Ear!v Human Deoelopmenr.

7 ( 1982) 119- 130 119

Elsevier Biomedical Press

Correlation between neurological examination and

behavioural assessment of the newborn infant
Ingemar Leijon and Orvar Finnstram
Department of Paedramcs, Umoerstty Hosprtal, Llnkbping, Sweden

Accepted for publication 7 July I982

Summary

A modified Prechtl neurological examination and the Brazelton Neonatal Be-

havioural Assessment Scale (BNBAS) were used on days 1 and 5 in 78 healthy
newborn infants. Correlations between variables in the neurological examination
and the behavioural items and subscales in the BNBAS were calculated. Especially
the total neurological score and optimality score were significantly correlated to
motor performance (days 1 and 5) and to orienting responses to animate and
inanimate stimuli (day 1) in the BNBAS. The neurological variables showed poor or
no correlation to the habituation items and to certain items concerned with changes
of lbehavioural state in the BNBAS.

neurological examination; behavioural assessment; newborn infant

Introduction

Several neurological examination methods have been developed for assessment of

full-term newborn infants (e.g., [ 16,181). Prechtl and Beintema’s neurological ex-
am:ination [ 161 is one of the most comprehensive and rigorously standardized
examinations. During recent decades the behavioural or interactive capacities of the
newborn infant have been rediscovered. Graham [6], who developed one of the first
behavioural assessments for newborn infants (later modified by Rosenblith [17]),
quantified the responses in order to distinguish normal infants from those who have
been traumatized or brain-injured. Another extensive examination of neonatal
behaviour was described by Brazelton [3], whose Neonatal Behavioural Assessment
Scale (BNBAS) has been used in a large number of studies (for review see [22]). It

Correspondence mq be addressed to: Ingemar Leijon, M.D.. Department of Paediatrics. University

Hoqpital. S-581 85 Linkbping, Sweden.

0378-3782/82/0000-0000/$02.75 ‘0 1982 Elsevier Biomedical Press

120

allows assessment of the infant’s behaviour in a systematic and quantifiable manner,

and it is claimed to measure the wide variety of behaviours which are significant for
the infant’s social interaction with his environment [ 11.
One of the most important factors in neurological assessments of newborn infants
is the standardization of the examination procedures. According to Prechtl [ 141 this
includes the environmental conditions, the behavioural state of the infant, and the
technique of handling the infants. In the Prechtl examination the important optimal-
ity concept is also employed for neurological findings. In the BNBAS there are
similar standardization criteria regarding environmental conditions and the infant’s
behavioural state. In Prechtl’s examination the sequence for performing the ex-
amination is defined, whereas Brazelton recommends a fixed order for the tests and
manoeuvers but “the examiner is free to vary the order of administration of items to
take maximum advantage of the infant’s state and readiness to respond at a
particular moment” [3].
In recent studies [e.g., 5,201 it has been common to select items from the BNBAS
in combination with ‘pure’ neurological items. Such a procedure is justified if the
behavioural items assess characteristics of the newborn infant not detected by the
other technique. The aim of the present study was therefore to correlate the results
of a modified Prechtl examination to those of BNBAS in a group of newborn
full-term infants born without serious obstetrical complications.

Material and Methods

The series is described elsewhere in a study on the effect of elective induction of

