Construction of an Infant Neurological International

Battery (INFANIB) for the Assessment of

Neurological Integrity in Infancy
Patricia H Ellison, John L Horn and Carol A Browning
PHYS THER. 1985; 65:1326-1331.

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Construction of an Infant Neurological International
Battery (INFANIB) for the Assessment of Neurological
Integrity in Infancy

PATRICIA H. ELLISON,
JOHN L. HORN,
and CAROL A. BROWNING

In this article, we describe the construction of an instrument for the assessment

of the neurological integrity of infants. In a follow-up program for infants from the
neonatal intensive care unit, 365 evaluations of 308 infants were made by using
a 32-item battery with items from four methods. Factor analyses were used for
data analyses, which yielded a 20-item instrument with five factors. We named
the instrument the Infant Neurological International Battery (Infanib). The Infanib
has sufficient reliability for clinical and research purposes. We have formed
scoring sheets, which permit clinical use of the instrument. Cut points are
recommended for the separation of infants with normal, transiently abnormal,
and abnormal neurologic development. The quantified scoring system enables
comparison of infants on item scores, subscores (factor scores), and total scores.
It also permits entry of these scores in the computer so that more complex
descriptions are possible of the relationship of the neurological assessment of
infants both to earlier (eg, birth) and later variables (eg, cerebral palsy, cognitive
function, and school performance).
Key Words: Abnormalities, Evaluation studies, Infants, Neurologic manifestations.

We constructed an instrument to as-
sess the neurological integrity of infants
tofillan important gap for professionals
working in follow-up programs for the
neonatal intensive care unit. Neurolog-
ical assessment of infants is of key im-
portance for three reasons: 1) for iden-
tification of abnormalities that should
be referred for physical and occupa-
tional therapy,1"3 2) as a marker for
problems during the early school
years,4-6 and 3) for research about the
causes and outcomes of these abnor-
malities.4"7
A neurological assessment instrument
that meets these needs must have the
following qualities: 1) quantification
and easy computer entry; 2) reliability
across the age range of infancy (many
changes occur in this age range that
Dr. Ellison is Research Professor, Department
of Psychology, University of Denver, 2030 S York
St, Denver, CO 80208 (USA).
Dr. Horn is Professor of Psychology, University
of Denver.
Dr. Browning is Assistant Professor of Pediatrics,
Medical College of Wisconsin, 8700 W Wisconsin
Ave, Milwaukee, WI 53226.
Funds for this research were supported partially
by NINCDS—IF33NS07435.
This article was submitted August 9, 1984; was
with the authors for revision six weeks; and was
accepted March 21, 1985.
must be adequately documented); 3)
sufficient reliability and validity for both
clinical and research purposes; and 4)
acceptability by clinicians for the time
required for assessment, clarity of items,
and simplicity of scoring.
We have formed the assessment in-
strument the Infant Neurological Inter-
national Battery (Infanib) on the basis
of factor analysis. This analysis implies
that the items in each group are inter-
related. It also permits the formation of
a subscore for each factor and a total
score for the combined factors.
The Infanib is practical for clinical
use. The examination can be completed
in a few minutes. Both subscores and
total scores can be compared from one
evaluation to the next, from one infant
to another, or from infants with one type
of condition (eg, infants who had grade
3 or 4 intraventricular hemorrhage) to
infants with another condition (eg, in-
fants who did not have intraventricular
hemorrhage).
METHOD
The subjects were infants followed in
the Southeastern Wisconsin Regional
Perinatal Follow-through Program from
October 1, 1981, to November 30, 1982.
Appropriate informed consent was ob-
tained.
Follow-up assessments were sched-
uled for 6- and 15-months corrected
gestational age. As we have found pre-
viously in follow-up work, however, as-
sessments were also made throughout
infancy. A full neurological assessment
was done at each visit.
Outside validation of neurologic ab-
normality was obtained through evalu-
ation in programs to which those infants
were referred and from evaluation by
pediatric neurologists at the Medical
College of Wisconsin. All younger in-
fants were followed beyond the time
range in which data were collected as a
part of the scheduled evaluation. In pre-
vious work, we have found that identi-
fication of neurological abnormality was
possible in infants aged 10 to 15 months
old. Other researchers have confirmed
thisfindingas well.4,6,8 Very few infants
who have been carefully examined re-
turn later with undiagnosed abnormali-
ties unless there has been an intervening
event such as meningitis or head injury.
The follow-up evaluation consisted of
an examination by a pediatric nurse
practitioner who obtained anthropo-
metric measures and performed the

