Primitive Reflex Testing

and Integration Packet

Asymmetrical Tonic Neck Reflex (ATNR)

Overview

The Asymmetrical Tonic Neck Reflex (ATNR) is a primitive postural reflex that plays a key role in
early visuomotor development. It is triggered by head rotation and results in a "fencing
position"—extension of the arm and leg on the face side and flexion of the limbs on the skull
side. This reflex is crucial in prenatal positioning, birthing, early visual tracking, and
development of bilateral coordination and hemispheric specialization.

●​ Emergence: ~18 weeks gestation​

●​ Integration: By 3–9 months of age​

●​ Activated by: Head rotation in a horizontal plane​

●​ Controlled by: Labyrinth in the inner ear​

ATNR is most commonly retained in children with neurological conditions and is frequently
associated with disrupted motor patterns, sensory integration issues, and learning difficulties.

Symptoms if Retained

If the ATNR persists beyond the typical integration period, it can interfere with multiple areas of
development:

●​ Poor rolling, crawling, and cross-pattern movements​

 ●​ Homologous movement patterns (e.g., both arms moving together instead of alternately)​

●​ Balance issues and instability, especially when the head is turned​

●​ Difficulty crossing the midline or establishing hand dominance​

●​ Impaired eye-hand coordination, visual tracking, and symmetry recognition​

●​ Reading and writing difficulties (e.g., dyslexia, mirrored writing)​

●​ Strabismus, poor binocular vision, and reduced depth perception​

●​ Clumsiness, spatial disorientation, and postural instability​

Assessment

Position:​
Child positioned in quadruped with hips and shoulders at 90°, elbows extended, and hands flat
on the floor.

Procedure:​
Slowly rotate the child’s head to one side, hold for 5 seconds, then rotate to the other side.
Repeat four times.

Indicators of Retention:
 ●​ Elbow on the skull side bends​

●​ Weight shifts posteriorly or the child collapses into one side​

●​ Loss of alignment or difficulty bearing weight

Scoring (Scale 0–4):

●​ 0 – No response​

●​ 1 – Slight deflection of opposite limbs​

●​ 2 – Clear deflection of the opposite arm and/or leg​

●​ 3 – Significant movement with postural disruption​

●​ 4 – Full extension with collapse or compensatory hip movement​

Functional Observation:​
Observe crawling with head turning. Look for asymmetrical arm use, bending at the elbows, or
disrupted rhythm.

Integration Exercises and Intervention Strategies

Lizard Crawling:

●​ Lie prone​

●​ Look to the left, bend left elbow and knee​

●​ Look to the right, bend right elbow and knee​

 ●​ Repeat 10 times​

Balloon Tracking with Head Turns:

●​ Track a balloon in the air while turning the head side to side​

Zombie Walks:

●​ Extend arms forward​

●​ Turn the head slowly from side to side without moving the arms​

Cross-Crawls:

●​ Alternate touching opposite hands to knees while marching in place​

Simon Says Activities:

●​ “Act like a bird” (flap arms and turn head)​

●​ “Give yourself a big hug” (cross midline)​

Additional Therapies:

●​ Movement transitions: Supine → side-lying → prone​

●​ Trunk control: Prone on Swiss ball with head lift​

●​ Balance training: BOSU or balance board activities​

●​ Vestibular and visual stimulation: Rhythmic swinging, contrasting visual objects​

 Rooting Reflex

Overview

The Rooting Reflex is a primitive reflex essential for early feeding behavior. It helps newborns
orient their mouth toward the source of tactile stimulation near the face, such as a breast or
bottle. This reflex facilitates the development of sucking, swallowing, and head-turning
coordination during infancy.

●​ Function: Supports early feeding and survival by prompting the infant to turn toward
tactile stimulation near the mouth.​

●​ Emergence: At birth​

●​ Integration: By 3–4 months of age​

Symptoms if Retained

If the Rooting Reflex is retained beyond infancy, it may lead to the following challenges:

●​ Oral motor coordination difficulties (e.g., drooling, poor lip closure)​

●​ Hypersensitivity around the face or mouth (dislike of toothbrushing, messy play, or food
textures)​

●​ Articulation and speech clarity issues​

●​ Overreaction to light touch on the face​

 ●​ Poor attention and distractibility, especially during table-top or academic tasks​

Assessment

Procedure:

●​ Gently stroke the side of the cheek or nasolabial fold with a finger or soft brush in a
circular or downward motion.​

Indicators of Retention:

●​ Involuntary turning of the head toward the stimulus​

●​ Opening of the mouth or searching motions​

●​ Continued seeking behavior despite age​

Integration Exercises and Intervention Strategies

Rooting Brushing Protocol:

 ●​ Use a soft brush to gently stroke down the nasolabial fold and diagonally across the
cheek​

●​ Start with 5 repetitions per side, progressing to 30 repetitions daily as tolerated​

●​ Repeat throughout the day to promote desensitization and reflex integration​

Play-Based Strategies (Simon Says):

●​ “Pretend to smell a flower” – encourages nose/mouth awareness and midline orientation​

●​ “Blow a kiss” – promotes lip rounding and controlled oral movement​

Additional Activities:

●​ Oral desensitization with textured objects (e.g., chewy tubes, Nuk brushes)​

●​ Facial massage with lotions or cold washcloths to normalize tactile input​

●​ Drinking from straws and blowing games to develop controlled oral motor movements​

Clinical Relevance

The Rooting Reflex, if retained, can significantly interfere with oral-motor function, attention, and
social engagement. It is particularly relevant in children with speech delays, feeding difficulties,
and sensory processing challenges. Reflex integration strategies should be paired with oral
motor and sensory-based interventions to support regulation, communication, and self-care
skills such as eating and grooming.
.