labour where 80 mothers were selected at regular prenatal visits during the last
trimester [ 111. Primiparae and multiparae fulfilling normal criteria were included. In
39 women labour was induced at full term by amniotomy followed by intravenous
infusion of oxytocin using the Cardiff infusing system Mark-II [4]. The others went
into labour spontaneously, and amniotomy was done when definite labour activity
could be demonstrated. Intrauterine pressure measurements and fetal heart rate were
recorded via a scalp electrode. The mothers received standard obstetric analgesia
(nitrous oxide/oxygen (50: 50) and/or pethidine chloride-hydroxizine chloride (50
mg/50 mg) and/or pudendal block with 20 ml 0.5% mepivacaine chloride). There
were three vacuum extractions, two of them because of impending prenatal asphyxia.
All infants had a normal postnatal period, and remained with their mothers in the
maternity ward. There was no postnatal asphyxia as evaluated by Apgar scores or in
measurements of cord pH.
All infants were examined by the same doctor (IL). A neurological exemination
mainly based on Prechtl and Beintema [16] was done at the same occasion as the
BNBAS. It comprised 36 items, most evaluated on a 4-point scale (see Table I).
Muscle tonus and excitability scores were calculated from the items reflecting mainly
these factors, as described by Schulte et al. [21]. Optimal responses were consistent
with Prechtl’s optimality criteria [ 141. The number of optimal responses in items for
which an optimal response could be evaluated (optimality score) and the total
 121

TABLE, 1

Grouping of items in the neurological examination

Itemsmeumring musculttr tonus ’ (range X-31) (n =8)

Spontaneous posture. supine position (l-3)
Resistance against passive movements. body and neck ( 1-4)
Resistance against passive movements, arms (I-4)
Resistance against passive movements. legs (l-4)
Recoil. arms ( l-4)
Tractton response, arms ( l-4)
Traction response, head ( l-4)
Head control. vertical position ( l-4)
Itemsn~easuring excitahrlq h (range 9-33) (n = 9)
Optical blink reflex (l-3)
Acoustic blink reflex (l-3)
Patellar reflex ( 1-4)
Palrnar grasp ( l-4)
Withdrawal reflex (l-4)
Rooting reflex (l-4)
Ability to suck (l-4)
Moro tremor (l-3)
Spontaneous motility (I-4)

Optunol rtems ( n = 27)

Items measuring muscular tonus (see above)
Items measurtng excitability (see above, Moro tremor excluded)
Facial expression (I -2)
Cry ( I-4)
Symmetry in body position ( l-2)
Eyes. following a red ball (I-3)
Doll’s eye test (l-2)
Pupillary reaction to light (l-3)
Glabellar reflex (l-2)
Moro reflex ( l-4)
Crawling (l-4)
PIacIng response (1-2)
Automatic walking ( l-3)

Total neurolog~rrl score ’ (range 36 116) ( ,I = 36)

Optimal items (see above) (27-92)
Neurological signs
dr~owsiness (I -3)
jitlteriness (l-2)
convulsions (l-2)
others (l-2)
Fontanelle tension (l-6)
Position and movements of eyes (l-2)
Difference between sides in resistance against passive movements ( l-2)
Asymmetrtcal Moro (l-2)
Moro tremor (I-3)

,’ A high muscle tonus score means low muscle tonus.

h A lhigh excitability score means low excitability (apathy).
’ A high total neurological score mainly means low muscle tonus and/or low excitability (apathy).
Figures in parentheses indicate potential scores. The maximum value for an item may indicate an absent
response
122

neurological score were also calculated for each infant. The distributions of neuro-
logical scores are shown in Figs. l-4. High muscle tonus and excitability scores
mean low muscle tonus and low excitability. A high total neurological score mainly
indicates low tonus and/or low excitability. The examination was done with the
infant in an optimal and well-defined behavioural state [15]. Figures for interob-
server reliability between two independent examiners assessed on 19 unselected
newborn infants in an earlier interobserver study were 0.87 for tonus score, 0.94 for
excitability score, 0.95 for total score, and 0.94 for optimality score.
The Brazelton Neonatal Behavioural Assessment Scale (BNBAS) [3] includes 27
behavioural items on a 9-point scale. ‘Lability of skin colour’, ‘number of smiles’,
and reflex items were not analysed. Some items in the BNBAS were restored so that
high scores always indicated good performance (Lester et al., personal communica-
tion; [S]). The results of BNBAS were analysed by combining the items into 6
subscales (Lester et al., personal communication; [8]). (For grouping of items into
subscales, see Tables II and III.) The scores for individual items in a subscale were
added, and the sum was divided by the number of items for the relevant subscale to
give a subscale score; the subscale score could not be calculated if one item was
missed. The distributions of the subscale scores are shown in Figs. 5-10. The initial
and predominant states were recorded at each examination, as recommended by
Brazelton [3]. The interobserver reliability of the test was studied earlier and found
in general to be satisfactory, with high reliability of independent observers for most
items [lo]. The test-retest reliability varied between items and subscales, and was in
general less good than the interobserver reliability [lo].
Product-moment correlations were used for describing the relationships between
the neurological examination and the BNBAS.
The investigation was approved by the Ethics Committee of the Faculty of
Medicine, University of Linkoping. Informed consent was given by all mothers.