1326 PHYSICAL THERAPY

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 RESEARCH

Denver Developmental Screening Test.9 The physical therapist scored each in- their accuracy in predicting each of the
One of two physical therapists assessed fant in two other ways: 1) degree of categories of normality-abnormality.17
and scored each infant on 32 neurolog- neurologic normality-abnormality (se- Two types of variations were used in
ical items for the neurological assess- verely abnormal, moderately abnormal, these analyses: 1) a variation using
ment; both physical therapists were mildly abnormal, minimally abnormal, standard scores for the subscores or
skilled in the neurological evaluation of or normal) and 2) category of normality- squares of standard scores for the sub-
infants using the quantified Milani- abnormality (spastic tetraparesis and scores and 2) a variation in categories of
Comparetti and Gidoni (MCG) dyskinesia, spastic hemiparesis, spastic abnormalities. These latter variations
method.10 diplegia, hypotonia, transient abnor- were 1) a grouping of six categories of
mality, and normal). normality-abnormality (spastic tetrapa-
resis/dyskinesia, spastic diplegia, hypo-
Neurological Items and Scoring Data Analysis tonia, two gradations of transient ab-
normality, and normal) and 2) a group
The items for the neurological assess- We obtained correlations among the
ment were selected from four methods 32 items. The matrix of these correla-
of neurological examination: 1) the tions was factored by using several pro- TABLE 1
MCG method,11 2) the French "angles" cedures of factor analysis. The root one Description of 365 Infants by Corrected
method,8 3) the primitive reflexes criterion15, 16 was examined along with Gestational Age and Sex
method,12, 13 and 4) the Paine and Oppe other criteria for determining the correct
method.14 number of factors. In rotation, we con- Corrected
Number of
Gestational Age
In previous work, we used three types sidered both the Varimax (orthogonal) Infants
(mo)
of data analyses—chi-square, product- and Promax (oblique) solutions. The
moment correlation, and analysis of oblique rotation with afive-factorsolu- 3 1
variance (ANOVA) at six age levels (6, tion described the data well. Four high 4 1
5 8
7 to 8, 9 to 10, 11 to 12, 15 to 16, and loading items were selected to measure
6 95
17 to 21 months old)—to reduce the each factor, although most factors had 7 41
items of the MCG method from 27 to more than four items with loadings 8 41
20 items.10 We used those 20 MCG greater than .30. Thus, a 20-item battery 9 26
items in this study. Five items were used with five factors was formed. Internal 10 13
from the French angles method. We consistencies or reliabilities were calcu- 11 10
consider that these five items represent lated for each factor. 12 7
distinctive aspects of that method and Although the five factors were math- 13 6
have used them previously,1 We used all ematically independent, they were pos- 14 3
items from the primitive reflex method, itively correlated. We therefore summed 15 63
and chose three items from the Paine 16 27
the subscores from the five factors to
17 7
and Oppe method on the basis of clini- obtain a total score. Internal consisten- 18 7
cal experience. The 32 items that com- cies or reliabilities were calculated for 19 2
prised the neurological assessment are the items for the total score for two age 20 6
shown in Appendix A. ranges: 7 months or less and 8 months 22 1
A scoring system was developed so or more, corrected gestational age. TOTAL
that each item was scored from 1 to 5 205 (boys)
points (severely abnormal to normal). Mean of Total Scores,
160 (girls)
For the MCG items, the scoring was the Subscores, and Normality and
same as that described in our previous Abnormality Scores
work.10 For the French angles method, TABLE 2
items one age level away from the ex- Because some items were not scored Description of 365 Infants by Degree and
pected developmental level were scored in the earlier ages (eg, forward para- Category of Normality-Abnormality
3 or 4; items two or more age levels chute), means and standard deviations Normality- Number of
away from the expected developmental for the total score were obtained for two Abnormality Infants
level were scored 1 or 2. The primitive age groups: infants 7 months or less and
infants 8 months or more, corrected Degree
reflexes were scored as described by Ca-
severely abnormal 6
pute et al.13 Reflexes were scored 5 gestational age. These scores were ob-
moderately abnormal 49
points for normal or 2+ reflexes, 3 to 4 tained for the five degrees of normality- mildly abnormal 38
points for 1+ or 3+ reflexes, and 1 to 2 abnormality that the examiners had minimally abnormal 101
points for 0 or 4+ reflexes. Hand posi- been asked to rate. An ANOVA was normal 169
tion was scored 5 points for open, 3 to obtained for each of the two age cate- Category
4 points for closed recurrently, and 1 to gories to assess whether the five degrees spastic tetraparesis/ 28
2 points for usually closed. (An open of normality-abnormality were signifi- dyskinesia
hand pattern was considered normal be- cantly different from each other, as spastic hemiparesis 5
cause all the infants were 3 months of measured by the total score. spastic diplegia 17
hypotonia 21
age or older.) A full set of the scoring Subscores, obtained by summing the
transient abnormality 134
for all 32 items is available from the item scores for each factor, were used in 160
normal
senior author (P.H.E.). several discriminant analyses to assess

