the arms and/o r open i n g of the hands.
1 . Forward extension of the arm s ; open i n g of the hands a n d dorsi­
flexion of the wri sts occu rred o n ly o n touc h i n g the su rface.
2. Forward extension of the arms and openi n g and dorsifl exion of the
hands during the downward m ovement.
S co res 1 and 2 were regarded to refl ect the moments of fi rst and fi na l
changes respectively.
Optical placing reaction of the hands

Vl

� I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.
I I I I I I I I I I I I I I I I I I I I I

0 3 6 9 12 15 18 21
age,months
F i g . 32

Th e p rediction b a nd fo r the o ptical p l aci n g reaction of the hands i s

p resented i n fi g u re 3 2 . T h e reacti o n showed a rap i d developme ntal
co u rse from th e ei g hth assessment o nward s ; about half of the i nfants
d i s p l ayed a weak response at the eighth assessment and two th i rds
of them s howed a fu l l response at th e tenth assessment, i . e. at about
40 weeks of age. The vari ati o n range fo r the total g ro u p was l a rge; it
depended o n a small m i n o rity of i nfants who, with regard to the d evel­
opment of this response, were very early and very l ate respectively.
I nconsistencies occu rred in a m i nority of i nfants. There were no statis­
tica l ly s i g n ifi cant d ifferences b etween b oys and g i rl s with respect to
the m o me nts of the fi rst changes, the fi na l chan ges, the len gths of the
developmental ran ges o r the occu rre nce of i nco nsistencies. There was
no rel ati o n s h i p b etween the m oment of the fi rst change and th e le ngth

92
of the d evelopmental ran g e ; the m o m ent of the fi rst change does not
p redict t h e amount of ti m e n eeded to devel o p a m ature response.
Sti l l , the fi n a l change and the develop m ental ran ge were closely rel at­
ed (r . 745) . This i m p l ies that the m o ment of fin a l stabi l izati o n is ra­
=

ther fixed i n t i m e, w h i ch m ay refl ect the sensori m otor m atu rati o n n eed­
ed fo r visual p l a ci n g. A nd re-Thomas co nsi dered the response as an
acq u i red reaction and even �ostul ated it as a m a nifestation of m ental
d evelopm ent (An d re-Thomas an d Saint Anne D argassi es, 1 952) , which
can n ever b e exp l ai n ed by the p resent fi n d i n gs .
Th ere w a s a statistical ly s i g n ificant rel ati o n s h i p (r .483, p < 0.01 ) =

b etween the fu l l estab l i shment of the o ptical p l aci n g reaction of the

hands a n d the fi rst app earance of the p a rachute reaction of the h ands.
There was n o s i g nifi cant relati o n s h i p b etween the fi rst chan ges of both
reactions, whi l e the corre l ation coeffi cient for the rel ati o n b etween the
fi n al chan ges was a l so .483. With a vi ew to the s i m i l arity of the two
reaction typ es a rel ation cou l d be exp ected ; sti l l the corre lation coef­
ficients a re l ow, so that the response of the one reaction can not be re­
garded as i n d i cative or p redictive of the response of the other (see also
the n ext s ection).
Parachute reaction of arms and h ands i n prone s uspensi o n
Procedure: The i nfant h e l d i n p ro n e suspension was sudden l y arop­
ped a few centi m eters, vi sual contro l not b e i n g p erm itted. As b l i n dfo l d i n g
th e i n fants wou l d i m p ly a d i sturb a nce of a n adequate behaviou ral state,
e l i m i n ati on of visual control was b rou ght about by drawi n g the i nfant' s
attentio n to an i nteresti n g toy, d i s p l ayed i n fro nt a n d a l ittl e above h i m .
I n t h i s way it was poss i b l e t o standardize t h e h ea d positio n a n d conse­
q ue ntly the i nfluence of th e position of the h ea d o n the m uscle ton e
activity o f t h e a rm s . State 3 o r 4. A positive response co nsisted o f a
forward extension of t he a rm s and dorsiflexion and open i n g of the
hands d u ri n g the m ovement.
Recording:
0. No fo rward extension of the arm an d/o r o p en i n g of the h a n ds.
1 . S l i g ht forward extension of the a rm s , o ccasio n a l ly fo l l owed by ope­
n i n g of the h an ds .
2. Evi dent forward extension of t h e a rm s , accom pa n i ed by o p en i n g o f
the hands.
S cores 1 a n d 2 were regarded to refl ect the fi rst a n d fi n a l chan ges res­
p ectively.
Parachute reaction

Cll
1
t'"l
�0
�
1 2 3 4 5 6 7 8 9 10 11 12 13 14 _ 15 16 17 18 19 20 21 22 23 24
exam.
I I I I I I I I I I I I I I I I I ,-1 I I I
0 3 6 9 12 15 18 21
age,months
Fig. 33
93
The p rediction band fo r the parach ute reaction is presented i n fi g u re
33. Com p ari son with fi g u re 32 sh ows a l ater appearance and a m o re
p rotracted developmenta l co u rse as the m a i n differences between the
parach ute reaction and o ptical placi n g of the hands. The i rregu l ar shape
of the en d of the p rediction band i s caused by the decrease of the num­
ber of in fants i n the g roup at the e nd of the p eriod of study. I n m any
i nfants one or m o re i n co nsi stencies were fou n d ; i n the g i rls s l ig htly
m ore often th an in the boys . Statisti ca l ly this differe nce reached a 5°/o
l evel of confidence (Mann-Wh itney U test) . Th i s was also the case with
the len gth of the developm ental ran ge, which was s l i g htly l o n ger in the
g i rls. A stati stically s i g n ificant rel ati o n s h i p was fo u n d between the fi­
n al change and the developm ental ra nge (r = . 67 1 , p < 0.0 1 ) and be­
tween the m o m ents of fi rst and fi n al chan ges (r = . 62 1 , p < 0.01 ) .
Thus o n e can n ot assume either a fixed end o f t h e developmental co u r­
se o r a fixed amo u nt of ti m e needed fo r the development of thi s item ,
as both m ay o ccu r i n each i n d ividual i nfant. There was a s i g n ificant
rel ationsh i p b etween the l en gth of the d evel opmental ran ge and the
n umb er of i n con s isten cies (r = .648, p < 0.0 1 ) (Spe arm an Rank Cor­
relation), which may refl ect the p ro b l em of operati onal izatio n a n d
standard i zatio n ; it m i ght also b e consi dered as an i l l ustration of t h e
stra i n on t h e nervo us system w h e n this m otor o rga ni zati o n develops,
i .e. when neuro n a l responses to a p a rti cu l ar sti m u l us are i ntegrated i nto
one recog n izabl e and cons istent pattern. The m a i n difference between
the eli citation of the opti cal p l aci n g reaction and the parach ute reaction
as defi n ed i n th e p resent study was the p resence of vi sual control in
the form er. The steeri n g i nfl uence of vi sual contro l appears to affect
the occu rrence of arm extension d u ri n g downwa rd m ovement in p ro n e
suspens i o n co nsi dera b ly a n d i l l ustrates the rei nfo rc i n g effect o f vi su a l
on vestib u l a r i n p ut. Pai ne ( 1 960) states that t he pa rach ute reaction i s
p resent w h e n a b aby o l der than ei g ht o r n i n e m o nths i s sudden ly d rop­
ped towards a flat su rface. The menti o n i n g of the su rface, together
with an i l l u strati n g p hoto graph i n his paper, shows that h e deals with
the optical p l a c i n g reaction of the h a n d s ; if this is ri ght the resu lts of
th e p resent study are in accordance with h i s fi n d i n g s .

O ptical placing reaction o f t h e feet

Procedure: Th e exa m i ner kept the i nfant u nder the sho u lders in ver­
tical suspension a n d m oved h i m towards a flat su rface. The res ponse
consisted of a n extension of the legs o n approach of the su rface. State
3 or 4.

Recording:
0. No extension of the legs on approach of the surface.
1 . S l i ght extension of the legs.
2. Evi dent extension of the legs, anti c i p ati n g p l ac i n g of the feet.
Scores 1 and 2 were co nsi dered to refl ect fi rst and fi na l chan ges res­
p ectively.

94
 Optical placing reaction of the feet

V>

� I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

I I
exam.
1 -1----, 1 T I 1- I I I I I I
o 3 6 9 u B m n
age,months
Fig. 34

The p redicti on b an d fo r this resp onse i s p resented i n fi g u re 34. Alth o u g h

some i nfants a l ready sta rted t o show an evi dent extens i o n of the l egs
at abou t 4 0 weeks, half of t he m showed a com p l ete response a t about
o n e year of age; i n m o re than 80°/0 of the i nfants the fi n a l change took
p l ace at about 60 weeks of age. A com parison of this p rediction b an d
with that fo r th e postu re o f t h e l eg s i n vertica l suspension (fi g. 1 1 ) a n d
with t h e p redicti on b a n d fo r t h e deve l o p ment o f stand i n g u p (fi g. 24),
s hows that the fi rst changes of the o pti cal p l a c i n g reaction of the feet
a n d of sta n d i n g up occu r in th e same p eriod when p red o m i nantly sym­
m etrical motil ity of the l eg s in vertical suspension is fou n d . In a l l these
i n stan ces sym m etrical m otor p atterns are i nvo lved. Thi s i l l u strates a
typ i ca l developm ental p rocess of the n ervou s system i n which, i n vo­
l u ntary m oto r b eh avi o u r, i nfanti l e m otor p atterns a re i n tegrated.
I ncon s i sten cies occu rred i n one th i rd of the i nfants, without a n evi dent
sex difference. Neither were evi dent sex differe nces observed with res­
p ect to the m o ments of th e fi rst chan ges, fi na l ch anges or le ngths of
develop m ental ran ges. Th ere was a close rel ati o n s h i p between the mo­
ments of the fi rst aod the fi n a l change (r .777), whi l e the rel ati o n s h i p
=

b etween the m oment of the fi na l chan ge and the l e n gth of the d evelop­
m ental ran g e was appreci ably l ower, though sti l l s i g n ificant (r .505, =

p < 0.01 ). These rel ati o n s h i p s su g gest that the amo unt of tim e n eeded
fo r th e d evel op m ent of th i s react i o n i s fixed , and th at the m om ent of
fi n al sta b i l i zatio n can b e fixed i n time as wel l .
The l e n gth o f t h e develop m ental ran g e and t h e occu rre nce o f i n co nsi s­
ten c i es were a lso rel ated (r = .559, p < 0.01 ). The rel ati o n s h i ps with
p ara m eters of othe r items have al ready b een d i s cussed in p revio u s
secti ons.

Foo·tsole response
Procedure: The footso l e response was e l i cited accord i n g to Prechtl
and Bei ntema ( 1 964). The i nfant's h i p , knee and foot were kept in a sem i­
flexed position and with his th u m b n a i l the exa m i n er scratched from
the toes h eelwards a l o n g the l ateral side of the so l e of the foot. Thi s
particular d i recti on of t h e sti m u l ation is necessary i n o rder t o avo i d t h e
e l i citati on of a p l antar g rasp reflex. Espec i al ly i n o l d e r i nfants i t was
often d iffi cult to avo i d a withd rawal response. Fo r this reason the sti­
m u l us i ntens ity was varied i nteri ndivi d u a l ly. The m ovem ents of the b i g
toe a n d t h e s m a l l toes a s a reaction t o t h e sti m u l ation were recorded

95
separately. Th e test was ca rri ed out five times co nsecutively and the
fi nal sco re was b ased o n at l east th ree co m parab l e m ovements of the
toes. State 3 o r 4.
Recording:
0. No vis i b l e movement of the b i g toe or the s m a l l toes, or alternati n g
dorsi- and p lantar-fl exi o n o f t h e b i g t o e o r s m a l l toes. A t the e n d of
the fol l ow-u p a consistent and sustai n ed p l a ntar flexion of the b i g
toe or t h e s m a l l toes occu rred o n l y i n a m i n o rity o f t h e i nfants. I f
p resent i t was a l s o scored 0.
I . Weak, often n ot l o n g susta i ned, dorsifl exion of the b i g toe and fan­
n i n g of the s m a l l toes.
2. Evident, sustai ned dorsifl exi o n of the big toe and fan n i n g of the
small toes.
A score 1 was regarded as the fi rst change of the response and a sco re
0 as the fi n al chan ge.
Footsole reflex

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.
1 1 1 1 1 1 1 1 1 1 1 1 1 1 , 1----r- 1 1 1 � -�
0 3 6 9 12 15 18 21
age,months
Fig. 35
A p redicti on band fo r the footso l e response of the b i g toe i s p resented
in fi g u re 35. lt shows that the development of the footso le response i s
rath er p rotracted . The va riati o n range was l a rge, though m o re than
90% of the i nfants sh owed an evi dent and susta i ned do rsifl exion of the
big toe u ntil th e fifth assessment. I n about o n e thi rd of the i nfants this
was sti l l th e case at the age of 40 weeks (1 Oth assessment). At the same
age 40% of the in fants showed an unequivocal response (score 0). The
i rregu l ar shape of the p rediction b an d and the ful l range demonstrate
th e occu rrence of i nco n s i stencies. The tota l numbe r of i nco nsistencies
was 79, d i stri b uted over 39 i nfants ; there was no d ifference between
boys a n d g i rl s . Th e small toes showed an evi dent a n d sustained fan­
n i n g and dorsifl exi on in mo re than 80% of the i nfants u nti l the n i nth
assessm ent, i . e. u nti l about 36 weeks. 24o/0 of th e i nfants showed this
type of response unti l the age of one yea r. A sco re 1 for the b i g toe as
wel l as for the s m a l l toes cou l d b e fou n d during the who l e perio d of
i nfancy.
l t was observed that a consensual reaction, i . e. an identical and s i m u l­
taneous m ovement pattern of the toes of the op posite foot, occu rred
in more than 80o/0 of the i nfants b etween five and sixteen weeks of
age. S u b sequently a con sensual reaction was fo u n d in a rapi dly decreas­
i n g p ercentag e of the i nfants, but it cou l d b e observed i n a s m a l l m i­
nority until th e end of the fo l l ow-up stu dy.

96
Attention shou l d be paid to the position of the h ead d u ri n g the e l i ci ta­
tion of the footsole respon se. In m o re than half of the i nfants the do rsi­
fl exi on was weaker o n the si d e towards whi ch the face was turned at
any time between the seco n d and the seventh assessm ent. The i nflu­
en ce exerted by the positi o n of the head was stro n gest at the age of
about 1 6 weeks, when this p h enomenon was observed in three qu a rters
of the i n fants. lt m ay be exp l a i n ed by the effect of the asym m etric to n i c
n eck reacti on (Wals he '23).
A co nsistent asym m etri cal p attern , m a i n ly with regard to the m o m ent
of d isap p ea ra n ce of an evi dent dorsifl exi o n such as repo rted by Babki n
( 1 969) , was n ot fou n d .
There were n o stati sti cal ly s i g nificant d ifferences b etwee n boys a n d
g i rl s , alth o u g h i n th e g i rl s the m ean l e ngth of th e developm ental ran ge
was s l i g htly m o re p rotracted than i n the b oys. Th i s difference d i d not
reach stati sti cal s i g n ifi cance. Th e ti m e of onset of the fi rst change was
n egatively rel ated to the l e n gth of the develop m ental ran g e (r = -.551 ,
p < 0.01 ) , wh i l e the fi n al change and the deve l o p mental range were po­
s itively rel ated (r = . 679) . Th i s m ay b e exp l ai ne d by the fact that i n
healthy i nfants, when bei n g h an d l ed , vo l u ntary activity wi l l be p rovoked,
so that the sti m u l us m ay not only result i n a footso le response b ut in
oth er m ovem ents a l so, which, dependent o n their i nten sity, m ay b l u r the
actua l response.

A rel ati o n s h i p was fo u n d b etween the ti m e of o nset of th e fi n a l change

and th e n u m ber of i n co n s i stencies (r = .542, p < 0.0 1 ). Th i s i l l u strates
the p ro b l em of defi n i n g the m o m ent of the l ast change unequi vocally.
There was n o statistical l y s i g n ificant rel ati o n sh i p b etwee n th e moments
of th e fi rst changes of the footso l e refl ex an d standi n g o r walki n g res­
p ectively, or b etween the l e n gths of the developm ental ran g es of these
th ree items.

There was a s i gnificant rel ati o n s h i p b etween the m oment of the l ast
change of the foots o l e response and sta n d i n g free, though with a l ow
correl atio n coeffi cient (r = .409, p < 0.01 ) whi le the rel ati o n s h i p with
wa l k i n g free h ad a correl atio n coeffi cient of r .376 (p < 0.01 ).
=

Alth o u g h these corre l ation coeffi cients s i gn a l statistical s i gnificance

they are so low that any i ndivi d u a l p redictive validity, whi ch m ay be
of c l i n i ca l val u e i s p recl u ded.
The rel ati o n s h i p s of the fi na l change of the footso le response with the
onset of the development of stan d i n g u p a n d wal k i n g h ave b een dis­
cussed i n the sections deal i n g with these two items.
Alth oug h phen otypi cally the d o rs iflex io n type footso le response in in­
fancy resem b l es the so-cal l ed B ab i n sk i refl ex, th e i nfanti l e response
has a d ifferent c l i n ical s i gn ifi can ce. In a c l i n i ca l n eu ro lo gical co n n o­
tation the B ab i n ski reflex consists of an isol ated do rs ifl exion of the
b i g toe, caused mainly by su p ra nuclear l es i o n s of the Central Nervou s
System. I n t h e p resent g ro u p i s o l ated d o rs ifl exi o n of the b i g to e o ccu r-

97
red rarely a n d i n consistently. C l i n ical ly, fan n i n g of the s m a l l to es, usu­
ally coupled with a d o rsifl exi o n of th e big toes and comparab l e with
the fan n i n g and dorsifl exion of the s m a l l toes in i nfa ncy, is kn own as
the Babi nski 11 or S i g n e de l ' eventa i l . Babi nski regarded this movement
pattern of the s m a l l toes as bei n g a sign of probabi l ity in favo u r of a
d i sturbance of th e pyra m i dal system (B abinski 1 903 , rep ri nted by Wi l­
kins and B ro dy, 1 967) and belonging to the o rigi nal pattern , wh i ch con­
si sted of toe m ovements, knee fl exi o n and hip fl exi on on sti m u l ation
of the footsole. l t wou l d occu r as a neurol o g i cal s i g n of a mo re exten­
sive l esion of th e b ra i n . Th i s is dou bted by G ri m by (1 963b), who assum­
es that "the i n d ividual variati ons fou nd i n the path o l og i cal material
are too m an ifo l d to b e ascribed so lely to l esions of varyi ng degrees of
severity" . H e emph asizes that a l so in healthy i n d ivi d u a ls Bab i n ski type
responses m ay b e fou n d , wh ich is i n acco rdance wi th the fi n d i n gs pu­
b l ished by M ado n i ck (1 960) who reported an i ncidence of 4.3°/o Babi nski
responses i n a g ro up of 2500 non-neuro l og i ca l (adult) subj ects. Bab i n ski
h i mself descri bed an extension of the b i g toe and abduction of
the toes in n ewb o rns and recog n i zed its different c l i n i cal s i g n ificance,
com pa red with the respon se as observed in adults, b ecause in h i s opi­
n i o n it reflected the i m m atu rity of the pyram idal tract. Sti l l , he used th is
fi n d i n g to s u p port his idea that "the toe phenomenon is rel ated to a
disorder of the pyra m i dal syste m " . (Babi nski, 1 903, repri nted by Wil­
kins and B ro dy, 1 967). Bra i n and Wilkinson (1 959), i n their extensive
review of the Babi nski refl ex, poi nted out that it i s h i g h ly i m p robab le
that a p athological and neuro l ogical s i g n wou l d exist i n healthy i nfants.
Genera lly speaking, a patho l o g i cal sign is characterized by a h i g h
amount o f stereotypy, whi l e vari a b i l ity, i n c l u di n g i n consistency is cha­
racteri stic of a h ealthy nervo us system .
With a view to th e large amount of i n co nsistencies and variab i l ity du­
rin g the developmental course of the footsole response d u ri n g infancy,
its m ust b e em p h asized th at c l i n i ca l ly the i nfanti l e footsole res ponse
can n ot be regarded as a Babi nski in th e adult con notati o n .

A s amo ng others Kugel berg e t al (1 969), G ri mb y (1 963a, b) and G assel

(1 970) h ave poi nted out, the p h en otype of the toe movement (the dorsi­
flexion a n d fan n i n g o n the one hand and p l antar fl exi o n on the other
h and) resu lts from a shifti n g of bala nce between toe exten sors and
toe flexors due to ch a n g i n g suprasegm ental i nfl uences. In a healthy i n­
dividual th e supraseg m ental organization generally promotes a p l antar
fl exion as a result of sti m u l ation of the sole of the foot, especi a l ly when
this sti m u l ation i s ca rri ed out at the latera l side of the sole (as Kugel­
berg et al. (1 960) and G ri mby (1 963a) h ave shown, the m ovement pattern
of th e b i g toe is l a rgely depen dent on the sti m u l ated si de of the sole).
When th e susprasegm ental i nfluences are affected by a neuro l o gi cal
di sease, a dorsiflexi o n of the big toe m ay b e p ro moted. D u ri ng early
in fan cy dorsiflexion of the big to e appears to be th e usual (segm ental)
response to sti m u l ation of the sole of the foot; the transition to the
fl exo r typ e respo nses (p l antar fl exion) o r a perfect ba l ance between

98
exten sor and flexo r activity (no vi s i b l e m ovem ents of the toes , i .e.
" i n different" reaction) refl ects a m o d ificati on of the s u p rasegmental i n ­
fl uence on the s p i n a l mech a n i s m , res u lti n g from the m atu ration of t h e
cerebrosp i na l m echanisms. Th i s p rocess s h o u l d not b e confused with
th at of a m o d ifi cati on of the s u p rasegmental i nfl u en ces th e oth e r way
ro u n d (i.e. from p l antar flexi o n to d o rsiflexi on) due to a d i sturba nce of
th e cerebrosp i n a l o rganization.
I n c l i n ical n e u ro l o gy m any oth er m odes of sti m u l ation of the legs o r
even o f t h e b ody m ay res u lt i n a d o rs iflexi on of t h e b i g toe. Th ey are
usually ascribed to an expansion of the refl exogenic area of the foot­
s ole response as such . D u ri n g the fi rst seven or ei ght m onths of i nfan ­
c y these respon ses c a n a l s o b e observed i n i n fants as w a s stated b y
B ra i n and Wi l k i n son (1 959). I n t h e . p resent study O ppe n h e i m ' s response
(ru b b i n g the skin i n a downward d i recti o n resu lti n g in do rsiflexi o n of
th e big toe) occu rred in m o re than 80% of the i n fants u nt i l about 32
weeks. The resp onse was often weak and rath er i nco n s i stent. Ch ad­
dock's response (ru b b i n g the ski n aro u n d the extern al ankle res u lti n g
i n dorsiflexi on o f the b i g toe) occu rred i n about 75 0/o o f th e i n fants u n­
t i l about 20 weeks of age; it cou l d b e e l i cited i n about 25°/o of the i n­
fants u nti l the age of about 50 weeks. Especially during the seco n d
h al f o f t h e fi rst year th e response turned out t o b e i n creasi n g ly i nconsi s­
tent. In about half of the i n fants a gentle downwards stroki n g of the
skin of the i n ner s u rface of the th i gh resu lted i n an evi dent dors iflexi o n
of the b ig t oe a n d a d o rsiflexi o n of the s m a l l t o e s d u ri n g the fi rst 20
weeks. A weak n on-s usta i ned d o rsiflexi o n occu rred i n a m in o rity of
i nfants u nti l the end of the fi rst year. Ross o l i m o' s response (tap p i n g the
b a l l of t h e fi rst toe resu l ti n g i n fan n i n g of the toes) was i n co n si stently
p resent in about half of the i nfants d u ri n g the fi rst 20 weeks. Sub­
seq uently the frequency of the response decreased rap i d ly. Compara­
b l e resu lts were fou n d fo r the response of Me ndei-B echterew (gentl e
tappi n g on th e cubo i d b o ne of the foot resu l ti n g i n fan n i n g of the toes).
I n a l l e these respon ses m ovem ents of the b i g to e were acco mpa ni e d
by m ovem ents of the sma l l toes. Th e i nconsisten cy a n d vari a b i li ty o f
the respon ses d ifferenti ate them s pectacu l a rl y from the u s u a l l y stereo­
typ ed p ath o l o g i ca l co n d iti o n . O ne m ay a g ree with H a lt's co n c l us i o n th at
an exten s ively en la rged reflexogeni c a rea after th e fi rst h a l f year, a n d
a p ersi sten ce of a d o rs ifl exion of the toes after the a g e of two years
s h o u l d b e regarded as a b no rm a l (Ho lt, 1 961 ) .

Acoustical orienting
Procedure: Wh i l e the i nfant was seated on the m other' s l a p , the exa­
m in e r ran g a s m a l l n u rsery b e l l b e h i n d the i nfant' s h ea d outsi de h i s
vis ua l fi eld , on t h e l eft a n d ri ght s i d e con secutively. O ri enti n g m ove­
m ents of the i nfant's h ea d trying to loca l i ze th e source of the sou n d ,
were reco rded. State 3.

99
 Recording:
0. Diffuse reaction of the i nfant witho ut evi dent o riented m ovements
of the head. Some h o rizontal m ovements could be observed.
1 . Tu rn i n g the h ead towards the side of the sti m u l ation without i m m e­
d iate l ocal izati o n . The m ovem e nt consisted of two clearly d isti n g u ish­
able parts : a lateral rotation of the head, fol l owed by vertical or
o b l i q u e searc h i n g m ovem ents of the head.
2. I m med iate l ocal ization of the source of the sou nd in one smooth
orienti n g m ovem ent.
Scores 1 and 2 were consi dered to refl ect fi rst and fi na l changes res­
pectively.
Acoustical orienting

"'

� 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.
I I I I I I I I I I I I I I I I I I I I I I I
0 3 6 9 12 15 18 21
age,months
Fig. 36

Th e developmenta l co u rse of acoustical o ri enti n g i s p resented i n fi gu re

36. The developmental co urse was rap i d ; 50o/0 of the i nfants showed
the onset of o rienti n g at the age of about 20 weeks, wh i l e half of the
i nfants showed adequate o rie nti n g at the age of 24 weeks ; 96°/0 of the
i nfants l ocalized the sound accurately at the age of about 32 weeks.
I n con s istencies h a rd ly occu rred. There were no diffen rences between
b oys and g i rl s . The fi n d i n gs are in acco rdance with the data g iven by
Koupern i k and Dai l ly (1 968) and by M u rp hy (1 962). Accu rate o rienti n g
t o t h e l eft bei n g p receded b y o rienti n g t o t h e ri ght, or vice versa a s
fou n d b y M u rphy w a s not observed.
There was a l ow but s i g nificant rel ati o n s h i p between the moments of
the fi rst and the fi n a l chang es (r .399, p < 0.01 ) ; the fi rst change and
=

the developm ental ran g e were also rel ated (with a negative correlati o n
coeffi cient: r -.395, p < 0 . 0 1 ) , wh i l e the closest rel ati o n s h i p was
=

fou n d b etween the developme ntal ra nge and the fi na l change (r .685) . =

Th i s set of rel atio nshi p s su g gests th at i n the m aj o rity of i nfants the m o­

ment of stab i l izati o n of the response is m o re or l ess fixed, i rrespective
of the m oment of the fi rst developm ental man ifestation. In oth er i n ­
fants it seem s th at it i s the amount of time needed fo r t h e fu l l devel­
opment of acoustical o rienti n g which i s m o re o r l ess fixed. Sti l l , the
l ow co rrelation-coeffi ci ents show that only a sma l l p roportion of th e
variance wh ich m ay occur in the g ro up (r2) is expl ai n ed by this re l ation­
ship. Obvi o u s ly th e p rediction of the developm ental range of aco u stical
orienti n g solely o n the basis of its fi rst ap pearance i s ha rd ly feasi b l e.
Relations with p a rameters of other items were n ot fou n d .

