On retained primitive reflexes

Each year I receive several emails from colleagues about 'retained primitive reflexes.'  I am also seeing an increased number of reports from local 'health care' providers who are documenting these alleged problems so I thought I would write a summary of my opinion on this topic.  

Predatory 'health care' providers including some OTs, PTs, chiropractors, and behavioral optometrists are creating a new 'market' for treating this alleged 'problem.'  Parents should be very wary of these practitioners and other professionals should challenge these practices whenever they are seen.

The following is the kind of information that causes concern and was provided to me by a colleague as a sample from a student's IEP:
The student continues to demonstrate the following retained primitive reflexes that at times interfere with his ability to demonstrate appropriate adaptive responses: Fear Paralysis Reflex, Moro Reflex, Palmer Reflex, Tonic Labyrinthine Reflex, Asymmetrical Tonic Neck Reflex (ATNR) and Symmetrical Tonic Neck Reflex (STNR). If the primitive reflexes are retained past the first year of life (at the very latest) they can interfere with social, academic and motor learning. Basically, the perception of our inner and outer environment and our response to it may be disturbed; that is, conscious life may be disturbed. Each reflex is associated with one or more of the Sensory Processing Systems: Auditory, Taste, Tactile, Smell, Visual, Vestibular, Proprioceptive and/or Interoceptive (automatic “gut” responses related to emotions). Therefore, if retained, a child may experience dysfunction within one or several of the sensory processing systems. This can lead to what is known as Sensory Processing Disorder.

This is the kind of hokum that is being placed in the IEPs of our children and is being subsidized by taxpayers.  This will ultimately lead to the demise of related services in schools if our tax-supported colleagues who work in educational programs don't get on board with science-based and evidence-based practices.

 Reflexes are normal motor patterns that are developmentally specific and they tend to become 'integrated' as motor skill increases.  In simple terms, a baby's initial movements will be reflex-based and those movements are predictable, repetitive, and subject to specific incoming stimulus.  If a newborn baby is on its belly then it will tend to curl up into a ball.  That reflex is integrated as the child learns to crawl and sit and walk.

In children who have nervous system damage, like cerebral palsy, some of those reflexes never go away.  You can see them long after the child should have 'integrated' that reflex and those reflexes are often associated with motor delay.

There have been some observations over time that some children with mild learning problems have some small evidence of those reflexes. These children don't have the same motor deficits as a child who has cerebral palsy, but they may have some mild or even moderate motor incoordination even if they can walk and talk and keep up with their peers (to varying degrees). 

There is great variability in whether or not there is any residual evidence of those reflexes in children with mild learning problems, and even more problematically, there has never been any research that indicates that 'integrating' those reflexes does anything to help the children!  There is also no standard or recognized protocol for evaluating, quantifying, or even treating the problem - although the Internet is full of snake oil about this topic.

So what do we know:

1. Children who have severe nervous system damage (like cerebral palsy) don't develop their motor skills and primitive reflexes persist.  We know that motor learning, normal practice, constraint-induced practice, and similar techniques help some children with these problems learn how to move with more skill.  For many years therapists used techniques based around those reflexes and their was very little evidence that those techniques were helpful.  Most therapists have largely abandoned those practices.

2. Children who have mild neurological or behavioral problems sometimes have very slight evidence of those residual reflexes.  No one knows if that is significant, and in fact it likely is NOT significant because it is so variable and there is no evidence to support the premise.  At best, there is a weak CORRELATION between those reflexes and some learning problems.  We also know that CORRELATION DOES NOT INDICATE CAUSATION.

3. We know that there are no studies that indicate that any protocol to 'integrate' anything that is being called a 'retained primitive reflex' is effective for any child.  Since there are many evidence-based methods which are KNOWN to help children who have specific motor or learning problems, it is UNETHICAL to subject children to experimental theories.

4. Practitioners who are not influenced by evidence, science, and standards of acceptable practice should be avoided.  Seeing statements in an IEP that  'retained reflexes' and 'sensory processing disorder' causes 'conscious life to be disturbed' is an embarrassment to any thinking person who is actually trying to help children.

+++

If parents see statements on their child's IEP about retained primitive reflexes they should immediately complain to their CSE and school board.  Therapists or other practitioners have no right experimenting with outdated and largely discredited theories on children.  Parents should demand that evidence-based methods are used to educate their children in public schools.

