Child Development, Reflex Retention

and the Impact on Learning

POTA ANNUAL CONFERENCE NOVEMBER 1, 2014

Presen ted by

Jenn i fe r Doy le , MA OTR/L & Karen Gua l t ie r i , MS OTR/L

Neurodevelopment

Learning Objectives

Develop a basic understanding of the progression of reflex activation and integration in typical development

Understand the role of movement and play on the developmental progression

Identify barriers that interfere with reflex integration

Identify the behavioral and sensory challenges of children with unintegrated reflex patterns across environments

Understand basic principles and techniques for identifying these children through direct testing and clinical observation

Learn simple, effective activities to implement into your practice

About Us

❖ Jennifer Doyle has been practicing occupational therapy

in pediatrics for 14 years. She is certified in Sensory Integration (SIPT) and Neurodevelopmental Treatment (NDT). She is also trained in The Listening Program, Therapeutic Listening, Rhythmic Movement Training Interactive Metronome, and has completed her Level 1 mentorship with Lucy Jane Miller.

❖ Karen Gualtieri has been practicing occupational therapy for 11 years with extensive training in sensory integration. Karen is DIR/Floortime trained. She also has certifications in The Listening Program, Advanced Therapeutic Listening, Rhythmic Movement Trainingand Handwriting Without Tears.

Developmental Milestones

➢Lifting head

➢Rolling

➢Crawling

➢Sitting unsupported

➢Pulling to stand

➢Cruising

➢Walking

Central Nervous System

• Consists of the brain and spinal

cord.

• In the first year, your baby’s brain

triples in weight.

• By the end of the second year, your

toddler’s brain weighs three

quarters that of an adult’s brain.

Central Nervous System

• Brain gets bigger=more activity.

• The metabolism of a baby’s brain,

(measured by how much blood

sugar it uses) increases steadily

until age 3.

• At age 3, a child’s brain is more

than twice as active as an adult’s

brain

Central Nervous System

• Most of the brain cells are developed in-utero.

• After birth, there is extensive branching through

axons and dendrites.

• Extensions allow for connection and

communication within the CNS

• Pruning of unused brain cells and connections is

equally important for specialization of brain areas

and efficiency of processing

• More connections=more able to process a variety

of sensory input

Central Nervous System

• Myelination begins before

birth and continues

throughout childhood.

• Myelin (fatty sheath) protects the growing

nerves and helps them communicate better by

increasing the rate at which impulses travel

within the system.

• The brain undertakes this task in stages and

may not be completed until age 10.

Environmental Changes Impacting Development

• Shift toward a more sedentary lifestyle

– Decreased recess and gym time due to budget cuts

– Decreased opportunity for outside play

• Electronic games and toys, television, video

games

– less movement during play

– instant gratification affecting coping skill development

• Back to sleep initiative leading to children

having less tummy time– Children are not spending enough time in antigravity positions to

properly elicit reflex patterns and/or integrate them

Environmental Changes Impacting Development

• Devices for propping baby or confining baby

(carseat carriers, bouncy saucers, jumpers, etc)

– Decreased opportunity for movement and

environmental exploration

– Decreased sensory information from the environment

Purpose of Primitive and Transitional

Reflexes

• The primitive reflexes develop at different

times provide movement patterns for baby’s

survival.

• As the baby’s central nervous system

becomes myelenated through antigravity

and core postural activation, these reflexes

become integrated and the child can move

within these patterns but also against these

patterns.

Purpose of Primitive and Transitional

Reflexes

• The reflexes allow a baby to move through

the birth canal (ATNR, STNR, Spinal

Galant, TLR), find food when the visual

system has not fully developed (rooting),

and begin to move his/her body against

gravity to roll, crawl and walk.

Reflexes and Early

Development

• Researchers have found differences in

reflexes and movement patterns in

children with autism as young as 3 months.

Infantile Reflexes Gone Astray in Autism, University of Florida, Departments of Psychiatry, Psychology and

Computer Science. Philip Teitelbaum (1), Osnat B. Teitelbaum (1), Joshua Fryman (2), and Ralph Maurer (3)

2004.

