NEUROLOGICAL EXAMINATION FOR CHILDREN (NEC) MANUAL Version 5
INTRODUCTION
The Neurological Examination for Children (NEC) is a structured examination that was initially developed to assess neurologic abnormalities associated with HIV infection; it is also appropriate for other conditions, particularly those associated with pyramidal tract dysfunction.
The items comprising the NEC tap several domains, including head size, tone, power, reflexes, symmetry, movement disorders, vision and ocular movements. The majority of items (e.g., reflex and tone assessments, angle measures) in the NEC are applicable to children of all ages.
Earlier versions of the NEC have been studied for test-retest reliability in two samples: one comprised 31 children under age 4 years and another 35 children under age 3 years. Version 5 of the NEC includes revisions that followed on these reliability studies. These studies indicate that training in examination administration procedures and coding is necessary to produce consistent measures on items.
The NEC includes items from the Physical and Neurological Examination for Subtle Signs (PANESS, Denckla, M.B., Revised Neurological Examination for Subtle Signs (1985), Psychopharmacology Bulletin, 21(4), 773-800) to assess motor speed and coordination in children 36 months of age or older. We did not test these items in our reliability studies.
We recommend that all NEC users be trained by us in its administration and coding. We request that trained users forward computerized copies of their NEC data to us. These data will be used with our own to study redundancy and internal consistency between items and to develop composite scores for the domains measured by the NEC.
Inquiries regarding training or use of the NEC can be forwarded to Drs. Kairam, Chiriboga and Kline, Psychiatric Institute, Unit 53, 722 West 168th Street, New York, N.Y. 10032 (telephone: 212‑960‑5820).
© 1991: Kairam, Chiriboga, Kline Version 5: May 7, 2007
GENERAL INSTRUCTIONS
The Neurological Examination for Children (NEC) should be performed with the child fully awake since other states may affect responses. Sleepiness is associated with diminished muscle tone and sluggish or absent reactions. Irritability and crying may increase resting tone. A few items (e.g., head circumference measures) can be administered to sleeping or unresponsive children.
APPROPRIATE STATE: To increase the validity and reliability of the examination, items should be administered only when the child is in the APPROPRIATE STATE for the item. Both the manual and examination form indicate the appropriate state. If the child does not attain this state during the examination, the item should be coded "9" (not in appropriate state). If necessary, items may be administered out of order. For example, if the appropriate state for an item is reached later in the examination, the examiner may administer it then. We stress that it is essential that no item be administered when the child is not in the appropriate state for that item.
Every effort should be made to relax the child prior to and during the examination to ensure that all items can be administered. If the appropriate state cannot be attained for most items because the child is crying or uncooperative, the examination should be rescheduled.
Code "8" (not assessed) for all items which the examiner does not attempt to administer. This code also applies to items not administered because the examination is not completed.
Code "9" (not in appropriate state) for children who do not attain the appropriate state or who refuse to cooperate on a particular item.
CLOTHING: The child should wear only underclothes or a tight top and shorts.
ASSISTANT: You will need an assistant during measurement of the angles, and for young children to assess items which require that the child be in a sitting position. This assistant may be the parent, caretaker or other helper.
Instructions for administration of items in the NEC Version 5 follow.
· ID NUMBER.
· CHILD'S INITIALS: First, middle and last initials.
·· DATE OF EXAMINATION: Code the month, the day and the year of the examination.
· EXAMINER'S INITIALS: First, middle and last initials.
· DATE OF BIRTH: Code the month, the day and the year of the child's date of birth.
· SEX.
· HEAD CIRCUMFERENCE:
Position: Sitting or supine
Equipment: Inser-tape (millimeter)
State: Any
Insert the distal tip of the measuring tape through the first slot of the tape.
Locate the tape firmly above the supraorbital ridges covering the most prominent part of the frontal bulge and over the most prominent occipital region to yield maximum head circumference.
Measure twice, removing and relocating the tape for the second measurement.
Record both measurements on the examination form.
CRANIAL NERVES
· VISUAL ACUITY (ROSENBAUM CHART)
· FOLLOWS FACE/OBJECT ACROSS MIDLINE:
Position: Facing the examiner, sitting or supine
Equipment: Interesting object (e.g., ring, puppet)
State: Awake, no crying
Secure the child's gaze on your face or an object.