Tonua score Excitability scora

N _eL
50
Oay I Oay I
??

II
??
0 Oay 5 0 Day 5
40

30

20

III

n
II 12 I3 I4 I5 16 I7 I6 llrcora 19 score

Fig. 1. The distribution of tonus score. Fig. 2. The distribution of excitability score.
 123

N OPNmaNly
score N Total score
50 50~
i3 Clay I c Day 1
40 I 0 Day 5 40. 0 Oay 5

3oi 30.

20.

20 21 22 23 24 25 26 27 acora
10

,,all,l-kldL,a,~,rl,_,_
49 50 I 52 53 54 55 56 57 56 59 60 61 62rcors

Fig. 3. The distribution of optimality score Fig. 4. The distribution of total neurological score.

N Habituation
50
N49 o Day 1
40 N=50 0 Day6
1
301

201

‘I I.O6%l%66- 2.50-3.06 3.56 4.00. 4.50-5.00. 5.50-6.00. 6.50. 7.00. 7.50.6.00-6.50-

r-q-
1.49 1.99 2.49 2.99 3.49 3.99 4.49 4.99 5.49 5.99 6.49 6.99 7.49 7.99 8.49 8.99 QCOr6

Fig. 5~.The distribution of scores in habituation subscale

N Orianlatalion
501 N.65 u Oay 1
40 N-75 ? ?Oar5

30I

2oj

10 L
t.OOz:-2.00~ 2.50.3.00. 3.50~
r-&lrrl
4.00. 4.50. 5.06
1 6.56 6.06 6.60. 7.00. 7.50-6.00.
A, 8.50.
1.4!11.99 2.49 2.99 3.49 3.99 4.49 4.99 5.49 5.99 6.49 6.99 7.49 7.99 6.49 8.99 SCOr6

Fig. 6. The distribution of scores in orientation subscale.

124

N M0hlr

so-
N=74 o DayI
40. N.76 0 Day5

20.
IO- 1

n r ,_
LOO-I.56 LOO-2.50- 3.00. 3.50. 4.00. 4.50. 5.00. 5.50. 6.00- 6.50. 7.00. 7.60. 6.00. 6.50.
1.49 1.99 2.49 2.99 3.49 3.99 4.49 4.99 5.49 5.99 6.49 6.99 7.49 7.99 6.49 0.99 SCOl6

Fig. 7. The distribution of scores in motor subscale.

N ofstata
RanlJo
50.
N.73 n Day 1
N.77 0 Day 5
40.

30.

I;
20.

‘“LA 1.00. l.!iO-

1.49 1.99
LOO- 2.50. 3.00. 3.60. 66. 4.60. 5.00. 6.50. 6.00. 6.50. 7.00. 7.50. 6.00- 6.50.
2.49 2.99 3.49 3.99 4.49 4.99 5.49 5.99 6.49 6.99 7.49 7.99 6.49 6.99 SCOT6

Fig. 8. The distribution of scores in range of state subscale.

N
50
I 1.65 Day
?? I
N-73 0 OaY 5
40

30!