• They found a lack of head verticalization when the infant

was tilted to the left and right, with the head remaining in

midline instead of righting itself. This can persist into

grade school.

Reflexes and Early Development

• They also found atypical rolling in children

with a persistent ATNR later diagnosed with

Asperger’s Syndrome.

• When these children turned their head to

the left, their left arm extended (ATNR). The

rolled to the opposite side using extension

instead of flexion as is typical. They used

their extended arm as a leaver.

Biomarkers for Autism

Researchers from the Children’s National Health System have identified that head circumference and head tilting reflex are reliable biomarkers for autism between 9 and 12 months of age.

1000 subjects. 49 with abnormal results.

15 at risk for ASD, 34 at risk for developmental language delay.

14/15 children at risk for ASD eventually sustained the diagnosis.

C.A. Samango-Sprouse, E.J. Stapleton, F. Alibadi, R. Graw, R. Vickers, K. Haskell, T. Sadeghin, R.

Jameson, C.L. Parmele, A.L. Gropman. Idenitification of infants at risk for autism spectrum disorder and

developmental language delay prior to 12 months. Autism, 2014

Moro Reflex

• The “startle reflex”

• Elicited by posterior loss of

support

• Usually present until 4 or 5

months of age

• Has 2 distinct phases

– 1st phase: Abduction of

arms and extension of

neck

– 2nd phase: adduction of

arms and flexion of trunk

Moro Reflex

• If this reflex is unintegrated, the child can

have difficulty with self-soothing and may be

frequently anxious and on ‘high alert’

• Functions as an alarm, and overstimulates

“flight or flight”.

• When overstimulated, hypersensitivity can

develop in sensory systems especially in

the visual, auditory, and tactile systems

(specifically light touch and vibration).

Moro Reflex

• Integrated response: Person is able to clasp

hands quickly and without emotional

response.

• Retained reactions include: delay in

reaction, incomplete arm movement, breath

holding, skin changes, leg extension or

arms away from chest.

Tonic Labyrinthine Reflex

• A primitive reflex which is present at birth and

integrated by 6 months of age

• (prone) When the head is tipped back the body

goes into extension and (supine) when the bends

forward, the body goes into flexion

• This reflex helps the baby move through the birth

canal.

Tonic Labyrinthine Reflex• Provides opportunity for head alignment and eye

pairing for the foundation for bilateral

coordination and posture

• In typically developing children, eyes converge

when head tilts forward and eyes diverge when

neck is extended.

• Low muscle tone and slouched

posture may result when

unintegrated.

• Fear of heights is also common.

Tonic Labyrinthine Reflex

• Integrated response: Body remains relaxed

and does not move.

• Retained reactions include changes in

muscle tone in legs, loss of balance,

nausea, dizziness, changes in skin color or

changes in breathing.

Landau

• This reflex emerges at 3 months of age (transitional reflex)

and is integrated by 12 months

• Characterized by extension or arching of the back when

the infant is placed in the horizontal plane

• If this reflex does not develop, this can be an indication of

a motor development issue. If not integrated, movements

can be stiff, in lower body with challenges in hopping and

jumping.

Landau

• Retained reactions include involuntary

movement of the feet and legs off the floor,

extensor tone throughout body.

• When integrated, you should be able to move

in and out of this position without difficulty

and without affecting your ability to learn

move movements.

Asymmetrical Tonic Neck Reflex

• This reflex is present at birth and

is usually integrated by 6 months

of age

• When the infant turns her head,

the arm and leg on the side the

head is turned to extend and the

opposite side bends

• This reflex is also known as the

fencing reflex

• If this reflex is not integrated,

difficulties arise with crossing

midline and using hands together.

Effects of Retained ATNR

Problems with handwriting

Difficulties with reading

Mixed laterality

Difficulty or inability to cross midline

Asymmetrical Tonic Neck Reflex

• Integrated response: Arms

should remain extended

and not follow movement of

the head.

• Retained response includes

slight to significant

movement of the arm in the

direction of head

movement.

Symmetrical Tonic Neck Reflex

• When the neck flexes or

bends, the body responds

with extension at the hips

and knees, arms flex.

• When the neck extends,

the hips and knees flex,

arms extend.

• This reflex prepares the

child to move into crawling.

