International Journal of Neuroscience

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Asymmetric tonic neck reflex and symptoms of

attention deficit and hyperactivity disorder in
children

Jana Konicarova & Petr Bob

To cite this article: Jana Konicarova & Petr Bob (2013) Asymmetric tonic neck reflex and
symptoms of attention deficit and hyperactivity disorder in children, International Journal of
Neuroscience, 123:11, 766-769, DOI: 10.3109/00207454.2013.801471

To link to this article: https://doi.org/10.3109/00207454.2013.801471

Published online: 05 Jun 2013.

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International Journal of Neuroscience, 2013; 123(11): 766–769
Copyright © 2013 Informa Healthcare USA, Inc.
ISSN: 0020-7454 print / 1543-5245 online
DOI: 10.3109/00207454.2013.801471

Asymmetric tonic neck reflex and symptoms of attention

deficit and hyperactivity disorder in children
Jana Konicarova1,2 and Petr Bob2,3
1
Department of Psychology, Faculty of Social Studies, Masaryk University, Brno, Czech Republic; 2 Center for
Neuropsychiatric Research of Traumatic Stress, Department of Psychiatry and UHSL, 1st Faculty of Medicine, Charles
University, Prague, Czech Republic, and; 3 Central European Institute of Technology, Faculty of Medicine, Masaryk
University, Brno, Czech Republic

One of the particularly important postnatal developmental reflexes that diminish in later stages of development is
asymmetric tonic neck reflex (ATNR), which belongs among the so-called primitive reflexes. According to current
evidence, certain later developed functions during ontogenesis of the central nervous system tend to replace the
primitive reflexes, and their persistence is related to certain specific neuropsychiatric or neurological disorders.
According to current knowledge, there is no evidence to which extent persistence of these reflexes may play
a role in attention deficit and hyperactivity disorder (ADHD). With respect to these findings, we have tested a
hypothesis to which extent persisting primitive reflex ATNR in 60 children in the school age (8–11 years) will be
related to symptoms of ADHD and compared the results with 30 children of the same age. Results of this study
show that ADHD symptoms are closely linked to persisting ATNR, which indicates that ADHD symptoms may
present a compensation of unfinished developmental stages related to diminishing ATNR.
KEYWORDS: ADHD, asymmetric tonic neck reflex, developmental disorders, primitive reflexes

Introduction In agreement with this evidence, recent findings also

According to current evidence, brain functions in their
developmental stages are particularly vulnerable to var-
ious insults such as brain damages, toxic influences or
psychological stress [1–3]. An important postnatal de-
velopmental deficit that likely may have various etiolog-
ical backgrounds is persisting of the so-called primitive
reflexes that are in early developmental stages in postna-
tal periods replaced by higher motor and cognitive func-
tions [4–6]. One of the particularly important primitive
reflexes that may pathologically persist in later stages of
development is asymmetric tonic neck reflex (ATNR),
which typically occurs when turning of the head to one
side causes an increase in the ipsilateral and a decrease in
the contralateral extensor muscle tone and may be used
as a diagnostic instrument to assess spasticity and cog-
nitive functions related to certain specific movements
[7,8].
Received 12 November 2012; revised 29 April 2013; accepted 29 April 2013
Correspondence: Petr Bob, PhD, Department of Psychiatry, 1st Faculty of
Medicine, Charles University, Ke Karlovu 11, 128 00 Prague, Czech Republic.
E-mail: petr.bob@lf1.cuni.cz
indicate that persisting primitive reflexes are related to
certain specific neuropsychiatric or neurological disor-
ders [5,6,9–12], although according to PubMed search
in the current scientific literature there is no evidence
whether these persisting reflexes play a role in attention
deficit and hyperactivity disorder (ADHD), likely they
may have some specific relationship to ADHD symp-
toms. With respect to these missing findings (or at least
very rare), we have proposed and tested the hypoth-
esis to which extent symptoms of ADHD will be re-
lated to persisting ATNR in children in the school age
(8–11 years).
Methods
Participants
Within the framework of ELSPAC (European Longi-
tudinal Study of Parenthood and Childhood) study,
data of 60 children (mean age 9.32, age range 8–11,
27 girls and 33 boys) with ADHD diagnosed according
to Diagnostic and Statistical Manual of Mental Disor-
ders – fourth edition (DSM-IV) criteria characterizing