1 00
The M oro reactio n
Procedure:
The M o ro reacti o n was e l i cited in t hree different ways : by h eaddro p, l i ft
and h it o n the s u rface·, as d escri bed by Prechtl and B e i ntem a (1 964)� Ab­
ducti o n and extension of the arms on the one hand, and flexi o n a n d
adduction o f the a rm s o n the oth er h a n d , were scored separately fo r
a l l the th ree m odes of e l i citat i o n. State 3 o r 4.

Headdrop method, abductio n/extension

Recording:
0. No reacti on.
1 . S l ight abduction/extension of the a rm s not s u rpassi n g 70° - 90° ex­
ten s i o n i n the el b ow j o i nt and 45° abduction i n the s h o u l de r joint
resp ectively.
2. Evi dent abductio n/exte n s i o n of the a rm s (m o re than 90° and 45°
respectively).
3. Co m p l ete abdu cti on/extension of the arms (a score 3 d i d n ot occur
in t h is g rou p of i nfants).

H e ad drop method, adduction/flexi o n

Recording:
0. No reaction.
1. S l i ght adductio n/flexion of the arms.
2. Evident adductio n/fl exi o n of the arm s .
3. Fu l l adductio n/fl exi o n o f the a r m s ( a sco re 3 d i d not o ccur i n t h i s
g rou p) .

Lift method, abduction/extension

Recording:
0. No reaction.
1 . Extension a n d s p rea d i n g of the fi n gers o n ly.
2. S l i ght abduction/extension of the arms, not exceedi n g 70° - 90° ex­
tensi o n i n the el b ow j o i nt a n d 45° abduction i n the shou l der j o i nt
resp ectively.
3. Fu l l abd u ction/extension of the arms (a score 3 d i d not occur i n the
g roup).

Lift m ethod, adduction/flexion

Recording:
0. No reaction.
1 . S li g h t adduction/fl exi o n of th e a rms.
2. Evident adductio n/fl exi o n of the arms.
3. Com p l ete adduction/fl exi o n of the arms (a score 3 d i d not occu r i n
this g roup).

1 01
 H it method, abduction/extension
Recording:
0. No reaction.
1 . S l i g ht abductio n/extension of the arm s , not exceed i n g 70° - 90° ex­
ten s i o n i n the e l bow j o i nt and 45 ° abduction i n the shoulder joint
resp ectively.
2. Evi dent abduction/extension of the arm s (more than 90 ° and 45 °
resp ectively) .
3. Com p lete abd uctio n/extension o f the a r m s (a score 3 di d not occur
i n this g rou p of i nfants).
H it method, add uction/flexion
Recording:
0. No reactio n .
1. SHght add uction/fl exion of the arm s .
2. Evi dent adductio n/fl exi o n of the arm s .
3. Fast and ab ru pt adduction/fl exi o n o f t h e arms.
Th e fast and abrupt adductio nlfl exion of the a rm s caused by a h it o n the
surface (score 3) was considered by McG raw (1 943) as the m atu re
p h ase of th e M o ro . The difference with the s l i ght adduction/flexion of
the arm s (coded as 1 ), is exp ressed by the speed of the movements and
the i nvolvement of l a rger parts of the b ody i n the movement pattern.
Th e m ovement p attern, rep rese nted by a sco re 3, showed a very h i g h
speed co m pared with t h e gentle, sm ooth and rather s l ow adduction/
fl exi on m ovem ent sco red as 1 ; m o reover i n the fast and abrupt move­
ment virtu al ly the whole body was i nvo lved, sh owi n g a m ass fl exi o n
pattern with flexion o f t he knees, h i ps, trunk, neck, fo rward movem ent
of the s h ou ld ers etc. lt closely rese mb l ed the fri ght reacti o n of the
o l der ch i l d and the adult fo r i nsta nce to a su dden noise. As it was not
fo u n d in a l l the i nfants and when fou n d not consistently present it co u l d
not b e uti l ized as t h e defi n ite fi na l change of the respon se. I t s poss i b l e
conn ection with the M o ro reaction wi l l b e d i scussed l ater.
The scores defi ned as s l i g ht abduction/extension or adductio n/flexio n
respectively were co nsi dered as the fi rst c ha nge s. Absence o f the res­
ponse or, in the case of the adductio n/fl exi o n m ovements of the M o ra­
hi t, the absence, o r the p resence of fast and abrupt adductio n/flexi o n
movements, was co nsi dered as the fi na l change.
Moro headdrop� abduction I extension

2
1
�('"') 0
V>

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

r- 1 1 1 -1
exam.
1 r- ·� �-----r- 1
0 3 6 9 U � lli B
age,months
Fig. 37

1 02
 Moro headdrop adductionlflexion J

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

I . I
exam.
I I I I I I I I I I I I I I I
9
I I I I I
0 3 6 12 15 18 21
age,months

F i g . 38

Moro lift� abduction Iextension

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.
I I r --r-----. I 1 ·u --T
-
9
I r I
0 3 6 15

Fig. 39

Moro lift, adduction I flexion

2
1
(")
(J}

g 0
("!)
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.
1 -1 1 1 1 1
9
1 1 1 r 1 1 1 1 1 1 1 1 1
0 3 6 12 15 18 21
age,montps
Fig . 40

Moro hit� abduction Iextension

(J}

�
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18. 19 20 21 22 23 24

I I
exam.
I I I l l 1 1�
0 3 9
6 15
Fig. 4 1

1 03
 Moro hit, adduction lflexion

I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
exam.
I I I I I I l -T l l I
0 3 6 9 12 15 18 21
age,months
F i g . 42

The p rediction bands fo r the Moro reactions are presented in fi g u res

37 to 42. Th e h eadd rop-Moro has a rap i d developmental course com­
pared with the lift- Mora . In 78°/0 of the i nfants it had d i sappeared at
the age of about 20 weeks . Th i s can be attri b uted to the fact that d u r­
i n g the fi rst m onths of l ife the i nfants b eca m e i n creasi n g ly a b l e to
keep th eir n eck m u scles contracted, and prevent a backward d ro p of
the head. Cowie's fi n d i n g that in i nfants sufferi n g from Down ' s di sease
the headdrop-Moro can be e l i ci ted m u ch l o ng e r than in norm a l i nfants,
can b e ascribed to the hyp oto n i a of the Down-patients which i nval i ­
dates an effi cient use o f t h e neck m u sc l es (Cowie, 1 970; To uwen,
1 97 1 ) .
The p redicti on bands for the Mo ro el i cited by the l ift m ethod show that
the reacti on m ay persist m uch l o n ger than the headdro p m ethod wou l d
s ugg est. Th i s i s true fo r t h e abductio n/extension co mpo nents, as wel l
a s for the adductio n/fl exio n com po n ents (fi g . 37-42) . A t the seventh
assessment (28 weeks of age) an evi dent abductio n/extension was sti l l
observed i n 20o/0 o f t h e i nfants. A t the n i nth assessment (i.e. 8 weeks
l ater) a s l i gth abd uction/extension p attern was sti l l fo und in 20°/0 of the
i nfants, wh i l e 1 2 o/0 of the i nfants sh owed s l i ght but co nsistent finger­
m ovements at the age of one year.
Adduction/flexio n movements disa p peared earl i er, though twi ce as l ate
as in th e case of the headdro p-method.
As the p rediction b a nd fo r the abducti on/exten si o n m ovements of the
Moro eli cited by the h i t m ethod (fi g. 41 ) shows, the abductio n/extension
m ovements of th i s typ e of Mo ro d i sappear earl ier than those of the
M o ra-lift and l ater than those of the Mo ro-headdrop. At the eighth as­
sessm ent (c. 33 weeks of age) 90°/0 of the i nfants showed a n eg ative
response.
The p rediction band fo r the add uctio n/flexion compo nent of the M o ro
e l i cited by th e h it-m ethod (fi g . 42) shows a d ifferent shape due to the
occurrence of the fast add uctio n/fl exi o n m ovements . About one th i rd of
the i nfants sh owed these fast movements at the s ixth assessm ent (i .e.
25 weeks of age) ; the peak freq uency occu rred between the ei ghth and
tenth assessment. Su bseq uently their frequen cy decreased slowly.

1 04
I n the th ree types of e l i citation of the Mo ro response the n u m b e r of i n­
consisten cies varied co nsiderab ly. The i r frequency was h i g h est i n the
l i ft-M o ro a n d the h it-Mo ro . The n u m ber of i nconsi stencies appeared to
i n creas e i n accordance with the i ncrease of the l e n gth of the develop­
m e ntal ran g e (r' s ran g i n g fro m .37 1 to .594, p < 0.01 ).

I n the c a s e of the li ft- Mo ro and the h i t- M o ro stati sti cal ly s i gn ificant re­
l ati o n s h i p s were fou n d (with a negative correlati o n coeffi cient) between
th e fi rst change and the d evelopm e ntal ran g e (r =-.478 and -.668
respectively, p < 0.01 ). Mo reover a s i gn ificant rel ati o n s h i p was fo u n d
b etween the fi n al change and the developmental ran g e (r = .646 a n d
.636, p < 0 . 0 1 res pectively) . T hi s suggests t h a t the m o m en t of t h e fi nal
change i s rather fixed in ti m e.

There were no co nsistent differe nces b etween the boys and the g i rl s ,
except for the occu rrence of i n con s i sten cies i n the M o ro e li cited b y t h e
l i ft m etho d ; these were fo u n d m o re often i n t h e boys t h a n i n t h e gi rl s
(Man n-Wh itney U test , p < 0.01 ) . This m ay b e attri b uted t o cou n te ract­
i n g vo l u nta ry m otor activity, often m o re p revalent i n the boys than i n
th e g i rl s .
System atic rel ati onsh i p s b etween t he th ree modes o f eli citati o n o f t h e
M o ro reaction were looked fo r. Th ey were fou n d o n ly with respect to
the fi n a l change. As these rel ati o n s h i p s vari ed in the case of b oys and
g i rls , they h ave to b e dealt with separately.

In the gi rl s there was a s i g n ifi cant rel ati o n s h i p b etween the abd u ction/
extension co mponents of the Moro el i ci ted by th e l ift method and those
of th e h it m ethod (r = .591 , p < 0.01 ) . They a l so showed a s i g n ificant
rel ati o n s h i p b etween the adduction/fl exio n components of the M o ro
e l icited by the h eaddro p m ethod a n d h i t m etho d a n d those of the l i ft
m ethod a n d h it m ethod (r = .569 r = .906 resp ective ly). Both boys
a n d g i rl s s h owed a s i g n ifi cant rel ati o n s h i p b etween the adduction/
flexion co m p onent of the Mo ro e l i cited by the headdro p m ethod and
that of the l i ft m ethod (r = .564 a n d r = .742 resp ectively).

Withi n o n e m od e of e l i citation, s i g n ificant rel ati o n s h i p s were fo u n d b e­

tween the abductio n/extension compo nent and adductio n/flexion com­
p onent with corre l atio n-coefficients rang i ng from r = .508 to r = .9 1 4.
Usua l ly the corre l ation-coefficients were a l ittl e h i g her i n the case of
the g i rl s , whi l e in the c ase of the b oys no rel ati o n s h i p was fo u n d be­
twee n the two p atterns of the Mo ro e l i cited by the l ift m etho d .
No s i gn ifi cant rel ati o n s h i p s were fou n d b etween the fi rst c h an ges a n d
th e fi n a l chan ges of th e vari o u s M o ra-reacti o ns. Neither were corre l a­
tions fou n d with any other item, except fo r an i n expl i cab l e set of nega­
tive co rrelations b etween the fi n a l change of the abduction/extensio n
com ponent o f the M o ro e l i cited b y t h e h eaddro p m etho d (whi ch shows
the s h ortest developm e ntal course) a n d items deali n g with s itti n g (see
Appendix D).

1 05
On the basis of this pattern of rel ati onships two m a i n conclusions can
b e d rawn . Fi rstly the development of the M o ro reaction seems to be
i n dependent of the developm ent o f o t he r item s as rep res ented i n th i s
study. T h i s is demon strated b y the l a c k o f rel ati o nshi ps between t h e
parameters o f t h e M o ro reaction, eli cited b y th ree m ethods, a n d the
parameters of the oth er item s which a re used to inve ntory the neuro l o­
gi cal development in i nfancy.
Secondly the th ree types of the M o ro reaction (headdro p, lift and h i t
on the su rface) a re not i de ntical as fa r as thei r developmental co u rse i s
con cerned. Th is m ay i m p ly that they a re based on differe nt b ra i n m echa­
nisms o r that thei r afferent i n p ut is differenti a l . The l atter hypoth esis
seems m o re p l au s i b l e as the p h enotyp ical exp ression of the different
com p o n ents is s i m i l a r in a l l the th ree methods of eli citation, with the
excepti on of the fast and abrupt adducti on/fl exion p attern eli cited by a
h it on the s u rface which is qualitatively different an d not fo u n d i n al l the
i nfants.
Pei per' s (1 963) and And re-Th om as' (And re-Th omas and Ha no n, 1 947)
o p i n i o n s differ with regard to the ca usal m echanisms of the Moro . Pei­
per bel i eves that the M o ro can m a i n ly b e ascribed to a vesti b u l ar sti ­
m u lation , wh i l e And re-Th omas contends that a p rop rio ceptive i n p ut
from the n eck joi nts i s the m a i n source. Exp eri m ents ca rri ed out by
Prechtl (1 965) favo u r Peiper's o p i n i o n . If one tri es to el i cit the Moro re­
action by a " b ody-d ro p " wh i l e keep i n g the i nfant's head position un­
chan ged (i.e. a reversa l of the headdrop method) even i n the newbo rn
no M o ro reacti on occurs. A contradi ctory p h enomenon was fou n d by
Karlsson (1 962 , cited by Prechtl , 1 965) , who observed an i nfa nt without
l abyri nths, sti l l sh owi ng a co m p l ete Moro reacti o n ; this can be exp la i n­
ed b y the argument that if vesti b u l a r afference i s absent the neck
p ro p riocep sis "takes over" .
Yet eve n this n eed not be necessary b ecause i n this case other re­
ceptive fi elds (e. g . tacti l e receptors) a re sti m u l ated beside the neck
p ropriocepsis. Th e ,body d rop" appl i ed to an i nfant with l abyri nth s
does n ot resu lt i n a Moro reaction ; in this case the l abyri nth s seem to
be m a i n ly repon s i b l e fo r the reaction.
As the Moro reaction can b e e l i cited by h eaddrop and l ift m ethod it
seem s obvi ous that the oto l iths of the l abyri nths are the m ai n receptors.
Th is view i s supported by the resu lts of the hit m ethod. Th is sti m.u lu s
s ee m s to b e m a i n ly o f a vib ratory ki n d ; it i s regi stered by the oto l iths
and not by the sem i c i rcular cana l s. Th i s noti o n i s fo u nded o n the fact
that h itti n g a ferro-co ncrete s u rface on which a baby is lyi n g does not
res ult i n a M o ro reaction wh i l e a hi t o n fo r i nstance a wooden s u rface
does so. V ib rati on of wood can b e i n d uced rather easi ly, wh i l e vi b rati o n
of a h eavy ferro-co ncrete u n der- l ayer i s p racti cal ly i m p ossibl e.
Accord i n g to Parm elee (1 964) the sti m u l i h ave a differenti al effect, i n­
vo lvi n g va riou s affe rent p athways ; he sti l l does not sha re Peiper' s o r
Andre-Thomas' views thoro u g h ly. H e states merely that t h e mode of
e l i citati on determ i n es to a l arge extent whi ch afference is resp o n s i b l e
for t h e resu lti n g m otor patte rns.

1 06
lt i s also co ntended freque ntly (fo r i n stan ce Paine, 1 960; Ko upern i k a n d
D a i l ly, 1 968) that the d ifferent mo des o f el i citatio n of th e M o ro reaction
m e rely vary the i ntensity of the response. Th i s reaso n i n g seems to be
to o s i m p l i stic. lt is worthwh i l e again t o p a y attenti on to Cowi e ' s ( 1 970)
rem a rks on t h e d i sso l ution of th e M o ro when the headdro p m ethod i s
appl ied i n i nfants sufferi n g from D own' s synd ro m e. H ere i t was not
the i ntensity of the sti m u l us but the poss i b i l ity of app lyi n g the sti m u­
l u s whi ch determ i ned the resu l t.

lt i s noteworthy that fl exi o n of hands a n d fi n gers ("fisti ng") i n h i b its the

Moro reaction co n s i derab ly. Th i s i s not so obvi o u s in n ewbo rn i nfa nts
in whom the e l i citati o n of the refl ex seems to overbear the i n hi biting i n­
fluence of fisti n g . I n o l der i nfants, especi a l ly at th e age of 2 - 4 month s ,
when spontaneous fisti n g often occurs (to gether with a p ropensity to
f l exion p osture of the arms a n d b ody d u ri n g l ifti ng), this i n h i b iti n g i n ­
fl uence i s m uch m o re evi dent and has to b e reco g n i zed i n o rder t o be
ab le to e l i cit a p roper Mo ro reaction.
Prechtl ' s (1 965) demonstration that a s l i g ht pull on the wri sts i n h i b its
the abduction/extension of the Mo ro reacti o n effectively in favo u r of
th e add u cti on/fl exi o n components (teleo l o g i cally i mportant in the case
of a yo u n g m on key c l i n g i n g to his mother whi l e she c l i m b s trees) s h o u l d
n ot b e confused with thi s gene ra l i n h i b ition of the two com p o n ents o f
the M o ro.
Lamote de G ri g n o n (1 955) menti o n ed this i n hi b iti n g effect b ut d i d not
co u nteract it b efore e l i citi n g the M o ro response. H i s fi n d i n g that h an d­
and fi n ger-m ovements as a p a rt of the M o ro reaction di sappear earl i er
th an a rm - a n d s h o u l d er-movements, can be attrib uted rather to h i s
m ethod o f standard izati o n t h a n that it wo u l d b e characteri sti c o f the
developme ntal course of the M o ro reaction. If o n e ensures that the i n ­
fant' s h a n d s are o p e n during t h e e l i citatio n o f t h e M o ro , h an d- a n d
fi n ger-m ovem ents m ay b e observed as the l ast m a n ifestation o f t h e p re­
sence of the response.

D u ri n g the developm ent of the Mo ro reacti o n e l i ci ted by the hit-method

a fast and ab rupt adduction/fl exion m ovement appeared as has b�en
menti o n ed in the descripti o n of the Mo ro responses. Thi s ha ppened
from about th e s ixth m o nth o nward s, tho u g h not i n a l l the i nfants ; n ei ­
ther d i d it a p p ear co nsistently i n i n divi d u a l i nfants. Someti m es the fast
a n d ab rupt m ovem ents app eared after a co m p l ete dissol uti o n of the
s l ow a n d s mooth m ovem ents sco red as 1 of 2 . Th i s m ovem ent type d i d
n o t m erely cons ist o f fl exion a n d adduction o f t h e arm s b ut i nvo lved
the whole b ody. As stated b efo re, i t s h owed resem b la n ce to the fri ght
reaction of old er ch i l d ren a n d adu lts, cons isti n g of a m ass fl exo r-pat­
tern i n which t h e wh o l e body p a rtakes. Phenotyp i cally th i s m ovement
p attern i s q u ite d i stinct fro m the adductio n/fl exi o n compo nent of the
Moro reacti o n ; this vi ew i s supported b y the l ack of any rel ati o n s h i p
b etween its occurrence and a n y of the co mp o n ents of the M o ro reac­
tion as el icited by the vari o us m ethods.

1 07
The argument that it occu rred o nl y as a result of a h it on the su rface
was refuted by the rep ort of several m others ; they stated that their i n­
fants, wh o showed this reacti o n , disp l ayed s i m i l ar m ovement p atterns
on sudden fri g ht. When McG raw (1 943) asserts that the abrupt and fast
movement p attern is the " m atu re" phase of the Moro, she co nfuses the
actual Moro, which i s a vesti b u l a r reaction, with fri ght reactions wh i ch
are of q u ite a different character. lt i s not i m poss i b l e that an acute
fri ght-reacti o n p rovokes a Mo ro reacti o n . Th i s m ay be the case in very
you n g i nfants. The Moro reaction m ay then o utstri p the o ri g i n a l fri ght
m ovem ent to such a n extent that the l atter i s no l o n ger recognized as a
separate phenomenon. O n e may co ntend that the fast add uctio n/
fl exio n m ovements seen after the age of six m o nths represent a m ature
fri ght reaction (i .e. a response to rather a-specifi c sti m u l i) . The i n co n­
s istency of their occu rrence, i nter- as wel l as i ntra-i nd ivi d u al ly, m ay be
accounted for by the i nfant's ad aptatio n to various kinds of no ises in
his envi ron m ent, and by d iffe rences i n i ntensity of the sti m u l i o r diffe­
rences in th e state in wh ich the i nfant happens to be during the sti m u ­
l ati on .

The term "fri ght reaction" o r " fright m ovem ent" s h o u l d not be co nfu­
sed with the term " startle" wh i ch has g rad u a l ly beco m e the term with
which m ass-movement p atterns occu rri ng duri n g s l eep are descri bed.
Although possib ly i n the very yo ung i nfant similar m ass-movement p at­
tern s m ay be cau sed by sudden sti m u l i , which subsequently e li cit a
Moro reaction, they m ay sti l l not be co nsidered as i de ntical with the fast
and abrupt fri ght m ovement occu rri n g at o l der ages. The l atter is a we l l
orga n ized fl exor m otor p attern , wh i l e t h e sta rtl e o f t h e newbo rn an d
very yo u n g i nfa nt is m o re i rreg u l a r, not so wel l o rga ni zed and often
co nsi derab ly slower.

1 08
C h a pte r X Group IV: Item s with so m any i n co n s i stent
c h a n ges d u rin g the fol l ow- u p p eriod t h at
a d efinite deve l o p m ental s e q u e n ce cou l d
n ot be estab l i s h e d

I n th is ch apter those items wi l l b e d iscussed wh i ch show evi dent

chan ges d u ri n g devel o p ment, b ut for which the operati o n a li zati o n of the
m o m ent of the fin a l change turned out to b e very difficult. This m i ght
b e d u e to the fact that no sta b l e p h ase was reach ed b efo re the e nd
of the fo l l ow-u p stu dy o r to th e fact that the resp o nse, which was reflex
i n ori g i n , g radual ly m erged i nto vol u ntary m ot i l i ty.
The items are l i sted in Tabl e VI I I . They are o rdered in su b g ro u ps for
reasons of conveni ent p resentati o n . When t he defi n ition g iven fo r i n ­
cons isten cies i s a p p l ied (see ch apter 1 1) the items of thi s g ro u p a re
ch aracterized by a h i g h frequency of rel apses i n sco re i n a l a rge n u m ­
b e r of the i nfants. H owever, as the developmental sequence of these
item s cou l d n ot a lways b e operatio n a l i zed adequ ately, i t is doubtful
wh ether the rel apses m ay b e cal l ed i n consisten cies, as defin ed a n d ap­
p l i ed i n th e p revious ch apters. (Table VI I I , page 1 1 4)
As a lso th e m o m ent of the fi na l ch an ge and consequently the l e n gth
of the develo pmental rang e usually cou l d not be d efi ned u nequivoca l l y
the items of t h i s g ro u p were omitted from th e an alys i s o f th e i nterrela­
tionships.

Observation of posture a n d motility

S p o ntaneous p osture of the h ands
Procedure: The i nfant was put i n s u p i n e positi o n . D u ri ng th e i n itial
observation peri o d th e p redom i n ant spontaneo u s postu re of the hands
was reco rded.
State 3 o r 4. Possib l e scores were: hands closed o r fi sted, open h a n d s
a n d arbitrary o r vo l u ntary postures without a p redom i n ant p attern.
Due to the amount of spontaneous motil ity a n d the rap i d deve lopm ent
of fu n cti onal motil i ty of the hands i t was d iffi cult to operati o n a l ize a
reli ab l e fi n a l chan ge. I n the n ewbo rn p e ri o d the m ajority of the i nfants
showed fl exion of the fi n gers although th ei r hands were not ti ghtly fi sted.
At the seco n d assessment, h owever, i .e. at th e age of about 5 weeks , two
th i rds of the i nfants d i s p l ayed ti ghtly closed h an ds d u ri n g th e g reater
part of the observation period. D u ri n g th e th i rd assessm ent, thi s fl exio n
posture was sti l l p redo m i n an t i n about h a l f of the i nfants, b ut su bse­
q uently decreased rap i dly. Th e cJisappea rance of thi s flexi o n postu re of
th e h an ds p receded the fi rst decrease of i nten sity of the p a l m a r g rasp
refl ex, occu rring at about eight o r nine weeks. lt was fol l owed by a
p h ase d u ri n q wh i ch th e hands were m a i n ly open, o r showed alte rn ati n g
open i n g a n d clos i n g m ovem ents. These m ovem ents cou l d h a rdly b e
d isti n g u ished fro m a rb itrary m ovem ents, alth o u gh t h e two p nases seem­
ed n ot to b e i dentical . As sponta neo us g rasp i n g b eh avi o u r a nd goal-

1 09
di rected moti l ity of arm s and hands developed rapi dly during the same
period, it seems probabl e that th e ph ases of open hands and/o r alter­
nati ng open i n g and c l o s i n g m ovements m erge so rap i d ly i nto the ph ase
of vo l u ntary and goal-d i rected hand-moti l ity that they can not be dif­
ferentiated, the freq uency of the fol l ow-up assessments of the p resent
study taken i nto regard . As fo r the development of the postu re of
hands, it is notewo rthy that between 4 and 1 0 weeks of age closed
hands may be observed i n many normal i nfants. The i nfl uence of fist­
i n g on the Moro reactions has been discussed i n the paragraph deal­
ing with the development of the l atter.
Posture of head and tmnk d uring prone suspension (Landau)
Th is item is dealt with u nder the head ing "observati on of posture and
motil ity" because i t cons ists of a m oto r p h enomenon eli cited by keep­
i n g the i nfant in a specifi c postu re without app lyi n g a specifi c sti m u­
lus as is done in the case of the item s described in the secti on Je­
fl exes and responses " .
Procedure: T h e exami ner kept t h e i nfant i n prone suspension, sup­
porti n g h i m u n der the thorax with one hand (see Prechtl and Bei ntem a,
1 964) .
State 3 a n d 4 . T h e postu re o f head a n d tru n k was described.
Recording:
0. The i nfa nt was not able to strai ghten his back; his body and head
h u n g down l i m p ly; an evi dent downwa rd co n cavity of the s p i n e
cou l d b e observed.
1 . The i nfant straightened h i s back, but he was not ab l e to l ift h i s h ead
suffici ently h i g h so that h i s occiput wou l d be i n one l i n e with h i s
spi ne.
2. The i nfant stra i g htened h i s back so that he kept head, shoulders
and pelvis in one hori zontal p l ane.
3. The i nfa nt l ifted head and pelvis so that he sh owed an upward in­
curvation of h i s spi ne.
4. The i nfa nt l i fted h i s head and pelvis and hyperextended h i s s p i n e
so i ntensively that an evident u pwards con cavity of the spine cou l d
be observed (Landau).
Landau

I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

I
exam.
I I I I I I I I I I I 1 I I I
0 3 6 9 U � lli B
age,months
F i g . 43

1 10
The p rediction band for the scores fo r p ostu re of head and tru n k d u r­
i n g p rone suspension is p resented i n fi g u re 43. As a sco re 0 rep re­
sents a hypoto n i a of neck and tru n k mu sc u l ature an d n o rmoto n i a was
one of the selection criteri a fo r the p resent g ro u p , n o n e of the i nfants of
the sam p l e obtai ned a sco re 0 at the newborn exa m i n ati o n. Neither was
th i s the case during the co u rse of development. Two i nfants obtained a
score 1 at the th i rd assess ment. D u ri n g the fi rst and seco n d assess­
m ents half of the in fants obtained a sco re 2 , but subsequently the m a­
jority of i nfants obta i ned a sco re 2 or 3. Between the fifth and tenth
assessm ent, i . e. b etween about 20 and 40 weeks of age, m o re than 70°/o
of the infants d i s p l ayed a stro n g i n cu rvati on · of th e b ack, thu s obta i n i n g
a sco re 4 . After th e 40th week a score 2 occu rred with i n creasi n g fre­
quency. Yet at the age of o n e year h al f of th e i nfants sti l l showed a
stro n g i n cu rvation of the s p i n e and about one th i rd of the i n fants who
were sti l l p resent in th e study g ro u p , sh owed this posture u ntil the end
of the fo l l ow-u p peri o d .
Th e Landau c a n b e rei nfo rced by i m p o s i n g passive hyperextension of
the n eck. If this was done b etween 24 and 40 weeks of age an evi dent
extension of spi n e, h i p s and kn ees was observed in m o re than 90% of
the i nfants.
After the age of one year this m ovem ent- p attern could sti l l be e l i cited
in m o re than half of the i nfants, b ut it became i n creas i n gly difficult to
d i sti n gu is h an actu al Landau from vo l u nta ry m otor b eh avi o u r cons isti n g
o f t h e i nfant's active resi stance against i m posed m a n i p u l atio n . Landau,
q uoted by M itch e l l (1 960), fo u n d the stro n g upward i ncurvation of the
spine b etween the age of seven weeks and fifteen mo nths, And re­
Tho m as located it o n the ti m e-scale b etween th e ages of th ree and
seven m onths (And re-Th o m as and St. Anne- D a rgassies, 1 952), whi l e
Mitch ell menti o n s th ree mo nths t o about o n e year a s th e peri o d d u ri n g
which a stro n g i n cu rvation o ccu rs. Pei per (1 963) consi ders t h e vesti b u l a r
system as th e p repo n derant afferenti al i np ut. A ndre-Thomas states that
n eck- p rb p riocepsis p l ays th e m a i n rol e , whi l e M itch e l l assu m es that this
postu re i s a comb i ned effect of labyri nth i ne , n eck a n d visual reacti o n s .
I n deed th e La ndau co nsists of two typ es of refl exes , the fi rst o n e o ri gi­
n ati n g i n the l abyri nths, resulti n g i n an o ri entation of the head i n space
(head l ift) wh i ch in its turn , due to the i m p osed posture of the neck, re­
sults in a , ketten refl ex" , namely an extension of s p i n e , h i ps and kn ees .
The fi n d i n g th at g radua l ly the response is fou n d m o re frequently fro m
t h e a g e of two m o nths o nwards su g gests that v i s u a l i nput m ay p l ay a
gui d i n g and rei nforci n g ro l e i n the o ri e ntati o n of the h ead, although at
the same ti m e the power of the neck m uscles i ncreases so that the
h ead can be lifted m o re adeq u ately and the wel l-ori e nted h ead posture
can be m ai ntai n ed m o re easily (see also Bobath (1 966)).

