Primitive Reflexes & Atypical Development

Reflex =

Stereotyped response to sensory input

primitive reflexes

Reflexes that develop in the womb to facilitate postural control, health and safety of the infant

Predictable Motor Response triggered by proprioceptive, tactile, and vestibular stimulation

Purpose is to facilitate typical development for purposes of survival and new movement patterns

Postural Reflexes

(supine flexion, prone extension)

goal of primitive reflexes

is to help an individual move against gravity and develop voluntary movement

integration

•Typically integrate in 1^st year of life

•When a reflex is “integrated” it has developed into a more mature movement pattern.

•The reflex is no longer present

persistence

•RETAINED

•May indicate atypical development

•The reflex is still present

•The more mature movement pattern has not developed

•Child did not experience enough movement related to that reflex and the response.

•lower-level developmental delays

• Hindered development of the advanced stage of the nervous system

Palmar Grasp Reflex

Onset: Birth

Integration: 5-6 Months

Voluntary Grasp replaces it

Automatic flexing fingers to grab objects

Palmar Grasp Reflex test

Placing your finger or an object into your baby's open palm, which will cause a reflex grasp or grip

Retained Reflex:

Poor manual dexterity, Poor pencil grip, Messy handwriting,

palmar grasp reflex case example

10m old female baby with PMH of torticollis and low tone.

OT referral: Increased flexion of digits when crawling

Standardized Assessment: PDMS-2

Grasping Standard score 6; VMI standard score 7 (Below average)

Grasp

Immature grasp with ulnar side of hand; gross raking without thumb, no clear open web space

Index finger not integrated with grasp; pincer grasp not observed

VM:

Poor precision with Put in tasks (removing pegs) Poor graded control (placing cubes in cup)

Goal Areas: Promote radial digital grasp, WB with full wrist and digit extension; Graded control with grasp and release

MORO Reflex

Onset: 28 Weeks Gestation

Integration: 4-6 Months

Occurs in response to unexpected changes in environment

Noise

Change in position

Light

Sudden Touch

Function: Flight or Fight Response

Moro reflex test

Rapidly Drop Head Backwards

Response

Phase 1: Arm Extension & Abduction

Phase 2: Arm Flexion & Adduction

moro reflex integrated test results

test: •Rapidly Drop Head Backwards

•Result: NO  Arm Extension/Flexion & Abduction/Adduction

Retained Moro Reflex

•Persistence Effects: Impacts sensory modulation, hypersensitivity

•Visual, auditory, vestibular: Decreased balance and coordination, Gravitational Insecurity

•Constant state of “fight or flight”

•Poor impulse control: Distractibility

•Mood swings, emotional outbursts

Asymmetrical Tonic Neck Reflex (ATNR)

Onset: 37 Weeks Gestation

Integration: 4-6 Months

Function: Precursor to Hand Eye Coordination

Rolling over stomach

Crawling

Reading/writing

Crossing Midline

Distribution of Muscle tone

Asymmetrical Tonic Neck Reflex (ATNR) test

•Test: Position Baby in Supine & Rotate Head

•to 90 Degrees.

•Response

•Face Side: Arm Extension

Skull Side:  Arm Flexion

Persistence Effects of ATNR

Unable to Cross Midline (eyes/hands): impacts creeping and crawling

Poor Reading Comprehension

Poor Visual Tracking & Eye Pursuits

Poor Handwriting

Poor Hand Eye Coordination

Poor bilateral coordination

Writing compensations bc of ATNR

tight pencil grasp, turning paper, decreased fluency, extended arm, writing w/ slant, letter reversals

Tonic Labyrinthine Reflex (TLR)

•Onset: 37 Weeks Gestation

•Integration: 6 Months

•Function:

•Development of Balance, Body Position & Stability

•Balances Flexion and Extension Tone

•Head Neck Alignment and control

•Body/Head Trunk Dissociation

There are 2 aspects of TLR:

TLR Test

TLR PRONE and TLR Supine.

Retained: TLR: prone flexion and supine extension

persistence effects of TLR

Difficulty with Prone Extension (Increased Flexor Tone)

Difficulty with supine to sit (Increased Extensor Tone)

Poor Posture (W sit)

Poor Coordination

Impacts Auditory Processing

Impacts Visual Perception

Low muscle tone

Decreased chin tuck (impacts feeding)

Symmetrical Tonic Neck Reflex (STNR)

Onset: 4-6 months

Integration: 8-12 Months

Function: Precursor to Crawling –

Ability to sustain static Quadruped Position

Disassociation of the upper and lower body

Assists in Bilateral Patterns of Movement

Allows for antigravity movement

STNR Test

place in crawling position and flex the head → arms flex, legs extend

place in crawling position and extend the head → arms extend, legs bend

UB & Head = same response   ->  NO UB & Head Dissociation

persistence effects of STNR

•Difficulty sitting up from supine

•Poor muscle tone and posture (W-sit)

•Impacts Focus

Research ConnectionRetained Reflexes and ADHD

•Survival-oriented and automatic movements are not integrated within infant development

•Prone to hyperactivity or impulsivity due to sensory and motor dysfunction

•Systematic Review (189 articles)

•Retained primitive reflex results in over active brainstem; which inhibits the limbic system and cerebral cortex which may lead to neurodevelopmental disorders

•Systematic Review (189 articles)

•Significant positive and moderate Correlation between primitive reflexes and ADHD.

•Higher the degree of ATNR and STNR non-integration, more severe the ADHD symptoms in children.

•Correlation with ADHD and retained ATNR: anxiety, impulsivity-hyperactivity, and learning problems in children with ADHD.

Primitive Reflex Integration Impact on Motor Milestones at 4-6 M

Moro and ANTR

Primitive Reflex Integration Impact on Motor Milestones at 6 M

TLR reflex

Primitive Reflex Integration Impact on Motor Milestones at 8-12 M

STNR

Primitive Reflexes: Take Away

•GOAL: Help integrate Reflexes that are retained longer than usual

•Choose standardized tools to connect impairment to occupational performance.

•Always Link it to Occupation!

postural control

•Foundation for movement:

•Postural stability allows for distal mobility

•Ability to control  center of mass in relation to base of support

•Postural Reflexes:

•Supine Flexion

•Prone Extension

assessment of movement

Quality of Movement and Postural Control

Impact on Occupational Performance:

Feeding, Play, Functional Mobility, Dressing

Consideration in all Pediatric Settings

NICU

In patient Rehabilitation

Acute

School

Early Intervention

Outpatient

Development of Postural Control

1. ring

2. long

3. side

4. tailor

sagittal plane of movement (double check)

right and left

frontal plane of movement (double check)

up and down

transverse plane of movement (double check)

cross body

sagittal weight shifts

frontal weight shifts

Transverse Weight Shifts

Prone to sit: Moving Different planes

Transitional Movements (sit)

transitional movements: 4 point/Quadruped

transitional movements: half kneel → tall kneel → tall kneel to stand