Introduction

Behavioral development depends on the growth and functional maturation of the central nervous system. In the evaluation of the infant or child, there is considerable overlap between the neurological and the behavioral aspects. The behavioral or developmental assessment is a measure of a person's achievements or accomplishments in functional areas. This involves a steady, largely predictable increase of abilities with increasing age as a result of the interaction between the central nervous system and environmental experiences. The neurological assessment measures the integrity of neural mechanisms appropriate to the age of the subject. Although these two different assessments will usually parallel or complement each other, exceptions can exist.

Evaluation of the individual actually begins in utero with documentation of appropriate growth and movement (see Chapter 15). The fetus exhibits reflex movements in a very crude way as early as 8 or 9 weeks. These consist of flexion of the trunk, retraction of the head, and retraction or backward movement of the arms. By 14 to 16 weeks, the fetus is quite active, showing elementary movements of short excursion involving the extremities, trunk,and neck.The motor and most of the reflex behavior in later fetal life is mainly under the control of the medulla and spinal cord. Many of the so-called primitive reflexes, especially those involving the limbs, depend on the tonic and myotactic reflexes—that is, recoil from stretch. These reflexes appear by or after 32 weeks of gestation. One of the earliest reflex patterns to crystallize is that of sucking. By 14 to 16 weeks gestation, the fetus will protrude the lips in unmistakable preparation for sucking. The tongue and pharynx can adequately adapt to swallowing by this time. Figure 14.1 provides detail of the evolution of neonatal reflexes.

After birth, the first neurodevelopmental assessment is the assignment of an Apgar score based on heart rate, respiratory effort, muscle tone, color, and reflex (Fig. 14.2). At birth tonicity and activity are equal bilaterally, and the resting position assumed is one in which there is a

Fig. 14.1 Evolution of neonatal reflexes

Reflex

Appears (fetal week)

Disappears (postnatal mo.)

Tonic-neck

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Cure Tennis Elbow Without Surgery

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