The fi n d i n gs demonstrated a l a rge vari ab i l ity of postu res inter- as wel l

a s i ntra- i n d ividual ly, which i s refl ected by the l arge n u mber of i n consis­
tencies. Fo rty-fo u r of the i nfants showed n i n ety-th ree i n co nsi stencies.

111
The number of i ncon si stencies per i nfant ran ged from one to five, but
there was n o difference b etween b oys and girls. The l a rge vari a b i l ity
sug gests that active vo l u ntary m otil ity, and the behavio u ra l state, p l ay
an i m p o rtant ro l e in the mai ntenance of the postu re i n p rone suspen­
sion, especi a l ly after the fi rst mo nths. lt is rem arkab l e that only seven
of the total n u m ber of 93 i n consistencies occu rred befo re the age of
1 6 weeks. At this age m o re than 80°/0 of the i nfants showed a m i l d up­
ward in c u rvation of the sp i ne and an evi dent head li ft with el bow sup­
port and exp l o ratory l ooki ng a ro u nd i n p rone positi o n . Th e vari ab i l ity
of the posture in p ro n e suspension i n creased with age, as is evi dent
from the shape of the p redicti on-band. The development of posture i n
p rone suspension may therefo re b e consi dered a s a n i l l ustration o f the
way i n which reflex-mecha n i s m s are i n co rpo rated i n spontaneous vo l u n­
tary activity.

Reactions and res ponses

Reaction to tactile stimulation of the dorsum of hand and fingers
Procedure: With a fi n ger the exa m i ner gently stroked the dorsum
of the i nfant' s h an d and fi n gers d i stalwards, starting from the b ack of
the h an d and end in g at the nails of the fi ng ers . State 3 o r 4.
The response consisted of a fl exi o n of wri st and fi n gers fo l l owed by an
extension which then resu lted i n g ras p i n g the sti m u l ati n g fi n ger.

Recording:
0. No respon se, or o n ly an open i n g of the ha nd without subsequent
g rasp i n g .
1 . Weak response, consisti n g of a s l ow fl exi o n and extension m ove­
ment fo l l owed by i n adequate g ras p i n g, which seemed to occu r ac­
c idental ly.
An open i n g of the ha nd fo l l owed by wasp i n g occu rri n g when the
sti m u l u s h a d reach ed the d i stal h a lf of the fi n gers, was also sco red 1 .
2. Evi dent and rap i d response i m m ediately after stroki n g the back of
the h an d .

A t th e newborn exa m i n ation al l the i nfants opened the i r hands o n tac­

tile stim u l ati on of the back of the ha nd , b ut g rasp i n g of the sti m u l atin g
fi n ger d i d not occur. Th i s me re open i n g o f the ha nd, which m ay be re­
g arded as the op posite of the p a l m a r g rasp reflex (i.e. closi n g the h a n d
on sti m u l ation o f th e palm) was not co nsid ered as a positive reaction to
dorsal sti m u l ation as operati o na l i zed here and therefore was sco red 0.
At the secon d exa m i nati o n 1 6°/o of the i nfants showed a slow flexi o n of
h an d and wrists fo l l owed by an extension, but without adequate g ras­
p i n g . A compl ete response was obtai ned from the th i rd assessm ent
onwards, with a rap i d ly i nc reasi n g freq uency, reach i n g its peak at the
fifth exam i nation (67°/o) . At the same time, spontaneous grasp i n g de­
veloped rap i d ly, and the area of the back of the h an d from which the

1 12
response c ou ld b e o btai ned, was d i s p l aced towards the di stal e nd of
,-
th e fin gers.
Th us i t b eca m e i ncreas i n gly diffi c u l t to d i sti n gui sh b etween active g rasp­
ing and a n i n vo l u ntary response. Visual g u i dance of the g ras p i n g d i d
n ot seem t o b e n ecessary, neither d u ri n g t h e e l ic itatio n o f t h e response
in the fi rst m o nths n o r afterwards, so that it was con c l u ded that tacti l e
sti m u l ation was suffi cient fo r t h e evo cation o f th i s m an i p u l ative moto r
pattern , even when it was i n corporated in vol u ntary m otil ity of the
h an ds. A m i n o rity of the i nfants did not show the respo nse d u ri n g the
whole p eri od of th e fo l l ow-up study.
The response shows a resem b l ance with th e tacti l e p l aci n g reaction of
the feet, and seem s to p l ay a ro l e in the development of expl o ratory
b eh avi o u r of th e h a n d s . Rem arka b ly, i ts g radually m erg i n g i nto vo l u n­
tary behavi o u r (wh i c h m akes th e d isti n ction b etween the response a n d
vol u ntary b eh avi o u r h a rd ly feasi b l e) occurs a t about t h e s a m e time when .
the i ntensity of th e p a l m a r g rasp refl ex d i m i n i sh es. l t m ay b e argu e d
that an i nterpl ay b etween t he p a l m ar g rasp refl ex and the reaction to
do rsal stim u l ation of the h an d and fi n gers p l ays a ro le i n the deve lop­
ment of vol u nta ry g raspi n g , in which they beco m e i n co rporated su bse­
quently.

Palmomental res ponse

Procedure: With his th u m b n a i l the exa m i n er scratche d the rad i a l a rea
of the i n fant's pal m . The response consi sted of a vi s i b l e contraction of
th e mental m u sc les . State 3 or 4.
The respon ses were g raded o n a 3-p o i nt s ca l e :
0. N o co ntract ion o f t he m ental m uscl es.
1 . Vi s i b l e contraction of the m ental m uscles con secutjve to the fi rst
stim u l ation on ly.
2. Evid ent contracti o n of the m ental m uscles as a reactio n to at least
th ree o r fo u r consecutive sti m u l ations.

Vis i b l e contracti o n s of the m ental m uscles were fou n d in m o re th a n

80% of the in fants d u ri n g th e fi rst t e n assessments. T h e ratio b etween
th e n u mber of i nfants showi n g one and m ore vi si ble contractions was
1 : 2 d u ri n g the first assessments, and g ra du a l l y ch an ged into 2 : 1
d u ri n g the n i nth , tenth a n d e l eventh assessment. The n u m ber of i nfants
n ot s howi n g any positive reaction i ncreased fro m about 1 O% d u ri n g the
first ten assessm ents to m o re than half of th e i nfants d u ri n g subseq u ent
assessments.
Th e p a l m o m ental refl ex belongs to the g ro up of the so-cal l ed b ra i n
stem reflexes. I n cli n i ca l n e u ro l o gy they c a n b e fou n d i n the case o f
b ra i n stem syn d ro m es , as evi dence of an i m p a i rm ent of the b ra i n . I n
h ea lthy i nd ivi d u a l s often a weak vi s i b l e response m ay b e obta i n ed but
h ab itu ation takes p l ace rap i dly. If o n e con s iders the p a l m o m ental reflex
as an exp ression of b ra i n stem-mechanisms , i ts d evelo p m ental chan ges
during i n fa n cy refl ect the i n co rp o ratio n of b ra i n stem�m ech a n i s m s in
th e o rgan i zatio n of th e b ra i n d u ri n g devel o p ment.

1 13
TAB LE VIII
Items with many i nconsiste ncies and a protracted d evelop me ntal course,
so that a defi n ite developmental sequence could not be established
Observation of posture and motility
Spontaneous postu re of the hands
Posture of h ead and tru n k duri n g p rone suspension (Landau)
Reactions and responses
Reacti on to tacti l e sti m u l ation of the dorsum of h an d and fi n gers
Pal mo-m ental res ponse
Knee jerk
Ankle c lon u s
Plantar g rasp
Magnet response
Crossed exten sion response
Positive supporting reaction
Tact ile p l aci n g of the feet
Schaltenbrandt reaction
Bauer reaction
G aHlnt response
Th reaten reflex

Knee jerk
Procedure: The exa mi ner kept the l eg i n sem iflexion of h i p and kne�
joint and gave a b risk tap o n the pate l l a-tendon a l ittl e below the p atell a .
State 3. T h e response co nsisted o f a contracti o n o f t h e extenso r m us­
cles of the knee.
Recording:
0. No visi b l e or p a l p a b l e reaction.
1. Weak contraction of the knee extenso rs.
2. Evi dent contracti o n of t he k ne e extensors.
3. Stro n g respon se, often with after-beat, consisti n g of an expansion
of the reflexo genic zone below the i n sertion of the pate l l a-tendon at
the tibia, an d/o r evi dent eo-contractions of the adducto rs of the op­
p osite l e g .
An absence o f the response o r a weak co ntraction w a s not observed
d u ri n g th e whole fol l ow- up peri od in any of the infants. D u ri n g the n ew­
born exa m i n ation 86o/0 of the i nfants sh owed a medium response, wh i l e
i n 1 4°/o o f t h e infants a stro n g response was observed . At t h e seco n d
assessment t h e reverse took p l ace an d u nti l t h e tenth exa m i n ation , i . e.
u ntil the age of about 40 weeks, in m o re than 80°/0 of the i nfants a
stro n g resp on se was fo u n d . Subsequently the percentage of stro n g
responses d ecreased. Th ere was no rel ati on with t h e m o me nt o f stand­
ing or walki n g . Because the i nfa nts who had become able to wal k u n­
supported were o m itted from t he fo l l ow- u p study, it could no t be deter­
m i ned at which age a stro n g knee jerk had disappeared.
A clonic knee jerk was observed in one i nfant at the ei ghth assess­
m ent, without the i nfant bei n g evi dently i n a poor con dition.
1 14
Accord i n g to Andre-Th o m as b e l ow the age of six to seven m o nths the
knee jerk is often fou n d to be acco m pa n i ed by a contracti o n of the
contral atera l adductor- mu scles wh i l e the refl exo gen i c zon e i s extensi ve
(An d re-Th omas a n d St. Anne- Da rgassies, 1 952) . P a i n e (1 960) ha s the
same o p i n i o n . I n the p resent study this typ e of knee jerk is com p arab l e
with a stro n g response (score 3).
A stro n g response was observed in a varyi n g n u mb e r of i nfants, n ot
only d uri n g the first half yea r of l ife but a lso afterwards. Yet the h i g h est
frequency of exa ggerated respon ses was fou n d d u ri n g the fi rst half
year of l i fe, which i s i n accordance with the fi n d i n g of the auth o rs cited
above.

Ankle clonus
Procedure: The i nfant was put in s u p i n e positi o n ; the l eg was fix ated
with the h i p and knee in sem ifl exio n , and the foot was ab ruptly do rsi­
fl exed , wh i ch caused a sudden stretch of t he calf m u scl es. C l o n i c be ats
of the foot were cou nted if p resent. State 3 or 4.
Recording:
0. No ankle clonus p resent.
1. One to th ree b eats.
2. Four to six b eats.
3. M o re than six b eats .

D u ri n g the n ewborn exa m i n ati o n i n about h al f of the i nfants an ankl e

clonus was fou n d ; 1 6o/0 of the i nfants showed fo u r to six beats a n d i n
4o/0 of t h e i nfants m o re than six b eats of ankl e cl o nus were fo und. D u r­
i n g th e seco n d assessment 30% of the i nfants showed o n e to th ree
b eats of a n kl e clonus, wh i l e in 20% of th e cases fo u r to six b eats were
fou n d . S ubsequently the frequency of ankle clonus d ecreased rap i d ly,
but u nti l the end of the fo l l ow-u p study ankle clonus of one to th ree
b eats co u l d i rregu l arly a n d i n co nsi stently be fou n d in some i nfants of
varyi n g identity.

Plantar g rasp
Procedure: The p l antar g rasp was e l icited acco rd i n g to P rechtl a n d
Bei ntema (1 964) , by p ressi n g the t h u m b agai nst the sol e j ust b el ow th e
toes. State 3 o r 4.
Th e respo nse co n s i sted of a flexi o n of the toes.
Recording:
0. No reacti o n .
1. S l ig h t fl exi on o f t h e toes.
2. Evident and s usta i ned flexi o n of the toes.
3. Stro n g and sustai ned fl exi o n of th e toes.

D u ri n g the fi rst n i n e assessm ents, i .e. u nti l the age of about 36 weeks,
m ore than 80o/0 of the i nfants obtai ned a score 2 . Fro m the seventh as­
s essm ent o nwards, the i ntensity of th e p l antar grasp decreased in an
i n crea s i n g b ut varyi n g number of i nfants.

1 15
 From the 1 4th assessment o nwa rds, i n some i nfants a negative respon­
se was scored, but at the same ti m e the samp l e size decreased as a
result of i nfants beco m i n g ab l e to wal k unsupported. Sti l l there was no
cle a r rel ati o n s h i p between a d i sap pearance o f the p l a ntar grasp and
the onset of wal k i n g u n supported. An exaggerated response occu rred
in a s m a l l and vari a b l e n u m ber of i nfants (not exceed i n g eleven), at
some time d u ri n g the fi rst yea r of age. In o n e i nfant an exaggerated
response was fou n d at the 1 9th assessment, i . e. at the age of about 75
weeks. Th e developm ent of the p l a ntar g rasp app eared to be q u ite va­
ri ab l e, which is i l l u strated by the occu rrence of m any i n consistencies
in the respon ses, i . e. 63 in 36 of the i nfants. Th e i nco n s i stencies were
d i stributed ra n d o m ly over th e l e ngth of the developme ntal course and
it was i m p oss i b l e to defi n e a sta b l e fi na l change with i n the period of the
fol l ow-u p stu dy. Koupern i k and Dai l ly' s (1 968) view that the p l antar
g rasp is less intens ive than the palmar g rasp reflex co u l d not be confirm­
ed. Pai ne's concepti o n that the p l antar g ras p wo uld decrease in i nten­
sity at about eight mo nths, which sug gests that it wou l d di sappear short­
ly afterwa rds , is not supported either by the p resent fi n d i ngs (Pai ne, et
?1. 1 964). The resu lts are in acco rd ance with Zappel l a's fi nding that the
·
l!) l antar g rasp can b e observed d u ri n g the who l e fi rst year of l ife (Za­
pel l a, 1 966) . As in the p resent study o n ly one type of sti m u l ation, i . e.
p ress u re with th e thu m b , was appl i ed, the effect of the qu a l ity of the
sti m u l u s on the response could not be investi gated (Zapel la , 1 967) .
Poecks' o p i n i on th at the p l a ntar g rasp disap pears when the i nfant starts
to stan d up and walk, co u l d not be co nfi rm ed (Poeck, 1 968).

M agnet response
Procedure: The magnet response was e l i cited by gently touch i n g the
soles of th e i nfant' s feet wh i l e he was lyi n g i n supine with flexed h i ps
and knees, and by s l owly withd rawi n g the sti m u l u s without l o s i n g con­
tact with the sole of the foot.
The response cons ists of a grad ual extension of the l egs, so that the
foot does not l ose contact with the sti m u l u s (Prechtl and Bei ntema, ' 64).
D u ri n g the fi rst th ree assessments a p ositive response was obta i n ed i n
m ore th an 80% o f the i nfants. lt became i ncreas i ng ly d ifficult t o d i s­
tinguish b etween a positive m agnet response on the o n e ha nd and vo­
l untary flexio n/extension movem ents of the l egs on the other hand, d u e
t o the i ncreasi n g m oti l ity of t h e l egs with i ncreas i n g a g e .

Crossed extension response

Procedure: Th e i nfant was p ut in s u p i n e positio n . With one hand the
exam iner fixated the i nfa nt's leg i n exte n s i o n ; with his other hand he
appl ied a s l i g htly pai nfu l sti m u l us to the sole of his foot, using his
t h u m b nai l . T h e response consisted o f a flexion o f t h e opposite leg
fo l lowed by a n extension and adducti o n.

1 16
D u ri n g the fi rst fou r assessm ents, i .e. u nt i l the age of about 1 6 weeks,
a resp onse co nsisti n g of a stereotyped fl exi o n fol l owed by an extension
and adduction of the opposite leg was obta i n ed . Fro m about the thi rd
assessment o nwards, h owever, the i n fants were rem arkably capabl e
of d i recti n g t h e extension m ovement o f t h e opp osite l eg towards the
sti m u l us .Th i s seemed to b e a n active p rotecti o n reaction. M o reover,
from about the fou rth assessment o nwards the flexion p attern of the
op posite l e g became i ncreas i ngly vari ab l e, whi l e at the same tim e the
i nfant s h owed a n inc reased genera l i zed m oti l i ty consecutive to the sti­
m u l ation. l t was - co ncluded th at the reflex-l i ke reaction of the fi rst
m o nt h s rap i d l y m ��g e d i nto an a ctive defense p attern, which cou l d n ot
b e call ed a crossed extension _ refl ex. T hi s i s i n accordance with S ai n t
A n n e- Dargaqsi�s' view that the n eo natal response rap i dly d evelops i nto
an ac�ive. moto r . p attern wh_i ch them rem a i n s . p resent _ t h ro u g h o ut l ife
(Saint Anne- Da rgassies, 1 964). -
Pain e poi nts out that the response p attern observed i n n o rm a l i nfants
s h o u l d b e d isti n gu i s h ed fro m the crossed extension reflex seen in in­
fants with s p i n a l cord l esions. I n t hi s l atter reflex the n eatly di rected
extension towards the sti m u l u s is not fou n d ; it is also m o re stereotyped
(Pa i n e, '60).
Positive s u p porting reactio n
Procedure: The exa m i ner supported the i nfant u nder the s h o u lders
a n d p laced h i m on a fl at surface i n stand i n g positio n. H e took care that
th i s s u rface had an a g reeab l e texture a n d tem p e rature. The response
was considered to b e positive if the i nfant extended h i s l egs i n o rder
to bear wei ght. State 3 o r 4 .
Recording:
0. No extension of the l egs, the i nfant c o ul d not bear wei ght, h i s l egs
gave way i m mediately.
1 . Evi dent extension of the l egs, of sho rt d u rati o n . The i nfant coul d
bear wei ght o n ly m o m entari ly.
2. Evident exten s io n of the l egs, the i nfant was ab l e to bear wei ght
fo r at l east 5 seconds.
l t appeared to b e h a rd l y fe as i bl e. to d i sti n g u i s h b etween a positive s u p­
porti n g reaction a n d active stand i n g , as the one gradu al ly m erged i nto
th e other. Thus it was i m possi b l e to determ i n e a d i stin ct m oment of the
fin a l change of the positive suppo rti n g reaction.
No reacti on was fo u n d i n about two thi rds of the i n fants d u ri n g the fi rst
five assessm ents ; subsequ ently the n u mber of negative responses d e­
creased and from about the e l eventh assessm ent o nwards, i . e. from the
age of about 4 4 weeks, m o re than 90o/0 of t he i n fants cou l d bear wei ght
if p l aced o n their feet. An evi dently positive resp o nse, with wei ght bea­
ri n g fo r lon g er than five seco nds, was fou n d d u ri n g the fi rst h al f year
of l ife in 1 5o/0 of the i nfants or l ess. Thus a positive reacti o n seem-
ed to co in cid e with the p h ase i n which an i nfant co.u l d stand with su p­
p o rt b ut was n ot yet ab l e to stan d u p a n d s it down agai n of h i s own

1 17
accord. Sti l l , there was no rel ation b etween the occu rrence of a stro n g
positive supporti n g reaction and t h e a g e o f sta n d i n g with support. The
positive supporti n g reaction defi ned i n th is way appeared to be very
i n co nsistent, 71 i n consisten ci es b ei n g s p read b etween 40 i nfants .There
was no difference b etween boys and g i rl s.
McG raw (1 943) a n d Andr e -Tho m as (1 952) made a di sti n ction between
two p hases of the po sitive supporting reaction. The first one wou l d be
p resent during th e first m o nths of l ife and wo u l d be fo l lowed by a
p hase of decreased intens ity or even d i sappearance of the response.
subsequ ently the seco nd p hase wou l d set in, bel o n g i ng to active stand­
ing up beh avio u r. Such a b i p hasic devel opm ental co u rse was not
fo und i n the p resent study. Th e i n consi stencies were scattered over
th e wh ol e p eri od of th e d evelopm ental cou rse. No rel ati onsh i p could b e
fou n d with t h e ocu rre nce o f t h e magnet respo nse, which is someti mes
regard ed as a po sitive supporting reaction in a h o ri zo ntal position
(Pei per, 1 963).
Peiper conten ded that fo r a positive supporti n g reaction wei ght bea ri n g
was n ot i n d ispensable. I n the case o f the magnet reaction only tacti l e
stim u l ation i s appl i ed , i n the case o f the positive supporti n g reacti o n
tacti l e sti m u l ation i s fol l owed b y p ro p rioceptive sti m u l ati o n, a s a re­
s u lt of th e wei ght on the feet. If o n e excl udes poss i b l e vestib u l a r i n­
fl uences o n the response, it m ay be assumed that in the positive sup­
p rati n g reaction tacti l e a n d p roprioceptive sti m u l ation are both involv­
ed a n d th at the l atter sti m u l ati o n rei nfo rces the effect of the fo rm er.
Yet it is poss i b l e th at vesti b u l a r i n p ut does p l ay an i m po rtant ro l e i n
t h e generati on o f the respon se. I n that case t h e positive supporti n g
reacti on m ay b e another exam p l e o f th e p henomenon, p roper t o norm a l
d evelopment, th at a p h en otypically co mparab l e moto r b eh avi o u r m ay
resu lt from variou s m echanisms which fi nal ly converge i nto vo l u ntary
motor behaviou r. Actu al ly, th i s i l l u strates the m a i n d ifference between
a norm a l and a path o l o g i cal nervo us system , i n which th is vari ab l e i n ­
terp l ay b etween vari ous b rai n m echanisms d o e s not occu r, resu lti n g i n
a decrease of vari a b i l ity.
Tactile placing of the feet
Procedure: The exami ner supported the i nfant u nder h i s shou lders
and kept h i m in verti cal suspensi o n. He b ro u g ht the dorsum of the
feet into l i ght contact with the edge of a tab le. The response consi sted
of an i n itial p l antar flexion of the foot, fo l l owed by a flexion of the
who l e leg wh ich i n its turn was fol l owed by an extension of the l egs so
that fi n a l ly th e foot was p l aced o n the tab l e . Thi s p laci n g may o r may
n ot be accompan ied by wei ght beari n g. State 3 or 4.
D u ri n g the fi rst two assessments more than 80% of the i nfants showed
a b risk p laci n g resp o nse without wei ght beari n g . Th i s percentage de­
creased d u ri n g th e su b sequent assessm ents, so that d u ri n g the fifth a n d
s ixth assessm ents about half of the i nfants sh owed a b risk respo nse.
Subseq uently th e p e rcentage of b risk respon ses i ncreased and fro m th e
e l eventh assessment onwa rds more than 80°/0 of the infants agai n sh ow-