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 collapsing the two categories of spastic­ TABLE 3
ity into one and the two categories of The 20 Items Selected for the Infanib Using Factor Analysis (Promax Rotation)
transient abnormality into one. The re­
sulting four categories of normality-ab­ Factor Items Factor Loading Reliabilitya
normality were spasticity, hypotonia, 1. Spasticity asymmetric tonic neck reflex .71
transient abnormality, and normal. The tonic labyrinthine in prone .78
number of infants with spastic hemipa- tonic labyrinthine in supine .77
resis was too small to permit inclusion hands held open or closed .61 .86
of that as a category. II. Vestibular function backward parachute .88
forward parachute .88
sideway parachute .63
Clinical Application
body rotative .89 .89
The 20-item scoring method was then III. Head and trunk sitting .65
pulled to sitting .71
used in clinics and follow-up programs
all fours .73
by physicians and physical therapists to .74
body derotative .86
test its practicality. Because many clini­ IV. French angles scarf sign .67
cians had difficulty scoring a 5-point heel to ear .75
range for each item, we rescored the data popliteal angle .78
and repeated the data analyses. Items abductor's angle .82 .89
originally scored 5 were retained as 5, V. Legs standing .56
items scored 3 or 4 were rescored as 3, foot grasp .70
and items scored 1 or 2 were rescored dorsiflexion of foot .67
as 1. Cut points for three degrees of positive support reflex .66 .72
normality-abnormality were then made a
Total score reliabilities: All subjects .91, 7 months or less .88, 8 months or more .93.
for total scores of infants 4 to 8 months
old and infants 8 months or older. A
similar cut point was made for infants TABLE 4
Means, Standard Deviations, and ANOVA F Values for the Total Score (Summation of
less than 4 months old on the basis of
Scores from the 20 Infanib Items)
infants seen in the clinics.
Degree of Normality-
Age s ANOVA F
Abnormality
RESULTS
7 months or less severely abnormal 32.3 2.9
Three hundred and sixty-five neuro­ moderately abnormal 55.3 10.1
logical assessments were made. Two mildly abnormal 64.9 6.8
hundred and sixty-one infants were minimally abnormal 71.0 4.6
evaluated on one occasion, 37 were eval­ normal 76.6 3.6 82.0(<.001)
uated on two occasions, and 10 were 8 months or more severely abnormal 38.1 7.5
evaluated on three occasions. The num­ moderately abnormal 60.9 11,5
mildly abnormal 74.3 10.4
ber of infants between 3 and 22 months
minimally abnormal 85.2 7.2
old evaluated each month is shown in normal 95.6 6.1 140.1 (<.01)
Table 1.
The number of infants with each of
the five degrees of normality-abnormal­ The means, standard deviations, and scores and not of item scores. Hypotonia
ity and the number of infants in each ANOVA F values with the level of sig­ was less accurately identified as a sepa­
category of normality-abnormality are nificance for the five degrees of normal­ rate category than other categories; spas­
shown in Table 2. A wide spectrum of ity-abnormality are shown in Table 4. ticity, transient abnormality, and nor­
normality-abnormality was assessed. Clinicians may choose to divide nor­ mality were accurately discriminated
Thus, the instrument for assessment was mality-abnormality into different num­ with the use of subscores.
- constructed on the basis of the evalua­ bers of degrees. In previous work, we The cut points for infants less than 4
tion of infants with normal and abnor­ have used three degrees: normal, tran­ months old were established as follows:
mal neurologic development. siently abnormal, and abnormal.1, 10 We abnormal ≤ 48, transient = 49-65, nor­
The factor loadings for the 20 items consider that five degrees are as many mal≥66. For infants 4 to 8 months old,
obtained in the five-factor solution with as we need for practical use. Even with the cut points were abnormal ≤ 54,
a Promax (oblique) rotation are shown this large number of degrees, the 20- transient = 55-71, and normal ≥ 72.
in Table 3. The internal consistencies or item Infanib discriminates significantly For infants 8 months old or more, the
reliabilities for each factor are also given. between the degrees of normality-abnor­ cut points were abnormal ≤ 68, tran­
Each of the factors except Factor V (legs) mality. sient = 69-82, and normal ≥ 83.
had sufficient reliability as a separate The percentage of infants who were
factor at the upper age levels (8 months identified correctly by discriminant
or older). The reliability for the total analyses for two different categoriza­ DISCUSSION
score is large enough, both above and tions of normality-abnormality are
below age 8 months old, for clinical and shown in Table 5. The discriminant The construction of an instrument for
research purposes.18 analyses were based on the use of sub- the measurement of neurological integ-

