Reflexes?!?! What is the big deal?

If you have been around No Limits Pediatric Therapies long, you have probably heard one of the occupational therapists mention “primitive reflexes.”  You may be wondering what is a primitive reflex?  And what is the big deal?

According to Webster Dictionary, a reflex can be defined as “an automatic and often inborn response to a stimulus that typical involves a nerve impulse passing inward from a receptor to the spinal cord and then passing outward from the spinal cord to an effector (such as a muscle or gland) without reaching the level of consciousness and often without passing to the brain.”  For this blog post, we will be focusing on primitive motor reflexes and how they can impact your child’s function.

According to the Medical Dictionary, a primitive reflex is defined as “any of various simple, stereotypic, automatic neuromuscular responses characteristics of the mature fetus and newborn but typical inhibited (or integrated) during the first year of life: primitive reflexes are directed by the brainstem centers and include Moro, rooting, and tonic neck reflexes.” It is thought that these reflexes help infants learn to organize motor behavior.  Integration can be defined as “the inhibition by higher centers of neurological control which modify the reflex in such a way that the pattern of response is no longer stereotypical.  The reflex does not disappear; it may reactivate under stress or during activities requiring great strength.”  If these so called “primitive reflexes” continually remain to be displayed beyond the expected of typical developmental time period, their presence by indicate an underlying developmental of neurological issue.  When a child’s primitive reflexes do not integrate, they may interfere with a child’s development of more advanced motor skills, which could lead to difficulty participating in one home, educational or community environments to their highest potential.  

Now, let’s take a look at the three primary tonic reflexes:

Asymmetrical Tonic Neck Reflex (ATNR):

Onset: 0-2 months    

Integration: 4-6months

Stimulus: Rotation of the head

Response: Arm and leg on the “jaw” side extends. Arm and leg on the “skull” side flex.

Importance for Baby: Assists with early eye-hand regard, provides vestibular stimulation, changes the distribution of muscle tone.

Significance on Early Development if Persists: May impair ability to roll, use hands smoothly together at midline, poor visual regard for object(s) being held, poor balance. May impair creeping or crawling. Baby loses balance and/or falls when rotates his head from midline; very frustrating and causes excessive fatigue.

Symmetrical Tonic Neck Reflex (STNR):

Onset: 4-6 months      

Integration: 8-12 months

Stimulus: Flexion and extension of the head (neck)

Response: With neck flexion the upper extremities will flex and the lower extremities will extend. With neck extension the upper extremities will extend and the lower extremities will flex.

Importance for Baby: The STNR assists in the development of bilateral patterns of body movement. Allows the child to move up against gravity and assume quadruped (on all fours like a dog). Integrates as the child begins to crawl and can lift the buttocks from the heels without flexing the neck. Integrated when rocking back and forth on hands and knees.

Significance on Early Development if Persists: Interferes with advanced reciprocal creeping. Impairs dissociation between the two lower extremities and transitioning between quadruped to sitting to kneeling to standing and vice versa. If strongly influenced by the STNR a baby will not be able to creep; will bunny hop versus true creeping/crawling on the floor.

Tonic Labyrinthine-Prone & Supine (TLR):

Onset: Birth              

Integration: 6 months

Stimulus: Change of orientation of the head in space; position of head in relation to gravity while prone (on belly) and supine (on back).

Response: In prone flexor tone will predominate with arms flexed by the child’s chest. In supine extensor tone will predominate.

Importance for Baby: Allows the baby’s posture to adapt to that of the head.

Significance on Early Development if Persists: Will interfere with movement that requires smooth grading of flexor and extensor muscles. In supine child will have a compromised ability to raise their head up against gravity; this will affect anti-gravity control for movements such as bringing feet and hands together and rolling. In prone (on belly) child will have compromised ability to raise head, extend spine, and bear weight on elbows.  This, in turn, will limit time spent on his/her tummy for crawling and developing the movement in their pelvis and shoulders that sets the stage for moving in and out of various body positions (sitting to stand). Without such ability, the baby will be without options for exploring. This will affect social and cognitive gains. 

(Above graphics from “Primitive Motor Reflexes & Their Impact on a Child’s Function”)

Now that we have reviewed tonic reflexes, how can  the presence of these primitive reflexes effect your older child?

Influences of Retained Asymmetrical Tonic Neck Reflex (ATNR): 

• Poor isolation of individual body movements
• Pore sitting posture
• Attention & Focus
• Impaired pre-writing and writing
• Impaired scissor use
• Fasteners/Typing/Musical Instruments
• Impairments in reading
• Keyboard Use
• Impairment in gait (walking)
• Running

Influences of Retained Symmetrical Tonic Neck Reflex (STNR):

• Decreased strength and balance
• Sitting
• Floor Sitting
• Walking
• Writing
• Ball handling skills

Influences of Retained Tonic Labyrinthine Reflex (TLR):

• Walking
• Sitting
• Writing 
• Balance

Now, we have discussed primitive reflexes and how they may present in your older child; as well as the difficulties they may lead to.  Let’s look at some activities to help integrate these reflexes.