Symmetrical Tonic Neck Reflex

• When this reflex is not integrated, the child typically crawls late, does ‘bunny hop’ crawl, or does not crawl at all.

• Balance may challenging.

• This reflex is clearly observed in children

with significant neurological issues, such as

cerebral palsy.

Effects of retained STNR

Poor posture

Poor hand-eye coordination

Messy eating

Poor copying from blackboard

Child tends to be farsighted with poor visual accommodation

Symmetrical Tonic Neck Reflex

• Integrated response: Body should remain in

position as head moves.

• Retained response includes hip movement,

bending of arms, arching of back, moving

into cat sit position, difficulty moving head

and breathing/pallor changes.

Spinal Galant Reflex

• This reflex is elicited by touching sides of

the spine. It helps the baby move through

the birth canal and begin to move from

their tummy.

• It is present at birth and integrated

between 3 and 9 months.

• The body will respond by rotating the hip

and flexing toward and on the side of the

touch.

Spinal Galant Reflex

• Lack of integration can result in fatigue,

bedwetting, hyperactivity and attention

difficulties.

• It can make sitting still very difficult.

• Children may also develop sensitivity to

waist bands that presents as tactile

hypersensitivity.

Spinal Galant Reflex

• Integrated response: No movement of the

back with touch.

• Retained response includes movement of

the hip towards the stimulation.

Signs of Reflex Retention

• The person should be able to move with the reflexive

pattern but also move against the reflexive movement

pattern without significant effort

• Behavioral Signs

– Trouble staying seated in chair; falls out of chair

– Difficulty with fluidity between eye convergence and

divergence such as copying from the board

– Difficulty with attention, focus, and concentration

– Low tone, clumsiness

Case Study: Eli

Background information

∗Eli is an 11 year old boy with a diagnosis of

cerebral palsy. Increased tone on the right

compared to the left side.

∗He has difficulty with balance and

coordination and often falls. Wears AFOs all

of the time

∗Has difficulties with peer interaction at

school, participation in school activities and

completion of assignments (has a 1:1 aide all

day at school).

Case Study: Eli (cont.)

Strengths

∗Desires peer interaction

∗Enjoys coming to therapy and

wants to participate

∗Reports enjoying school

∗Loves his iPad and has an

interest in cell phones and

computers

Challenges

∗Poor communication skills

∗Poor balance/ clumsy -

needs close supervision or

contact guard assist to

navigate environment

∗Shallow breath which affects

arousal level and speech

quality

∗Poor bilateral coordination

due to spasticity

Previous Interventions Trialed

with Eli∗ Behavioral approaches

∗ Occupational Therapy in the school setting – focused on

remediation of fine motor deficits and classroom

accommodations

∗ Interactive Metronome – Eli’s mother originally sought out

our clinic for IM Home. Eli was unable to focus and

participate for a long enough duration for significant change

Eli’s Treatment Progression

Integration of Moro Reflex

∗Breath activities

∗ Bubbles/ bubbles with straw/ bubble bowls

∗ Whistles/ pinwheeels

∗Supine Flexion activities

∗ Pillow pull

∗ Egg rock

∗ Tear drop swing

∗Prone Extension activities – balance tone and work on

bilateral coordination/ symmetrical movement patterns

∗ Prone extension in hammock swing with upper extremity pull

∗ Scooterboard wall push offs

Eli’s Treatment Progression

(cont.)∗ Cross- lateral movement patterns (ATNR and STNR integration)

∗ Crawling through resistive tunnel

∗ Resistive crawling

∗ Interactive Metronome was revisited after 6 months of clinic based

sensory integrative treatment. Eli was able to participate in the

program. Eli continued with clinic based treatment for an additional 6

months with a frequency every other week and participated in the IM-

Home program.

∗ A home exercise/ activity program was established for home and was

completed on a daily basis

∗ Eli participated in Therapeutic Listening during treatment sessions at

the clinic

A Case Study…Sherri

Sherri is a 7 year old adopted girl who comes to our clinic for occupational therapy services.

She has a diagnosis of an immature bladder with a history of toileting accidents…this is a main concern for mom as she feels it affects Sherri’s function in all areas of Sherri’s life.