1328 PHYSICAL THERAPY

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TABLE 5
Percentage Correct Achieved in Discriminant Function Analyses in Two Categorizations
of Diagnosis
Grouping Category of Normality-Abnormality
First spastic tetraparesis/dyskinesia
spastic diplegia
hypotonia
less transient
more transient
normal
Second spasticity
hypotonia
transient abnormality
normal
rity should be based firmly on the prin-
ciples and theories of measurement the-
ory.18 The first step is descriptive. The
neurological function and movement of
infants have been described by several
observant clinicians.8, 11, 14, 19-21 The
monograph of Bly is noteworthy for its
rich detail.21 Thus, some consensus of
normality and of deviance or abnor-
mality has been achieved in the area.
The next step is the formation of sin-
gle items as representations of these gen-
eral descriptions. In the construction of
the Infanib, items from four methods of
neurological evaluations were used to
expand the scope of the assessment. In
test development, this expansion is
phrased as "generating an item pool."22
The assembled items were then ad-
ministered to a representative sample.
Because the initial goal of our study was
the construction of an instrument for
clinical and research purposes for neo-
natal programs, we chose a sample of
infants who were initially treated in the
neonatal intensive care unit. Sample size
is important as well. We considered that
a sample of 200 or 300 infants was
needed to assure stability of results. By
using a large sample, we increased the
probability that the testing of a second
or third sample of infants would show
similar results. Chandler et al used a
similar process in developing the Move-
ment Assessment Instrument.23 An item
pool was generated and a sample of
infants was tested. Their results need
confirmation with other samples be-
cause of the very small sample size.
The next step is one of data analyses
in which the relationships among items
and the relationships of items to the
objective are described. When a large
pool of items is used, part of this process
is usually one of reducing the number
of items. One method for this is factor
analysis, through which the number of
items can be reduced on the basis of
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% correct
84.6
70.6
53.8
76.0
88.0
88.0
93.0
38.5
84.0
88.0
overidentification of a factor. In general,
the process of describing interrelation-
ships among variables, of reducing the
number of variables, and of determining
reliabilities among variables has re-
ceived little attention in neurological
testing.
After initial construction, most in-
struments need refinement. The Infanib
was used in several clinical settings by
both physicians and physical therapists.
Adjustments were then made on the
basis of this experience.
Some clinicians asked us why we did
not use all of the items from any one
method. They expressed concerns that
some items were not included. This is a
major issue in measurement. How
many items are required to identify or
adequately measure a quality? Beyond
a certain point, items that measure the
same aspect of neurological abnormality
become redundant. They increase the
reliability of the assessment marginally.
Our decision to limit the number of
items was not based on a lack of avail-
able items or even on the lack of avail-
able items with large loadings on a fac-
tor. Our decision was based on practi-
cality and psychometric principles. We
obtained values for internal consistency
both as a measure of the strength of
association among the items and as an
indicator that sufficient items were in-
cluded. The factors of the Infanib have
high internal consistencies with only
four items. Using more items gains little
reliability. Because many items from the
MCG method loaded on two factors
(Factors II and III), inclusion of even 20
MCG items was considered excessive.