Slowly move your face or the object from right to left to right up to three times.
Credit if the child's eyes follow your face or the object from right to left and back past the midline.
· EYE MOVEMENTS ON FOLLOWING FACE/OBJECT:
Position: Facing the examiner, sitting or supine
Equipment: Interesting object (e.g., ring, puppet)
State: Awake, no crying
Secure the child's gaze on your face or an object.
With your free hand, gently restrain the child's forehead.
Move your face or the object from right to left to right at least three times at a steady rate.
Eye movements are full (1) when, in the direction followed, the iris of the eye touches the canthus with no sclera visible in between. If eye movements are not full, code whether eye fails to adduct only (2), fails to abduct only (3), or both (4).
· FACIAL SYMMETRY ON GRIMACING OR SMILING
REFLEXES
Tap each reflex firmly three times and record the maximal response. If there is no response in three taps, tap five more times and record the maximal response.
Regardless of the reflex being elicited, the goal is to stretch the child's limb just until a little bit of resistance is felt in the relaxed position.
· BICEPS REFLEX:
Position: Child seated or supine with head midline, arms semiflexed
Equipment: Tomahawk reflex hammer
State: Awake, no crying
Hold the child's arm at the elbow with the forearm semiflexed.
Place the finger of one hand on the biceps tendon in the antecubital fossa.
With the other hand, tap your finger with the reflex hammer.
Note whether or not the child's biceps muscle contracts and the presence or absence of clonus.
· KNEE JERK:
Position: Child seated or supine with head midline, legs semiflexed
Equipment: Tomahawk reflex hammer
State: Awake, no crying
When the child is seated, optimal stretch may be obtained when the child's knees are draped over the edge of the seat or the side of the assistant's thigh (that is, the child should be seated sideways on the assistant's lap).
When the child is supine with head midline, optimal stretch may be obtained when the child's knees are supported on your forearm in a semiflexed position.
Tap the middle of the quadriceps tendon just below the patella with the reflex hammer.
Note whether or not the quadriceps muscle contracts and the presence or absence of clonus.
· ANKLE JERK:
Position: Child seated or supine with head midline
Equipment: Tomahawk reflex hammer
State: Awake, no crying
When the child is seated, optimal stretch may be obtained when the child's knees are draped over the edge of the seat or the side of the assistant's thigh.
When the child is supine with head midline, rotate one thigh outward and flex the knee.
Hold the child's foot by placing your thumb on the dorsum and your fingers on the sole of the foot (or vice versa, i.e., fingers on dorsum, thumb on sole). Dorsiflex the foot slightly.
With your other hand, tap the back of the Achilles tendon with the hammer. If there is no response, tap the part of your hand that is on the sole of the foot.
Note whether or not the gastrocnemius contracts and the presence or absence of clonus.
· ANKLE CLONUS:
Position: Child seated or supine with head midline
State: Awake, no crying
When the child is seated, optimal stretch may be obtained when the child's knees are draped over the edge of the seat or the side of the assistant's thigh.
When the child is supine with head midline, rotate one thigh outward and flex the knee.
With one hand, hold the child's foot just above the ankle to secure it in place. With your other hand, grasp the foot at the root of the toes. Dorsiflex the foot abruptly.
Observe for clonus─a rhythmic jerking of the foot of low amplitude and high frequency. If clonus occurs, estimate the number of beats.
Repeat this procedure on the same side.
If one to four beats are elicited on both trials, code "2." If five or more beats are elicited on either trial, code "3." If clonus occurs without stimulation, code "spontaneous clonus" (4).
· CROSSED ADDUCTOR RESPONSE:
Position: Child supine with head midline and legs straight or seated with legs semiflexed
Equipment: Tomahawk reflex hammer
State: Awake, no crying
When the child is seated, the knees should be draped over the edge of the seat or assistant's thigh and the legs should be separated slightly.
When the child is supine with head midline, the child's legs should be separated slightly, externally rotated at the hips and semiflexed at the knees.
Place one finger over the distal tendon of the adductor muscle just above the knee.
Tap your finger with the reflex hammer.
The crossed adductor reflex is present (2) when the tapping elicits a contraction of the contralateral adductor muscle.
Code the response by the site of tapping (not the site of contraction). For example, right crossed adductor reflex is defined as response in the left adductor when you tap the right adductor.