766

their primitive reflex (ATNR) responses and psychome-
tric measures of ADHD symptoms were collected. Par-
ents of all the participants gave written informed con-
sent, and the ELSPAC study was approved by Masaryk
University, Faculty of Medicine Ethical Committee. To
compare the results, we have assessed also 30 healthy
children of the same age (mean age 9.57, age range
8–11, 14 girls and 16 boys) who had not ADHD or other
neuropsychiatric diagnosis.
Measurement of primitive reflex
Asymmetric tonic neck reflex usually measured by
Schilder test [13,14] presents the tonic reflex response
that occurs in newborn babies and normally vanishes
around 3 months of age.
Test position: Standing, feet together, with the arms
held straight out at shoulder level and height, but with
the hands relaxed at wrists.
Test procedure: The tester stands behind the subject
and gives the instruction: “When I turn your head. I
want you keep your arms straight out in front of you, as
they are now. This means your arms remain in the same
position, and only your head moves.” Then the tester
slowly rotates the subject’s head until the chin is paral-
lel with the shoulder. Pause for 10 seconds. Return the
head to the midline. Pause for 10 seconds. Rotate the
head to the other side and pause for 10 seconds. Repeat
the procedure up to four times.
Observations: Any movement of the hand and arm
on the side to which the head is turned, i.e., do the arms
automatically follow the movement of head?
Scoring: 0 – no response; 1 – a slight movement of the
arms in the direction the face is pointed, a movement of
the arms in the direction of head to 45◦ ; 2 – an arm
movement to 60◦ or flexion of the opposite side, a 90◦
rotation of the arms and/or loss of balance as a result of
head rotation [13,14].
Psychometric measure of ADHD symptoms
Frequently used measure of ADHD symptoms is
Children’s Parent Questionnaire (CPQ) by Conners
[15–17]. The CPQ is 93-item scale of symptoms that
are most commonly associated with behavioral disorders
and related to children and adolescents (aged 3–17),
and can measure treatment changes and outcome as-
sessment purposes.
The questionnaire enables to calculate total score,
and it has also subscales based on factor structure of the
questionnaire – I. conduct problems (items 39, 40, 41,
47, 48, 51, 69); II. anxiety (items 8, 9, 10, 11, 42 ,43,
64); III. impulsivity–hyperactivity (items 78, 80, 81, 82,
83, 84, 89, 90); IV. learning problems (items 45, 62, 63,
67); V. psychosomatic difficulties (items 6, 21, 22, 23,

C 2013 Informa Healthcare USA, Inc.
ATNR and ADHD in children 767
24); VI. perfectionism (items 3, 76, 77, 78); VII. anti-
social behavior (items 71, 72, 73, 75); VIII. muscular
tension (items 12, 13, 14, 36). The symptoms are rated
on a 4-point Likert scale (from 0 to 3) by either one or
both parents of the child.
Statistical analysis
Statistical evaluation of scores of the measures of ATNR
and ADHD symptoms included descriptive statistics,
Mann–Whitney tests for independent samples, Spear-
man correlation coefficients and multiple linear regres-
sion analysis. The general purpose of multiple regres-
sions is to analyze the relationship between several
independent or predictor variables and a dependent or
criterion variable and may be used as either a hypothesis
testing or exploratory method.
All the methods of statistical evaluation were
performed using the software package Statistica
Version 6.
Results
Results of the analysis show that the ATNR scores are
significantly correlated with ADHD symptoms mea-
sured by CPQ total score (r = 0.59, p < 0.01)
[Figure 1] and its subscales, i.e., with conduct prob-
lems (r = 0.34, p < 0.01); anxiety (r = 0.39, p < 0.01);
impulsivity–hyperactivity (r = 0.52, p < 0.01); learning
problems (r = 0.35, p < 0.01); Perfectionism (r = 0.39,
p < 0.01); muscular tension (r = 0.34, p < 0.01) but not
with psychosomatic difficulties and antisocial behavior
subscales. These correlations indicate that majority of
ADHD symptoms are associated with symptoms of per-
sisting ATNR responses. Statistically significant differ-
ences for ADHD symptoms and ATNR score between
girls and boys were also found (Table 1).
To assess the relations of ADHD psychopatho-
logical symptoms with ATNR, multiple linear re-
gression was used to predict ATNR scores from
reported symptoms related to conduct problems, anx-
iety, impulsivity–hyperactivity, learning problems, per-
fectionism and muscular tension in their specific in-
teractions are linked to ATNR. The result shows that
multiple R = 0.64 is statistically significant (p < 0.01;
F = 6.43) and describes ATNR scores as a linear func-
tion of these ADHD symptoms from which psychoso-
matic difficulties and antisocial behavior subscales did
not enter the equation.
To assess whether ATNR and ADHD symptoms
could be associated with any unknown other factors,
we have used data from an adequate control group of
30 children at the same age who were assessed for
CPQ and ATNR score. The children were without
768 J. Konicarova & P. Bob

Table 1. Statistical comparison of ADHD symptoms and ATNR score in ADHD children (n = 60) between girls
(N = 27) and boys (N = 33) using Mann–Whitney test.