118
ed a b risk p l aci n g response, which at that time was acco mp a n i ed by
wei g ht beari ng . In o n ly one i nfant was the response co m p l etely absent
during the fou rth, fifth and sixth assessment. This devel o pmental course
s u g gestst the i nvo lvement o f vari ous b ra i n m echanisms i n the gene­
ration of t h is m otor beh avi o u r. D u ri n g the fi rst m onths the stim u l ati o n
i s m ai n ly tacti l e, wh i l e p ro p rioceptive rei nfo rcem ent do e s n ot en l a rge
the effect. D u ri n g the secon d h alf of the fi rst year o f age p rop rioceptive
i nfl u en ces s eem to p l ay an i n c reas i n g ly i m po rtant ro l e. Thi s phase
coincides with th e i n iti a l p h ase of standi n g-up b eh avi o u r. Evi d ently the
mecha n i s m s for the i n iti al p l ac i n g reacti o n a re i n co rp a rated i n the o r­
g a n i zati o n of vo l u ntary sta n d i n g behavio u r. Th i s is i n accord a n ce with
Zapel la ' s fi n d i n g that vari o us facto rs, as e.g. the temperatu re of the
sti m u l us , i nfluence tacti l e p l aci n g of the feet i n the fi rst m o nths of l ife,
but that t h is i s no l o n ger true in s ubsequent m o nths. In h i s vi ew the
i n itial p lacin g reacti on can m a i n ly b e attrib uted to m i d-bra l n activity,
whi l e the variou s characteri stics of the l ater p l aci n g reactio n i ndi cate a
cerebra l cortical m e d i ation of t he response as a p art of vo l untary p l ac i ng.
(Zape l l a , 1 967).
The m ajority of the i nfants s h owed o n e o r m o re i nconsistencies, scatter­
ed over the whole d evelop m ental ran g e, but th ere was no difference
b etween b oys and g i rl s . The l arge n u m b e r of i nconsi stencies (74) m ay
b e regarded as an i l l ustration of the vari abi l i ty of performance charac­
teristic of the n o rm a l ly deve l o p i n g nervo us system , in contrast with the
stereotyped p erfo rm ance typ i cal of the d a m aged nervo u s system .
Schaltenbrandt reactio n
Procedure: T h e Schalte n b randt reaction i s the reverse of the Lan dau ;
it is often cal l ed the Lan dau 2. Wh i l e keep i n g t he i nfant i n p ro n e su s­
pension the exa m i n er flexed th e i nfant' s h ead. The positive response
con s isted of a fl exion of tru n k a n d h i ps.
The resu lts were com pa rab l e with the resu lts of the Lan dau. Thu s the
Lan da u a n d Schalten b ra n dt reacti o n s need not b e reg arded as essen­
tial ly different. Th e occurrence of i ncon s i stencies was a lso s i m i la r i n
b oth cases, alth o u g h i n the case o f the Schaltenb randt reactio n the
i n co n s i stencies appea red to b e scattered over t he who l e developmental
course; they were n ot l i m ited to the l atte r p a rt as was the case with
the Lan d au . Th i s m ay refl ect the i nfant's i n creased active resi stance
agai n st fl exi on of h i s h ead i n p ro n e suspens i o n , wh i ch cou l d a l ready
be observed at a you n g age.
Bauer reactio n
Procedure: T h e i nfant was put i n p ro n e positi o n with h i ps a n d knees
flexed. Th e exa m i ner p l aced his h a n d s behi n d the i nfant's feet so that
h e t o u ch ed the so l es. A positive response con s i sted of a forceful ex­
ten s i o n of h i ps and knees, re s u lti n g i n forward p ro g ressi o n of the i n ­
fant. State 3 a n d 4.
D u ri n g the n ewborn exa m i n ation all the i nfants s howed a n evi dent for­
cefu l extension of h i p s and knees ; d u ri n g the second exa m i n ati o n thi s

1 19
was the case i n o n ly 3 1 % of the i nfants a n d afterwards the percentage
decreased rap i d ly. D u ri n g th e seco nd assessm ent a weak reactio n was
fou n d i n 53o/0 of the i nfants, b ut this percentage also decreased rapi d ly
d u ri n g th e su bsequent assessm ents. Sti l l , during the whole period of
th e fol low-u p study a smal m i n o rity of i nfants of varyi n g i dentity (o ne o r
two at a time) i n co nsistently showed an evi dent o r weak response to
th i s type of sti m u l atio n of the so l e of the foot i n prone positio n . These
responses seemed to b e rel ated p rep o nderantly to the amount of m otor
activity of the i nfants ; it was very diffi cult, and in some i n stan ces eve n
i mpossib l e, t o d i sti n g u i s h b etween the B a ue r reaction o n the o n e h a n d
and acti ve m oti l ity o n the other h and. There appeared t o be no rel ati on­
s h i p with th e deve l opm ent of l ocomotion i n p rone.
Galant response (incurvatio n of t h e tru n k)
Procedure: The i nfant was put i n p ro n e positi o n . With a p i n the exa m i ne r
scratch ed the ski n o f the i nfant' s b ack s l owly a n d gently fro m the
shoulders downwards, a t a b o ut th ree cm l atera l ly from the s p i n e. The
response consisted of an i ncurvation of th e tru n k with the con cavity o n
t h e sti m u l ated side. State 3 o r 4 .
D u ri n g t h e fi rst ten assessm ents an evi dent i n curvatio n o f t h e tru n k to­
wards the sti m u l ated si d e was fou n d in more th an 80o/0 of the i nfa nts.
Thi s i n cu rvation was characteri zed by a stereotyped contracti o n of the
b ack m u scles, resulti n g i n a co n s i stent and rep roduci b l e m ovement p at­
tern . This p rotracted persistance of the G a l ant response is i n contradic­
tion with An dre-Thomas' view that the response sho u ld o n ly be p resent
d u ri n g the fi rst weeks of l ife (And re-Th omas and Saint Anne Dargass i es
' 52). Kou p ern ik and Dai l ly ('68) state that the response d i sappears g ra­
dually in th e seco n d half year of l ife. In th e p resent study from the age
of about 40 weeks o nward s the tru n k m ovem ents beca m e i ncreasi n g ly
h eterogeneous; as a conseq uence it b ecame i n creas i n g ly d iffic u lt to
d i sti n gu i s h b etween an evi dent i ncurvati o n of the tru n k a n d a "tickle re­
acti o n " . I n the l atter reaction the co nsistent a n d rep roduceb l e m ovement
p attern is lost. Th i s reaction persi sted in all the infants d u ri n g the whole
p eriod of study. Thus a rel i a b l e G a lant reaction which m ay h ave c l i n ical
sign ifi can ce i n cases of sp i na l cord disorders seems to b e p resent o nly
during the fi rst n i n e m o nths o f l ife.
Threaten-reflex
Procedure: The exami ner m oved h i s extended fi n gers rap i dly towards
th e i nfant' s eyes. He took care to avo i d sti m u l ation of the cornea. A
pos itive response consisted of a b l i n k of the eyes. State 3 o r 4 .
More than 80°/0 of the i nfants did not show any positive reaction u ntil
th e age of about 20 weeks. From th at age o nward s the n u mber of posi­
tive respon ses in c reased rap i d ly. Sti l l , 1 8% of the i nfants d i d not show
a pos itive th reaten reaction at th e age of o n e yea r.
lt is poss i b l e th at envi ro nmental conditi o n s affect the ti m e of onset of
th is reaction. Facto rs l i ke num ber, age and b eh avi o u r of s i b l i n gs, the

1 20
active p l ayi n g b eh aviour of t li e father, a nd the p resence of dom esti c ani­
mals s eemed to b e i nvo lved. The co nclusion seemed j ustified that this
reaction i s p a rtly age-dependent and partly envi ronment-dependent.
White fo u n d that a b l i n k response to an approachi n g vi s i b le target de­
veloped rap i d l y b etween the m i d d l e of th e second month of l ife and the
age of fou r m onths (Wh ite, 1 970) . His findings a re not comparab l e with
the fi n di n g s of the p resent stu dy as his desi g n was more elaborate and
adapted to a specifi c research of the d evelopment of this pa rtic u la r re­
acti o n . He stated a close correspondance b etween the developm ent of
the response and the flexi b i l ity of what he cal l s the "accom modative
system " . Also, the fi n d i n gs of the p resent study po int at a comparab l e
developmenta l cou rse o f these two p henomena.

Comment
The items of this g roup can b e divided i nto two subgroups. The fi rst
g roup contai n s those items of wh ich the developm ental cou rse h ad not
yet fi n i shed at the age of wal ki n g free. The seco nd contai ns those items
which sh owed n o evi dent fi na l change, due to a g radual merging i nto
vol u ntary activity. Conseq uently it was not possi b l e to estimate th e d e­
velopmental ran ge, i . e. the develop mental rate, and the freq uency of in­
consi stencies .
The fi rst sub g roup i n c l udes the knee jerk, ankle clonus, p lantar grasp,
Landau and Schalte nb ran dt-reactio n . The fi rst th ree items a re l eg- a nd
foot- responses, wh i l e the l atter two invo l ve the sensorimotor apparatus
of n eck, tru n k and l egs. Their p rotracted developm enta l course can be
s ee n as an i l l u stration of the cep ha locaudad matu rati on o f the nervous
system. lt i s n otewo rthy that th eir, as yet u nsta b i l i zed, development does
not i nterfere with th e development of sta n d i n g and Wqlki ng as defined in
this stu dy. App arently, nervo us m echanisms i nvo lvi n g p arti cu la r motor
activities can b e operational wh i l e some compon ents h ave not yet reach­
ed stabil ization. l t stands to reason that walki n g· free, as defi ned i n
this study, i s not a fi na l poi nt i n the developm ent o f this moto r beha­
vio u r, nor does it refl ect a fi nal p hase of m atu ration of the b rain m echa­
n isms i nvolved.
The fi n a l m atu ration of these mechanisms is not o n ly reflected by the
differenti ati on of wal k i ng i n fo r i n stance toddlers, b ut also by the fi n a l
changes i n th e items o f this subgroup.
The respon ses of the items i n the secon d su b g roup cou l d be recognized
origi n a l ly as specifi c sti m u l us-responses, but g radual ly this specificity
d i m i n is h ed so that fi n a l ly comparab l e responses occu rred d u ri n g vo l u n­
tary b eh avi o u r. lt was not possi b l e to d i sti n g u ish an evident transiti o n
b etween eli cited respo nses and vo luntary moto r p atterns. Actua l ly the
main characteri stic difference b etween those two was a vo luntary use
of the fi n a l m otor p attern.
l t seemed that du ri n g their devel opment the infants gradual ly became
able to m ake vo l u nta ry use of n ervous m ech anisms which o ri gi n a l ly ope­
rated more autonomously. A close i nspection of the responses, however,

1 21
m ade clear that there were d i sti n ct q u a l i tative d i fferences between vo­
l u ntary and i nvo l u ntary m otor behaviour, but the fi n a l responses deve l­
oped too grad u a l ly to be p i n po i nted to a speci fic m oment. For i n stance,
the reflex- l i ke crossed extension fol l owi n g a noci ceptive sti m u l us o n the
co ntra- l atera l foots o l e of a very yo u n g i nfant differed essentia l ly from
the wel l-d i rected defense reaction of the o l d er i nfant to the same sti ­
m u l us . Sti l l , it co u l d not be ascerta i n ed at which m o m ent the actual cha­
racter of the response changed. The same can be sa id of items l i ke the
tacti l e p l aci n g of the feet, the positive supporti n g reaction or the Gal ant
response. One m ay assume that the neural m echanisms i nvolved beco­
me subord i n ated to n ewly develop i n g mechan i s m s . The G ala nt response,
fo r i n stance, cannot be obs erved after a parti cu la r age, because then a
very com p l ex ti ckl e-response p revai l s.
Th e m a i n d i fference b etween the items of this gro u p and those of group
I l l (chapter IX) l i es in the fact that i n the l atter the fi n al po int of stab i l i­
zati o n co u l d be defi ned on the ti m e scale more easi ly, because there
was a co nspicuous change in the exp ressi on of the neural mechanisms
i nvo lved . I n th is co n n ecti o n i ssues of operati onal izati o n h ave to be taken
i nto co nsiderati o n ; especi a l ly with regard to the items i nvolvi n g spon­
taneous m oti l ity of a rm s and l egs it was diffi cult to deci de whether to
i n clu d e them in g ro u p I l l o r in g ro up IV. This i m p l i es that no sharp d i s­
ti nction b etween g ro u p I l l and IV can be m ade. The majo rity of the items
of g rou p I l l deal with motor fu ncti ons which are easi ly reco gnizable and
which are frequently used in developm ental testi n g-procedures. The
changes i n the m at uri n g nervo us mechanisms of these items seem to
m an ifest them selves mo re consp icuously than i s the case with spo nta­
n eou s mot i l ity or m a ny responses and reactions of group IV. Actu al ly,
the m aturi n g b ra i n m echanisms which are responsi b l e fo r the great ex­
p a n s ion of the i nfa nt's neuro l ogical rep ertory, can be d ivi ded i nto two
categ o ri es. I n the o n e category an i nteg rati o n of various, sometimes
even ori g i n a l ly i n dependent, b ra i n mech a n i s m s takes p lace, as i s the
case i n s itt i n g without support o r wa l k i ng free, where mechanisms fo r
m oto r m ovem ents a n d balance are i nvo lved. The oth er category conta i n s
t h o s e m ec h a n i s m s which develop g ra d ual ly. I t e m s b ased o n mechanisms
b e l o n g i n g to the fi rst category show developm ental chan ges which can
cl early be d i scerned.
Item s based o n m echan isms b e l o n gi n g to the secon d c ategory m ay also
show cl ea rly d i scern a b l e developmental changes, but they may show
such a g radual deve l opm ent that transiti o ns fro m the o n e developmental
phase to the other b eco me hard ly d i scerna ble . Although there is a
l arge overl ap , the m ajo rity of the items of g ro up I l l bel o n g to the former,
the items of g rou p IV to the latter category.

From a c l i n ical p o i n t of view the i tems of gro up IV can ha rdly be used

in developmental test i ng o r neuro l o g i cal d i agnosi s ; o n ly evi dent devia­
tions such as co nsi stent l eft-ri g ht differences seem to be useful fo r the
l atter p u rpose.

1 22
 Chapter X I Anthropometri c a n d Psychosocial ite m s

Th is chapter d e a l s with th e developm ental cou rse o f severa l items which

descri be the g ro u p from an anth ropometric p o i nt of view. These items
are : b ody wei ght, body l e ngth, ci rcumference of the skul l and fo ntanels
(Tab l e IX).
They serve the p u rpose of docum enti n g the p resent gro u p. Also, some
items wi l l be discu ssed which may refl ect psychosocial and auto n o m i c
developm ent a n d which are u s u a l l y i n c l u ded i n the neurolo gical exami ­
nation. T h es e items are : developm ent of vocal i zati o n a nd speech, s m i l­
i n g , lacrim ation a n d reacti o n to stra ng ers (Table X) .

TABLE IX TABLE X

Anth ropometric items Psychosocial items

body wei ght Voca l i zati o n and speech
body length smiling
sku l l circu mference reacti on t o strangers
fontanel les l acri mation

Anth ropometric items

Body weight
At bi rth th e wei g ht- range of the infants was b etween 2800 a n d 4200
grams. O n ly one i nfant wei g hted l ess than 3000 g rams a n d 8 i nfants
weighted m o re th an 4000 g rams at b i rth.
D u ri n g the assessm ents the infants were wei ghed with their clothes on,
on the scales avai la b l e in the resp ective househo l ds. D u ri n g their d evel­
opm ent th eir wei ght ran ged between the tenth and n i netieth centi les
for the D utch popu l ation, as p resented by Van Wieri n gen (1 972).

Body length
Body length was defi ned as crown-foot length and measured wh i l e the
chi l d was i n supi n e positi o n . D u ri n g the period of study the l engths of
the i n fants ran g ed between th e tenth and n i n etieth centi l es fo r the
Dutch popu lation, as p resented by Van Wi eri ngen (1 972).

Skull circu mference

For the meas u rem ent of sku l l ci rcumference the measuri n g tape was ap­
p l i ed arou n d the fro nto-occipital diameter of the h ead. At b i rth about ha lf
of the i n fants had a sku l l ci rcumference l arger than 36 cm . When the
p resent d ata a re compared with the centi l e curves of Falkner (1 958)
(D utch data are n ot avai lab l e) there is a fai r agreement.

Fontanels
The varia b i l ity of the size and closure of the fontanels was large. In three
i nfants the anteri or fo ntanel was closed at about half a year of age,

1 23
wh i l e i n o n e i nfant the anterior fo nta nel _ was sti l l palpably open at the
age of 1 5 month s . The size of the fontanels varied consi dera bly among
th e i nfants. There was no difference b etween boys and g i rls. Th e fi nd­
i n gs are i n accord a n ce with D i leo's report that th e statistical mean for
clos u re of the ante ri o r fontanel is at 1 3.5 mo nths ( D i l eo, 1 967) a n d with
Popich' s (1 972) ran ges of n o rm al size.
The posteri or fonta nel was sti l l pal p ab l e i n 25o/0 of the i nfants at the
n ewborn assessm ent, b ut fro m the secon d assessment o nward s no
open p osterior fo nta nel was fo u n d .

Psychosocial item s
Vocalizatio n a n d s peech
In the p resent study speech was defi ned as vocal i zation aimed at com­
m u n i cati o n . Spontaneous vo ca l i zati o n s e . g . cryi n g , were not taken i nto
considerati o n . D u ri n g the exam i n ations the m othe r was asked to com­
m u n i cate with the i nfant and the i nfant' s reactions were scored o n a
4-p o i n t scale. State 3 or 4.

Recording:
0. No vocali zation at a l l .
1 . C o o i n g , i . e. p ri m itive voca l izati o n , i n w h i c h no sp ecific vowels o r con­
sonants are d i scern a b l e.
2. Vocalizati o n cons isti n g of vowels, usual ly a-sounds, with begi n n i n g
arti c u l ation.
3 . Voca l i zati on consisti n g of reco g n i zab l e words, i rrespective of i nten­
tional use.

Vocalization and speech

0 3 6 9 12 15 18 21
age,months
Fig'. 44

The p redicti o n b a n d for the sco res i s p resented i n fi gu re 44. Coo i n g ap­
peared to b e p resent in about half of the i nfants during the seco n d as­
sessment; it was the o n ly typ e of vocalizatio n fou n d duri n g the fi rst 20
weeks . In some i nfants the use of vowels, parti c u l arly of the a-so und,
started to occu r at about the 24th week; subseq uently the n u m ber of
i nfants with a sco re 2 i nc reased rap i d ly.

1 24
 A small m i nority of the i nfants showed voca l i zati on of a coo i n g qual ity
as the on ly m an ifestation of speech developm ent u nti l the age of about
45 weeks. Fo u r i nfants started to say wo rds l i ke " papa" and " mama" at
the age of about 35 weeks, one quarter of the infants p ro no u nced reco g­
nizable words at the age of about 40 weeks wh i l e at the age of -one
year more tlian 80°/o of the i nfants were able to say at l east th ree or
fou r recogn izab l e wo rds. Th is does not i m p ly that the infants made pro­
per use of these words.
I n the boys the coo i n g typ e of vocal i zation was fou n d somewhat earl ier
than i n the g i rl s ; this difference was not statisti cal ly sign ificant. There
was a statisti ca l ly s i gn ificant difference b etween g i rls and boys with
respect to the p ronou nci ng of recogn izable words (p < 0.01 , M ann­
Wh itney U test) . H ard ly any i n consisten cies i n sp eech developm ent oc­
cu rred, neither i n the group of the boys nor in the gro u p of the g i rl s .
lt i s evident that this mo d e of assessi n g sp eech develo p m ent i s com­
p letely insuffi cient if a scruti ny of the developm ental co u rse of vo ca l i­
zation and sp eech is a i m ed at. lt o n ly a l l ows fo r a crude c l i n i cal apprai­
sal of speech developm ent, so that i n case of doubt the i nfant can be
referred to a special ized assessment. T he fi nd i ng s a re i n acco rdance
with reports i n the l iteratu re (Byers B rown et a l . 1 974) .
Smiling
S m i l i n g was op erati onal i zed as co m m u n i cative s m i l i n g at the mother.
D uri n g the newborn assessment no co m m u n i cative smi l i n g was observed
in any of the i nfa nts. D u ri n g the seco n d assessm ent one th i rd of the
i nfants smi led at thei r mother, wh i l e one fou rth of the i nfants also s m i l ed
at other people. Fro m the th i rd assessm ent onwards, i.e. from the age
of about 1 0 weeks, this was the case i n all the i nfants. Th i s i s i n ac­
cordance with the fi n d i n gs of E mde & H a rmo n (1 972) with regard to
exogenous s m i l i n g in infan cy.
Ambrose (1 961 ) fou n d a l ater onset of s m i l i n g ; h e uti l i zed a speci fic de­
sign (e. g. labo ratory setti n g , unfam i l i ar face as a sti m u l us) and studi ed
response-sm i l i n g i n i n stitutio na l i zed infants . In h i s smal l gro u p of i n fants
he d i d not find d ifferences of the onset of s m i l i n g between i n stituti onal i zed
infants and hom e-rea red i nfants. His subtle desi g n for the study of the
developm ent of reactive s m i l i n g duri n g ontogeny, p recl udes a comparison
with the fi ndings of the p resent stu dy, in which me rely the absence
or the p resence of s m i l i n g were reco rded.
Reactio n to strangers
All th e chan ges i n posture, attitude a n d behaviour of the i nfant on ap­
p roach of the exam i ner were defi ned as reaction to a stranger. lt was
scored on a 3-point scale:
0. No reacti on .
1 . Sl i g ht reaction, consisting m a i n ly of a s l i g ht withdrawa l , o r a dis­
conti n u ation of activities.
2. Evident reaction consisti ng of evi dent withd rawal fo r several m i n utes
and/or cryi ng.

1 25
As the exam i n er visited the homes of the i nfants o n ly once per fo ur
weeks it was assumed that h e remai ned more o r less a stran ger to the
i nfa nts. H owever, t h i s was not a lways the case; o l der i nfants i n par­
ticular often seemed to reco g n ize the exami ner. As the i nfant's coo pe­
ration was a p rereq u i s ite fo r a p roper exami natio n , the exam iner tried
to avo i d n egative reactions as m uch as possi b l e . Th i s modulated hi s
mode of a p p roach a n d m ay exp l a i n t he absence o f i ntense withdrawa l
behaviou r. I n some infants s l i ght reactions towards stran gers, manifest­
i n g the i nfa nt' s a b i l ity to disti n g ui sh between fam i l iar und unfam i l iar at­
te ndants, sta rted to occu r d u ri n g the fou rth assessm ent, i . e. at the age
of about 16 weeks. O n e i nfa nt co nsistently sh owed an evi dent negative
reaction towa rds the exa m i ne r from the thi rd asessm ent o nwa rds. Re­
action towards the exami ner, co nsisti n g of with drawal behavi o u r and/o r
cryi n g , occu rred in one th i rd of the i nfants at the seventh assessment,
i . e. at th e age of abo ut six and a ha lf months, th ree quarters of the i n­
fants sh owed such reactions at the age of about e i g ht and a half months.

lt i s rema rka b l e that consistent cryi ng occu rred only i n a smal l m i n o rity
of th e i nfants. Th e m ajo rity of tht i nfants showed a withdrawa l reacti on
of varyi n g d u rati o n which co u l d be overcome rather easi ly. The length of
th e adaptati on peri o d which was d i rectly rel ated to the i ntensity of the
reacti on to stra n g ers, was the m ost p rotracted between the age of seven
months and o n e year and after th i s age decreased rather rap i dly.

Lacrimation
Lacri m ati on was d efi ned as the p resence of tears rol l i n g down the
ch eeks d u ri n g cryi n g. In 61 o/0 of the i nfants l acri m ation was observed at
the second assessment, in 84°/0 at the third assessment, and in a l l the
infants d u ri n g all the su bseq u ent exa m i n ati ons.

1 26
Chapter XII Sex d iffe re nces

After the discussion of the s i n g l e items of the neurolo gical exa mi n ati o n,
which were s u b divided i nto five g roups, i n this chapter the sex differen­
ces wi l l be analyzed. Th is wi l l be done o n ly in th e case of those items of
wh ich the fou r p aram ete rs could b e defi ned, namely fi rst change, fi nal
change, length of devel o p mental ra nge, a n d n u m ber of i n co nsi sten c ies;
conseq uently the items of g roup I l l and some of group 11 were i n cl uded,
beside speech developm ent.

I n the di scussion of the s i n g l e items sex d ifferences were me nti o n ed if

p resent. In the p resent chapter it wi l l be exami ned wheth er sex differen­
ces occur systematical ly.

In the literature it is assumed that duri ng i nfa ncy differences in m oto r

development b etween boys and g i rls are virtually absent. Neither An­
dre-Thom as, nor G esel l , McG raw or Pai ne, even co nsider the possi b i l i­
ty of differences bei n g p resent (Gesel l and Am atru da, 1 947 ; Andre­
Thomas and St. Anne D argassies, 1 952 ; M cG raw 1 943 ; Paine, 1 960) .
The authors who do rep ort sex differences often differ i n opi n io n ; Tan­
n er (1 970) fo r i n stan ce states th at usually g i rl s are ahead of boys in mo­
tor developm ent, wh i l e Zachau-C hristiansen (1 972) concludes that the
op posite is true; thoug h he menti ons the differen ces to be very smal l
i n deed.
Ne li g an did not fi nd appreciable d ifferences between boys and g i rls
with regard t o th e m i l esto nes of sitting and wa l ki n g free (Nel i gan a nd
Prudham, 1 969). O n t he contrary H i n d l ey, i n a re-analysis of Sm ith's
data (1 930) on different eth nological subgro ups in the U . S .A. , fou n d that
g i rl s wa l ked earlier than boys , although he co u l d not confi rm this fi n d­
i n g in h i s an alysis of five European l o n g itud i n a l sam p l es (H i n d ley et a l .
1 966 ; H i n d l ey, 1 967). Koupern i k a n d D ai l ly (1 968) refer t o Stambak' s
statem ent th at spontaneous u n i l atera l m oti l ity of the arms (com parab l e to
th e asymmetri cal spontaneous movement pattern in the p resent study) i n
g irls wou l d disappear somewhat ea rli e r t h a n i n boys. Sti l l it is generally
ag reed that gi rls mature somewhat faster than boys with regard to
speech developm ent (l l l i n gworth , 1 966 ; Nel i gan and Pru d h a m , 1 969).

I n the p resent stu dy differen ces between boys and gi rls were fo u n d in 1 7
items; they are l i sted i n the tab l es XI and X I I . Sex differences were estim­
ated to be appreci able if they reached a statistical confi dence l evel of
5 percent o r lower (Man n-Whitney U test) . The stati sti cal tests were ap­
p l i ed two-tai l ed , i . e. without any hypothesis about the d i recti o n of the
differen ces, except in the case of speech with respect to wh i ch o n the
basis . of the l iteratu re one m i g ht expect the g i rl s to show a faster devel­
opment than the boys . Sex differen ces were analysed fo r a l l fo u r para­
m eters , i . e. fi rst change, fi na l chan ge, length of developmental range
and n u m ber of i nco ns istencies.

1 27
TABLE XI

Items which s h owed significant sex d ifferences i n the favou r of the boys
(Mann-Whitney U test, two-tailed)

rJ)
(J)
()
(J) '-
0') .�
(J) '-
�
'-
'
c
(ij rJ)
O') (J)
co co -;:
2
� �(J) � E >=
c -;:: rJ) rJ) rJ)
·o, .� :E
·a g? -�
I tem
-B (J) i5 (J)
m ·a Cl

tl � �
- (f) m m rJ) c
c c 0
� � eo C >. CO
..c U :>, ..c
-.: .o -:5
O O
CO
co
� _g £ '- ...a .....
c
·- .0 .....

slitt i n g u p .01
wa l ki n g .01
locomotion i n pro n e p o s i t i o n .03
ro l l i ng over i nto pro n e position . 02
ro l l i n g back i nto s u p i ne position .0 1
parachute rea ct i o n h a n d S' .04 .02
f o o t so l e reflex .02
l ip-tap reflex .03 .01
fixati>on time < .01

TABLE XII

Items which showed s i g nificant sex differences i n the favour of the g i rls
(Mann-Whitney U test, two-tailed)

(J) '-
9) (J)
-;:
c rJ)
·-
CO >.
I te m s ..CCO 0
<.)
(J) ...a
- rJ) c
� E ..cco
4: Cl .....

speech (one-ta i led)

converg e n c e of t h e eyes .01

.01
.01
I < .O I

pu p i l l ary react i o n o n co nverg e n ce < .01 .04

co njugated eye m o ve m en ts .03
type of g ra s p i n g .01
re c o N .04
s ponta n eo u s postu re of t h e l eg s . 04
M o ro l ift, abduction/exten s i o n
1 < . 01

1 28
Fo r the developm ental assessment the fi na l change can be co nsi dered
as the most i m portant p aram eter. Sti l l from the d evelopmental neuro l o­
g ist' s p o i nt of view the fi rs t change, the length of the devel o pmental
ran ge and the n u m ber of i n consistencies may b e as i mporta nt, as they
m ay yi eld i nfo rm ation about a differenti al d evel opm ental co urse of b ra i n
m echanisms i n the c a s e of boys and o f g i rl s.