· UPGOING TOE:
Position: Child seated or supine with head midline
Equipment: Tomahawk reflex hammer
State: Awake, no crying
Scratch the plantar surface of the foot with your thumbnail or the metal end of the reflex hammer. The scratch should begin at the heel and move forward along the lateral border of the sole, crossing over the metatarsals to the base of the big toe.
Repeat this procedure.
Note whether, on either procedure, the big toe does not go up (1) or goes up (2).
An upgoing toe can also be a withdrawal response with concomitant dorsiflexion of the foot and leg withdrawal. If withdrawal is elicited, repeat the maneuver up to five times. If two informative trials are not obtained in five tries, code "two informative trials not obtained" (8).
· RIGIDITY ON EXTENSION:
Position: Supine or sitting
State: Awake, no crying
Elbow extension:
The child should be relaxed.
Hold the child's upper arm firmly in place.
Flex and slowly extend the child's forearm as far as possible at the elbow three times.
Code rigidity as present (2) if constant or intermittent resistance to passive extension occurs on any of the three maneuvers.
Note: if the limb is spastic, code "could not be assessed" (8).
Knee extension:
The child should be relaxed.
When the child is seated, the knees should be draped over the edge of the seat or assistant's thigh.
When the child is supine, rotate the thigh of one leg outward.
Hold the thigh firmly in place.
Flex and slowly extend the leg three times.
Code rigidity as present (2) if constant or intermittent resistance to passive extension occurs on any of the three maneuvers.
ANGLES
· POPLITEAL:
Position: Supine with head midline, legs extended
Equipment: Goniometer
State: Awake, no crying
Have the assistant hold the contralateral leg straight.
Flex the thigh of one leg towards the abdomen as far as possible without causing distress to the child.
Place the goniometer fulcrum on the lateral epicondyle of the femur of the flexed thigh. Align the end of the fixed arm with the greater trochanter.
Hold the goniometer in place with one hand. With your other hand, hold the free arm of the goniometer against the lower leg, aligned with the external malleolus.
Extend the child's lower leg at the knee at a steady pace until the first resistance is met.
Record the angle indicated by the marking line on the moving arm.
Repeat this procedure.
Code the average of the two angle measures.
· ANKLE:
Position: Supine with head midline, legs extended
Equipment: Goniometer
State: Awake, no crying
Have the assistant hold the child's contralateral leg straight.
Place the goniometer fulcrum on the external malleolus. Align the other end of the fixed arm with the head of the fibula.
Hold the goniometer in place with one hand. With your other hand, place the moving arm of the goniometer parallel to the outer border of the foot. Hold the goniometer in place by inserting your finger(s) between the dorsum of the foot and goniometer arm and your thumb on top of the goniometer arm.
Dorsiflex the foot slowly and as far as possible until the first resistance is met.
Record the angle indicated by the marking line on the moving arm.
Repeat this procedure.
Code the average of the two angle measures.
GAIT
Position: Walking
State: Awake
To encourage walking, have the caretaker stand on one side of the room and place the child on the other side of the room.
Ask the child to walk away from you for a distance of at least six feet, turn around, and walk back. Ask the child to walk back and forth again; this time observe the child from the side.
Code whether the sign is absent (1) or present (2).
· KNEE FLEXION:
Knee flexion is present (2) if the child walks with the knees bent forward.
· KNEE HYPEREXTENSION:
Knee hyperextension is present (2) if the child walks with the knees bent backwards.
· TOE WALKING:
Toe walking is present (2) if the child walks on his/her toes.
· CIRCUMDUCTING GAIT:
Circumducting gait is present (2) when the leg on one side drags stiffly and swings outward while the child is walking.
· DECREASED ARM SWING:
Arm swing during walking should be symmetric with both arms traversing the same distance. Code whether either arm has decreased range of swing compared with the other. If both arms traverse the same distance, code decreased arm swing as absent (1) for both.
· CORTICAL ARM POSTURE:
Cortical arm posture is defined as persistent adduction at the shoulder with flexion at the elbow, with or without forearm pronation.
· DYSTONIC ARM POSTURE:
Dystonic arm posture is defined as a non-purposeful intermittent posturing of the limb, usually with extension at the elbow, with or without pronation of the arm.