Essay The Primitive Reflexes: Considerations in the Infant Samuel A. Berne, OD Private Practice, Santa Fe, NM ABSTRACT self direct themselves through treatment programs that The primitive reflexes are a set of movement patterns will provide them with the opportunity to integrate the in the newborn that emerge during the prenatal period. reflexes. Infants and developmentally delayed toddlers These primitive reflexes are present at birth and provide do not have the opportunity to follow these activities an indication of the neurological development of the secondary to their lack of development. Therefore, an newborn. The reflexes are movements that are automatic integration program can be initiated that can include and do not require thinking. The reflexes help in the activities in which the caregiver or therapist can move the birthing process; they help the newborn adjust to its new infant through the activities as needed. This can provide environment outside the womb; and help to build a an opportunity for the infant to develop more foundation for motor and cognitive skills. appropriately and within the developmental sequence. The reflexes involve changes in the level and KEY WORDS distribution of tone which primarily can affect posture Asymmetrical Tonic Neck, Moro, Spinal Galant, and movement. These reflexes along with postural Symmetrical Tonic Neck Reflexes, Tonic Labyrinthine control are basic developmental patterns. They are integrated and modified into the more complex patterns INTRODUCTION which lead to voluntary movement and skills. These are During the prenatal period, a set of reflexes emerge integrated by the higher centers of the brain. Lack of that are referred to as the primitive reflexes. These integration of these primitive reflexes can lead to poor reflexes originate in the brainstem, are present at birth eye movements and poor fixation from far to near. In and provide an indication of the neurological addition, one may have difficulty with visual development of the newborn. They help the newborn coordination, hand-eye coordination and visual memory. integrate the overwhelming amount of stimuli the young When an infant is delayed in the integration of these child receives once they leave the mother’s womb and reflexes, developmentally appropriate treatment plans are crucial for the baby’s survival in the first few weeks. should be considered. Traditionally older children can As the child matures, the higher brain centers inhibit the primitive reflexes so more advanced movement Correspondence regarding this essay can be e-mailed to patterns can develop. The reflexes are integrated in a [email protected] or sent to Dr. Samuel A. Berne 227 E. sequential fashion from 6-12 months. This assimilation Palace Ave Suite G, Santa Fe, NM 87501. All statements are the allows more sophisticated neural organization to author’s personal opinion and may not reflect the opinions of the College of Optometrists in Vision Development, Optometry and increase, which then allows the infant control of Vision Development or any institution or organization to which he intentional responses. If these reflexes are retained may be affiliated. Copyright 2006 College of Optometrists in Vision beyond 6-12 months post birth, they can interfere with Development. cortical processing as well as impede normal development. An abbreviated version of this paper was previously published as Berne SA. The primitive survival reflexes. J Optom Vis Dev Sally Goddard’s work found that the persistence of 2003;34(Summer):83-85 these reflexes can lead to neuro-developmental delays. She defines a neuro-developmental delay as a significant Berne SA. The primitive reflexes: Treatment considerations in the immaturity in the performance of the nervous system as infant. Optom Vis Dev 2006:37(3):139-145. Volume 37/Number 3/2006 139 validated by a group of retained primitive and postural advanced motor and cognitive tasks can be undertaken. reflexes in a child above three and one-half years of age. Depending on the degree of abnormal reflex activity, this According to Goddard, such a group of aberrant reflexes poor organization of nerve fibers can affect the is accompanied by problems with control of body functioning of gross motor and fine motor coordination. orientation, gross and fine muscle coordination, visual These aberrant reflexes can also interfere with the tracking skills and visual-perceptual skills.1 development of normal sensory perception, cognition The visual system is intimately involved in the and audition. The primitive reflexes are essential for transition from primitive reflexes to cortical control of learning. If these reflexes are retained beyond the first movement patterns. In 2001, Bein-Wierzbinski year of life, many of the advanced cognitive and motor completed a research project supporting the relationship systems will be underdeveloped or inefficient despite between the visual system and the primitive reflexes. sufficient intellectual ability. It is as if later skills remain Her findings involved a study of 52 elementary school tied to an earlier stage of maturity and