20

,r-n,rTl ,
1.00. 1.50- 2.00. 2.50-3.00. 3.60. 4.06. 4.50. 5.60. 6.50. 6.60. 6.50. 7.00. 7.50. 6.00. 6.50-
1.49 1.99 2.49 2.99 3.49 3.99 4.49 4.99 6.49 5.99 6.49 6.99 7.49 7.99 6.49 6.99 lieOr

Fig. 9. The distribution of scores in regulation of state subscale.

Correlation coeffictents between neonatal neurological examination and hehavioural items in the BNBAS
on dav I
- -
Day I ,I Tonus Excttabiltty Total Optimality
Behavioural items and subscales score score score score
- -
(A) Habttuation subscale
Response decrement to:
repeated light stimuh 74 0.2 I -0.01 0.09 ~ 0.05
repeated rattle stimuli 58 0.35 ** 0.26 0.33 ** -0.03
repeated bell stimuli 60 0.23 0.13 0.15 - 0.04
repeated pinpricks 68 0.0 I 0.04 0.1 I -0.11
(B) Onentation subscale
Orientation to object 69 0.05 -0.43 *** ~-0.53 *** 0.51 ***
Orientation to sound 74 0.13 -0.27 * -0.30 * 0.36 **
Orientation to face 68 0.03 -0.38 ** -0.43 *** 0.39 ****
Orientation voice 72 0.07 ~-0.17 -0.30 * 0.34 **
Orientation to face and voice 67 -0.15 -0.30 * -0.40 *** 0.29 *
Alertness 74 - 0.07 -0.37 ** -0.42 *** 0.54 ***
(C) IMotor subscale
General tonus 75 -0.36 ** -0.43 *** -0.31 ** 0.12
Motor maturtty 76 0.1 1 0.03 ~.0.06 0.16
Pull-to-sit 76 -0.47 *** -0.33 ** -0.35 ** 0.35 **
Defenstve movements 75 -0.14 - 0.38 *** --0.44 *** 0.49 ***
Activity level 76 0.06 -0.37 ** -0.45 *** 0.55 ***
(D) Range of state subscale
Peak of excitement 74 0.05 0.0 I PO.22 0.18
Rapidity of build-up to crying 75 -0.12 -0.02 ~0.25 * 0.22
Irritability 76 -0.16 -0.23 * - 0.27 * 0.27 *
Labtlity of states 76 0.02 0.0 -0.20 0.06
(E) Regulation of state subscale
Cuddliness 76 -0.03 -0.40 *** -0.37 ** 0.46 ***
Consolability 65 -0.09 0.22 0.34 ** -0.31 *
Self-quieting activity 76 0.05 0.04 0.26 * -0.17
Hand-to-mouth activity 76 -0.16 -0.16 ~-0.15 0.05
(F) Physiological stability
Tremulousness 76 0.02 -- 0.05 0.06 -0.14
Startles 76 0.02 0.20 0.16 -0.10

* PiO.05, ** P<O.Ol. *** P~O.001.

Note: High raw values in tonus score and excitability score mean low tonus and low excitability. High
raw values in total score mean low tonus and/or low excitability.

I
Physiolo9ical stability
561
N-57 : Day I
40 N.69 LJ Day 5
I
30.

201

n mm n n
1.50,,.,.50. 3.09 3.50. 4.00- 4.50. 5.00. 5.50. 6.00-&SO-7.00. 7.59 9.09 9.50-
1.99 2.49 2.99 3.49 3.99 4.49 4.99 5.49 5.99 6.49 6.99 7.49 7.99 0.49 9.99 scoru

Fig. 10. The distribution of scores in physiological stability subscale

126

TABLE III

Correlation coefficients between neonatal neurological examination and behavioural items in the BNBAS
on day 5

