Retained Primitive Reflexes

From “Persistence of primitive reflexes and associated motor problems in healthy preschool childrenAMS-14-27750 ” – “Primitive reflexes are automatic movement patterns that commence during pregnancy and are fully present at birth in term infants. They are natural reactions that start a developmental process which releases a neural circuit for a specific function. Primitive reflexes should integrate and impede reflex reactions to allow development of natural motoric action. Brain injury can cause reoccurring reflex reactions. They can be observed in cerebral palsy patients or people who have suffered a stroke.”

There is sufficient evidence to support the following principles in therapy:

  1. Visual function integrates from three sources primarily, what can be called the Chair of Vision: Ocular (retinal/somatosensory), Somatosensory (body position), Vestibular (orientation/balance).
  2. As a rule, oculomotor, visuomotor, spatial awareness all improve with enhanced motor development opportunities.
  3. Children who are exposed to multimodal experiences, including full body development tend to excel in academics and show better self-control and attention.

It makes sense, then, to attend to ‘low level’ motor and vestibular integration as part of vision rehabilitation, but also as part of a broader program to address attention, learning, or to recover from TBI. Particular claims equating reflex ‘signs’ with behavioural outcomes need to be tempered in cautious reality, but I’ve included notes below to explore some of the thinking in this area that is popular among some OTs and Developmental Optometrists.

While the notes below are helpful, one can begin simply in addressing these low-level skills, the ‘core,  by reviewing this article.

Resources for Primitive Reflex Training:

Further Reading:

Retained Primitive Reflexes and Their Effects

Primitive Reflexes:

(Adapted from and with thanks to Sue Hyland, UK)

Note that while the concept of retained primitive reflexes (RPR‘s) can be easily demonstrated in affected children and adults, this fact does not ‘prove’ there is a direct role of delayed reflex development in reading and learning difficulties. The fact is, learning and reading problems are most often multi-faceted and require varied interventions for successful treatment. Indicators of delayed reflexes do correlate highly with reading and learning problems, sometimes as cause, sometimes as effect, often both. For examples, strong core reflexes are required for accurate visual functioning, especially with very fine targets such as text. Regardless, it is critically important to address fundamental concerns of ‘schema’ and body awareness at a foundational level prior to and while attempting to develop higher cognitive and motor skills and abilities.

The reader is cautioned against drawing conclusions from the checklists below; this is not a formal clinical diagnostic questionnaire and should serve mostly to prompt further discussion and to illustrate how neural development (call it ‘delayed’) can impact upon behavior and learning.

Read the section on ‘Neuro-developmental Delay‘ first.

In one view, the brain can be divided into two distinct parts: the brain stem, and the cerebral hemispheres. (For the purposes of this discussion, this description will suffice. Consult ‘Principles of Neural Science, 4th Ed.’ by Kandel, Schwartz, and Jessell for a much better review of brain anatomy.) [private] The brain stem is sometimes called the lizard brain because that’s all a lizard has. Its at the bottom of the large bulbous hemispheres just above the spinal cord and is composed of fibres going in and up, sensory nerve fibres, and fibres going down and out, motor nerve fibres. Nerve cells transmit electricity along the fibre of the nerve, an impulse, and a chemical across from one nerve to another. The brain stem receives impulses from the senses in the head and body, it either reacts directly to those impulses by creating a motor response, or relays the impulse to a higher centre. None of the reactions within the brain stem are conscious, it is only once the nerve fibre, and hence the impulse, reaches the higher levels of the cerebral hemispheres that conscious recognition and response takes place. Within the conscious brain there are many areas of specialisation which must be in communication with each other. It is within this area that sensory/motor integration takes place. Sensory/motor integration is the recognition and response to the vast and varying number of stimuli that enter the brain. It is what enables us to make sense of our world and where conscious adaptation and learning takes place.