In addition, our experience indicates
that clinicians do not use lengthy neu-
rological methods. We need a reasona-
ble compromise between measuring
everything and establishing a workable
scale that reflects accurately the different
RESEARCH
aspects of neurological integrity. The In-
fanib scale is short enough to be used in
practice and the reliabilities are ade-
quate for research purposes.
On the other hand, a single item
would hardly be sufficient to describe
neurological abnormality. Single items
can identify, however, some aspect of
abnormality. The Babinski maneuver,
for example, has been a sine qua non of
determining neurological abnormality.
Nevertheless, considerable neurological
abnormality may be present without a
positive Babinski sign. Patients with a
positive Babinski sign may also have a
spectrum of abnormalities. In general,
the neurological assessment requires a
variety of items.
Items must be scored, which is an-
other complex process. We described
the use of a 5-point scale in scoring the
MCG method.10 For some items, mak-
ing that many gradations was difficult.
The more gradations there are, the more
likely that interrater reliability will de-
crease. On a practical basis, we found
that many clinicians had difficulty
choosing among five gradations in neu-
rological items. Because the major goals
of this work were the creation of a prac-
tical and psychometrically sound assess-
ment instrument, we reduced the num-
ber of gradations to three: 1, 3, and 5
points. Each gradation was indicated on
a scoring sheet (Appendix B), so that the
clinician had a clear indication of how
to score.
As a result of the scoring, a total score
is achieved We have indicated three
degrees of normality-abnormality for
regular use even though the results show
that finer gradations were possible. In
Table 4, five degrees of abnormality
were significantly different when scored
by experienced examiners.
A subscore, indicated on the scoring
sheet as a factor score, is also achieved.
Based on clinical experience, we con-
sider Factor I an excellent indicator of
spasticity, although other factors also
contain items that measure spasticity.
Factor II assesses vestibular function
with three parachute items. The item,
"body rotative," is linked to parachute
items by the mathematical-statistical
analysis; it is also linked neurologically
in that a certain level of vestibular com-
petence is required before the infant can
perform the body rotative maneuver.
Factor III measures head and trunk con-
trol, Factor IV measures resting tone,
and Factor V describes the legs.
1329
 Which of these factors or which com-
bination of these factors is the best in-
dicator of neurological integrity? Fur-
ther work is needed to determine the
relationshp between the factor or sub-
scores and preceding events, such as fe-
tal bradycardia or neonatal seizures, and
to link these to outcome variables, such
as mental retardation, motor abnormal-
ity, learning disabilities, hyperactivity,
and behavioral abnormalities. A longi-
tudinal study with a large sample size
would be needed to study this properly.
Until such a project can be initiated and
completed, we recommend simply sum-
ming the factor or subscores to obtain a
total score. With this approach, each
factor or subscore is considered equal
(ie, unweighted). The summation of un-
weighted scores generally has more sta-
bility from one sample to another.24
What is the standard against which a
new scale should be compared? We con-
sider that further studies with the In-
fanib should compare physician-to-phy-
sician evaluation, physician-to-physical
therapist evaluation, physical therapist-
APPENDIX A
The 32 Items in the Neurological Evaluation
Test
Milani-Comparetti and Gidoni
(MCG)
French angles
Primitive reflex items (in addition
to those in the MCG)
Others
1330
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to-physical therapist evaluation, and