Day 5 n Tonus Excitability Total Optimality

Behavioural items and subscales score score score score
-
(A) Habituation subscale
Response decrement to
repeated light stimuli 68 - 0.09 0.07 - 0.09 0.2 1
repeated rattle stimuli 59 0.12 0.19 0.12 0.03
repeated bell stimuli 62 - 0.04 0.10 0.02 0.01
repeated pinpricks 60 -0.25 * 0.08 -0.21 0.16
(B) Orientation subscale
Orientation to object 78 -0.20 0.0 -0.19 0.19
Orientation to sound 75 - 0.06 0.05 -0.01 0.02
Orientation to face 78 -0.34 ** 0.09 -0.27 * 0.30 **
Orientation to voice 78 -0.16 0.08 0.04 0.08
Orientation to face and voice 78 -0.29 ** 0.09 -0.18 0.22 *
Alertness 78 -0.16 0.06 - 0.05 0.02
(C) Motor subscale
General tonus 78 -0.40 *** -0.18 -0.38 *** 0.35 **
Motor maturity 78 -0.27 * 0.10 -0.29 ** 0.37 **
Pull-to-sit 78 -0.40 *** -0.18 -0.51 *** 0.53 ***
Defensive movements 78 - 0.04 -0.07 -0.09 0.0
Activity level 78 -0.13 -0.50 *** -0.42 *** 0.14
(D) Range of state
Peak of excitement 78 0.02 -0.21 -0.10 0.09
Rapidity of build-up to crying 78 -0.17 -0.30 ** -0.24 * 0.05
Irritability 77 - 0.03 -0.25 * - 0.09 -0.03
Lability of states 78 -0.08 -0.23 * -0.21 0.14
(E) Regulation of state
Cuddliness 78 -0.27 * -0.19 -0.28 * 0.21
Consolability 74 -0.12 - 0.02 -0.11 0.10
Self-quieting activity 77 - 0.09 0.17 0.03 0.02
Hand-to-mouth activity 78 0.04 0.09 0.13 - 0.04
(F) Physiological stability
Tremulousness 78 0.12 -0.28 * -0.01 -0.14
Startles 78 -0.09 -0.15 -0.17 0.13

* P<O.O5, ** P<O.Ol, *** P<O.OOl.

Note: High raw values for tonus score and excitability score mean low tonus and low excitability. High
raw values for total score mean low tonus and/or low excitability.

Results

In the original group of 80 infants the results for 76 infants on day 1 and 78
infants on day 5 were available for correlation studies between neurological scores
and individual items on the one hand and subscales of the BNBAS on the other.
Some data were missing in the behavioural examinations, because only some
 I27

TABLE IV

Correlation coefficients between neonatal neurological examination and Brazelton subscale scores on da!

Behavioural subscales Neurological examination

n Tonus Excitability Total Optimality

score \core score X0X

Habituation 50 0.32 * 0.18 ~0.52 *** -0.26

Orientation 66 0.07 -0.37 ** ~0 52 *** 0.50 ***
Motor 15 -0.07 PO.30 ** PO.39 *** 0.55 ***
Range of state 74 - 0.02 ~ 0.23 - 0.20 0.36 **
Regulation of state 65 - 0.03 - 0.06 0.14 ~ 0.02
Physiological stability 58 0.03 PO.07 PO.15 0.19

* PCO.05. ** P-=0.01. *** P<O.OOl.

habituation items could be assessed in infants who changed their behavioural state
during the first part of the examination. A few infants could not be assessed for
orientation items on day 1 because they could not be kept sufficiently alert, or
because of conjunctivitis owing to silver nitrate treatment. Other missing data
referred to the item consolability, because some infants never cried during the
examination.
Tlhe correlation coefficients for days 1 and 5 are shown in Tables II and III. The
tonus score showed in general poor correlation with the BNBAS items except for a
few motor items. The excitability score was correlated on day 1 to most orientation
and motor items and to cuddliness. On day 5 excitability score was correlated to
activity and also to some range-of-state items. The total score and optimality score
were fairly well correlated to orientation, motor, and some ‘state’ items on day 1
(Table II). On day 5 there were fewer significant correlations: total score and

TABLE V

Correlation coefficients between neonatal neurological examination and Brazelton suhscale scores on day
5

Behavioural subscales Neurological examination

n Tonus Excita- Total Optlmality

score bility score score

Habitluation 50 - 0.06 0.18 PO.03 0.1 I

Orientation 76 -0.27 * 0.06 -0.16 0.18
Motor 79 -0.33 ** - 0.04 PO.41 *** 0.50 ***
Range of state 78 0.06 0.04 0.15 -0.07
Regulation of state 73 -0.14 0.08 0.02 0.09
Physiological stability 70 -0.12 0.24 0.08 0.03

* P<O.O5, ** P<O.Ol. *** Pc0.001

128

optimality score showed significant correlations to motor items.