Th e tota l n umber of 1 7 i t e ms with appreciab l e sex differences cou l d

be divided i nto two g roups, o ne con si sti ng o f n i n e items with statistical
d ifferences i n favou r of the boys (Tab l e XI), the other consisti n g of eight
i tems with differe n ces i n favour of the g i rl s (Table XII). Differen ces for
a l l fo u r parameters were fo u n d in none of the item s ; in the majority of
cases a statisti cal ly s i g n ificant d ifference was observed fo r one or two
p aram eters on ly.
The differences in the param eters of one item always tended i nto the
same d i recti on .
The headi n gs " boys earl i er" and " g i rl s earl i er" suggest that there m ay
be a system atic difference between the b oys and the g i rl s .
T h e co mmon d e n o m i n ato r o f t h e subgro up " boys earl ier" c a n be cal led
" g ross moto r d eve l o p m ent" . As for the subgro u p " gi rls earl i er" , besides
speech, items concern i n g the visual apparatus seem to p redom i n ate.
The difference in the numb e r of in co nsistenci es duri n g the development
of type of g rasp i n g s u gg ests that the fi n e motor abil ities tend to devel­
op mo re stead i ly in g i rl s than in boys.

TABLE X I I I
M e a n s and standard devations for both sexes of t h e items i n w h i c h t h e
boys were significantly advanced compared with t h e girls
boys g i rl s
I tems M / sigma M sigma

I
s itti n g up, fi rst change 5.93 1 .274 6 .50 1 .472
wa l k i n g , f i n a l c h a ng.e 1 7 .30 2 . 053 1 8.86 2.5 1 3
locomotion in prone pos iti o n ,
fi rst ch ange 6.93 1 .035 7 .55 1 .438
.ro l l i ng over i nto pro n e pos ition ,
i n consistencies 0 0 0.22 0.51 8
ro l l i n g back i nto s u p i n e positi o n ,
f i n a l change 7 . 64 1 .496 8.52 0.994
parachute reacti o n h a n d s ,
dev. range 2.1 1 1 .548 3.1 8 1 .893
parachute reaction h a n d s ,
incons istenc ies 0.71 0 .659 1 .217 0.985
foot s o l e res ponse, d ev. ra nge 4. 1 1 2 . 897 6 . 00 3 . 367
l i p-ta p res ponse, fi n al c h a n g e 4.43 2.2 1 8 5.39 1 .50
l i p-ta p res ponse, d e v . ra nge 1 . 93 2 .089 3.1 3 1 .632
fixati·on time, f i rst change 2.1 1 0 .31 5 2 .43 0 .507

1 29
TABLE XIV
Means and standard d eviations for both sexes of the ite ms i n which the
g irls were significantly advanced compared with the boys
boys g i rl s
I temS' M
I sig m a M
I sigma
voca l izat i o n a n d speech, 1 2.68 1 . 827 1 1 .68 1 .836
final change
voca l izat i o n a n d s peech, range 1 0. 2 1 1 .750 B.09 1 .900
c o nverg e nce of the eyes, 3.1 1 0.629 2 . 65 0.573
fi rst chagne·
c o nverg e n ce of the eyes, 4.54 1 . 261 3.57 0.945
fi n a l c h a n g e
pu p i l l a ry rea ct i o n to c o nvergence, 4.50 1 . 374 3.61 1 . 033
final change
pu p i l l a ry react i o n to c o nvergence, 1 .1 1 1 . 1 97 0 .57 1 . 1 61
dev. ra n g e
c o njugation of eyem ove me nts, 1 .32 0.548 1 .09 0.4 1 7
fi rst change
type of v o l u ntary g ra s p i n g , 0.61 0.567 0 .23 0 .429
i ncons i st e n c i es
reco i l , fi rst c h a n g e 2. 1 8 0.390 1 .96 0.3B7
s pontaneous postu re of the l eg s , 8. 1 4 1 .7 1 5 7 .22 1 .3:47
dev. ra n g e
M o ro l ift, a bdu ctio n/exte n s i o n , 1 .29 0.854 0.45 0.67 1
i n c o n s i stencieS'

I n specti on of sex d ifferen ces i n items which d i d not reach a 5 percent

l evel of confi dence reveals that items deal i n g with gross sen sori-motor
functi o n i n g often showed differences which poi nted at a s l i g htly h i gher
d evelop mental rate i n the boys. This was the case with, fo r i n stance,
head l i ft in s u p i ne, sta n d i n g up, parach ute reactions and footso le respon­
ses. Items deali n g with spo ntaneou s moti l ity appeared to develop s l i g ht­
ly faster in the g i r l s than in the boys . Thus, an i nterp retation of the fi nd­
i n g s of the p resent study may be that there is a systematic devel op­
m e ntal difference b etween the boys and the g i rl s . Wh i l e i n gross m oto r
areas the b oys develop som ewhat faster, the g i rl s appear to be more fo r­
ward i n fu ncti o n a l areas which req u i re more subtle motor activities. Thi s
difference i s very s m a l l and there is a l a rge overl ap o f t h e fi n d i n g s with
regard to the b oys and the g i rl s . In both areas some boys devel oped
m o re s l owly th an some g i rl s and vice versa. lt is cl ear that c l i n i ca l ly the
d ifferen ces do not h ave much p racti cal va l ue. This is i l l ustrated by the
Ta b l es X I I I a n d XIV, i n wh i ch the means and stan d ard devi ati ons of those
items are l i sted w hi ch show a statistically s i g n ifi cant difference (p <
0.05) ; they clearly show the overl ap between the boys a n d the gi rl s .
From this overl ap the co n c l u s i o n w a s drawn that t h e boys an d the g i rl s
s h o u l d b e considered a s b e l o n g i n g t o one gro u p when t h e descri pti o n
o f the devel o p m e ntal course o f the different item s, as presented i n the
p revi ou s paragraphs, i s i nvolved.
One can o n ly d raw attenti o n to the poss i b l e p resence of system ati c
d ifferen ces b etween boys and g i rl s, for an adequ ate expl o ratio n of which
a m o re specifi c design should b e d rawn up.

1 30
C h a pter XIII The parameters - i ntra-ite m
rel ationsh ips

The developm ental co urse of the items has b een described in terms of
fi rst chan ge, fi n al change, l e ngth of developmental range and n umber
of i n consistencies. The fi rst change and the fi nal change defi ne specific
chang es on the time-axis, i . e. in wh i ch the i nfa nt' s age is i nvo lved, wh i l e
t h e le n gth o f t h e developmental ran ge reflects t h e develop mental rate,
i n depen dent of age. The n u m ber of i n consisten cies q uantifies one as­
pect of the variab i l ity of the responses d u ri n g development, defi ned as
relapses in score; they wi l l be d i scussed separately (see chapter XIV).

Thi s chapter deals with the rel ati onships of the param eters fi rst change,
fi n al chan ge, and developm ental ra nge occurri n g with i n s i n g l e items ; an
analys is of the developm ent i n term s of age and rate may elu ci date the
matu ration of b ra i n m echan isms u n derlyi ng these items.

What kind of rel ationships can b e fo und between these parameters?

There are six poss i b i l ities, wh i ch are p resented schematically in fi g. 45.
I. T h e fi rst c h a n g e and t h e fi nal change c a n b e rel ated po sitively o r ne­
gatively (fi g . 45a and b .) I n the case of a positive relationship the
developm ental ran g e, i . e. the rate of the developm ent, wi l l be fixed,
i rresp ective of the age at wh i ch th e fi rst and l ast developmental
changes occu r. lt is self-evi dent that the mom ents of the fi rst and
l ast developm ental chan ges (i.e. the fi rst and fi n al chan ges respecti­
vely) s h ou ld have more or l ess eq ual va ri ati o n ran ges, ten d i n g to
a s i m i l a r d i recti on . lt is not surp ri s i n g that th i s type of re lationship
occurs ; it wou l d i m ply a m o re o r less fixed devel opmental rate of a
neural mech a n i s m .
A negative rel ati on between t h e fi rst and fi na l changes (fi g. 45b)
wo u l d i m p ly a decrease of the developmenta l range (i.e. an i ncrease
of rate) if the fi rst developm ental change takes p l ace l ate, and an i n ­
crease o f t h e developm e nta l range in th e case of an early fi rst chan­
ge. At the same time the vari ati on ran ges of the first and fina l chan­
g es wou l d be of equal width, though ten d i n g to opposite d i rections.
One can h a rdly i m ag i n e that such a relati onship wou l d be co mpatib l e
with a norm a l a n d h a rmonious development.

11. The next pai r of poss i b l e re lationships are a po sitive and a negative
rel ation between the fi rst change and the devel opmental ran ge.
They are p resented schemati ca l ly i n fi g. 45c and d. In the case of a
p ositive rel ati o n s h i p , an early fi rst change (i .e. a low valu e on the
time scale) wou l d i m p ly a short developmental ra nge, and a late first
change wo u l d imply a p rotracted ran ge, i . e . a slow developmental
rate. Th is latter possi b i l i ty can b e expected i n the case of neuro logi­
cal ly d amaged i nfants who sta rt to develop l ate a n d with i n creas i n g

1 31
 a
B
c

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Examinations
• •

• • b
• A

1 2 3 4 5 6 7 8 9 10 11 12 1 3 14 15 16
Examinations
G • •
c
H • •

I • •

1 2 3 4 5 6 7 8 9 10 11 12 1 3 14 15 16
Examinations
• •

L • • d
M • •

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Examinations
N • •
e
0 • •
p • •

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Examinations
• •

• • f
• A

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1 32 Examinations
 age lag b e h i n d m o re and mo re. Maybe the fo rmer situati on (i .e. a n
early fi rst c h a n g e rel ated t o a fast developm ental rate) c a n be observ­
ed in s l i g htly i m p a i red i nfants, fo r i nstan ce in i nfants sufferi ng from
the hyperexcitab i l ity synd rome. Some of these i nfants may start to
develop fo r i n stan ce lo comoti o n at an early age and m ay be able to
wal k several m onths befo re the age of one year (personal observati­
on). lt seem s u n l i kely th at d u ri n g a normal developm ent there wou l d
be a p ositive rel ati onshi p b etween t h e fi rst change a n d the develop­
mental ran ge.
A neg ative rel ati o n b etween the fi rst change and the developmental
ran ge (fi g . 45d) reflects a l ate start and a " catch i n g-up" d u ri n g devel­
opm ent so that the l ast develop mental change sti l l takes p l ace "on
time " . Th i s m ay i m p ly that the mo ment of the l ast developmental
change i s fixed, w h i l e the m o ment of the fi rst devel opmental change
m ay vary.
Fi g . 45d shows that the vari ati on range of the fi na l change m ust b e
zero , or a t l east consi derab ly smal ler than t h e vari ati o n range o f the
fi rst change. Alth o u g h a zero vari ation ran g e of the fi na l change i s
hard ly co m p ati b l e with norm a l developm ent, sti l l , theoretica l ly speak­
in g , the variation range of the fi na l change m ay be smaller than the
variation ran ge of the fi rst change. Th e repo rt of some m others who
state that their vari ous i nfants all wal ked at about the same age m ay
serve as an examp l e of a rel atively smal l va ri ati o n range. Presumably
there are fam i l i es of " early wal kers" and of " l ate wal kers " . On a l a r­
ger scale, systematic raci al differences i n motor development may i l­
lustrate rel atively n arrow variatio n ran g es of developmental chan ges.
Also, in p atients who h ave suffered fro m a di sease which i nterfered
with their developm ent, a " catch i n g-up" is often observed ; thus thi s
type o f rel ati o n s h i p c a n be exp ected both i n a n o rm a l an d i n a s l i g ht­
ly deviant developm ent.

Fi g:. 45:

D i ag rams re presenting the theoretical rel atio n s h i ps between the first changes,
the final c h a n g es a n d the deve l o pmental ranges.
Vertic a l axes : codes for i m a g i n a ry cases .
H o rizonta l axes : n u m be r of exa m i n ations.
The dots, squ a res and tri a n g l es re p resent the first c h a n ges a n d the final changes
res pective ly of the i m a g i nary caes, lettered A ti l l S.
The d i stances between the dots, squ ares and tri a n g l eS' refl ect the lengths of the
deve l opmenta l ra nges.

a: positive re l ations h i p between the fi rst an d fi n a l c h a n g es.

b: negative re l ations h i p between the first and final c ha nges.
c: pos itive rel at i on s h i p between the f i rst change and the deve l o pmental ran g e .
d: n eg ative re lati o n s h i p between the fi rst change a n d the deve l o pmental range.
e: pos itive re l at i o n s h i p between the deve l o pmenta l range a n d the f i na l change.
f: negat ive re l ati o n s h i p between the d eve l o pmenta l ra n g e a n d the f i n a l change.

1 33
I l l . Th e th i rd poss i b i l ity i m p l i es a positive or a negative rel atio n s h i p be­
tween the deve l o p me ntal range and th e fi n a l ch ange (fi g. 45e and f) .
I n the case of a positive relati o n s h i p , the mo ment of the l ast devel­
op m ental ch a n g e i s determ i ned by, o r determ i n es the l ength of, the
develop m ental ran ge. Fi g . 45e shows that for th i s rel ati on the vari a­
ti o n - range of t he fi rst change m u st be zero or very smal l , at l east
m u ch s m a l ler than the variati o n ra nge of the fi nal change. Th is rela­
ti o n s h i p i s also an exa m p l e of a fixed m o m ent of a fi nal developmen­
tal chan ge. In this case the vari ati o n ran ge of the fi na l change may
b e co nsi derab l y wide, wh i l e i n th e oth er type of p rogram m i n g of the
fi n a l ch a n ge th e vari ati o n ran g e of the fi rst change appeared to be
vari u b l e (cf. fi g . 45d) . In the fo rm er i nstan ce, the mo ment at which the
fi rst d evelopm e ntal change occu rs, does not have any predictive
va l ue, as th i s m o m ent is rather constant, whi l e the final change is va­
riab l e; in the l atter (i .e. the negative rel ati o n between the fi rst ch ange
a n d the developmental ra nge) this may be the case, th ough actually
th i s i s based on knowl edge that the m o m ent of the l ast change is ra­
th er con stant. Th i s rel ati o n s h i p seem s to be co m p ati b l e both with
n o rm a l and with devi ant d evelopm ent.
Th ere m i g ht b e a negative rel ati o n b etween the developm ental range
a n d the fi n a l c h a n ge (fi g . 45f) if a l ate occu rrence of the last devel­
op m ental change were accompan ied by a sho rt developmental ran ge,
i . e. if the fi rst change took p l ace extrao rdi n a ri ly l ate, so that after a l l
th e develop m e ntal ra nge turned o u t t o be q u ite short. Thi s m i ght b e
co n s idered as a ki nd o f " catch i n g u p " d u ri n g devel opment; t h e in­
fant m ay sta rt very l ate and end rel atively early, though co m p ared
with th e avera g e i nfant he is sti l l rather l ate beca use there was not
enough ti m e to catch up co m p l etely.
lt i s i m p robab l e that such a situ ati o n wou l d occur during normal de­
vel o p m ent. The oppos ite, i . e. an early fi na l change with a ve ry lo ng
d evel op m ental ran g e, wh ich m eans that th e fi rst c ha nge m ust have
taken p l ace at an excessivel y early m o m e nt, seems to be i ncompati­
b l e with any ki n d of developm ent.

l t can b e con c l u ded that in a g ro u p of healthy infants intra-item relation­

s h i p s b etween the first and the final chan ges (positive) are l i ke ly to oc­
cur, refl ecti n g a p reprogra m m i n g of developmenta l rate, also between
the fi rst change a n d the developmental ra n ge (negative), and between
the fin a l change a n d the developme ntal ra nge (positive) ; the l atter two
refl ect a p repro g ra m m i n g of the m o m ent of the l ast developmenta l ch an­
g e i n dependent of the developmental rate. Between these schematic
possi b i l i ti es transitions may be observed, depen dent o n the width and
the sym m etry of the va ri ation ra ng es of th e fi rst and fi na l ch an ges.
Fi g. 45 s h ows that a positive rel ati o n s h i p between th e developmental
ra n g e and th e fi n a l change o r b etween th e fi rst and fi nal changes (cf.
fi g . 45a a n d e) need not be i n con gruous, p rovi ded th at the variation­
ran ges of th e fi rst change i n crease i n the same d i recti on as those of the
final c h a n ge. In th e case of si m i l ar vari ati on-ra ng es of the fi rst and final

1 34
 chan ges, a positive rel ati o n s h i p between these two wi l l be fo u n d . If the
variation-ranges of the fi rst change are sma l l er than those of the fi na l
ch an g e it is l i kely th at a posi tive relati onship between the developmen­
tal ran ge and the fi n al change is fou n d .
However, it i s h i g h ly i m p robable th at a positive rel ati o n s h i p between t h e
fi rst change and t h e fi na l c h a n g e i s accompanied by a negative rel ation­
ship between the fi rst change and the developm ental range (cf. fi g . 45a
and d) in one s i n g l e g roup of i nfants.

In tabl e XV the correlation-coeffi cients (p < 0.0 1 ) of the Pearson Product

Moment correlations of the i ntra-item rel ati onships are s u m m arized (Ap­
pendix C p resents the m eans an d standard devi ati ons as a measure of
the vari ati on-width). lt appears that o n ly those rel ati o n s h i p s which were
expected are found. Relati o nshi p s wh ich were su p posed to be i n com­
patib l e with normal developm ent are absent. However, fo r seven items
a com b i n ation of rel ati onships was fou n d wh i ch was said to be u n l i kely
to occur i n a homogeneous g roup of i nfants. These seven items show
intra-item relation s h ip s between th e fi rst change and the devel opmental
range (with negative correlati o n-co effi ci ents as exp ected) with o r without
positive rel ation s h ip s between the developm ental range and the fi na l
ch an g e (both reflecti n g a p repro g ram m i n g o f t he fi n a l chan ge) b ut they
also show a (positive) rel ati onsh i p between the fi rst change and the fi na l
chan ge.
Six of these seven items deal with a nervous fu ncti o n concern i n g sitti n g.
· Th i s is evi dently the case in the items " sitti n g u p " , " postu re duri n g sitt­
i n g " , " d u rati on of sitti ng" and "visual fo l lowi ng of an object with rota­
tion of h ead and tru n k during s ittin g " . In adeq uate acoustical o rienti n g
com p arable b rain m echan i sms m ay b e i nvo lved, which enable the i nfant
to rotate his h ead and body towards the sti m u l us, w h i l e in m any i nfants
the fi n a l change of rol l i n g over fro m p rone i nto s u p i n e position consisted
of sitti n g up i n stead of merely turn i n g i nto p rone positi o n . On the basis
of the i deas about the possib l e co m b i nati ons of rel ationsh i p s m enti oned
above, one m ay assu m e that with regard to the developm ent of the�e
items, two sub g roups of i nfants shou l d b e disti n gu i sh ed . I n deed two d is­
ti n ct subgroups of i nfants were found to exist, as is i l l ustrated by the
p l otti n g of the mom ents of the fi rst and the fi nal ch ange and the devel­
opmental ran ge of the item " d urati o n of sitti ng" (fi g . 21 and 22).
The other com b i n ations of rel ati onships, p resented i n Tab l e XV are in
agreem ent with the theoretical co nsid erations mentioned above. Fo r
the m ajority of items the fi nal change appears to b e mo re or less fixed,
though with different variation wi dths (see Ap pen d ix J) as i s refl ected by
the occu rrence of rel ati onships between the developm ental range anq
the fi n al change often combi ned with (neg ative) rel ati o nshi ps between
fi rst change and developmental range. lt is rem arkab l e · that the l atter
rel ati onships m a i n ly occu r in items deal i n g with refl exes a n d respo nses
(Table XV). Part of the items show a com b i n ation of rel ationships be­
tween the develop m ental range and the fi nal change and between the
fi rst and the fin a l change; fro m th is one may co nclude that both the de-

1 35
TABLE XV
Correlation coeffic ients (p < 0.0 1 ) of i ntra-item relationships of the
items of g ro u p I l l , i ncluding s peech development. The items are d ivided
i nto a s u bg ro u p with and a s u bg roup without significant correlations be­
tween first change and developmental range, and are furthermore with i n
t h e subgroups ord e red t o t h e height o f t h e correlation coefficient o f the
relations between final change and developmental range (Pearson Pro­
duct-Moment correl ations).

Item

Goal di rected moti l i ty o f the arms + 97 1

Voca l ization and s pe e c h + 958
S pontaneous posture o f the l e g s + 946
Posture i n p r o n e p o s i t i o n + 937
Moro h e a d d rp , a bd u c t i o n/exten s i o n + 820
Locom oti o n i n p ro n e p o s i t i o n + 77 9 + 544
Sta n d i ng u p + 765 + 563
O ptical plac i n g rea ct i o n of the h a n d s + 745
Rol l i ng o v e r from s u p i n e i nto pro n e p o s i t i o n + 743 + 40 1
Parach ute reacti o n of t h e· h a n d s + 67 1 + 62 1
H e a d l ift i n s u p i ne p o s i t i o n + 574 + 75 1
O ptical p l a c i n g reactio n of the feet + 505 + 7 77
Wa l ki ng + 493 + 794
Type of vo l u ntary g ras p i ng -554 + 94 1
S p o ntaneouS' postu re of the legs i n
ve rtical s u s pens i•o n -454 + 94 1
S p o nta neous moti l ity of the l eg s -490 + 91 3
Asymm etri c to n i c neck reacti o n , s p o ntaneous -5 1 0 + 91 0
Asymmetri c t o n i c neck reacHo n , i m posed -520 + 902
Rooti ng -438 + 824
S po ntaneous post u re of the arms -650 + 797
qoord i n ation of the u p pe r extrem ities -449 + 787
S itti ng u p -382 + 686 + 41 1
Acoustical orient i n g -395 + 685 + 399
Footso l e res ponse -551 + 679
Ra l m a r g ra s p reflex -436 + 665 + 375
M o ro l i ft, abd uction/extenS'i o n -478 + 646
M oro h it, a bdu ction/extension -668 + 636
Res pons e to p u s h against s h o u l de r, s itti ng -531 + 628
Pos•ture du ring s itti n g �492 + 50 2 + 506
F•o l l owing1 a n o bject w i t h eyes, headl a n d
tru nk, s itti n g -565 + 591
R o l l i n g o v e r from p ro n e i n t o s u p i n e position -398 + 788
D u ration of s itti n g/ -479 + 695
S ponta neous m ot i l i ty of the a rms
M o ro h e a dld rop, ad d u ction/fl exi o n
M oro l ift, adducUon/fl exion
M o ro h it, a d d u ction/flexion

1 36
vel o p menta l rate and the moment of the final change are preprogram­
med. These items reflect brai n mechanisms u nderlyi ng the develo pment
of locomotion i n s u p in e via p rone i nto vertical position. Attention m ust
be paid to the fi n di n g that isol ated rel ati onships b etween th e fi rst a n d
t h e fi nal c h a n g e do not occur, as th is i m p l ies that i n no s i n g l e i n stance
i s the development of an item depen dent o n ly on the developme ntal rate.
For fou r items of Tab l e XV no correlation-coeffi cients were com p uted .
These items are the adduction/fl exion co mp o nents of the th ree types of
the Moro reactions and the spontaneous m oti l ity of the arms. Th i s was
not done b ecause the fi rst changes of spontaneous moti l ity of the a rm s
occurred a t t h e s a m e t i m e i n t h e case o f a l l i nfa nts ; as for t h e adduction/
flexion co m pon ents of the Mo ro reactions in the majority of infants the
fi rst change consi sted of a com p l ete disap pearance. I n both i n stan ces
the developmenta l ran g e was s i m i l a r to the fi nal change, wh i ch p reclud­
ed the co m p utation of mea n i n gfu l rel ati onships.

From these p attern s of relati onships it can be concl u ded that, i n the
n o rmal developm ent of b ra i n m echanisms u n derlyi n g the respon ses eli­
cited during the n euro l o g i cal exa m i n atio n, both the develop m ental rate
and the mo ment of the l ast devel opmental change may be pre prog ram­
med , often in combination with each other, wh i l e sometimes i n the case
of identica l items various develop mental strateg i es can be fo l l owed.
These rel ationships a re cl i n ically i m portant as they prove a p rediction
of the developmental range o n the basis of the mo ment of the first d e­
velop mental change to be i m possi b l e. Th is is mai n ly due to the p repon­
derance of the relati onships between the developmental ran ge a n d the
fi n al change.

1 37
C h a pter XIV Inter-ite m rel ations h i ps

I n th i s chapter the p o ss i b i l ity wi l l be co nsi dered of fo rm u l ati ng m ea n i n g­

fu l relati o n s h i p s b etween i d entical parameters of different items and of
fou n d i n g these rel at i o n s h i p s o n a statistical analysis of the data. Fo r the
l atter p u rpose Pearson P roduct Moment co rrelati ons were comp uted and
m atri ces p roduced w hi c h m ade factor a nalysi s feasible. As the sex diffe­
ren ces were s m a l l , boys and g i rl s were taken together. The distri bution
of the scores fo r t he p a rameters cou l d b e con s i dered as being suffi ci ent­
ly sym m etrical fo r t h i s p u rpose, except the d i stri bution of i n co nsisten cies
(Appendix C), so that i n th i s case Ranko rder tech n i ques (Sp earm an
Rank) were used fo r the stati sti cal analysis.
The item s of the n eu ro l ogical exam i n ation can be grouped accord i n g
t o hypotheti cal s u b systems of t h e nervo us system , whic h refl ect the
b rain mechan i s m s u n derlyi ng the nervous fu n cti ons assessed . In the
develop i n g n ervo u s system such a d i sti n ction between subsystems is
comp l i cated b y the fact th at some b ra i n mechanisms are a prerequisite
for th e exp ressi o n of oth ers. Befo re l ocomoti o n i n prone or i n vertical
position can efficie ntly be carri ed out fo r i n stance, postural mecha n i s m s
and m ech a n i sms fo r the m ai ntenance of ba lance have t o be eleborated.
Before an i nfa nt can develop p rogression i n prone position, h e m u st be
a b l e t o l ift h i s head w he n lyi n g i n p rone. Befo re h e i s capab l e of assum­
ing a stan d i n g posture, he m u st develop balance mechan isms in o rder
to b e able to sit, w h i l e balance m ust b e elaborated even m o re befo re
h e i s a b l e to wa l k w ithout supp ort. Developm ent of sitting up s h o u l d be
p receded b y th e a b i l ity t o l ift t he head i n supine position and o rientatio n
o f t h e head i n space, and b y t h e developm ent o f t h e ab i l ity t o turn over
from s u p i n e i nto p ro n e p ositi o n , i . e. mechan i s m s fo r differentiated rota­
tion of the b ody.
Fo r the developm ent of i n dependent goal di rected m an i p u l ative activity
d i fferentiation of arm and h an d motil ity i s a prereq ui site, and one m i ght
assume th at m ech a n i s m s u n d erlyi ng palmar grasp refl ex activity o r
asym m etric ton i c n eck refl ex activity p l ay an i m po rtant ro le i n the d�vel­
o p m ent of d i fferenti ated and vo l u nta ry use of the arms and hands. Th is
wou l d mean that t he p a l m a r g rasp refl ex and the asymmetric ton i c n eck
response wou l d d i m i n i s h p reviously to, or synchro nously with, the devel­
op m ent of arb itra ry use of h and s and arms, wh i l e at the same time visual
m echanisms h ave to develop at a very ea rly period i n order to g u i de the
m a n i p u l ative behavi o u r.
Con s i deri n g the p ro ces of d evelopment parti cularly with a view to fi rst
developmental c ha n ges, one m i ght assume a rel atio nship between the
fi rst changes of sitti n g , standi n g and walki ng and other items dea l i n g
with t h e b ra i n m ech a n i sm s i nvolved i n t h i s type of m otor behaviour, i . e.
p ostu ral m echan i s m s and bala nce. Th us there m i ght be a cluster co nsist­
i n g of the fi rst changes of sitti n g , wa l k i n g and standing, p l ac i n g reac­
tions, footso le response, rol l i n g i nto p ro n e and b ack, head l ift in s u p i n e
positi on , posture i n p ro n e position and l ocomoti o n i n prone.