instead of children in Germany. She had investigated whether becoming automatic, can only be mastered through disturbances in oculo-motor skill and visual perception consistent effort on the conscious level.1 could be corrected by means of an appropriate motor For example, visually tracking an object, shaping training program which focused on primitive reflexes letters with the mouth or holding a pencil require the and early motor development. All of the children were intentional control of the muscles. When an unconscious examined for abnormal reflexes with the eye movements reflex interferes with an intentional movement pattern, being assessed using an infra-red computerized eye the performance will generally not be smooth or tracking instrument. One half of the children who had coordinated. Once a retained reflex is integrated, the persistent reflexes were given a reflex stimulation/ performance can then become an automatic learned skill. integration program. The other half were examined both Learning occurs when basic physical skills such as at the beginning and end of the program but were not balance and interweaving of both sides of the body included in any training. Her results showed improvement (right-left coordination and upper-lower body in oculo-motor functioning and reading skills as coordination) become automatic. In order for the motor anomalous reflexes were integrated. Oculo-motor deficits skill to become automatic, it has to be learned beyond the continued to persist in the control group. mechanical level. To learn a motor skill beyond this level In a study conducted by Ten Hoopen, it was noted requires the patient to feel the body while doing the that if vision therapy was postponed until a child had at movement. It also requires the patient to develop better least six months treatment with a reflex integration self- awareness, and ultimately become his own program, in many cases, the vision therapy was not “error-detecting” system.2 This reciprocal interweaving required after the reflexes had integrated. In those cases is vital in the development of orientation.3 If the child where persistent oculo-motor problems remained, the does not develop automatic motor control, a parent may time needed in vision therapy was halved.1 observe behaviors such as reversals in writing and Sally Goddard has also reported that oculo-motor reading, poor attention and clumsiness.1,4 Although a and visual perceptual problems can be associated with a child may demonstrate good potential intelligence, retained moro reflex. She found that poor ocular pursuit further development may not occur until the delay is movements (especially at midline) are linked to a addressed. Part of addressing the developmental delays retained asymmetrical tonic neck reflex. She has also is learning to integrate the reflexes. determined that oculo- motor dysfunctions, spatial Testing problems and visual-perceptual difficulties occur with a Sally Goddard recommends a testing protocol of the retained labyrinthine reflex. And finally, her work has primitive reflexes. This identification process determined that struggles with hand-eye coordination determines what reflexes have been retained versus and poor near far focusing skills are related to a retained integrated.1 When any of the primitive reflexes persist symmetrical tonic reflex.1 beyond the time that they should be no longer be Considerations of development exhibited, the diagnostic assessment suggests that they Integrating these primitive survival reflexes helps have not been integrated. Therefore, one expects that the infant to learn the critical processes of movement. there will be interference in the general and specific There has been some controversy whether the reflexes motor skills of the child.2,5-7 Athletes who still have the become integrated or inhibited within the person. I primitive survival reflexes can become proficient with a believe that when the reflexes become integrated, certain specific motor movement but may not have the attention is shifted from basic motor systems so that more ability to develop more efficient movement patterns.1 140 Optometry and Vision Development Lack of integration of these reflexes can also lead to response to external vision problems.5 In cases with persistent primitive stimuli which is reflexes, the expectation is that eye movements are poor perceived as a and fixation from near to far is difficult.1 Visual threat. One of the coordination, hand-eye coordination and visual memory coping mechanisms may be below expected levels. Our visual function is to this stress is an intimately influenced by our brain processes. If the over stimulation of primitive reflexes are still persistent then some of the the sympathetic cortical processing is not available for higher level nervous system. If information processing. If the primitive reflexes remain the stress is chronic, a powerful force and have not been integrated, one may see an encouragement of the postural reflexes alone will rarely alpha omega pupil influence related transformation in the areas of fine motor response and a Figure 3.