The type of motor response to a sensory input that occurs within the brain stem is always a reflex reaction. A reflex is an automatic response to a stimulus, it is always an unconscious reaction, the sensory nerve in direct connection with a motor nerve, sensory/motor loop. Reflexes control the vital functions of life, breathing, heart beat, blood pressure control. These reflexes remain all of our lives. There are also a collection of reflexes called the Primitive Reflexes which develop very early in foetal life and should remain active for the first few months of life only. They are called primitive because they originate in the lower areas of the brain, the first part of the brain to develop. Movement is an important stimulator of nerve growth but until the baby has a conscious brain no conscious movement is possible. Equally, as our babies are born in a much more immature state than other animals, a great deal of development must take place after birth. To ascertain that this development does occur, and occurs in the proper sequential manner, the stimulation is programmed into the system. The stimulation is usually a random head movement; each specific head movement generating a specific response. The response being initiated by the Primitive Reflexes. All babies are tested at birth for the presence of the Primitive Reflexes to determine normal development. These Reflexes should naturally inhibit in sequential order during the first year of life. Inhibition means that nerve loops do not disappear, rather that stronger loops should emerge within the middle brain stem. These reactions are still reflex, they are still automatic and outside the realm of the conscious brain. These replacement reflexes are called the Postural Reflexes and control the tiny equilibrating mechanisms for balance and co-ordination once we have learned to sit, stand and move from an upright position. They enable us to live harmoniously with gravity, to maintain a steady visual image even though we or that image is moving,to cut out extraneous non essential sensations creating a more effective focus upon essential stimuli.

Retention of Primitive Reflexes has a fourfold effect:

  • The immature sensory / motor loop is still in place and results in inappropriate movements.
  • These movements have to be consciously compensated for.
  • Under development of the Postural Reflexes causes immaturity of adjustment or righting reflexes with regard to balance, movement and gravity. This lack of automatic adjustments will have to be consciously compensated for.
  • As most nerve pathways must pass through the brain stem to reach the other functional areas of the brain immaturity within this region will inevitably have detrimental effects upon all nerve networks leaving the brain stem and going to those higher centres. It will depend upon the degree of immaturity and the particular nerve networks involved that will determine the level of dysfunction. However, sleep, immunity, energy levels, impulse control, concentration and all levels of social, emotional, and intellectual learning can be involved.
  • Listed below are each Primitive Reflex with their actions and the effects upon the individual should they be retained beyond the usual time of inhibition. It is unlikely that any individual will have retained all of the Primitive Reflexes, a collection of 3 or more will be significant. It is also unlikely that any individual will experience all of the listed effects of a given reflex.

All of these reactions can be explained as a direct consequences of the known action of the reflex described. All of the above reactions can also be eliminated by replaying the stereotyped movements of infancy that is the initial method of inhibition. By redoing these movements it gives the brain a second chance to develop more normally. It is imperative that the regime of exercises must be undertaken as explained, both in terms of being done daily and in the control of application. It cannot be stressed sufficiently that a major cause of poor outcome is due to poor application. The treatment works by pinpointing selected nerve bundles, random movements will deviate from this selected stimulation. It must be remembered that stimulation of a nerve equates to growth of that nerve. To grow specific nerves the exercise regime must be very specific and precise.

For some children the exercise regime alone is sufficient to correct the reflex anomaly and therefore remove the unwanted effects. For many it is essential to eradicate the cause for the initial failure to inhibit the Primitive Reflexes. For a few it remains currently impossible to fully correct the difficulties; I am sure that this is because we, as yet, have not discovered the cause. Research in the field is continuous and rapidly extending as more and more appreciate the importance of this type of treatment.

Primitive Reflexes:

Moro Reflex

Sudden head movements on a vertical plane, that is forward and backward, will initiate the Moro reaction. This reaction is a rapid extension of the limbs, with a big inhalation of breath, followed by contraction of the limbs and a cry. This reaction is initiated by the Moro reflex and is perfectly normal from about 9 weeks after conception to about 12 weeks after birth. It is a reaction to potential danger and occurs as a result of both nerve/muscle stimulation and chemical release. The chemicals being adrenaline and cortisol. Adrenalin increases blood pressure, and heart contractions, both increase the circulating of blood. It also increases the amount of oxygen taken into the body, dilates the pupils of the eye and decreases digestion. The increased cortisol brings stored sugar from the muscles into the blood, for greater energy. Imagine a monkey clinging on to the hair of it’s mother, there is danger and mother moves faster, the babies head jerks back, the arms extend and then tighten their grasp. At the point of extension a big intake of breath occurs and the heart beats faster, the circulation is stronger. We are no longer covered in hair, our babies don’t cling on but the reflex still plays a vital roll in an emergency, with the reflex cry bringing aid. Sudden visual stimuli and loud noises, both a warning of danger, can also trigger the Moro Reaction.