1 38
There m i g ht also be a c!uster of the fi rst chan ges of items deal i n g with
the developm ent of m a n i p u l ative i . e. goal d i rected motor behavi o u r, i n ­
vo lvi n g t h e palmar g rasp refl ex, type of vo l u ntary grasp i n g , coordi na­
ti on of th e upper extrem ities, goal d i rected moti l ity of the arms and
hands, an d asymmetric to n i c neck res po nses.
Relationships betwee n the first changes ca n n ot b e expected fo r al l the
items. Items such as speech, rooti ng and acoustical orienti n g cannot
eas i ly be fitted i nto other g roups of items. One may expect the fi rst
changes of the Moro resp onses to be related, as they reflect devel op­
mental chan ges i n one m echanism, but a rel ati o n s h i p with other items is
not l i kely, except i n the case of spo ntaneous motil ity of the arm s.
As fo r the mo ment of the l ast develop mental changes (i . e. the final chan­
ges) an alogous clusters of items may be assu med to exist; with in these
clusters s u b groups m ay be found (fo r i nstance ba lance during sitti n g ,
m otor behavi our i n prone pos iti on, motor behavi o ur wh i l e standing) re­
flecti ng the differenti ation of the devel o p i n g b ra i n mechanisms for pos­
ture, ba lance and locom oti o n. As stated above, rel ati onships between
the fi rst changes and relationships between final chan ges wou l d not be
unexpected as these param eters i n d i cate the m aturation o f b rain mecha­
n i sms on the time scale. As was exp lai ned ab ove, some b rain mecha­
nisms m u st have developed before others can start to ach ieve expres­
sion. These rel ati onships may be rel atively l ow due to the variabil ity i n
development characteri sti c fo r a normal nervous system ; sti l l , they
should not be n eg l ected .
As fo r the developm ental rate, expressed in the l ength of the devel op­
mental ra nge, rel ati ons ca n n ot b e p redi cted so easi ly. The devel opmen­
tal rate of b rain mechanisms may vary co nsi d erab ly depen dent on the
degree to wh ich the first and/o r the fi nal change are fi xed. As has bee n
shown i n ch apter XI I I , the i nterdepen dency of the develop mental rate
and the moments of the fi rst and the final chan g es is very com p l ex, i ntra­
as wel l as i nter- i n d ividual ly.
Therefo re one may assume the n u m ber of rel ati onships between items
with regard to the devel o pmental range to b e smal l , and the rel ation­
s h i p s, if p resent, rath er l ow.
The statistical ly signifi cant rel ati onships (p < 0.01 ) between fi rst ch �n­
ges, fi nal chan ges and developmental ranges respectively are present­
ed in appendices E, F. and G .
First change
As for the fi rst change (Appendix E) a cl uster of i tems can be observed
wh ich concern sitti n g , crawl i n g, sta n d i n g and wa lki ng. Rol l i n g and the
optical p l aci n g reaction of the feet are also i n cl u ded i n thi s cluster: the
footso l e response, h owever, is not. On facto r an alysis it appears t h at
this g roup of items accou nts fo r 22 °/o of the vari ance of the materi al .
Other large clusters are not evi dent. As for the items dea l i n g with the
development of m a n i p u l ative motor activity, cl usteri ng is m erely reflect­
ed by the in terrelati ons of the coo rdi n ation of the upper extrem ities,

1 39
goal d i rected a rm a n d ha nd m oti lity, and typ e of vo l u ntary g ras p i n g . The
fi rst ch a n g e of the p a l m a r g rasp reflex is conspicuously absent i n th is
small c l u ster, which m eans that a decrease of palmar grasp refl ex ac­
tivity is not a p rereq u i site fo r the development of goal di rected and m a­
n i p u l ative m otor activity of the arms a n d ha nds. As was to be expect­
ed, th e rel ati o n sh i ps are rather weak, with the excepti o n of th e i nterrela­
ti o n s h i p s of item s d ea l i n g with sitti ng behavi o u r, which, h owever, are
conta m i n ated as a resu lt of their operati o na l i zati o n. There i s a strong
rel ati o n s h i p b etween stan d i n g and wal ki n g ; thi s i s not su rp ri s i n g as both
items reflect the co n c l u s i o n of developm ental sequen ces in co n nection
with the m atu rati o n of postural and balance mecha ni sms i n i nfancy. I n
thi s carefu l ly sel ected g roup o f l ow ri sk i nfa nts, which i s a lso rather ho­
mogeneous with reg a rd to envi ron mental and social co nditions, the ma­
jo rity of the weak (a lth o u g h statisti cal ly sign ifi cant) rel ati o n s h i p s i l l u­
strate the vari ab i l ity of the h ealthy nervo us system .
I n the case of n i n e items th ere were no i nterrelati o n s h i p s of the fi rst
ch anges. (Tab l e XVI ) . N either speech nor acoustical o ri enti n g showed
a s i g n i ficant rel ati o n s h i p with any other ite m . These items can be re­
garded as b e l o n g i n g to a separate category, in which m ental p rocesses
are i nvo lved , d ifferent from the sensori m otor devel opm ent represented
by the other items.

TABLE XVI
Items without any s i g n ificant relations h i ps (p < 0.0 1 ) with regard to
fi rst changes.
vocali zati o n and speech
acoustical o rienti n g
spontaneous p ostu re o f t h e l egs in vertical suspensi o n
spontaneous h ea d l ift i n sup i ne
sitti n g u p
foot s ole response
p a l m a r g rasp refl ex
p arach ute reaction of th e arm s
M oro h it abducti on/extension

The absence of s i g n ifi cant and mea n i n gful re l ati o nshi ps between res­
p onses l i ke th e p a l m a r g rasp refl ex, the footsole response and the M o ro
reactions on the o n e ha nd and fu ncti o n a l m oto r developm ent o n the
oth er h a n d i m p l ies that it i s h a rdly poss i b l e to predi ct the o n set of the
deve l o p m ent of m otor fu n ctions on the basis of changes as in these re...
acti o n s . The absence of a s i gn ificant rel ati o n sh i p b etwee n th e first
change of th e p a l m a r g rasp refl ex and the first occu rrence of vo l u ntary
g rasp i n g (" p a l m a r g rasp typ e") or of fu n ctio nal arm/hand m oti l ity (" l ook�
i n g at a n d p l ayi n g with the h ands") s u g gests th at the d i ssol uti o n of
the fo rm er does not affect the development of the l atter to a l a rge ex­
tent.

1 40
Final change
As Appendix F shows there were ma ny i nterrelati o nshi ps between the
fi n al chan ges with rather l ow correl ati o n-coeffi cients. The g roup of i tems
dea l i n g with g ross m oto r fu n cti o n i n g (crawl i n g , sitti n g , standi ng and wa l k­
i n g) appears as a m ajor cl uster; thi s cl uster reflects the integrati on of
postu ra l mechanisms and bal ance with vo l u ntary gross motor activity
duri n g m aturation.
The h i g hest correlatio n-coeffi cients are fo u n d i n the relationships be­
tween ful ly devel oped balance reactions (the items "fo l l owi ng of an ob­
ject with the eyes, a n d rotation of the head and tru n k d u ri ng sitti n g " and
" response to push against the sho ul der duri n g sitti n g ") and steady sitti n g
(th e items " sitti n g u p " , " posture during sitti n g " a n d " d u rati on o f sitti n g").
The items " stan d i n g u p " , "walki n g " , " postu re of the legs i n vertical
suspens i o n " , " o ptical placing of th e feet", " pro ne position" and " l oco­
m otion i n p rone positi o n " b e l o ng also to this cluster, .the height of the
co rrelation coeffi ci ents varyi n g . lt i s not surp ri s i n g that the fi nal score
fo r " spontaneous motil ity of the legs" (i.e. vo l u ntary and arb itrary moti­
l ity) is in c l uded in this cluster. " H ead l ift in su p i ne position" and the
qual ity of the footsole response can be co nsi dered to contri b ute to this
cl uster i n varying degrees. Also vo l u ntary i . e. arb itrary ro l l i n g behaviour
correl ates with the m ajo rity of the items mentio ne d. On facto r an alysis
this cl uster is rep resented in one facto r, accounti n g fo r 29% of the
variance.

A smal cl uster consists of the fi nal changes (i . e. dissol ution) of the Moro
reacti on , wh i ch is i n dependent of the l arge cl uster of vo lu ntary m oti lity.
Thi s s m a l l cl uster accou nts for another 1 O% of the variance.
In the secti on on th e devel opm ental course of the Moro reacti ons the
significance of the low va l u e of the correlati on-coefficients has been d i s­
cussed. There is n o separate g roup of items assessing m a n i p u l ative
motor activity. O n ly an isol ated rel ationship b etween the dissol ution of
the palmar g rasp refl ex and arbitrary arm/h and postu re was fou n d . Th i s
rel ation sug gests an i nterp l ay b etween t h e developm ent o f arb itra ry a n d
i n depen dent u s e of arms and h a n d s and t h e devel o pmental cou rse o f the
palmar g rasp reflex. No relati onship was fou n d b etween the di ssol uti o n
of the palmar g rasp refl ex a n d the matu re type of grasp i n g (p i n cer
g rasp) .

The m atu rati on of type of vo l u ntary grasp i n g and coordination of the up­
per extrem ities sh owed a rel ati o n s h i p with the fi na l change of sitti n g ,
sta n d i n g and walki n g , wh i ch reflects t h e i nteg rati on o f brain mechanisms
requ i red fo r m a n i p u l ative moto r behaviour with b rain mechan isms on
wh ich g ross moto r behavi o u r i s based. There were only five items wh ich
d i d n ot have a s i g n ificant rel ati o nshi p with any of the oth ers. They are
l i sted i n Tab l e XVI I .
Amo n g them are the items speech, acoustical orienti n g and, surpri si n gly,
goal-di rected m oti l ity of the arms and hands.

1 41
TABLE XVI I

Items without any s i g nificant relationships (p < 0.0 1 ) with regard to

final changes.

voca l i zati on and speech

acou sti cal o rienti ng
goal d i rected motil ity of t he arm s
asym m etri c to n i c neck reaction, spontaneous
asym m etric ton i c nec k reacti o n , i m posed.

As m entioned above , speech and acousti cal o rienti n g may perhaps be

regarded as b e l o n gi n g to a sep arate category wh en com pared with " pu­
re" sensori m otor developm ent. To some extent the same can be said of
the deve l o p m ent of goal di rected m oti l ity of the arms and hands.

Severa l auth o rs h ave reported that the i nfa nt' s development during th e
fi rst year of l i fe, wh i ch is appreci ated m ai n ly i n terms of sensori m otor
deve l o p m ent, i s rel ated o n ly weakly to the devel opm ent i n later l ife,
wh ich is m ai n ly app reciated by " m e nta l " criteria (Rutter (1 970) ; H i n d l ey
(1 960) , Knob loch an d Pasamanick (1 963)) . The fi n d i n g that the three
item s s peech , acoustical orienti ng and goal-di rected motil ity of the
arms and hands d i d not show any sign ifi cant rel ati onship with oth er
item s , i s i ntri g u i n g , a s these items may partly refl ect m ental developm ent.
lt wou l d b e worthwh i l e to exp lore the i r rel ati o n with the futu re menta l
d evel o p ment, wh i l e th ei r i nterrel ati o nshi p s - which were appreciably
low i n the p resent study - shou l d a l so b e_ scruti n i zed.

l t i s notewo rthy that the moment of a co m p l ete d i ssol ution of the asym­
m etri c to n i c n eck rea ctions d i d not show a s i g n ifi cant re lati onsh i p with
any oth er ite m . C l i n i ca l ly, this fi n d i n g is i m po rtant, as after a certa i n age
th e p resence of asym metri c to n i c n eck patterns is often co nsi dered as a
s i g n of deviant deve l o p m ent, or even as an ea rly s i g n of the develop­
m ent of cerebral pal sy. When th e wide vari ati o n range of the dissolution
of the asym m etric to n i c neck reacti ons and its isolation with regard to
interre l ati o n s h i p s with other items, is taken i nto accou nt, the c l i n i cal
va l u e of th i s s i n g l e fi ndi n g i s rather smal l . Yet, path o l o g i cal asym metri c
to n i c n eck refl exes s h o u l d be d i sti ng u i shed from the asym metri c ton i c
n eck reacti o n s n o rmally p resent. Besi des, i n a pathological nervo us
system oth er relati o n s h i ps between (pathological) signs can be expected
th an in the case of a hea lthy nervous system .

Developmen tal ran g e

Appen d ix G p resents t he rel ati o nshi p s between the developmental
ra n ges, which are stati stica l ly si gn ificant (p < 0.01 ) . Actual ly, the num­
ber of s i g n ificant rel ati onships is small. O n e sma l l c lu ster of items can be
observed with reg a rd to sitti n g behavi o ur. As is stated above, howeve r,
the fi rst chan ges in these items were conta m i n ated due to th eir operati o-

1 42
n a l i zati on , which m ay acco u nt for part of the re l ati o n s h i p s b etween the
develop mental ran g e s . Mo reover, it is evident that in these i tems com­
parab l e b ra i n m ech a n i s m s are i nvo lved. Th ere are no other evidently i n­
terrel ated g roups of item s , which m eans that the developm ental rate of
various b ra i n m ech a n i sm s i s rel atively i n dependent a n d m ay vary con­
s i derab ly. From a cl i n i cal p o i nt of view thi s means that in n o rm al i nfants
no prediction can be m ad e with regard to the d evelopm ental rate of o n e
n ervou s fu n cti o n o n t h e basis o f the developmental rate of another n er­
vous fu n ct i o n . Th i s i s i l l u strated by the c l i n ical ly wel l known fact that i n
some i nfants s o m e n ervo us fu n cti ons appear to develop faster than
oth ers, wh i l e the oppos ite may happen in other i nfants. In dam aged i n­
fants, h owever, a p rediction of th e d evelopm ental rate can often be
made on the basi s of fi n d i n g s refl ecti n g parti cular devi ant b ra i n m echa­
n i sms. Vari ab i l ity i n devel opmental rate can be co n s i d ered as an i n di vi ­
dual characteri sti c of healthy i nfa nts, wh i l e i n dam aged i nfants th i s vari­
a b i l ity m ay be l ost.

El even item s of the tota l n um b er of th i rty-one d i d n ot sh ow a s i gn i fi cant

correlation with any other item (Ta b l e XVI I I). Th e negative (low) correl a­
tion-coeffi ci ent b etween the developmental ra n g e of speech a n d posture
of the tru n k duri n g sitti n g can hard ly be exp l a i n ed and may perhaps be
attrib uted to accidental arithm eti cal co i n ci den ce. If we take th i s fo r grant­
ed, we fi n d agai n that the th ree fu n cti o n a l items "s peech", " aco u stical
ori enti n g" an d " goal d i rected m otil ity of arms and han ds" do not show
an evi dent coh erence with the d evelopmental ran g e of other items .

TABLE XVII I
Items without any sig nificant i nterrelationships (p < 0.01 ) with regard
to developmental ranges.

acousti cal orienti n g

goal-di rected mot i l ity o f t h e arm s
voca l i zati o n a n d speech
spontaneous moti l ity of the arms
sponta n eous postu re of th e l egs
ro l l i n g fro m su p i n e i nto p ro n e position
ro l l i n g fro m p ro n e i nto su p i n e position
wal k i n g
palmar grasp refl ex
asym metric ton ic n eck reaction, spontaneous
asym m etric to n i c n eck reaction, i mposed
Moro h eaddrop, abductio n/exte n s io n

1 43
I n co nsistencies

I n con s i stencies were defi n ed as relapses i n sco re, i rresp ective of the
l en gth of the period of ti m e during which the relapse occu rred. Thi s
m ea n s that if the scori n g-scal e of the i n d ividual items is assumed t o re­
fl ect the d evelopm e nt of the item respo nses in ti m e, there is a reg res­
s i o n to a p revi ous typ e of response, i . e. belongi n g to a yo u n ger age. I n
t h e m ajority o f i n st ances such a reg ression was observed during one
exa m i nati o n o n ly; i t was often fou n d that at the fol l owi n g assessm ent
the i nfant exceeded the sco re that h e had obtai ned before the regres­
s i o n , i . e. he had cau g ht up com p l etely.

12-15
Number of inconsistencies

F i g . 46:

The freq uency-d i stribution o f the tota l number of inconS'istencies, occu rring i n
a l l ite m s of g ro u p I l l taken together.
Vertical axi s : number of i nfants with i ncons iste n c i es.

1 44
TABLE XIX
The nu mber of i nconsistencies and the number of i nfants with inconsis­
tencies of the items of group I l l .
T h e items are ordered accord i n g t o t h e n umber o f inconsistencies p ro
item, and, withi n these g roups, accord i n g to the number of infants dis­
p layi ng i n consistencies.
N u m ber of i nfants Total n u m ber
Name of item with of
i nco nsistencies i nco nsisten cies

Stan d i n g up 2 2
Wal k i n g 2 2
Response to push, sitting 4 4
Aco ustical ori enti n g 6 6
Spontaneous motil ity of the arms 7 7
D u ration of sitti n g 7 7
Vo cal ization and speech 8 8
Optical p l aci n g reaction of the ha nds 8 8
Fol l owi n g of an object with the eyes,
head and trunk, s itti n g 9 9
Rol l i n g over from s u p ine i nto p rone 4 5
Spontaneous head lift :i n s u p i n e 6 7
Postu re of th e tru n k, sitti n g 10 11
Pal m a r g rasp reflex 12 13
Moro, h eaddrop, addudio n/flexion 11 13
Spontaneous postu re of the arms 12 13
Optical p l acing reaction of the feet 14 16
Asym . to n i c n eck respo nse, i m posed 17 18
Moro, headdrop, abductio n/ext. 19 20
Type of vo l untary grasp i n g 21 22
Goal-di rected m oti l ity o f the arms 22 24
Rol l i n g over from p rone i nto su p i ne 12 15
Locomotion i n p rone 23 27
Sitting up 26 31
Spo ntaneous motility o f the l egs 24 36
Coord i n ati on of the u pper extr. 27 36
Moro, h it, abduction/extension 28 37
Rooti n g 29 54
Moro, l ift, adduction/flexion 30 37
Asym . to n i c n eck response, spont. 30 38
Moro, li ft, abd uction/exten sion 32 46
Parach ute reaction of the hands 33 48
Spo ntaneous postu re of the l egs 38 52
Moro h it, adductio n/flexion 38 59
Footsole response 39 79
Postu re of head, tru n k an d arms i n
p rone position 40 59
Spontaneous postu re of the legs i n
vertica l suspen sion 48 1 13
1 45
Fi g . 46 shows th e freq uency d i stri buti o n of the total nu mber of i nconsis­
tencies wh iqh occ u rred in the items of g ro up I l l i n the total gro u p of i n­
fants (see also Appendix J). The peak frequencies are fo u n d between
sixteen a n d twenty-th ree i n c·o nsi stencies ; i n six infants eleven i n cons is­
tencies occu rred, and i n two i nfants twenty-ei ght or twenty-n i n e i n con­
s isten cies were fou n d . However, the eleven i nconsistencies which oc­
cu rred i n six i nfants were not i d enti cal . Altho u gh it was poss i b l e to o r­
der the items of gro u p I l l accord i n g to the n u m ber of i nconsistencies oc­
curri n g d u ri n g deve l o p m ent (Ta b l e XIX), and to o rder the i nfants accord­
ing to thei r ten d e n cy to d i s p l ay i n cons istencies, there was no rel ation­
ship b etween i nfants and items. Fo r i n sta nce, i n some of the six i nfants
who had e l even i n co nsi stencies, i nconsistencies appeared in items i n
which n o i nconsistencies were fou n d i n the case of the two i nfants who
showed most i nco n sisten cies. Th ere was no s i n g l e i nfant without any
i n co n s i stency i n one item o r a nother, neither were there any i nfants who
showed in c o n s isten c i es i n al l the item s.

H ow can i n co n s i stencies b e accounted for?

1 . I n co n s i stencies m ay be due to p ro b l em s of standardizatio n and ope­
rati o n a l i zati o n . Alth o u g h for the m ajority of reflexes and reactions
th e developm ental sequence of respon se-patterns cou l d be defi ned
�efo rehand, fo r spontan eo u s m oti l ity and posture this sequence had
to b e defi ned o n the basis of the observati o n s . Thus one m i g ht expect
th e n u m ber of i n co n si stencies be l arger in the case of spontaneous
m oti l ity and posture. Tab l e XIX sh ows that this i s not always the c ase.
Th e n u m ber of i n co nsi stencies i n fo r i nstance the item " spontaneous
m oti l ity of the arms" i s l ow, wh i l e it is m uch larger i n the item " spon­
taneous posture of the l egs i n verti cal suspensio n " . The number of
i n con s isten cies d u ri n g the develop ment of fo r i n stance th e footsole
response or t he rooti n g refl ex is also cons i derable, whi l e it i s m uch
s m a l ler in fo r i n stance the p a l m a r grasp refl ex.

2. lt is poss i b l e that the n u m ber of i nco nsistencies i ncreases on a pa­

ra l l el with th e d evelopmental ra ng e. Actua l l y the occu rrence of an
i n con s isten cy, i . e. a re lapse in sco re, postpones the mo m ent of the
fi n a l change and thus p ro l o n gs the developmental range. Conse­
q uently the l en gth of the developmental ran g e cannot accou nt fo r the
occurrence of i n co nsi stencies. O n ly in the case of a fixed deve lop­
mental range, i . e. a close relationsh i p b etween fi rst and fi n al ch an ge,
the i n consisten cies cannot p ro l o n g the developmental ran ge. Such
exclusive rel ati o n s h i p s were not fou n d i n the p resent gro u p .

Appen d ix H p resents the corre l ation-coeffi cients (Spearm an R a n k

Co rrel ati o n s) of stati sti cal ly s i g n ifi cant rel ati onships ( p < 0.01 ) be­
tween the n u m b er of i ncons istencies and the developmental ran ges.
In twe lve item s such a rel ati o n s h i p was fo u n d . The majority of the
items concerns respon ses which d u ri n g thei r developm ental cou rse
g radu a l ly m erg e i nto vol u ntary moti l ity (e. g . p l acing and parach ute

1 46
 reacti ons, rooti n g , asym metri c to n i c neck respon se). Some others are
activity-or state-depe n dent, such as the Mo ro reactions which are
easi ly i n h i b ited by vo luntary motor activity. I n the case of the few
i nstan ces of " spo ntaneous" moto r behaviour (ro l l i ng, type of vol un­
tary g rasp i n g and coo rd i nati on of upper extrem iti es) the occu rrence
of i nconsisten cies may a l so be state dependent. Therefo re, rather
than m erely depen dent o n the length of the developmental ran ge,
it is very wel l poss i b l e that the i nco nsistencies depend on the
behavi o u ra l state of the i nfant d u ri n g the assessm ent.
The occu rrence of i n consistencies, wh ich m ay cause a p ro l o n gati o n
of the devel op m ental ran ge, may also refl ect the strain u n der which
the neurons operate. Th us the i nconsisten cies wo u l d refl ect rel apses
of neuro n a l fun cti o n i n g, as a resu lt of tem po rary fai l i n g d u ri n g the
m aturation of b rai n-m ech an isms.

3. McG raw (1 943) drew attention to the fact that the vari ous co nsecutive
p h ases of th e developm ent of functi ons reflecti n g " neurom uscular
m atu ratio n " sh owed co nsi derab l e overlap. Th i s m eans that d u ri n g
o n e s i n g l e exa m i n atio n responses c a n be o bta i ned which belon g to
vari ous developm ental p hases. Consequently a response obta i n ed
at a parti cular assessm ent may be acci denta l to a certai n extent, as
the i nfa nt can display various respo nses at one p arti cular age, i . e.
duri n g one s i n g l e assessm ent. McG raw s h owed that this overl ap of
p h ases could extend over weeks or months. If seen i n this context,
th e i nconsistencies may be co nsidered as artifi ci a l , i.e. depen d i n g on
the (acci denta l) mo ment of exa m i n ation a nd observati o n.

4. Fi n a l ly, the i nco nsisten cies may refl ect the q u a l itative variabi l i ty o f
the nervous system duri n g developm ent. T he data of fi gu re 46 a nd
Tab l e XIX su g gest t ha t the occu rrence o f i n consistencies i s charac­
teristic of both i n d ividual items and i nd ivi d u al i nfants, without an
evident rel ati o n s h i p b etween these two characteri stics. Therefo re
the p resence of inconsi stencies may also be co nsi dered as resu lti n g
fro m the va ri a b i lity p roper t o t h e healthy o rgan i s m .
Theoretically, no specific clusters o f items c a n be expected with regard
to the occurrence of i n co nsistencies. Mo reover, the vari ab i l ity of thei r
occu rrence p ro item and p ro i nfa nt is so l arge and unsystematic that a
com putati on of relationships wou l d hardly give any m ean i n gful resu lts.
Th is is co nfi rm ed by the rank o rder correlation (Spearman Rank Co rre­
l ation). Th ere were l ow, b ut i so l ated rel ationsh i p s b etween ab out half of
the items, but a systemati c coh erence was not fou n d . lt appears that the
occurre nce of i n co nsisten cies depends on the typ e of item ; furtherm o re
they appear to occu r more or l ess random ly.

The p racti cal co nsequence of the occu rrence of i nco nsisten cies i s con­
siderabl e, because they i ndicate that the res u lts of a s i n g l e assessment
cannot be regarded as refl ecti n g the p roper neuro l o g i cal co nd ition of an
i nfant unequ ivocal ly.