There were more significant correlations between neurological variables and
subscale scores of the BNBAS on day 1 than on day 5 (see Tables IV and V). On day
1 the excitability score, the total score, and the optimality score showed correlations
to the orientation and motor subscales (Table IV). The tonus, total and optimality
scores were significantly correlated to the motor subscale on day 5 (TableV). The
neurological variables were not significantly correlated to regulation of state and
physiological stability on either day.

Discussion

Reliable methods for assessment of the neurological condition of the newborn

infant are needed. The opinion of Brazelton et al. [1,3] is that the neurological
examination is useful for detecting major neurological abnormalities, but that it is
not as good as a behavioural assessment for detecting minor dysfunction of the
central nervous system. Prechtl, on the other hand, argues that the BNBAS is not
sensitive enough to detect abnormal neurological conditions, but that it can comple-
ment neurological examination during the first weeks of life [15]. The neurological
examination used in this study has high interobserver reliability, and can differenti-
ate between controls and infants with intrauterine growth retardation [12] and also
between controls and infants born by vacuum extraction [9]. Data on reliability and
validity of the BNBAS have earlier been reported [7,10,19]. Interobserver reliability
is in general satisfactory, but many items show poor day-to-day stability in perfor-
mance. The purpose of the present study was to evaluate the relationships between a
modified Prechtl examination and the BNBAS in healthy full-term newborn infants.
No infants showed abnormal neurological signs during the neonatal period.
The correlations between the neurological variables and certain BNBAS items
and subscales indicate some common relationships between the findings in a
neurological examination and the performance in a behavioural assessment. Many
items in the BNBAS probably overlap or measure the same characteristics of an
infant. The neurological variables thus often showed relationships to several items
for a subscale. The orienting responses are not evaluated in the neurological
examination, but motor function, including muscular tonus, are characteristics
assessed in most neurological examination programmes. Motor performance in the
BNBAS was correlated to the neurological variables on both days. This finding is
expected, since Beintema [2] showed that spontaneous motor activity and resistance
against passive movements are the most consistent characteristics throughout the
neonatal period. Our neurological variables were poorly correlated to the subscales
range of state and regulation of state. Items in these subscales are concerned with
changes in behavioural state during the examination, and may constitute essential
characteristics of the procedure [15]. The results for habituation items are incon-
sistent, which probably indicates that they are highly state-dependent. The very poor
correlations between neurological variables and physiological stability can be ex-
plained by inadequate definitions of tremulousness and number of startles in
 129

BNBAS. Tremors of high frequency and low amplitude are seen in normal infants
during the first days of life [2], and spontaneous startles are seen regularly in sleep
states [ 131.
A correlation apparently exists between the results in the neurological assessment
and aspects of neonatal behaviour assessed by the BNBAS during the first days after
birth. Optimal performance in the neurological examination paralleled good perfor-
mance in orientation and motor behaviour. Poor correlations appeared between the
neurological variables and the behavioural items which deal with behavioural state.
e.g.. items in the subscales range of state and regulation of state. A neurological
examination ought therefore to be complemented with variables in the BNBAS
which characterize the infant’s temperament. Any such combined neuro-behavioural
examination must also be subjected to the same standardization requirements as a
full-scale examination of neurological or behavioural type.

Acknowledgements

This study was supported by grants from the Faculty of Medicine, University of
Linkoping; The County of Ostergotland; and the First of May Flower Annual
Campaign for Children’s Health.

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