Should this reflex reaction be retained after it’s normal time of inhibition then not only will unwanted muscular reactions occur but so will the release of the chemicals, every time the head is jerked backwards or there is a sudden visual stimuli or unexpected loud noise. Obviously these will sometimes auger danger, when a full blown flight or fight response is required, but frequently they do not. People with retained Moro reactions are over sensitive, over reactive, they jump out of their skins at minor frights. The chemical levels of the body are hard to maintain with sudden increases of blood levels of adrenaline and cortisol. Over time this can have serious implications for the body as certain organs and systems are over worked. Equally the nutrients that go to make adrenalin and cortisol are required in greater than normal amounts and ultimately the resources may be used up. In the more short term the individual will have difficulty focusing on objects, the Moro Reflex maintaining a reliance upon peripheral rather than central vision. They will find it difficult to discriminate small detail, they will be readily distracted. The same effect can also effect hearing, with difficulty cutting out the background noise and concentrating on the core verbal messages. It will be difficult for this person to concentrate and attend for any length of time. They will not like the unexpected, as it is always likely to initiate the Moro Reaction which is unpleasant, they need to control and restrict their environs.

3 or more of the following are the kinds of behaviour which suggest a retained Moro:

  • Mood swings
  • Unexpected sudden changes of behaviour
  • Aggressive outbursts
  • Withdrawn timidity (either of the last two can exist as major characteristics or they can alternate)
  • Tendency to observe others rather than join in play
  • Craving for sweet things
  • Snacking, inability to eat a whole meal
  • Dislike of rough and tumble
  • Dislike of fairground rides
  • Dislike of bright lights, headaches
  • Dislike of wind in face, water in face
  • Panic attacks
  • Distractibility
  • Copying difficulties
  • Perceptual difficulties both visual and auditory
  • Nervousness
  • Need to be in control
  • Dislike of change
  • Dislike of loud noise
  • Over sensitivity to particular frequencies of sounds
  • Over sensitivity to textures, labels etc
  • Sensitivity to a range of high frequencies normally outside human hearing (so that cars can be heard miles away, lift mechanics emitting a high pitch whistle)

The Grasping Reflexes

The Grasping Reflexes develop and inhibit at about the same time as the Moro, which in itself is really a grasping reflex, and can be divided into the Palmar, Plantar, Rooting and Infantile Suck Reflexes. They are therefore frequently found if the Moro is retained, usually all being present.

  • The Palmar Reflex is the automatic flexion of the fingers over the thumb whenever the palm is stimulated. Once initiated it takes time to relax so that anything grasped cannot be let go until the grasp relaxes over time.
  • The Plantar Reflex is a similar reaction in the foot with curling of the toes and flexion of the arch bringing the heel toward the ball of the foot.
  • The Rooting Reflex is a pursing of the lips and turning toward any stimulus on the cheek, an automatic searching for the nipple.
  • The Infantile Suck Reflex is a sucking reaction at the front of the mouth involving lips and jaw and tongue. The adult sucking reaction is much more tongue against palate at the back of the mouth.

These grasping reflexes frequently disappear as the Moro Reflex is inhibited. If not, specific treatments can be introduced.

3 or more of the following would lead you to suspect retention of these reflexes:

  • Poor pincer grip between thumb and forefinger
  • Immature pencil grip
  • Over sensitivity on the palms and bottom of feet, very ticklish
  • Poor knife and fork grasp and control
  • Difficulty with cup handles
  • Poor running skills
  • Complaints that shoes hurt especially over toes
  • Tripping, falling
  • Poor saliva control, dribbling, frothing at mouth corners, spitting whilst speaking
  • Over sensitivity around and in the mouth
  • Messy eating
  • Dislike of certain textures of foods
  • Tendency to suck rather than chew
  • Noisy eating
  • Inability to close mouth on eating
  • Narrow high arch to Palate
  • Poor tooth alignment and the need for orthodontic work
  • Poor control of mouth for speech
  • Poor co-ordination of breathing and speech
  • Retained thumb, jumper, pencil, hair sucking
  • Poor bladder control
  • Possible reflux from the stomach