perhaps even pediatric neurologist-to-
developmental pediatrician evaluation
because these are the professionals who
perform most of the neurological assess-
ments of infants. These studies are in
progress. Examiners from different
training backgrounds often use quite dif-
ferent methods of evaluation, for which
formal assessments of validity generally
have been lacking.3 Therefore, we rea-
soned that two types of rating by ex-
aminers experienced in the examination
of infants would best serve as the stand-
ard in this step of test construction. The
examiner was asked to rate the degree
of normality-abnormality (scored 1 to
5) and the type of normality-abnormal-
ity.
The role of physical therapists has not
been that of making diagnoses. Physical
therapists, however, who are experi-
enced in the evaluation and treatment
of infants (as were the two who per-
formed the evaluations in this study)
have considerable knowledge about di-
agnostic categories. As shown in Table
Items
body lying supine
asymmetrical tonic neck reflex (ATNR)
pulled to sitting
sitting
sideway parachute
backward parachute
head in space
downward parachute
standing
foot grasp
body in sagittal plane
forward parachute
all fours
symmetrical tonic neck reflex (STNR)
body derotative
standing from supine
body rotative
tilting prone
tilting sitting
scarf sign
heel to ear
popliteal angle
leg abduction
dorsiflexion angle of the foot
positive support reflex
tonic labyrinthine reflex—prone
tonic labyrinthine reflex—supine
galant reflex
hands held open or closed
head in extension or flexion
patellar reflexes
5, all categories except hypotonia, as
indicated by the physical therapists,
were accurately identified with the use
of discriminant analyses based on the
factor scores. We consider that the less
accurate identification of hypotonia
with discriminant analysis did not re-
flect shortcomings of either the exam-
iners or the assessment instrument.
Rather, the problem is how to separate
hypotonia from the category of "tran-
sient abnormality," because much tran-
sient abnormality is simply a mild hy-
potonia. In other words, this problem is
an issue of definitions and designation
of categories rather than an issue of
identification of abnormality. In the
scoring sheets and cut points, we pro-
vide appropriate approximate designa-
tions of categories for clinical and re-
search purposes.
The sample for this study consisted of
infants from the neonatal intensive care
unit. Such a sample will, of course, in-
clude abnormal infants (although in-
fants with spastic hemiparesis have
tended to be few). Testing the Infanib in
samples of infants who were not treated
in a neonatal intensive care unit, that is,
testing a basically well-baby sample, is
also important. Fewer infants with both
abnormality and transient neurological
abnormality are anticipated in such a
sample.
The present study was limited in the
number of infants 1 to 5 months old
and 9 to 12 months old. Future studies
should fill these gaps. Although defini-
tions of infancy vary, a sensible goal is
to make the Infanib appropriate for a 1-
to 18-month age range.
CONCLUSION
We constructed an assessment instru-
ment for the neurological evaluation of
infants. The 20-item instrument, named
the Infanib, has sufficient reliability for
both clinical and research purposes. The
results of the assessment are quantified
and ready for computer entry for item
scores, factor scores, and total scores.
The assessment is practical because it
can be completed by the clinician in
several minutes. A scoring sheet was also
constructed and has been tested in clin-
ical use by professionals with different
types of training.
The Infanib incorporates several
methods of the neurological evaluation
of infants in one instrument. The quan-
tified scores enable comparisons of eval-
uations from one assessment to the next,
PHYSICAL THERAPY