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Comments

Tonya said…
That scares me that statement being in an iep. ridiculous.
Cheryl said…
Thank you so much for sharing this. This seems to be one of the hot new things that people want to talk about, but of course not be able to discuss on an evidentiary level.
Rochelle said…
Yippee for evidence based thought! I speak to so many therapists who are doing interventions that have no evidence behind them or, evidence to the contrary (think weighted vests and blankets). We all know that reflex inhibiting postures did not work and don't provide any value. That statement you quoted is embarrassing and reflects poorly on our profession.
Thanks for writing!
Anonymous said…
The evidence exists, whether or not the author is aware of it.

Here is a randomized, double blind, placebo controlled, study, published in the Lancet, that shows working with primary movement patterns is supportive of children with learning challenges:
M. McPhillips
with P.G. Hepper and G. Mulhern
—“Effects of replicating primary-reflex movements on specific reading difficulties in children,” Lancet, 355 (9203), 537–41, 12 February 2000.

I suggest that the author comes up with research to back up his position, showing there is NOT a correlation between retained primitive reflex retention and sensory-motor, cognitive and behavioral dysfunction.

While it is true that we require more published research to show causation and efficacy of the supportiveness of primitive reflex movements, it is also true that relying only on opinions without experience and without knowledge of the literature is a dead end road.

List of supporting research won't all fit on this blog, here is some there is much more
J.-A. Jordan-Black
—“The effects of the Primary Movement programme on the academic performance of children attending ordinary primary school,” Journal of Research in Special Education Needs, 5(3), 101–11, 2005.

Jana Konicarova and Petr Bob
—“Asymmetric tonic neck reflex and symptoms of attention deficit and hyperactivity disorder in children,” International Journal of Neuroscience, 5, June 2013. Epub.
with Jiri Raboch
—“Persisting primitive reflexes in medication-naïve girls with attention-deficit and hyperactivity disorder,” Neuropsychiatric Disease Treatment, 9: 1457–61, 2013.

M. McPhillips
—“The role of persistent primary reflexes in reading delay,” Dyslexia Review: 13(1), 4–7, 2001.

with N. Sheehy
—“Prevalence of persistent primary reflexes and motor problems in children with reading difficulties,” Dyslexia, 10(4), 316–338, 2004.

Myra Taylor, Stephen Houghton and Elaine Chapman
—“Primitive reflexes and attention-deficit/hyperactivity disorder: Developmental origins of classroom dysfunction,” International Journal of Special Education, 19(1), 23–37, 2004.

Sergio Ramirez Gonzalez, MS, Kenneth J. Ciuffreda, Od, Phd, Luis Castillo Hernandez, Phd, and Jaimes Bernal Escalante, MS
—“The Correlation between Primitive Reflexes and Saccadic Eye Movements in 5th Grade Children with Teacher-Reported Reading Problems,” Optometry and Vision Development, 39(3): 140–45, 2008.

Hyde, Thomas M., Goldberg, Terry E., Egan, Michael F., Lener, Marc C., Weinberger, Daniel R.
—Frontal Release Signs and Cognition in People with schizophrenia, Their Siblings, and Healthy Controls. The British Journal of Psychiatry, July 2007, 191 (2) 120-125

Links, Ka.; Merims, D ; Binns, MA ; Freedman, M ; Chow, Tw
—Prevalence of primitive reflexes and Parkinsonian signs in dememtia, Canadian Journal Of Neurological Sciences, 2010 Sep, Vol.37(5), pp.601-607

Nicolson, Stephen E,; Chabon, Brenda ; Larsen, Kenneth A. ; Kelly, Susan E. ; Potter, Adam W. ; Stern, Theodore A.
—Primitive reflexes associated with delirium: a prospective trial. Psychosomatics, 2011, Vol.52(6), pp.507-512

Youssef, H.A; Waddington, J.L
—Primitive (developmental) reflexes and diffuse cerebral dysfunction in schizophrenia and bipolar affective disorder: overrepresentation in patients with tardive dyskinesia. Biological Psychiatry, 23, 791-6. 1988.

With respect,
Living Human Being
Dear "Living Human Being,"

I can't imagine that you really intended me to provide proof that something DOESN'T exist. Generally when someone makes a claim it is up to the person making that claim to provide evidence. I am not sure how you would expect me to provide evidence that there is no evidence.

I will gladly respond to your list of 'research' but would first like to invite you to share your actual name and affiliation. It is always much more cordial to address someone who is not just posting as a "Living Human Being."