Prone for fine motor activities & games- The elbows provide a point of stability for freeing the hands for manipulating.

1. Hold a large dowel with both hands, use this to push a ball back and forth
2. Use arms to push a ball back and forth
3. Color, paint, draw, read, or complete puzzle in prone
4. Use whistles or play games that require blowing through a straw
5. Pivot in both directions
6. Prone on therapy ball, platform swing, or over bolster
7. Prone on scooter board-push off with arms from wall to glide backward
8. Prone on scooter board-being pulled by a rope while grasping onto it with both hands 

Superman/SuperWoman – prone extension with arms and legs fully extended activates muscles antagonistic to the tonic labyrinthine prone reflex

Popcorn Position- activates muscles antagonistic to the tonic labyrinthine supine reflex

1. Child uses their own hands to place/remove stickers on knees or feet
2. Child uses their own hands to place/remove rings from their feet

Supine

1. Bounce ball off hands while child’s shoulders flexed to 90 degrees with elbows straight; therapist drops ball from above for child to volley back
2. Use legs to kick suspended ball
3. Supine on therapy ball; transition into sitting

Bridge Position

Rolling

1. Outside-down or up hills
2. With arms overhead or at side
3. Be sure to encourage chin tuck

The Side-lying Position offers the opportunity to increase strength and endurance while moving in 3 planes. The child will learn to balance by keeping their head and body oriented in midline; remember to not only focus on maintaining this static position, but transition into and out of side-lying. The child should remain static for brief periods; even minimal weight shifting from the child’s center of gravity may activate head and torso righting. Be sure to encourage the use of this position on their right and left sides. This will lengthen muscles needed for full rotation of the trunk. Remember…full expression of equilibrium reactions require torso rotation and freedom of movement in the upper and lower extremities.

Reach- Use free arm to encourage reaching and other movement/manipulation

1. Play games such as Connect Four in high side-lying
2. Swat at suspended ball with free arm while in high side-lying
3. Work puzzles with free hand while in high side-lying

While Side Sitting strive to have the child have both hands free to manipulate objects at midline; this may require considerable time and practice. To work toward this, encourage the child to adjust to small weight shifts away from their midline. Remember…diagonal control sets the stage for isolation of movement for each limb, important for minimizing the effects of primitive reflexes on functional movement.

1. Side Sit
2. String beads in side sit
3. Lace in side sit
4. Toss a ball while side sitting
5. Catch a balloon while in side sitting

Long Leg Sitting offers the opportunity to stretch muscles that are often tight in children that need to “fix” due to immature balance and ongoing influence from primitive reflexes. This position can help lengthen the hamstrings; a muscle that often tightens as children over-use to stabilize. Strive to have the child have both hands free to manipulate an object at midline. This position also provides a chance to develop balance by narrowing the child’s base of support.

4-Point Quadruped:

1. On tilt board
2. Turn head side to side, raise head up & down, or “roll” neck without moving knees or hands
3. Rock body back & forth or side to side while knees and hands planted

Creeping on Hands & Knees:

1. Creep through tunnel forward and backward
2. Creep over obstacles such as cushions, pillows, bolsters, etc.
3. Creep sideways

Donkey Kicks- raise one leg into extension, then flex/extend knee so as to kick

Two Point- Maintain one arm & one leg in full extension  

Transitioning between Tall and One-Half Kneel provides an excellent opportunity to develop the strength and balance to not only minimize the influence of primitive reflexes, but to develop motor planning for energy efficient and functional movements.

• Slowly transition between tall and one-half kneel
• Use hands to complete tasks placed on vertical surface

When encouraging transitional movements, such as Standing to Squat, be sure to focus not only on the end position, but accomplishing the movement in a smooth and efficient manner. This will set the stage for the child to adopt this pattern into their functional movements. Squatting provides opportunity for developing hip stability and balance.

When Standing & Walking:

1. Stand and roll a ball up & down the wall with head sideways and arms perpendicular to torso
2. Stand and balance on one foot for several seconds
3. Hop from one foot to another
4. Stand with feet planted while catching a ball thrown slightly out of reach toward his/her side
5. Stand facing wall with straight elbows and palms against wall, rotate head left to right without bending elbows
6. Stand with back to wall and legs apart; touch right foot to left hand, then left foot to right hand
7. Stand while using hands to complete tasks placed on vertical surface
8. Walk while holding a tray full of objects; pause and turn head side to side and up/down
9. Walk & catch objects with a play fishing pole; use one hand to hold the pole and other to remove “caught” object

(Above graphics from “Primitive Motor Reflexes & Their Impact on a Child’s Function”)

We hope this gives you a little more information on reflexes and why they play an important role in your child’s development.  If you have any questions, please reach out to your child’s treating occupational therapist.  We would love to answer all your questions, and work with you to create a home exercises program to help your child integrate their primitive reflexes.  

No Limits Pediatric Therapy Occupational Therapy Team

*For more information, read “Primitive Motor Reflexes & Their Impact on a Child’s Function” at https://www.toolstogrowot.com/blog/2016/01/11/primitive-motor-reflexes-their-impact-on-a-childs-function