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The ATNR stands for the asymmetrical tonic neck reflex and is initiated when the head is turned to left or right on a horizontal plane. It is triggered by the labyrinth in the inner ear. The reaction of the ATNR is extension of the limbs on the face side, with flexion of the limbs on the head side. The eyes are also controlled by the reflex so that they are drawn to the extending hand. The function of the reflex is to slow down the rate of birth, to initiate limb movement and the precursor of hand eye co-ordination. If this reflex is retained after the normal time of inhibition it will continue to influence limb movements each and every time the head is turned, so that writing becomes difficult as the hand and arm involuntarily extend as the head turns toward the hand. Maintaining a pen grip is difficult and has to be over compensated for with a tight grip causing writers cramp and illegible writing. Copying difficulties are common as the eye follows the hand not the text. If the reflex is very strongly retained in the legs there can be balance difficulties as the individual looks from left to right. As the reactions are asymmetrical, that means different on either side of the body, it is difficult to make symmetrical movements with hands, feet, and eye. It is also difficult for hands, feet and eye to cross the midline. This makes it difficult for the eye to perform pursuit reaction, so that the individual cannot track a moving or stationery image, making reading difficult. They cannot make the rapid forward and backward movements called saccades essential for reading. It is a reflex that prevents integration of the two sides of the brain so that dominance and cerebral specialisation do not develop. As it is a reflex that maintains the same reaction throughout the same side of the body it causes an inability to use the four quarters of the body independently, leaving clumsy stiff half and half movements. A persistent ATNR will prevent the development of the Amphibian Postural Reflex. The Amphibian Reflex is also an automatic response but originating from higher up the brain stem. Once established it should remain all of life and enables the individual to make cross pattern movements. It is essential for good rolling over, for crawling and marching using alternate leg and arm.

3 or more of the following would lead you to suspect that the ATNR is still retained are:

  • Poor reading skills, inability to follow a line, getting lost along the line, losing place
  • Blurring and double image as the two eyes cannot work together for binocular vision
  • Rubbing eyes, reddening of eyes
  • Inability to read small print, though can read large print
  • Inability to read when there are many lines on a page rather than the odd word and pictures
  • Difficulty eating
  • Messy eating
  • Poor writing and copying
  • Poor hand eye co-ordination
  • Tight pen grip, breaks pencil lead frequently
  • Complains of writers cramp
  • Hates writing, slow with much less achieved than would be expected
  • Frequently a great discrepancy between verbal expression and written expression
  • Difficulty with spelling and grammar and context both in reading and writing
  • Poor co-ordination, balance difficulties when moving
  • Difficulty swimming, especially breast stroke, but poor splashy rolling style with crawl
  • Poor running, skiing, roller-blading. Clumsy ½ and ½ body rolling rather than gliding, flowing
  • Poor left and right knowledge
  • Reversal of letters, numbers
  • Confusion with tens and units
  • When reading may start words or lines at the end
  • Continues to draw a circle in a clockwise direction
  • Frequently remains childish, poor behaviour control
  • Tendency to learn in a holistic, visual manner
  • Imaginative, artistic, but with poor sequential skills, poor at arithmetic, tables
  • Difficulty following multiple instructions, poor memory
  • Tendency to be selfish, ego-centric
  • Can’t wait for reward, wants everything NOW

As you can see the ATNR has serious effects upon all aspects of development, emotional, intellectual, and social. But by repeating the movements of infancy and treating any underlying cause the reflex can be inhibited and learning can then develop normally. I use the term learning to refer to personal and social development as well as intellectual.