Unfortunately the information that you provided is rather random and it is very unclear what you are intending to express. For example, what would you like me to take away from the article on people who have Parkinson's disease or other organic brain problems or mental health problems? What exactly does that have to do with alleged reflex integration programs?

The one article in the Lancet has very confusing results, small sample size, poorly matched controls, and it does not address many confounding factors. It is a very weak study and it is old and it has never been replicated. Many of the other studies you list are simply opinion pieces or weak correlation studies - again having nothing to do with prescriptive exercise programs that claim to 'integrate reflexes.'

Perhaps it would be helpful to state your claims a little more clearly. Take the top 3-5 articles that you want us to consider and tell us how they support your claims. Specifics are helpful.

As a final point, I would like to be clear that I never stated that correlations don't exist. However, as a clinician, we don't provide treatment based on correlations. Doing so is a very poor way of conducting yourself as an evidence-based practitioner. We should be looking for direct evidence of results based on specific actions - not just weak correlations that some different factors may somehow be related to each other.

Regards,
Chris

Suzie said…
Chris- are you saying that all sensory integration techniques are ineffective? I'm a recent grad and we were taught about Ayres , Miller, etc. as effective and evidence based strategies. Please explain a bit more. Thank you.

Hi Suzie,

Thanks for writing. I don't think that I made any statement that all sensory integration techniques are ineffective. I am curious what you saw here that made you think that.

I think that the construct is really poorly defined and even more poorly researched. That makes questions about effectiveness really challenging to figure out. I have a rather extensive collection of writing on SI and I encourage you to read through it by clicking on the 'sensory integration' label in the right hand column of this blog or by clicking http://abctherapeutics.blogspot.com/search/label/sensory%20integration

What remains problematic is that although efforts have been made to introduce fidelity constructs to the 'SI' brand it is rather obvious that many people have ignored those calls. That doesn't make the SI model 'ineffective' as much as it is 'pointless' because not enough people are willing to follow Fidelity constructs and even moreso the proponents of that theory have established structural and process elements that are apropos of nothing. Even if someone does choose to engage those Fidelity constructs I don't think that many people can really reach the bar that has been set for many pragmatic reasons. That is an entirely different topic.

All that aside, what we are left with is the reality that pseudoscience practitioners who are using 'reflex integration' are now linking it with 'sensory integration' theory, or rather their own interpretation of it.

I wrote a provocative piece a while back about sensory integration itself being pseudoscience. You can see that at http://abctherapeutics.blogspot.com/2007/01/pseudoscience-and-sensory-integration.html

Some people have really tried to push SI models into legitimacy but because there is not enough adoption of Fidelity in the concepts it is probably fair criticism when people label it negatively.

I understand that you have been taught that it is effective and evidence-based, but I encourage you to question your instructors, do your own research, and try to square what you have been told with the reality of how most people view sensory integration as a treatment model.

There is a reason why it is not reimbursed by most insurance plans and there is a reason why schools tend to embrace more function-based models. I assure you it is not a vast conspiracy. It is simply a matter of evidence (and lack thereof!).
That IEP statement is over the top and couldn't agree more that we will drive ourselves out of school based therapy with reports like that.

This was a great blog post. Thank you for your insight.
Thank you for your insight into your thoughts on primitive reflexes.
As an OT practicing in rural Wisconsin, I wear many hats including; hand therapy, birth to three early intervention, school based therapy and home health. I always strive to provide services which are considered to be the best practice. I have been practicing for 26 years and just this last month I was asked about primitive reflexes and SI. I can honestly say that I had never heard of this perspective. Hence my Google search on "evidenced based practice and primitive reflexes" that led me to a few scholarly articles and your blog! Your rational clearly fits with my initial reaction and I thank you for your candid approach to making our profession better.
Holly OT said…
Hi Chris,
I'm a paediatric OT in the UK and run the Criticalthinking4OT facebook group. My background before OT was sociology and I cannot escape my critical thinking roots. And so to my point, Ayres SI is establishing itself here in the UK with great enthusiasm.
I am a neuro based paeds OT primarily and really struggle with the assumptions that SI throws up (in particular the idea that 10 minutes of linear vestibular input increases education attention by 6-8 hours?!), and many therapists over here are looking for these clinical signs of retained reflexes in an otherwise healthy population of children.
I cannot help but regard with suspicion the testing methods to invoke these signs of retained reflexes and frankly wonder where on earth these therapists are deciding by getting a child into a frankly peculiar position, then observing a bent elbow that they conclude the child has a retained ATNR etc!
Thank you for the refreshing read and I would love it if you come over to our facebook group where hopefully we can engage in constructive critical thinking regarding OT.
Holly
helene p said…
excellent commentary!
Monlontar said…
So in a few words-primitive reflexes can not be integrate if retained-right?
Dear Molontar,