Areas of Weakness How does it Affect Function?

Low muscle tone in upper and lower extremities

Low-average strength in hands, arms and trunk

Postural reactions and postural control below average

Distracted by visual input in her environment

Trouble processing sensory information visually and auditorIly

Poor hand writing

Trouble using hands together

Falls out of chair

Trouble getting dressed

Falls and or trips with movement

Frequently is incontinent of urine

Physical Observations …

Treatment approaches trialed by Family Biofeedback at a Hospital in Philadelphia (Family

was told Sherri was not a good candidate due to limited attention)

Potty watch ( used at school and home; watch has a timer so Sherri has a reminder to empty her bladder)

Extracurricular activities for upper, lower body and core strengthening (Yoga, Gymnastics, Jazz & Soccer)

Reflexes Tested

Spinal Galant…Sherri tested positive when swiped on right and left sides of her spine

ATNR…Sherri unable to keep elbows straight when head was turned

Exercises used at Clinic and Home

Bottom Scooch (long sit on mat, weight shifting right side then left to get across the floor) Forward, backward & in a circle in both directions while scooching

The Crane (Quadraped position on mat with another person (parent or therapist)…shoulders touching and hips touching….ready set go! Try and knock over by pressing with shoulder and hip! Don’t forget to do both sides.

The Bull Dozer (Child in Quadrapedposition on mat …crawl towards parent or therapist while parent or therapist applies gentle resistance to shoulders while letting child move forward.

Speed Bump….. Back on Track!

Sherri’s mom fell during the winter and hurt her wrist…

Mom stopped doing the exercises at home

AS A RESULT… Sherri had an increase in

incontinence at school and home

Sherri started using Potty watch again

Sherri’s mom resumed exercises

Sherri’s incontinence decreased

Potty watch…Sherri no longer wears it

Sherri is more functional in her everyday life!

Sherri’s Progress when Exercises done at home and in clinic

Intervention Strategies

Posture and Respiration

“If you can’t breath, you can’t function”

● Proper postural alignment allows for optimal diaphragmatic excursion

● Movement through developmental (antigravity) movement patterns allows for mature spinal curves to develop full excursion of the diaphragm

● Control over respiration allows for regulation of basal levels and affects arousal level

Rhythmic Movement

• The cerebellum is the brain structure

responsible for providing timing and grading

of movements for efficient and accurate

motor output.

Rhythm and Timing

• Underlying theory: Neural timing is important to efficient processing of sensory input. Rhythm and timing are important for development of motor planning, language, academic skills.

Rhythm and Timing

o Developing rhythm and timing with music and movement

o Using metronome app during treatment/in home programs and having the child tap to the beat, tap on a ball, use rhythm sticks, jump to the beat, bounce a ball to the beat.

o Using music with a strong beat or a metronome set at 60 (heartbeat) to help regulation. Can be used in home programs.

o Using rhythm as an important part of movement to help children develop regulation.

o Humming, singing and using kazoos to incorporate voice to the beat

Resistive Movement

• Grade difficulty of exercise• Increase proprioceptive input for increased body

awareness

• Obtain desired response especially when

trying to elicit flexion with rolling (instead of

extension)

• Provide sensory regulation by slowing

movement down

References and Additional Reading

Ayres, A. J., PhD. (2005). Sensory Processing and the Child: 25th Anniversary Edition. Los Angeles, CA.

• Bloomburg, H. & Dempsey, M., (2011) Movements that Heal: Rhythmic Movement Training and Primitive Reflex Integration.

Blyth, S. G. (2004). The Well Balanced Child: Movement and Early Learning. Stroud, Gloucestershire.

• “Building Blocks for Sensory Integration”, (2012). Continuing education course taught by Sheila Frick, OTR. Westfield, NJ.

Frick, S., OTR and Young, S., PhD (2012). Therapeutic Listening: Listening with the Whole Body. Vital Links. Madison, WI.

Goddard, S., (2002).Reflexes, Learning and Behavior: A Window into the Child’s Mind.Fern Ridge Press, Eugene, Oregon.

W E B S I T E :

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L I K E U S O N F A C E B O O K

E M A I L

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Questions?