1 47
C h apter XV D i scussion a n d concl u sions

Th e nervous syste m c a n be consid ered as an i nfo rm ation p rocess i n g

apparatus wh i c h c o n s i sts o f a com p l ex set o f brai n mecha n i s m s . To
q u ote Prechtl (1 970) : " lt ( i . e. the nervous system) receives, conducts,
tran sfo rm s, co m p a res and generates m essages. In the deve l o p i n g ner­
vo us system th e o perations of the nervo us system at each developmen­
tal sta ge are adapted, as a res u lt of the h i stori cal processes of evo l ution,
to the i ntern a l and external conditions of the organ i s m " . I n th i s conno­
tation a b ra i n m echanism is defi ned as a netwo rk of neurons and syn ap­
ses, wh i c h co n s i sts of subrouti nes fo r specifi ed nervous activity. Usi n g
terms from co m p uter tech n o l o gy, once can say that a bra i n mech a n i sm
(or n e u ra l m ec h an i sm) p resup poses the presence of " h ard-wa re" , and
at th e same t i m e i m p l ies op erative "soft-ware" . One may gai n i n si ght in
the org a n i zati o n of these m echanisms d u ri n g their maturati o n by study­
i n g the developm ental changes occu rri ng i n thei r (m oto r) output.
Th e q u esti o n ari ses whether matu rati on and o rgan i zati o n of neura l me­
chan i sm s take p l ace i n accordance with a fixed ti me-schedu le , as hap­
r;>ens in m oto r b e h avi o u r, whi c h in general develops acco rd i n g to a ra­
ther reg u l a r seq u en ce. If th i s were the case, neu ral mecha ni sms req u i r­
ed for fu n cti o n s w h i ch develop early, wou l d m ature fi rst and i n due
cou rse they wo u l d b e fol l owed by mecha n i sms needed fo r fun ctions
wh i ch appear l ater. Th i s vi ew has been fo rwarded by Anokh i n (1 964) .
lt i s also poss i b l e that the vari ous neura l mech a n i sm s mature with wide
overl ap, or even sync hronously, but that the ir output becomes app arent
in a m o re or less fixed sequence of ti m e, depen dent o n the period of
t i m e n eeded fo r th e i nteg ration o r l i n k ing together of previ ously sepa­
rate modu l es . Fi n a l ly, there m ay be a com b i n ation of these two proces­
ses. In th i s connotation the term " m aturati o n " m eans the stru ctural cq.
m o rp h o l o g i cal chan ges which occur in the nervo us substrate d u ri n g
ontogeny a n d w h i c h are based on an i ntri cate i nterp lay between genetic
and envi ro n me ntal factors. In order to answer the qu estion mentio ned
above, a set of ite ms has been sel ected belon g i n g to the neuro l o g i cal
assessment d u ri n g i nfancy, which descri be the developmental expan­
sion of the i nfant's neuro l o g ic a l reperto ry.
Th e items co u l d be d ivided i nto fo u r g roups.
Th e fi rst g ro u p conta i n s those items wh i ch d i d not sh ow any substanti a l
chan ges from b i rth onwards. T h e seco nd gro u p conta i ns items w h i ch
developed rap i d ly. The th i rd gro up conta ins item s which showed a pro­
tracted but d i sti n ct develop mental course, wh i l e in the fo urth gro u p are
p l aced those ite ms which showed either an i n di sti nct devel opm ental
course, so that a f i n a l predefi ned l i m it of development cou l d not be de­
term i n ed u n e q u i vocal ly, o r a p rotracted developm ent exceed i n g the
period of the fo l l ow-u p , whi ch , fo r p ractical reasons, was ended at the
m i l esto n e of wal k i n g free.
The i tems of g ro u p I did not show any notab le chan ges fro m the fi rst
exam i n ation o nwards. From th i s one may co n clu de that thei r neura l me-

1 48
 chan isms are suffi ci ently m ature at b i rth . These m ec h anisms can be seen
as basic for the fu rther developm ental differenti ation of nervo us functi­
.on i n g.
As fo r the items of g ro u p 11, which showed a rap i d developmental co urse,
th eir fi n al sta b il izati o n took p l ace after a short peri od of ti me. Th i s
means that thei r n eu ra l m echanisms m ature rap i d ly. These items c a n be
consi dered t o b e b ased o n neural mechanisms which form an elaborati on
and expansion of the m ech anisms of the items of g ro u p I .
Undoubtedly, the fu n ctional exp ression o f these mechanisms is o f pri,.
mary importan ce for the i nfa nt' s sub seq uent development. To give an
example, the items deal i n g with the visual apparatu s refl ect a fu nctional
differentiation of this apparatus which i s a p rereq u isite fo r an adequate
developm ent of m otor patterns l i ke grasp i ng , sitti ng, crawl i n g and wal k­
in g .
Thus group I and 1 1 rep resent neural mechanisms who se m aturati o n
m ust take p l ace befo re other m ech anisms can p roperly man ifest them­
selves, and wh ich m ay even b e consi dered as a p rereq u i s ite fo r the ma­
turati on of the latter. Th i s does not i mp ly that ne ural mechanisms fo r
e.g. g raspi n g or pro g ression i n p rone position cannot develop when the
neural m echanisms un derlyi n g vi sual fu ncti ons for i n stance are deficient.
lt i s a wel l-known fact that b l i n d i nfants develop grasp i n g and crawl­
ing pattern s . H owever, these moto r patters develop differently from
those i n i nfa nts with a wel l developed vi sion. This example i l l ustrates
the m o u l d i n g effect of o n e neura l mechanism, or of th e expressions of
one mech a n i s m , on the subsequent devel opm ent of other mechan isms.
A special rem ark m ust be m ade about the " step p i n g m ovem ents" of the
very you n g i nfant. This motor p attern, based on a spinal coordination
mechanism, disappears i n the fi rst mo nths of l ife b ut reappears at wal k­
i n g age. lt seems h i g hly i m p robable that the neura l mechanism which
i s respon s i b l e fo r the step p i n g movem ents dissolves com p l etely, o n ly to
reappear at a l ater age. lt is mo re l i kely th at this m echanism becomes
dom i n ated by m ech anisms u nderlyi ng other motor patterns, such as
sym metrical and asym metri ca l flexi on and extension movem ents of the
l egs, wh ich appear at about the age when the " step p i n g movements"
va nish (cf. fi g . 7 , 9, 1 0). D uri n g this period of d o m i n ation of th e ori gi na l
spinal m echanism b y other m ech anisms (wh ich serve the differentiatio n
of l eg m oti l ity), t h e s p i na l m ech anism is i nco rpo rated i n mo re comp l ex
mech an is m s wh ich fi n a l ly resu lts i n vo l u ntary and variable wal king pat­
tern s. lt goes with out sayi ng that also the mech anisms fo r asymm etri cal
and sym m etrical leg m otil ity which tem porari ly repl ace the stepp i n g pat­
tern , are i ncorp o rated in this fi nal o rganizati o n of b ra i n mecha n isms fo r
wa l k i n g .
A s for th e items of gro u p I l l and IV, wh i ch showed a p rotracted develop­
mental co u rse, genera l ly thei r fi nal sta b i l izati o n takes p l ace after a con­
siderab l e peri od of time. Some items of g roup IV had not yet becom e
stab i l ized at th e close of the fo l l ow-up.
The rem a i n der of the items of g roup IV, i . e. th e items which reached
thei r fi n al sta b i l i zatio n b efore the mo ment of wa lking free, g radually

1 49
 m erged i nto vo l u ntary motor patterns, so th at it was impossi b l e to indi­
cate the m o m ent of fi n al stabi l izati o n o n the tim e-sca l e. Thi s was not
the case with the i tems of g roup I l l , fo r which an evi dent fi n a l change
or fi n a l sta b i l izati o n could b e defi ned. Th us the neural mechan isms
wh ich achieve exp ression i n the items of these two g roups, show a
p rotracted d eve l o p m enta l cou rse, which is not necessari ly fi ni shed at
the age of walki n g free (th i s co nfi rm s the arbitra ri ness of the age of
wa lki n g as the end of the fol l ow- up (cf. chapter 1 1)). D u ri ng this
d evelop m enta l cou rse va rious p rocesses take p lace. In some items
th e g radual deve l o p m ent of a m otor behavi ou r i nto its fi na l fo rm su g­
g ests a sm ooth a n d s l ow integ rati o n of its u n derlyi n g neura l mechanism
i n to m ore com p l ex m echan i sms. Th i s is for i n stance the case with tacti le
p l ac i n g of the feet o r the positive supporti n g reaction. I n others there
i s a m o re abrupt c ha ng e of response-type, as ha ppens, fo r i n stance, i n
the items d escri b i n g the mai ntenance of bal ance (e. g . response to push
d u ri n g sitti n g) a n d the o ptical p laci n g reacti ons. Thei r u nderlyi n g m e­
ch a n i s m s seem to ach ieve exp ression as soon as they h ave matured
suffi ci ently, i rrespective of th ei r rate of matu rati o n .
I n oth er item s different b ra i n mecha ni sms seem t o b e i nvo lved i n the
fi n a l sta b i l ization . I n this con n ecti on it is noteworthy that the fi nal chan­
ges of sitti n g up, stan d i n g and walki n g are closely co rrel ated. As l o n g
as these m otor activiti es need extern al support, t h e i r neural mecha ni sms
m ai n ly consist of the reg u l ation o f active power. I n sitti n g u p , sta n d i n g
o r wa lki n g i n depen dently neural m e c h a n i s m s fo r t h e ma i ntenance o f
bal ance m ust be i nvo lved . T h e development o f equi l i b ri u m reactions,
such as response to push against the sho u l der, o r vi sual fo l l owi n g an
obj ect with rotat i o n of h ead and tru n k duri ng s itti ng, shows that the
m aturati o n of n e u ra l m echanisms fo r b a l ance takes p lace at about the
same ti m e as the m atu rati o n of the neural m echanisms fo r the moto r
p ro g rammes req u i red fo r sitting up with hel p . Here is an exa m p l e of
variou s m o d u les which develop mo re or less i ndependently from each
other at about the sa me time, but w hi ch a re l ater l i n ked together.
Wh i l e in the case of the items of g ro u p I and g ro u p 1 1 there seems to be
a ti m e sequence in the m aturati o n of b ra i n m ech a n i s m s , in the case of
m an y items of gro u p I l l and IV th ere seems to be a contem p o rary matu­
rati o n of b ra i n m ec h a n i s m s wh ich may ach i eve exp ressi o n consecutively.
Th e d issol uti o n of the p a l m a r g rasp refl ex fo r i n stance takes p lace at
about th e same ti m e as the begi n n i n g of the developm ent of vo l u ntary
g rasp i n g , which m i ght i m p ly that a dissol ution of the p a l m a r grasp reflex
is a p rereq ui site fo r the developm ent of vo l untary grasp i n g . Yet the fi nd­
i n g s show that a p a l m ar g rasp reflex and the i n iti al type of vo l u ntary
g ras p i n g m ay co i n ci d e ; the rel ati o n s h i p b etween the dissol ution of the
form er a n d the fi rst appearance of the l atter was appreciably low. Thus
the n e u ral m ech an i s m s on which these items a re based m ay operate at
th e same ti m e with out being causal ly rel ated.
If b ra i n m echan i s m s m ature i ndependently d u ri n g the same period of
time, it m ay b e argued that the morp h o l o g i ca l m aturatio n of vario u s p arts
of the nervo u s system also takes p l ace i ndependently. Th i s hypoth esis

1 50
 is supported by an analys i s of the l ate r phases of the developm ent of
vol u ntary gras p i n g , i . e. the seq uence of sci ssor-type via i nferio r p i ncer­
typ e and p o i nting, to p i ncer-type. This typ e of vo l u ntary grasp i n g rep re­
sents differenti ated use of the ha nd and fi ngers, i .e. fi ne m a n i p u l ative
moto r activity; it is a co rti cal fu ncti o n, wh i l e the oth er types of gras p i n g
are o f non-cortical o ri g i n (see p a g e 56). T h e p hase o f " p o i nting" ap­
pears to b e a rather i n cap acitat i ng and u p setti ng period of development
fo r many i nfants, in which obviously oth er g raspin g-types do not occu r.
lt can be reg arded as the period during which the vari ous m odu les are
l i n ked togeth er. If th i s hypothesis is co rrect - experi ments with rhesus
m on key i nfants p o i nt in thi s d i rection - the devel opment of vol untary
g rasp i n g is an i l l ustration of the i ndependent maturation of b rain mecha­
nisms b ecause th eir u nderlyi n g neural stru ctures deve lop rel atively i nde­
pendently of each other.
As for the q u esti on raised at the beg i n n i n g of th i s ch apter, at least three
types of neural m echanisms can b e d i sti ng u ished. Fi rstly there are those
mechanisms whi ch are p resent at a very early stage of the i nfant' s de­
velop m ent. They are regarded as a p rereq uisite for further development.
Exa m p l es are the neural mecha ni sms for visual and acoustical perception
and the m ech anisms for the gen erati o n of adeq u ate m u scle tensi o n.
They can b e label led " p ri m ary" o r " b asic" neural m echanisms.
Seco n d ly, th ere are those neura l mechanisms wh ich grad ual ly merge
i nto l arg er and more c'o m p l ex mechan i sms, or wich seem i n g ly di sappear
comp l etely and reappear i n another from at a l ater phase of develop­
ment (e. g. stepp i n g m ovements and vo l u ntary walki n g p atterns). They
m ay reappear at periods of a break-down of the organism (e. g. reappea­
rance of " i nfanti l e response" - l i ke reactions in deteri orati ng patients).
These m echanisms seem to m ature accord i ng to a rather reg u l a r se­
q uence. Th i rd ly there are the m echan isms wh ich m ature mo re or less i n ­
dependently and become l i n ked together a t a parti c u la r moment, which
p rocess resu lts i n differenti ated m oto r patterns (e. g. the development of
vol u ntary gras p i n g, ending with the p i n cer g rasp and the development
of i n depen dent sitti n g-up, stan d i n g and wa l ki n g).
One m i ght exp ect some parti cular neural mechanisms to di sappear
during ontogeny, because they l ose thei r fu ncti onal sign ificance after
a parti cu l ar p h ase of development. Certai n ly the fu ncti onal expression
of some early neural mecha ni sms d i sappear, as fo r i nstance the palmar
g rasp respon se, the Moro reactions and rooti ng. M i l an i-Com paretti
contends th at such a d i sappearance is a prereq u i s ite fo r devel opment
of other sp ecifi c motor patterns. The palmar grasp reflex for i n stan ce
m ust h ave d i sappeared b efore an i nfant is ab l e to support h i m self
on his (opened) hands i n p rone po sitio n . The p l antar grasp reflex shou l d
have disappeared b efo re an i nfant i s a b l e to stand u p , a n d l i kewise
the M o ro reactions m ust h ave d i sso lved before parach ute-reactions or
p laci n g reactions occu r (M i l an i-Co mp aretti and G i d o n i , 1 967) . The p re­
d iction b ands for th e developmenta l co u rses of these items suggest
that the rel ati onships as postu l ated by M i l an i-Com paretti are weak, if
p resent at a l l . O n com p utation no si g n ifi cant corre lations were fou nd.

1 51
This is n ot s u rp ri s i n g , as the emperical fi n d i n g that some " i nfanti l e res­
p onses" wan e at a n age at which d ifferentiated motor behaviour has
not yet developed but sta rts to do so, does not i m p ly a causal re l atio n­
s h i p b etween these two sets of p h enomena, _

M oreover, it i s q u estionable whether the neural m echanisms themselves

d i sap p ea r. The n u m ber of syn apses chan ges considerab ly d u ri n g devel­
op m ent; consequently the fu ncti onal manifestati o n s of neu ral m echa­
n i sms a l so change d u r i n g developm ent. A defi n ite and tota l d i sappearan­
ce of n e u ra l m ec h a n i sms, h owever, wou l d i m p ly a tho rough rearrange­
m ent of n e u ra l con n ecti ons to such an extent that the o ri g i na l pattern
wo u l d no l o n ger be recogn izable. Th i s seems h ardly co mpati b l e with an
effi c ient m aturation of a com p l ex system which h as to ful l fi l present
functi o n a l dem an d s and at the same time must i ncrease in differenti ati on
a n d com p l exity i n o rder to fu l lfi l future demands. (cf. Eccl es, 1 973).
C l i n i ca l experi e n ce as wel as research reports support the view th at
neural m ech an ism s do not d i sappear defi n itely a n d tota l ly.
lt is a wel l-known c l i n ical experience that in some deterio rati ng di seases,
or in cases of seri o u s b ra i n dam age, m oto r patterns may become mani­
fest wh ich c l osely resem b l e patterns known from i nfancy, such as suck­
i n g responses, g ra sp refl exes etc. (Pau lson and Gottlieb , 1 968). Th us we
may ass u m e that d u ri n g o ntogeny some neura l m echanisms seem to di s­
ap pear because they become d o m i n ated or covered by oth er mecha­
n i sm s or because they expand or are combi ned with other m echanisms,
with out losi n g their characteri stics. This exp l ai ns their re appearance at
l ater ages u n der sp e cific c i rcumstances.
H owever, th e fu n ctional d i s p l ay of such neural m echanism s does not
d i sappear i n a l l i n stances. Fo r i n sta nce the ton i c neck responses seem
to disap pear d u ri n g development. Apart from thei r reappearan ce under
path o l o g i ca l c i rc u m sta nces, wh i ch shows that their neural m echanisms
do not di sso lve, they can be ob served a l so i n no n-path o l o gical conditi­
ons (i.e. in hea lthy i nd ivi duals) if p roper exa m i n ation techni ques are ap­
p l ied. Frankstei n et a l (1 972) demonstrated their presence in the resp i ra­
tory m u scles of healthy adu lts by m eans of el ectromyograp h i c record­
i n g s . A change of the position of the head (rotation as wel l as tilting)
m od ifed th e to nus of the respi ratory chest m u scles. We l l s (1 944) report­
ed s i m i la r fi n d i n g s for the l i m b-m uscu l ature i n n o rm a l humans. Another
exa m p l e of a seem i n g ly defi n ite change of a motor programme is the
Bab i n ski respon se, which u n der norm a l conditions di sappears d u ri n g
ontogeny as i s descri b ed i n the p resent stu dy, but which c a n sti l l b e
e l i cited i n n o rm a l a d u lts d u ri n g sl eep (Batti n i e t a l . 1 965).
The so-ca l l ed " i nfanti l e respon ses and reacti o n s" such as the grasp­
reflexes, the M o ro reactions, the step p i n g m ovements, the Bauer reac­
ti on etc. s h o u l d be considered as a d i s p l ay of neural mechanisms which
b elon g specifically to the very yo u n g nervo us system . Their chan ges re­
fl ect the o rganizatio n of the b ra i n d u ri n g development, whatever th ei r
fu n cti o n a l m ean i n g i n a tel eo l o g i cal sense m ay be (or may h ave been).
Fo r their fu n cti o n a l d i s p l ay the neura l m echanisms uti l i ze si m i la r fi nal
common p athways as other more differenti ated m echanisms wi l l do at

1 52
 a l <?ter stage of developm ent. Mo reover, it is possi ble (a n d in some in­
sta nces p robable, fo r exa m p l e step p i n g and crawl i n g movem ents) that
the mecha n i s m s them selves may be " uti l ized" by mecha ni sms wh i ch
develop l ater. I n this view they m ay b e regarded as p repa ratory fo r future
development, but there need not be a causal rel ati onship between the
dissolution of thei r fu ncti o n a l d i s p l ay and the genesis of l ater m oto r be­
h avi our. During o ntogeny t h ey wi l l beco me latent as a result of the devel­
opment of subsequent mechanisms, but they may be "taken up" again
if n eeded. The devel opment of such " d o m i n ating" mechanisms p l ays a
s ig nificant rol e in this p rocess. If in d ama ged o rgan isms these " domi nat­
i n g " m echanisms fa i l to develop p roperly, it is conceivabl e that the de­
velo p m ent of the fi n a l differenti ated motor behavi o u r may be ham pered.
For in stan ce if the palmar g rasp reflex fa i l s t o di ssolve, i . e. if the neu­
ral m ech anism fo r the p a l m a r g rasp reflex is not p rop erly do m i n ated by
mechanisms fo r vo l u nta ry m oto r behavi o ur of the hands and th � · fin­
gers, it is not surpri s i n g that th i s wi l l disturb the p roper development of
type of vo l u ntary grasp i n g (i.e. a specific type of vo l u ntary use of the
fi n gers). I n a s i m i la r way, the pers istan ce of an asymmetri c ton i c neck re­
flex (resulti n g from a defi cient developm ent of d o m i nati n g mechanisms
fo r flexi on/extension patterns of the arms o r l egs) m ay resu lt i n a d�fec­
tive developm ent of goal-di rected moti l ity of the arms and hands or of
vol u ntary sitti n g or wal k i n g .
I n the b egi n n i n g of this ch apter it w a s arg ued that in gen era l the ft.mc­
tional development of the hu ma n i nfant takes p l ace accord i n g to a r�gu­
lar seq uence. Th i s means that one can observe a gross outl i n e of de­
velopmental sequence, i n so fa r as parti cular fu nctions mu st h ave de­
veloped b efore others ach ieve exp ress i o n . This is not co ntradi cted by
the fact that th ere m ay be g reat variab i l ity in details, i nter- as wel l as
i ntra- i n d ividual ly. Fo r i nstan ce, an i nfant m u st b e able to l ift his head i n
s u p i n e position b efo re he i s c apab l e o f sitti n g up, and t h e majo rity of
infants a re able to sit u p befo re they can asume sta n d i n g posture. How­
ever, this is n ot a lways the case. In o u r g roup some i nfants developed
the abil ity to stan d b efore they were ab l e to sit up i n dependently. Ano­
ther examp le i s the co m m o n experi ence that many i nfants are ab le to
sit without support for a consi derable period of ti m e befo re they can
sit up i n depen dently, or that some i nfants do not c rawl at all before wal k­
i n g free.
The differences b etween boys and g i rl s, h owever s l i ght, with respect to
the development of d ifferent motor patterns also i n d i cates the i nter-;-i n di­
vi dual varia b il ity. In this case it may be caused by endocri n e infl uen ces.
Flech s ig ' s (1 927) opi n i on that g i rl s develop faster than boys i n all fu nc­
tional areas as a result of a general ly adva nced mye li nation in the case
of the g i rls, is contradi cted by the fi n d i n g that the differen ces between
the boys and the g i rl s of the p resent g ro up were variab l e with regard
to various fu n ctional areas.
Besi des a varia b il ity i n the seq u ence of the developm ent of m otor fun c­
tions, the rate of develop ment may vary widely. I n one and the same i n­
fant vari ous m oto r patterns may respectively develop rapi d ly or slowly;

1 53
they m ay also sta rt to develop early or l ate, wh i l e one and the same mo­
tor p attern m ay deve l o p rap idly o r s l owly, cf. ea rly or l ate, i n different
i nfants.
Apparently th ere is a ki n d of b l u ep rint of development characteri sti c fo r
each i n dividual i nfant, with poss i b ly a g reat va riety in deta i ls. Th i s m ay
res u lt i n a genetica l ly determ i ned vari a b i l ity i n d evelopm ent (Scott ' 57).
H owever l ittl e m ay be known about the contri b ution of i n nate and envi­
ro n m ental factors to the development of an i nfa nt, it i s evi dent that there
is an i ntricate but vari a b l e i nterp l ay b etween these two as is d i sc ussed
fo r i n stance by Bekoff and Fox ( 1 972).
Another exa m p l e of the i ntra -and i nteri ndivi d u a l vari a b i l ity duri n g d evel­
opment i s the occu rrence of i n consi sten cies. The frequ ency with wh i ch
these occur appears to be characteristic fo r i n divi dual i nfants as wel l
as for parti c u l a r ite m s . A s is d i scussed i n chapter XIV, i n some i nfants
parti c u l a r items tend to show m any i nconsi stenc i es duri n g thei r d evel..:
op m enta l co u rse; at the same time oth er i nfants show many inco nsi sten­
cies d u ri n g con secutive assessm ents, but defi n itely not i n all item s. lt
was postu l ated that the occu rrence of i n co nsi stencies can be considered
as a characteri sti c of a norm a l ly developi n g nervous system .

Fi n a l ly a few rem a rks wi l l be m ade about the p ractical i m p l i cati o n s of

the fi n d i n g s of th e p resent study.
1 . The items of g ro up I and 11 can b e consi dered to refl ect the i ntegrity
of basi c n eural m echa n i s m s which are a prereq uisite fo r adeq u ate
n eu ro lo g i ca l d evelopment d u ri n g i nfancy. Therefore they wou l d ap­
pear to b e of cl i n i ca l si g nificance fo r a neuro l o g i cal assessment.
2. The item s of g ro u p I l l wou l d appear to be of c l i n ical si gi nifi cance i n
so fa r a s they refl ect t h e q u al itative development o f neural m echa­
n i s m s ; these, h owever, show a developm ental course wh ich m ay
vary widely i nteri ndivi d u a l ly.
3. From a stri ctly d evelopmental p o i nt of vi ew, the items of gro u p IV
seem h ard ly usefu l , as th ei r vari a b i l ity is l a rge a n d in some i nstances
their deve l o p m e ntal course i s p rotracted excess ively. Fo r a neuro l o­
g i ca l assessm ent they a re usefu l o n ly i n the case of evi dent a nd
con s i stent q ua l i tative deviations from n o rmal respon ses, such as evi­
dent l eft- ri g ht d ifferen ces i n m otor performances.
4. lt i s not advisab l e to use isolated m otor perfo rm ances as i n d icato rs
for n e u ro l og i ca l devel o p ment a n d neuro l o g i ca l i ntegrity, due to the
la rg e variabi l ity of the deve l o p m ental rate of the various items and
the l ow relati o n s h i p s b etween the maj o rity of them. An eval uatio n of
the· n eu rol o g ical development as wel l as the neuro lo gical i ntegrity
can on ly be m ad e by m eans of a comprehen sive assessment of
the i nfant.
5. As a co nsequence of the l a rg e developm ental vari ab i l ity i ntra- as
well as i nter- i n d iv i d u a l ly, it i s hardly poss i b l e to l abel an i nfant as an
" early or a l ate d evelop er" o r as a " rapi d or s l ow deve loper" .
M i l estones i n th e i nfant' s fu ncti o n a l develop m ent are o f l i m ited va lu e
from a neuro l o gi ca l a n d developme ntal p o i nt of view.

1 54
6. The regu lar occu rrence of i nconsistencies i l l ustrates the s m a l l val u e
o f o n e s i n g l e assessm ent. Fo r an adequate eva l u ation of the neuro l o­
g i ca l develop ment a n d of the neuro lo g i ca l i nteg rity of an i nfant, re­
peated assessm ents a re needed.

"And being _:!''I O W at some pause, looking back into that I have passed
through, this writing seemeth to me, si nunquam fa/lit imago, (as far as
a man can judge of his own work) nbt much better than that noise or
sound which musicians make while they are tuning their instruments:
which is nothing pleasant to hear, bu t yet is a cause why the music is
sweeter afterwards" .
Francis Bacon (1605)
Refe re n ce s

Ambrose, J . A ( 1 961 ) : T h e d eve l o pment o f the s m i l i n g response i n early i nfancy.

I n : B . M. Foss (ed) : Determ i n ants of I nfant Behavior.
Wi ley, N ew York, 1 : 1 79-20 1 .
Andre-Thomas ; F. H a n on ( 1 947) : Les pre m i ers automatismes.
Revue N e u ro l o g i q u e 7 9 : 64 1 -648 .
Andre-Th omas ; S. S a i nt-Anne D a rgassi eS' ( 1 952) : Etu des neuro l og i q u es s u r l e
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Wo l ff, P. H. ( 1 968) : The s e ri a l orga n i zati o n of sucking in the you n g i nfant.
Pe d i atricS', 42 : 943-956.
Zachau-Ch risti a n s e n , B. ( 1 972) : The influence of p re nata l and peri n atal factors
on d evel o pment d u ri n g the fi rst year of l i fe .
Paul A . Andersens Forl a g , H e l s i n g o r.
Zappe l l a , M. ( 1 966}: The p l a c i n g reacti o n in the fi rst year of l ife.
D ev. M e d . C h i l d Neu ra l . 8: 3931-401 .
Zappe l l a , M . ( 1 967) : Placing a n d gras p i ng of the feet at variouS' temperatu res i n
e a r l y i nfancy.
Ped iatrics 39 : 93-96.
Zdans ka-B rin cken, M . ; N. Wo l a nski ( 1 969) : A g ra p h i c method for the eva l u ation
of m otor deve l o p m e nt i n i nfants.
Dev. Med. C h i l d Neura l . 1 1 : 228-24 1 .
Z e l azo, P h . R . ; N. A. Z e l azo ; S. Ko l b ( 1 972) : " Wa lrk i n g " in the N ewborn.
Science 1 76 , 31 4-3 1 5.