In a few words: If they are 'retained' then by definition they are not 'integrated' - but none of that matter anyway because there is no evidence to indicate that 'retained' reflexes are clinically significant for populations other than CP, ABI, etc.
Anonymous said…
I am so glad I came across this blog. I recently attended a CE that made claims that re-integrating reflexes was helping children with learning disabilities improve academically. I immediately started searching for any evidence for these claims. Frankly because as a physical therapist some of the claims I heard were a little too hard to swallow. Additionally some of the "tests" lacked in evidence for the population being discussed. One of the most absurd was the supposed "test" to determine if a child had a retained TLR. The claim was that a child should be able to hold a prone superman position without legs shaking or bent, breathe normally, look you in the eye, and answer questions all at once. If not, the child had a positive sign for a non-integrated TLR. This is hard to do! The most logical reason for child with a non-neuro impairment ( ie CP, TBI) inability to do this would be a weak core or poor spine mobility. Yet there was no discussion of this. In fact, the presenter was not a therapist and had to remove this portion of her presentation on video. My guess is that someone called her out on recommending these tests to anyone and everyone. I am concerned that people are scaring the parents to pieces. They claim to find scary non-integrated reflexes and then come up with interventions to fix them with no evidence they work or that they even have an impact on learning or development in children without any neuro impairment.
DanaHajek said…
I'm confused. Why would a retained Moro reflex that results in a heightened sense of fight or flight in my 7yo not be clinically significant? Are you saying it's not diagnostically significant? That making a correlation between the maintained presence of the moro reflex and a disorder/disease would be irresponsible? I may agree with that but I'm not sure clinically significant would be appropriate because it is absolutely significant to his treatment/care/success. Recognizing the retention and adapting care appropriately seems like a no brainer. Maybe I'm confused by the wording?
Hi Dana, Let's start simply. How do you know what is a retained Moro versus an adult startle reflex? Also, how do you know that nothing else is contributing to the difficulties that you were describing? Please provide support for your answer. I believe that you are making assumptions about the observation and then you are making spurious correlation about what you think that you were seeing and the behavior you are associating it with. What evidence do you have exactly that can support your very specific conclusion?

Unfortunately most of the assessment and treatment ideas that are being presented about this topic have no basis in evidence. That does not mean the children don't have regulatory problems but it does mean that there is faulty thinking about the cause and the alleged treatment that is being promoted.
DanaHajek said…
I'm a parent asking a professional for answers and direction. So I was hoping you would be the one to direct me to the evidence and the "proof". My questions were not rhetorical and I was hoping to actually gain some insight not just be met with more questions. Trust me the crazy amount of conflicting data and methods is making my head spin and all I I have is questions with very limited answers and I just want is my son to thrive. All I know is that reading about what a Moro reflex is and what a poor integration of the reflex could present like actually has made some logical sense to me as someone not trained in the profession. I struggle to see how teaching a child how to better recognize when this is leading him astray is harmful to him in anyway. I appreciate your prospective and am trying to find the best care for my son.
Thank you for clarifying that Dana - I read your question quickly and did not initially understand it was written as a parent. The best that I can tell you is that there is no evidence to support the interpretation of your child's behavior in terms of retained primitive reflexes. Scientific evidence is important when any intervention is used on a child. You should expect that any procedures and methods used on your child have some basis in scientific fact, have been validated and accepted by mainstream researchers and clinicians, and accepted for reimbursement by mainstream insurers. Under most circumstances, the behavior and actions of children (even if they have some learning or developmental problems), can be reasonably ascertained by thorough developmental testing. I encourage you to talk to your pediatrician who can refer you to a practitioner who will conduct accepted standardized assessments and who can help you plan treatment if needed for your child. I know that it is very hard to see so much information on the Internet that is supported by people who claim to be professionals or experts. Use your trusted pediatrician as a filter for this kind of decision making. I hope that they can refer you to a good psychologist and a good occupational therapist and other good professionals who can help you understand the difficulties that your child is happening and can help to develop an effective and evidence-based treatment. Tell your pediatrician that you value science and evidence and that you hope they can give you referrals to other professionals who do the same. Best of luck and please let me know if I can help in some other specific way. Again, I apologize for misreading your initial comment.

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