Mean ± SD Girls Mean ± SD Boys M–W U M–W Z p

ATNR reflex 1.37 ± 0.83 1.85 ± 0.44 311.50 −1.99 0.04

CPQ 30.44 ± 14.85 49.39 ± 13.76 149.00 −4.41 0.00001
I. Conduct problems 1.56 ± 1.71 3.73 ± 2.37 199.50 −3.66 0.0003
II. Anxiety 2.74 ± 1.97 4.39 ± 2.81 301.00 −2.15 0.03
III. Impulsivity–hyperactivity 4.41 ± 3.60 6.82 ± 3.42 270.50 −2.60 0.009
IV. Learning problems 1.85 ± 1.43 2.67 ± 1.42 285.50 −2.38 0.01
V. Psychosomatic 1.44 ± 1.69 1.61 ± 1.51 407.00 −0.57 0.56
VI. Perfectionism 1.15 ± 1.87 1.73 ± 1.94 354.50 −1.35 0.17
VII. Antisocial behavior 0.11 ± 0.42 0.09 ± 0.38 439.50 0.09 0.92
VIII. Muscular tension 0.63 ± 0.88 1.06 ± 1.36 367.00 −1.17 0.24

ADHD symptoms, and none of this group has man-
ifested ATNR (the score was zero in all cases). On
the other hand, in the sample of 60 ADHD children
we have found 7 children showing ADHD symptoms
who had not ATNR manifestation (ATNR score 0).
These children had mild form of ADHD symptoms
mean CPQ total score 11.28, SD = 3.98, with the score
range 8–19.
Discussion
Results of this study support the hypothesis that symp-
toms of ADHD are closely linked to persisting primi-
tive reflex ATNR in children in the school age, indicat-
ing that ADHD symptoms may present a compensation
of unfinished or delayed developmental stages related
to diminishing ATNR, which may be particularly influ-
enced by disproportional development. In this context,
80
70
ADHD symptoms- CPQ
results of this study, in agreement with several findings,
show gender differences in ADHD manifestations that
likely are related to delayed brain maturation in boys
compared with girls of which underlying mechanisms
are currently unknown [18–20].
Because of these unfinished or delayed developmen-
tal stages certain motor and cognitive functions have
been developed regularly and certain others not, which
likely is compensated by persisting more primitive func-
tions. This finding in ADHD patients is in agreement
with few reported studies in patients with dyslexia doc-
umenting higher level of persisting primitive reflexes
[21,22].
As a consequence, these persisting ATNR and likely
also other primitive reflexes in ADHD may occur as a
response to various stimuli during behavioral and cog-
nitive tasks, which may explain attentional dysregula-
tion and other ADHD symptoms due to a conflict be-
tween higher and lower level of cognitive and motor
functions during brain processing. In the light of current
findings, these data are in agreement with neurological
concept proposed by Hughlings Jackson, who suggested
that certain later developed functions during ontogen-
esis of the central nervous system (CNS) tend to re-
place the older ones when higher stages of development

60
of the CNS has been successfully achieved [23,24]. In
50 the sense of Jacksonian theory, persisting ATNR and
other primitive reflexes may cause “dissolution” (or dis-
40 integration) of mental functions and consciousness that
30 may result in ADHD patients into various symptomatic
forms [25,26]. This principle of dissolution is based on
20 disinhibition of neural functions or their release from
control, which leads to dysregulation of later developed
10
adaptive functions [23]. This concept of dissolution is
0 also in agreement with current clinical evidence indi-
0 1 2
cating that manifestations of retained primitive reflexes
ATNR reflex
as a consequence of frontal lobe damages and cortical
Figure 1. Dependency graph between ADHD symptoms mea- disinhibition may occur in various neuropsychiatric syn-
sured by CPQ total score and ATNR reflex score (r = 0.59, p < dromes such as schizophrenia, various forms of demen-
0.01). tia and others [5,6,9–12].

International Journal of Neuroscience


Declaration of Interest
The authors report no conflict of interest. The authors
alone are responsible for the content and writing of this
paper.
The study was supported by the grant GACR
P407/12/1957, project MSM0021620849 provided
by Czech Ministry of Education and the project
“CEITEC – Central European Institute of Technol-
ogy” (CZ.1.05/1.1.00/02.0068) from European Re-
gional Development Fund.
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