1 62
Acknowled g ments :

Many peo p l e h el p ed me d u ri n g th i s study and duri n g the analys i s of its

res u lts. l t is i m p o s s i b l e to tha n k a l l of them p erson a l ly. Sti l l , some h ave
to be menti on ed .
Fi rst of a l l I wan t t o exp ress my g rati tude t o the i n fants (al l o f wh ich are
able to read n ow, be it that their understand i n g of the E n g l i sh la n guage
is not yet fau ltless) and th e i r parents, who s pent so m uch ti m e and
energy on my behalf. I also want to thank Heinz Prechtl , who gu i ded my
fi rst steps in th e fi e l d of developmental neuro l o gy, who stim u lated me,
and who tri ed to counteract my p ropensity to "soft thi n ki n g " . Wi l lem
Hogerze i l s aid exactly the words wh ich kept me go i n g at the m o m ent
when I n eeded them most badly. Annelies and Janet turned my D utch­
En gl ish " p ot-p o u rri " i nto p roper E n g l i sh .
M a n y oth ers contrib uted t o th e p resent work, s o m e mo re, s o m e less. I
hope that they w i l l forgive me for not menti o n i n g thei r names ; b ut I
wo u l d l i ke to refer them to the secon d part of the l ast verse of St. J o h n ' s
Gospel.
Part of th i s study a n d part of its p u b l i cati o n were supported by the
D utch H ea lth org a ni zati on TNO (projectn o . G O 644-68). I am very
g ratefu l fo r th e i r support, and also fo r the p l easant way in wh ich thi ngs
were m an aged by M rs. E. d e Boer-Schreuder, adj . secretary of TNO.
Th e statistical co m p utati ons were carried out i n the Computer Centre o f
Gro n i ngen Un iversity, under t h e d i rection of Mr. L. Th. va n de r Weele.
The lay-out of the fi g u res was des i g ned by M r. P . Fru h m an n .

1 63
Appendix A: C ri teria for o pti mal obstetrical cond itions (adapted from Prechtl,
1 968).

maternal age 1 8-35 years·

marital state m arried
parity 1 -6
abo rtions i n h i story 0-2
pe lvis no d i s proportion
l u etic i nfection absent
Rhesus a ntagon i s m absent
b l o o d g rou p i ncompta b i l ity absent
nutritional state wel l nourished
anaemia absent
blee d i ngs duri n g pregnancy absent
i nfectionS' d u ri n g preg n ancy absent
X-ray abdomen d uri ng pregn ancy no
toxaemia of preg nancy absent or m i l d
b lood pressure n o t excee d i n g 1 40/85
a l b u m i n u ria a n d oedema a bs·ent
i ntra uterine position vertex
psychological stress absent
prolonged u nwanted steril ity (2 years) absent
hype rem esi s• absent
maternal chronic d iseases absent
gestational age 38-41 weeks
twi ns o r m u ltiple b i rth no
del ivery spo ntaneous
fetal presentation vertex
drugs g iven to mother 02, local anaesthetic
d u ration first stage 6-24 hours
d u rati o n second stage 1 0 m i nutes - 2 hourS'
contractions moderate or strong
cord around the neck no or loose
onset of res piration with i n fi rst m i n ute
treatment, resuscitat i o n no
b i rth wei g ht 2500-4000 g r.
body temperature n o rmal
d rugs g iven n il

1 64
 Appe n d ix B: Criteria for neonata l neu ro log ica l opti ma l ity (according to Prechtl
and Beintema , 1 964).
Resting posture :
Faci a l innervatio n :
Tremor, frequency:
Tremor, ampl itude:
Postu re i n s·u pine pos ition:
S pontaneous motil ity:
I ntensity of spontaneouS' motil ity: med i u m i ntens ity
Athetoi d movements :
Deviant mot i l ity:
Fonta n e l l es :
S pontaneous eye movements :
Nystagmus:
Pupil lary reactions:
Optical b l i nk:
Muscle consistency:
Motor apparatu s :
Abdomi n a l skin reflex:
B iceps tendon reflex:
Knee jerk:
Rooti n g :
Sucki ng :
Jaw jerk:
Pal m ar g rasp:
Plantar g ras p:
Posture of the a rmS' during
traction test:
Head contro l :
Foot s o l e response:
Withdrawal reflex:
Magnet response:
Cross·ed extension reflex:
Asymmetric ton i c n eck reflex:
Moro threshold :
Moro abduction, arms :
Moro extensi<;>n, arms:
Headl ift i n prone position:
Spontaneous crawling
movements :
Ga lant response:
Posture in prone suspension:
Tacti l e placing of the feet:
Stepping, movements :
Cryin g :
State changes:
symmetrical ; flexion, sem iflexion
symm etrical during rest and movement
no tremor, or tremor with h ig h frequency
(> 6/sec)
no tremor, or tremor with l ow ampl itude
(< 3 cm)
symmetrical ; sem iflexion of the extremities
alternating movements
med i u m i ntensity in the fingers and toes·
absent
normal range and consistency
occas i o n a l ly conjugated
absent
present and symmetrical
brisk
moderate
medium resistance against passive movements ;
moderate active power; range of movements
normal
present and symmetrical
bris·k and symmetrica l
brisk and symmetrical
present i n fou r d i rections
powerful and regu l ar
present
symmetrical ; med i u m i ntensity
symmetri ca l ; med i u m intensity
flexion of the e l bows
present during 4-1 0 S'e conds
evident and sym m etrical dorsiflexion of the b i g
toe
present and symmetrical
present
present and symmetrical
symmetrical if pres·ent
med i u m
symmetrical ; medi u m
symmetrical, med i u m
present during 3 - 1 0 secon ds
present and symmetrical
present and sym metrical
head in one l in e w ith trunk
present and symmetrical
present and symmetrical
normal pitch
absent, or mild and easi ly i nfluenced
1 65
Appendix C: M e a n s , stan d a rd deviations a n d coeffici ents of s kewness and kur­
tos i s for the items of gro u p I l l , i nc l u d i ng s p eech deve l opment (tota l
gro u p) .

F i rst c h a nge

Observation of posture and motility

S pontaneous posture of the arms 2 . 60 0.904 1 .71 1 5.95
S pontaneous posture of the legs 2.26 0.527 1 .899 5.72
S pontaneous m ot i l ity of the a rm s 2.00 c c c
S po nta n e o u s m o t i l ity of the l egs 2 .90 0. 763 0.446 2 . 65
S po nt . mot. of the l egS' in vert.suspe ns i o n 2 . 74 0.777 ·] . 008 3.91
G o al d i rected m oti l ity of the arms 3.22 0.545 0. 1 07 2.80
Type of vo l u n tary g ras p i n g 4.48 0.677 0.272 2.81
Coord i n at i o n of u pper extrem ities 6.62 1 .067 -0..2 1 5 2.61
Post. of h e a d , tru n k , a rms i n prone positi o n 3.50 0.8 1 4 0.000 2.51
Locomotion i n prone position 7. 1 8 1 .257 0.030 3.92
R o l l i n g over fro m s u p i n e i nto pro n e pos'ition 6.74 1 .352 0.382 3.64
R o l l i n g over from pro n e i nto s u p i n e positi o n 6.90 1 .488 0.023 2.99
S pontaneous h e a d l ift in s u p i ne position 7.20 1 .294 -0. 1 49 2.89
S itti n g u p 6. 1 8 1 .380 1 0. 660 3. 33
D u ration of s i tti n g 9.24 1 .636 0.428 2.48
Postu re of the tru n k d u ri ng S'itti n g 9.20 1 .629 0. 389 2 .48
Stand i n g u p 1 2 .30 1 .502 0.39 1 3.01
Wal k ing 1 3.48 2 . 073 0.536 3. 1 3

Reactions and Responses I I

R o ot i n g 8. 58 1 . 1 62 0. 238 2 .03
Asym . ton ic neck res ponse, i m pos·ed 2.06 0.580 0.623 4.91
Asy m . t o n i c neck res p o nse, s p o ntaneous 2 . 00 0. 600 0.561 4.72
Pa l m a r g rasp ref l ex 5.68 1 .058 -0.690 2.97
Reacti o n to p u s h a g a i nst s h ou l de r d .s itti n g 9.22 1 .682 0.403 2.33
Fo l l ow.an obj. w i t h eyes head and tru n k d . s itti n g 9.28 1 .642 0.382 2.42
O ptica l p l a c i ng of the hands 8.26 1 .065 -'0 .022 3. 1 3
Parach ute reacti o n o f arms a n d h a n d s i n prone susp. 9.96 1 .678 -0.041 4. 1 4
O ptical p l a c i n g reacti on o f the feet
Foots o l e res p o n s e
1 1 .58 1 .6 1 7 0.41 0 3.35
I
8.70 2. 435 0 . 045 4.06
Acoustical o rienti n g 4.92 0. 752 -0. 1 62 2.47
M o ro h e a d d ro p , a d ductio n/flexio n - - - -

M o ro h e a d d ro p , a bducti on/exte n s i o n 2 .50 0 . 789 1 .385 3.88

Moro l ift, add u c t i o n/flexi o n - - - -

M o ro l i ft, a b d u ct i o n /exte n s i o n 5.76 1 . 66 1 -0.450 2.78

M o ro h it, a d d u ct i o n/flex i o n - - - -

Moro h it, a bducti o n/exte n s i on 4.28 1 .629 0.256 2.27

Voc a l ization a n d s peech 2.52 0.544 0.306 f.88
 Corre l ation coefficie nts (p < 0 . 0 1 ) of the re l ations h i ps between the f i rst a n d the final c ha
nges
A p pe n d ix D
of the itemS' of g ro u p I l l , i n c l u d ing s peech development (total g ro u p) (Pearson Produ ct-Moment
C o rre l at i o ns)
I
Type of volu ntary g ra s p i n g .449 . 376
.370
Coordinati on u p per extr.
-.365 .354
Loco moti o n in prone .455 .404 .544 . 529

.381 .390 .386 .387 .405 .374 .4 1 8 .424

.368 . 358 . 753 .497
R o l l i ng s u p i ne i nto p ro ne
.396 . 362 .384 .393
. 574 . 639
R o l l i n g pro n e i nto s u p i n e
,351 .41 1 .377 .364 .367 .403
S itti n g u p
.695 .498 .40 1 .423 .652 .602 .438 - .368
.368 .43 1 .440 .:499 .383 .426 .455 .382
D u rati on of sitti ng
.395 . 685 .5CJ6 . 368 .399 .642 .587 .41 3 -.379
.393 .4 1 3 .40 1 .478 .364 .41 2 .444 .357
Posture, s itti n g
.805 .594 . 748 .846 .871 .456 .400 .724 . 703 .438 .697
. 659 . 798 .495 .371 .690 .651 .484 . 396
Stand ing u p
. 762 .820 . 794 ' .736 .717 .476 .697
.71 5 .452 . 640 . 620 .543 .495 .460 .8 1 2 . 626 .404 .426
Wal king .598
.3_75
P a l m a r g rasp refl ex .449 .376
.480 .360 .391 .628 .577 .393 -.376
.420 .41 6 .474 .373 .38 1 .447 .36'4 .674
React i o n to push, S'itting .366
.483 . 396 .41 1 . 355 .639 .591 .436 -.395
,4 1 3 .433 .501 . 374 .4 1 5 .446 . 380 .392 .682
Fol l owing object, s itti ng . 352
.358
0 ptical placi ng· hands .376
.483 .621
Parachute react i o n hands
.469 .522 .600 .400 . 557 .369 .375 .777 -. 356 .407
0 ptical p l a c i n g feet . 505 .354 . 733 .461 .558 .423 .497 . 363
.361 . 555 .371
I
.363
M oro l ift abd./ext.
-.361 -.366
M oro h i t abd ./ext.
.396
R ooting
.399
A coustical orienting

s peech
.376

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App e n d ix F Corre l ation coeffi cients (p < 0.01 ) of the i nterrelati o n s h i ps of the fin al changes of the items of
g ro u p I l l (total group) (Pearson Product- M o m e nt Correl at i o n s)

s pontaneous post. a rms X

s pontaneous post. legs X

s pontaneous m ot.arms .594 X

s pontaneous m ot . l egS'. X

s p . m ot. l egs• vert.susp. .653 X

Type volunt.gra sp i ng X
c o o rd. u p p e r extrem . .4 1 3 X

p ostu re p ro n e pos it. .473 .563 .496 X

L acorn. i n p rone .494 . 647 .378 .506 X

R o i l i n g su p-pro n e .468 .485 .462 .433 X

R o i l i ng prone-s u p ine .567 .389 .409 .488 X

H e a d l ift i n s u p i ne .461 X

s itting u p .548 . 665 .474 .678 .6-52 .475 . 482 . 3 74 X

D u ration of s i tti n g .437 .485 . 4 64 .451 .480 .41 2 .401 . 634 X

p ost u re , s itti n g .559 .580 . 559 . 386 .61 7 .60 1 .495 .444 .391 .842 .707 X

s ta nd i ng u p , 5 f2 .71 7 .378 . 679 .641 .464 .393 . 803 .61 2 .644 X

wa I k i n g .562 . 800 .439 . 359 . 726 .600 .483 .747 .546 .672 .890 X

pa l m ar g ra s p refl . .4 20 .478 .422 .374 X

Footso l e res ponse .371 .423 .409 .376 X

R eact. to p u s h·, s itti n g . 394 .474 .575 .395 .561 .559 .503 .450 .366 . 78 7 .886 .831 .721 . 662 .383 X

F o l l . obj. s itti n g .357 .469 .535 .458 .540 .495 .42-3 .474 . 780 .91 3 . 825 . 7 00 ,643 .400 .947 X

0 pt. p l a c i n g h a n d s .400 .402 .369 .3_86 X

pa ra c h ute react . h a n ds·

1
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0 pt. p l a c i n g feet .51 5 . 675 .439 .597 .476 .376 , 359 .609 .478 .475 .644 .621 .451 .456 .444 .385 ,41 1 X
X
M o ra head d r. a b d ./ext.
a d d ./flex i o n .61 7 X
X
M o ra l i ft a b d ./ext.

a d d ./fl exi o n 4.35 .572 X

M o ra h it a b d ./ext. .372 . 502 .371 X

. 536 .3�1 . 753 X

a dd ./flex i on
R ooting
I
X
.41 2

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Appen d ix E Corre l at i o n coeffici ents (p < 0.01 ) of the i nterrelations h i pS' of t h e fi rst changes of t h e items
of g ro u p I l l (tota l g ro u p) (Pears o n Product-Mom e nt C o rre l at i ons)

S p o ntaneous post.arms X
S p o ntaneous post. a rm s X
S p o ntaneous m ot . l e g s .385 X
G o a l-d i r. m ot i l ity a rm s .365 X
Type of v o l . g ra s p i n g x
Coord . u p pe r extrem . .392 3 7 1 X
Post . i n p ro n e p o s i t. . 390 X
Locomotion in pro n e x
R o l l i ng s u p-pro n e .436 X
R o l l i n g p r. S'u p i n e 605 X
D u ration of s itti n g . 396 4 9 0 .429 X
Postu re s itti n g .39 1 478 . 4 1 3 .993 x
Sta n d i ng u p .361 .41 9 . 384 X
Wa l ki n g . 497 4 7 2 .399 . 3 7 0 . 8 9 7 X
Asym.to n . n eck. i m posed. .41 1 X
Asymm .ton.neck. s p o n . 379 .862 x
Resp. to pu s h , s itting .483 .409 .989 .989 . 385 .367 X
Fo l l . obj. S'itt i n g . 4 0 0 . 4 9 3 .421 .993 .986 . 4 2 0 .392 .990 X
O pt . p l ac i n g h a n d s . 4 1 2 .452 X
O pt . p l a c i n g: feet .389 .388 . 486 .466 . 6 E8 .59 1 . 4 7 0 . 499 X
M o ro h e a d d r. a b d ./ext. .544 408 -.360 X
M o ro l ift a b d ./ext. -. 398 x
Rooting .403 X
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Appendix G: Correlation coeffic ients (p < 0.0 1 ) of the i nterrelationships of the developmenta l ran geS' of
the items of g roup I l l (total g ro u p) (Pea:rs o n Pro duct-Moment Correlat i o ns).

I I I
I I I
Spontaneous post.a rms
Spontaneous mot.legs .359 X I
S pont.mot.legs vert.susp. . 554 X
Type of vol u n t. grasp i n g X
Coord . upper extrem. X
Post.pro n e poS'ition .394 . 504 .51 5 41 5 X
Loco m . i n p ro n e .366 X
Headl ift i n s u p i n e x
S itti n g u p 41 5 .454 566 374 X
Duration of s i ttin g X
Posture, s ittin g .406 459 .694 X
Standi n g u p 368 x
Footsole response .378 359 395 X
React. to puS'h , s itting .836 .836 X
Fol l. o bj.S'itt i n g . 8 9 2 .840 .934 X
Opt.placing hands 367 x
Parachute react.hands 461 X
O pt.placing feet .408 X
Moro l ift, abd./ext. x
M � ro h it, abd./ext. X

I I I I
.377 377
x
Root i n g 41 9
j

DEVELOPMENTAL
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 Final change dev.range i ncons istencies

l
Aean s i g m a
I
Skew-
n ess
1 K u r-
tos is
1 j
Mean s i g m a 1 8kew- K u�-
n ess tos·1s
� � \
Mean s i g ma Skew- I
Ku�:
n ess tos 1s
1
I
I I I I I I I
5.oo l 1 . 1 37 0.51 6 2 . 93 2.41 1 .485 0 .354 2.47 0.24 0. 480 1 .742 5. 1 6
1 0.04 1 .54 1 0 . 1 38 2.31 7 . 78 1 .598 0. 2 1 7 2.J 7 1 .00 0.791 0.51 1 2. 94
4 . 78 1 .1 41 0.363 3. 1 2 2.78 1 .1 41 0.363 3.1 2 0. 1 4 0.354 2.041 5. 1 7
1 2,08 1 .605 0 .4 7 7 3.36 9. 1 4 1 :.:803 0.043 2 . 78 0.51 0.582 0.602 2.38
1 4. 1 2 2.058 0.31 2 3. 1 2 1 1 .39 2 . 289 0. 1 41 2.8 2 2.24 0.969 0.050 2.45
1 3.47 2.459 0.04 1 3.26 1 0.20 2 .475 0.047 2. 9 1 0.49 0 .582 0.68 1 2A7
1 3.29 1 .594 0.427 2 . 79 8 . 80 1 .87 1 0.281 2 . 62 0.43 0.540 0.687 2. 2 8
1 0. 7 1 1 .607 0.0 1 7 2.86 4.1 6 1 .929 0.856 4.62 0.67 0.774 1 . 1 74 4.31
1 2. 1 6 2. 230 0.61 3 3.8 9 8.65 2 .350 0 . 1 70 2.92 f. 1 2 0.80 7 0.257 2.51
1 3,73 1 .998 -0.231 2.82 6.53 1 .685 0. 1 05 2. 1 5 0.55 0.647 0 .740 2.52
7.59 1 .848 1 .555 6.86 0.84 1 .2 1 4 2 .93 1 1 4.78 0. 1 0 0.368 3.794 1 7.37
8.06 1 .345 0.251 3.86 1 .1 2 1 .201 0 .92 9 2 .96 0.29 0.577 1 .875 5.41
8 . 39 1 .539 -0. 1 1 6 2 . 73 1 .1 6 1 .028 0.833 3.50 0.1 4 0.408 2.9 1 7 1 1 .19
1 2.45 1 .757 0.225 3.74 6. 2 7 1 . 729 -0. 1 47 2. 55 0. 6 1 0.671 0 .628 2 .34
1 1 .65 1 .508 0.385 3.07 L.45 1 .243 0.875 3.26 0. 1 4 0.354 2.041 5.27
1 2.35 1 .640 0.461 3.25 3. 1 8 1 .642 0.958 4.44 0.22 0.468 1 .9 1 6 5.87
1 6.37 2.243 0.092 2.65 4. 1 0 1 .246 0.067 2 . 08 0 .04 0.200 4.641 22.54
1 8,00 2.380 0.0561 3. 1 2 4.57 1 .472 0.373 4. 0 1 0. 04 0 . 2 00 4 .64 1 22.54
I I
1 2.92 1 .8 1 2 0.335 3.06 4.37 2 .038 0.760 3.06 1 .04 1 .1 1 7 0.825 2.65
5.59 1 . 1 34 0 . 1 1 1 2.75 3.51 1 .36 2 0 . 1 23 2.77 0.35 0. 522 1 .035 2.93
�.1 8 1 .244 - 1 .282 7.51 6. 1 8 1 .438 -0.924 5. 1 6 0.78 0:757 0.654 2.93
8 . 69 1 .3'1 0 0 . 0 76 2.01 3.06 1 .329 0 .532 3.08 0.27 0.49 1 1 .585 4.5]
1 ?. 1 2 1 .467 0.507 4.45 2.94 1 .39 1 0.392 2.36 n.o8 0.277 3.056 1 0.34
1 1 . 96 1 .443 0.6 1 8 4.74 2.71 1 .4 1 4 0.561 2.46 0. 1 8 0.391 1 .634 3.67
'1 0.29 1 .5 1 4 0.999 5.85 2.02 1 .507 1 .405 6.56 0. 1 6 0.373 1 .822 4 . 3 2
1 2.51 2.247 0.3 1 5 3.58 2.55 f.78 0 0.341 2.23 0 .9 7 0.865 0. 468 2. 35
1 2.94 1 .8 1 9 0.427 2.92 1 .37 1 . 1 31 0.639 2.51 0.29 0.500 1 .443 4.08
1 3.61 2.790 0.249 2.58 4. 94 3 .256 0.469 2 .63 1 .57 1 .1 1 8 0.0 1 .98
6.4!: 0.937 0.380 2.88 1 .51 0.893 0.235 3.07 0. 1 0 0.306 2.629 7. 9 1
3.06 1 . 1 26 0.942 3. 1 3 - - - -
0. 27 0.531 1 .866 5.58
4.06 1 .3 1 4 0.221 2 .25 1 .55 1 .276 0.341 2 . 06 0.41 0.537 0.779 2.42
5.73 1 . 934 0.3 1 1 4 20
. - - - -
0.69 0.683 0.461 2. 2 0
1 0. 73 1 .890 0.668 3.41 4.94 2 . 045 0. 1 28 2. 95 0. 90 0.872 0._769 2.97
7.1 2 1 .943 0.463 3.80 - I - - -
1 .1 4 0. 890 0.256 2.22
7 . 06 1 .533 1 .053 6. 03 2.78 2.1 1 4 1 . 1 41 6.1 1 0.71 0.736 0.498 2 . 0 1
1 2.22 1 .896 1 .008 5.45 9.71 1 .9 04 1 .001 4. 7 6 0. 1 6 0.373 1.822 4.32
Appendix J: Variation ranges of the first a n d the f i n a l changes and the n u m be r
of incons isten c i es of t h e items of g ro u p I l l (total g ro u p) .
T h e n u m be r of i n fants w i t h i ncons i sten c ieS', t h e length of the scoring
sca l e a nd the max i m u m n u m be r of scores found at a single asseS's-
ment a re a lso preS'ented.
Key: a : max i m a l va riation range o f the f i rst change
b: m ax i m a l va riation ran g e of the final change
c: n u m be r of i nfants with inconsistencies
d: n u m b e r of i ncons iste n c ies
e: length o f the scori n g s cal e
f: max i m a l number of scores at o ne exam ination

I temS' a b c d / e
Observation of posture and motility
s pontaneous posture of the arms 2- 6 3- 8 12 13 4 4
s ponta neous posture of the l egs 2- 4 7- 1 3 38 52 4 4
s pontaneous mot i l ity of the a rms 2 3- 8 7 7 5 4
s pontaneous moti l ity of the l egs 2- 5 9- 1 6 24 36 4 3
s pontaneous moti l ity of the legs i n
vertical sus pens i o n 2- 5 9- 1 9 50 1 13 6 6
g o a l - d i rected motil ity of the a rms a n d
hands 2- 4 8- 1 9 22 24 7 5
type of voluntary gras p i n g 3- 6 1 0- 1 7 21 22 7 5
coord i nation of the u pper extre m i ties 4- 9 7- 1 5 27 36 3 3
postu re of h ead, tru n k and arm s i n
p rone position 2- 5 7- 1 9 40 59 7 6
l ocomotion in p rone pos ition
rol l i ng ove r from supine i nto prone 4-1 1 9- 1 8 23 27 6 6
pos ition 4-1 1 5- 1 5 4 5 3 3
ro l l i ng back from prone i nto s u p i n e
pos ition 4- 1 1 5- 1 2 12 15 4 4
s po ntaneouS' head l ift in s u p i n e position 4- 1 0 5- 1 2 6 7 3 3
s itti ng u p 4- 1 0 8-1 7 26 31 4 4
d u ration of s itti n g 6- 1 3 9-l6 7 7 5 5
posture of the tru n k d u r i n g s itti n g 6- 1 3 9- 1 7 10 11 5 5
sta n d i n g u p 3- 1 6 1 1 -2 1 2 2 5 5
wa l k i n g 1 0- 1 9 1 2-24 2 2 5 5

Reactions and Responses

root i n g 7-1 1 9- 1 7 29 54 5 5
a symmetric ton i c neck res ponse
- imposed 1- 4 3- 8 17 18 3 3
- spontaneous 1- 4 6- 1 1 30 38 3 3
p a l m a r g rasp reflex 3 7 6-1 1 12 13 3 3
reaction to pus h a g a i n st the s h o u l d er,
when s itti n g 6- 1 3 9- 1 7 4 4 4 4
fol lowi ng an obj e ct with the eyes, a n d
w ith rotation of the h e a d a n d tru n k ,
w h e n s itti n g 6- 1 3 9- 1 7 9 9 5 5
o pt ical p l a c i n g reacti o n of the h a nds. 6-1 1 7- 1 6 8 8 3 3
parachute reaction of arms a n d hands
i n pro n e suspension 5-1 4 7-'1 9 33 48 3 3
optical p l ac i n g reaction of the feet 8- 1 6 9-1 8 14 16 3 3
foot s o l e res pons e 2-1 5 8-20 39 79 3 3
acoustical orienti n g 3- 7 5- 9 6 6 3 3
M oro - h ea ddro p , a bd u ction/exte n s i o n 2- 5 2- 6 19 20 3 3
adduction/fl exion 2- 4 2- 6 11 13 3 3
l i ft, abduction/exte n s ion 2- 9 7-1 6 32 46 4 4
adduction/flexi o n 2- 5 1 -1 2 30 37 3 3
h it on s u rface,
a b d uction/extens ion 2- 8 4-1 3 28 37 3 3
a d d uction/flexio n 2- 7 3-1 3 38 59 4 4
Appendix H : Correlatio n coeffic ientS' (p < 0.01 ) of the relationsh ips between
the developmental ranges and the number of i nconsistencies of the
items of g ro u p I l l (total g rou p) (Spearman Rank Correlations).

Parachute reaction of the hands .661

Optical placing reactien of the feet .637
Moro, h it, abduction/extension .634
Rooti ng .603
Moro, hea d d rop, abductio n/extension .590
Footsole respo nse .564
Optical placing reaction of the hands .477
Rol l ing over from s u p i n e into prone position .461
Asymmetric ton i c neck response, s pontaneous .458
Type of voluntary g ra s p i n g .440
Moro l ift, abductio n/extension .421
Coord i nation of u pper extrem ities .377