from one infant to another, and from
one study to another. The use of sub-
scores facilitates research that can link
neurological integrity in infancy to pre-
natal, labor and delivery, and neonatal
events and identify those aspects of the
neurological evaluation of infants that
predict abnormality at older ages.
Acknowledgments. We thank the
professional staff of the Southeastern
Wisconsin Regional Perinatal Follow-
through Program of Milwaukee, Wis-
consin, who scheduled and evaluated
the infants. Special thanks are also given
to Ralph Mason who performed the
computer runs.
REFERENCES
1. Ellison P, Browning C, Trostmiller T: Evaluation
of neurological status in infancy: Physical ther-
apist versus pediatric neurologist. Journal of
the California Perinatal Association 2:63-66,
1982
2. Ellison P: Neonatal follow-up studies: The pre-
dictive value of neurologic abnormalities in the
first year of life. In Moss AJ (ed): Pediatrics
Update. New York, NY, Elsevier Science Pub-
lishing Co Inc. 1984, pp 187-202
3. Ellison P: Neurologic development of the high-
risk infant. Clin Perinatal 11:41-58,1984
1. Hands closed or open: Observe whether
hands held fisted, closed sometimes, or
open most of the time.
2. Scarf sign: Place infant in supine posi-
tion. Grasp upper arm near shoulder joint
and move arm across upper chest. Ob-
serve the angle formed by the upper arm
and a line parallel to the body. Second-
arily, observe the place at which the
elbow lands on the chest.
3. Heel to ear: Place infant in supine posi-
tion. Grasp legs above ankles, then
move the infant's feet toward his nose.
Observe the angle between the infant's
trunk and legs.
4. Popliteal angle: Place infant in supine
position. Grasp legs at knee. Keep in-
fant's buttocks on the table while ex-
tending the legs at the knees. Observe
the angle formed by the back of the
infant's upper leg, knee, and lower leg.
5. Leg abduction: Place infant in supine
position. Grasp legs above the knee.
Abduct the legs. Observe the angle of
leg-crotch-leg.
6. Dorsiflexion of foot: Press each foot up
against its leg. Observe the angle be-
tween foot and leg.
7. Foot grasp: Place your thumb at the
base of the toes of each foot of the
infant. Watch for curling of the toes to-
ward your thumb.
8. Tonic labyrinthine—supine: Place infant
in supine position; place your hand mid-
Volume 65/ Number 9, September 1985
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4. Drillien C, Thomson A, Burgoyne K: Low
birthweight children at early school age: A lon-
gitudinal study. Dev Med Child Neurol 22:26-
47,1980
5. Ellison P, Prasse D, Siewert J, et al: The out-
come of neurologic abnormality in infancy. In
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Infant. Baltimore, MD, Paul H Brookes Publish-
ing Co, 1984
6. Knobloch H, Pasamanick B: Prediction from
the assessment of neuromotor and intellectual
status in infancy. In Zubin J, Jervis G (eds):
Psychopathotogy of Mental Development. New
York, NY, Grune and Stratton, 1967
7. Ellison P, Horn JL, Browning C: A large sample,
many variable study of motor dysfunction of
infancy. Journal of Pediatric Psychology
8:345-357,1983
8. Amiel-Tison C, Grenier A: Neurologic Evalua-
tion of the Infant and Newborn. New York, NY,
Masson Publishing USA Inc. 1983
9. Frankenberg W, Dobbs J: The Denver Devel-
opmental Screening Test. J Pediatr 71:181-
191,1967
10. Ellison P, Browning C, Larson B, et al: Devel-
opment of scoring sytem for the Milani-Com-
paretti and Gidoni method of assessing neu-
rologic abnormality in infancy. Phys Ther
63:1414-1423,1983
11. Milani-Comparetti A, Gidoni EA: Routine de-
velopmental examination in normal and re-
tarded children. Dev Med Child Neurol 9:631-
638,1967
12. Capute AJ, Accardo PJ, Vining E, et al: Primi-
tive Reflex Profile. Baltimore, MD, University
Park Press, 1978
13. Capute AJ, Accardo PJ, Vining E, et al:
Primitive reflex profile: A pilot study. Phys Ther
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APPENDIX B
Description of Items
way between the scapulae and rub the
back. Observe for shoulder retraction,
secondary flexion of arms (decorticate
sign) or extension of arms (decerebrate