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The TLR or Tonic Labyrinthine Reflex is again an automatic reaction of the limbs and body caused by head movement, in this instant head movement on a vertical plane, tilting of the head forwards and backwards. The movement being monitored by the primitive loop of the vestibular system, which is comprised of the labyrinth in the inner ear, the vestibular nerve, and the cerebellum. There are two distinct reactions, flexion with the head tilted forward and extension with the head tilted backward. The TLR in flexion is present from about 12 weeks after conception and is responsible for the curled foetal position. Tilting of the head forward will cause automatic contraction of the muscles on the front of the body and limbs. This reflex is present at birth, so that when a baby is lying on it’s front it will automatically adopt a curled up position. When the head is tilted backwards it causes the opposite reaction, the muscles on the back of the body and limbs contracting resulting in extension of the arms and legs and an arching of the back. This reaction is only possible in the early stages of pregnancy when there is sufficient room, and after birth. As the infant has no conscious control over head movement, head movement in this direction will be primarily caused by gravity. It is closely linked to the Moro reaction, to balance and to posture. The head is heavy and once the child stands any tilting of the head should cause the opposite, compensatory, reaction to prevent falling. Retention of this reflex is therefore likely to destabilize the individual. Retention also prevents the normal development of spatial orientation and the Head Righting Reflexes. Head Righting Reflexes are examples of Postural Reflexes, the type of automatic reaction that should replace the Primitive Reflexes. Head Righting is the automatic repositioning of the head so that the top of the head always remains at the top. If you hang a new born baby upside down the head will remain in that positionas there wil l be no Head Righting Reflexes; however, at about 8-12 weeks the baby will automatically twist it’s head so that the top is uppermost. Once this reaction has developed it should remain for life and is essential for the proper development of eye control. People with a retained TLR have difficulty with convergence of the eyes and therefore with adjustment from near to far vision.

3 or more of the following reactions would lead you to suspect that a TLR is retained:

  • Poor posture with either stooping or arching of the body backwards
  • Poor balance, falling
  • Abnormal wear of shoes because of increased pressure on the heels of toes
  • Poor spatial awareness, difficulty knowing where self is relation to space and others: sitting too close, poor development of personal space, hitting head in swimming pool
  • Poor arrangement of work on paper
  • Poor depth perception, banging into things, snatching, knocking things over
  • Poor near vision, reading and copying difficulty
  • Fear of heights as the ground appears to move toward and back
  • Under or over active muscle tone, so that the individual is floppy or tense
  • Problems with spatial concepts in maths, algebra, geometry
  • Problems with grammar and tense
  • Poor development of self identity, shy, tendency to be easily influenced by others
  • Poor short term memory
  • Dislike of arms being held above the head
  • Inability to swing from or climb a rope
  • Poor leg control

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The Symetrical Tonic Neck Reflex is not a Primitive Reflex in the same way as the others in that it is not present before or at birth. It does not emerge until 8-10 months. Many refer to it as a transitory reflex, others believe it is simply a stage of the development of the TLR in extension.

The STNR is the reflex that enables the baby to defy gravity. The STNR precedes the ability to crawl. With the head up the arms automatically straighten, lifting the chest and shoulders, the hips and knees automatically flex. The child is in the position sometimes referred to as the cat position. When the head is lowered the arms automatically flex, lowering the chest and shoulders, at the same time the hips and knees straighten, so that the child is in a supplicant position. The aim of this reflex is to enable the child to get onto it’s knees, either toward a crawl or standing position. During the execution of this reflex the eyes make adjustment from near to far vision as the eyes are lowered to the floor or raised to view the horizon.

3 or more of the following reactions would lead you to suspect that a STNR is retained:

  • Poor standing position, stooped shoulders, bent knees, flexed hips
  • Poor sitting position, head lowering to desk as working
  • Swinging back on chair, legs wrapped around chair, sitting on legs
  • Preference to sit on the floor, or lie on floor or couch
  • Fidgeting whilst sitting, concentration difficulties
  • Poor attention to work, poor quality and amount
  • May even stand up, wander around classroom
  • Reading difficulty from seated position
  • Poor writing and copying, many errors in copying, very slow
  • Poor impulse control
  • Poor concentration and short term memory
  • Tendency to be long sighted
  • Poor control of legs

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Spinal Galant Reflex

The spinal galant reflex is present before birth and should no longer be evident after 9 months. It’s effect is to cause hip rotation on the same side as stimulation of the small of the back. It’s purpose is to bring about movement, to develop the range of movement essential in the hip. It is also thought by some authorities to instigate emptying the bladder, the reason why babies do so as the nappy is tightened around their back. It is also believed by some to transmit vibration along the vertebra having an impact upon hearing.

3 or more of the following reactions would lead you to suspect that a Spinal Galant Reflex is retained:

  • Poor control of legs
  • Poor bladder control
  • Possibly poor bowel control
  • Fidgetiness whilst sitting
  • Dislike of anything tight around the waist
  • Very ticklish around the back
  • Poor speech development
  • Poor listening skills
  • Poor development of grammar and spelling

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