sign), and extensor posturing of legs.
9. Asymmetric tonic neck reflex: Place in-
fant in supine position, lining up neck
and body. Turn head to side and watch
for fencing position (arm extended in
direction faced, arm flexed on opposite
side). Test both sides.
10. Pull to sitting: With infant in supine po-
sition, hold forearms and pull to sitting;
observe head and arms for lag and for
flexion. Observe the arms for flexion and
extension at elbows.
11. Body derotative: Place infant in supine
position. Grasp both his feet. Twist him
with the feet as though initiating rolling
over. Observe for segmental twisting (ie,
infant does not roll all-in-one, like a log).
If infant is over 4 months old and does
not respond, ask the mother if he rolls
over spontaneously. Give credit for nor-
mal for a positive answer.
12. Body rotative: Observe for spontaneous
segmental rolling vs. log-rolling from su-
pine to prone position and pull to stand-
ing with use of object such as chair or
crib. Parental report is sufficient evi-
dence for passing this item.
13. All fours: Place infant in prone position
and observe head, arms, and legs.
RESEARCH
14. Paine R, Oppe T: Neurologic Examination of
Children. Philadelphia, PA, J B Lippincott Co,
1966, pp 171-195
15. Horn JL: A rationale and test for the number of
factors in factor analysis. Psychometrika
30:179-185,1965
16. Kaiser HF: The Varimax criterion for analytic
rotation in factor analysis. Psychometrika
23:187-200,1958
17. Tatsuoka MM: Multivariate Analysis: Tech-
niques for Educational and Psychological Re-
search. New York, NY, John Wiley & Sons Inc,
1971, pp 157-177
18. Nunnally J: Psychometric Theory. New York,
NY, McGraw-Hill Book Co, 1978, pp 225-255
19. Touwen B: Neurological Development in In-
fancy. Philadelphia, PA, J B Lippincott Co,
1976
20. Vojta V: Die zerebralen Bewegungstorungen
im Saulingsalter. Stuttgart, Federal Republic of
Germany, Ferdinand Enke Verlag, 1981
21. Bly L: The components of normal movement
during the first year of life and abnormal motor
development. In Slaton BF: Proceedings of
Development of Movement in Infancy, 1980
conference at Chapel Hill, NC. Published by
Division of Physical Therapy, University of
North Carolina at Chapel Hill, NC, October
1981, pp 85-123
22. Cangelosi JS: Another answer to the cut-off
score question. Educational Measurement: Is-
sues and Practice, Winter:23-24,1984
23. Chandler LS, Andrews MS, Swanson MW, et
al: Movement Assessment of Infants: A Man-
ual. Rolling Bay, WA, Chandler, Andrews, and
Swanson, 1980
24. Horn JL: Equations representing combinations
of components in scoring psychological varia-
bles. Acta Psychol (Amst) 21:184-217,1963
14. Tonic labyrinthine—prone: Place infant
in prone position. Flex the head and
observe for increase in flexion of extrem-
ities.
15. Sitting: Place the infant in sitting position.
Observe the rounding or straightening of
the back and the lumbar vertebra that
demarcates the straightened part of the
back.
16. Sideway parachute: Hold infant in sitting
position, tip deliberately to each side,
and observe for extension of arm on that
side.
17. Backward parachute: Hold infant in sit-
ting position with one hand on back and
one hand on abdomen, then deliberately
tip backwards, and observe for exten-
sion of arms backwards or turning to
one side.
18. Weight bearing: Lower infant slowly to-
ward examining table until his feet touch
the table; observe his ability to support
his weight. Also observe for flexing of
the knee and positioning of the hips.
19. Positive support reaction: Hold infant un-
der each armpit and lower to the table
surface; observe whether the feet are
flat on the table surface or are positioned
with toes touching and heels elevated.
20. Forward parachute: Hold the infant at
mid-trunk with your hands at his sides
and tip him forward quickly; observe for
extension of arms forward.
1331
 Construction of an Infant Neurological International
Battery (INFANIB) for the Assessment of
Neurological Integrity in Infancy
Patricia H Ellison, John L Horn and Carol A Browning
PHYS THER. 1985; 65:1326-1331.

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