Tonic Labyrinthine Reflex (TLR)

Overview

The Tonic Labyrinthine Reflex (TLR) is a primitive vestibular reflex that helps newborns develop
muscle tone and postural control by responding to head movements. This reflex facilitates
coordination between the head and body in relation to gravity. It plays a foundational role in
establishing balance and orientation in space.

●​ Function: Coordinates vestibular input with muscle tone; supports development of

posture and spatial awareness​

●​ Emergence: At birth​

●​ Integration: Typically by 2–4 months of age​

Symptoms if Retained

Retention of the TLR can disrupt the development of posture, balance, and motor coordination.
Symptoms may include:

●​ Difficulty with balance and postural stability​

●​ Disorientation when changing head position​

●​ Impaired timing and sequencing during movement​

●​ Fluctuating or poorly regulated muscle tone (either hypotonia or hypertonia)​

 ●​ Dizziness, clumsiness, and motion sensitivity​

●​ Visual perceptual challenges, including poor eye tracking and convergence​

Assessment

Procedure:

●​ In a standing position with feet together and eyes closed, ask the child to slowly tilt their
head backward (as if looking at the ceiling) and then forward (as if looking at the toes).
Observe for balance disruption or compensatory movement.​

Scoring (Scale 0–4 scale):

●​ 0 – No response​

●​ 1 – Minimal balance disturbance​

●​ 2 – Observable balance shift or muscle tone changes​

●​ 3 – Near loss of balance and/or signs of disorientation​

 ●​ 4 – Complete loss of balance, significant tone changes, or nausea​

Integration Exercises and Intervention Strategies

Landau Superman Exercise:

●​ Child lies prone on the floor​

●​ Lift both arms and legs off the ground while arching the back​

●​ Hold for 10–30 seconds depending on tolerance​

●​ Repeat 5 times to strengthen extensor tone and improve postural control​

Tummy Time Activities:

●​ Encourage prone play during daily routines (e.g., reading, puzzles, drawing)​

●​ Supports vestibular and postural development through head and trunk extension​

●​ Promotes integration through sustained and repeated weight-bearing in prone​

Additional Activities:

●​ Ball rocking: Slow rhythmic motion while prone on a therapy ball​

●​ Wheelbarrow walking to activate postural reflexes​

●​ Prone positioning on wedge or peanut ball with head lifts for trunk extension​
Clinical Relevance

A retained TLR may interfere with the child's ability to maintain upright posture, especially in
school environments requiring prolonged sitting, balance, or fine motor control. Children may
appear clumsy, avoid head movement, or display gravitational insecurity. Integration of TLR is
critical for establishing a stable base of support for higher-level motor and cognitive tasks.
Moro Reflex

Overview

The Moro Reflex is a multisensory startle reflex that is triggered by sudden changes in sensory
input—vestibular (head position), visual, tactile, auditory, or olfactory. It prepares the infant for
survival by eliciting a fight-or-flight response. The reflex typically emerges in utero and
integrates within the first few months after birth.

●​ Function: Protective survival reflex that activates the sympathetic nervous system in
response to perceived threats​

●​ Emergence: ~9 weeks in utero​

●​ Integration: By 3–6 months of age​

The Moro reflex is the only primitive reflex that can be triggered by multiple sensory pathways
simultaneously, making it particularly disruptive if retained.

Symptoms if Retained

A retained Moro Reflex may lead to chronic physiological overactivation and sensory processing
difficulties:

●​ Vestibular hypersensitivity: Fear of movement, poor balance, motion sickness​

●​ Visual and auditory hypersensitivity: Difficulty filtering background noise, light sensitivity​

●​ Poor eye-hand coordination: Impaired motor control and fine motor delays​
 ●​ Emotional dysregulation: Anxiety, mood swings, frequent tantrums, social immaturity​

●​ Hypervigilance: Easily startled, overreacts to stimuli, sleep disturbances​

●​ Learning difficulties: Inattention, poor memory retention, reading/writing issues​

●​ Behavioral symptoms: ADHD-like traits, panic attacks, impulsivity​

Assessment

Procedure:

●​ Gently lower the child backward while seated or place the child upside down over a
therapy ball.​

●​ Observe for signs of distress such as:​

○​ Startle reaction​

○​ Stiffening or freezing​

○​ Verbal refusal or visible discomfort​

Red Flags:

●​ Exaggerated startle​

●​ Stiff body or refusal to complete the task​

●​ Emotional distress or fear response​

Integration Exercises and Intervention Strategies

Starfish Exercise :

1.​ Sit in a cross-legged “X” position (arms and legs extended)​

2.​ Inhale and cross the right arm and leg over the left (fetal-like position)​

3.​ Exhale and open back to “X” shape​

4.​ Repeat with opposite limbs​

5.​ Perform 10 repetitions per session (Blythe & Blythe, 2012)​

Popcorn Pose:

●​ While lying on the back, hug the knees to the chest and hold for 20 seconds​

●​ “Pop” arms and legs outward simultaneously​

●​ Repeat 3 times​

Vestibular Training:
 ●​ Slow rhythmic rocking on a therapy ball or swing for 10–15 minutes​

●​ Movement should be predictable and soothing​

Trunk Control Exercises:

●​ Prone weight-bearing on a Swiss ball​

●​ Weight shifts on ball or wedge to strengthen core and postural muscles​

Visual Stimulation:

●​ Use high-contrast objects (black and white patterns or colored lights)​

●​ Slowly move the object across the visual field​

●​ Can be performed in a dim room to reduce overstimulation​

●​ Recommended: 10–12 minutes, 4x/week, twice daily​

Clinical Relevance

Retention of the Moro reflex can place a child in a chronic state of physiological stress,
impacting not only sensory processing but also behavior, emotion regulation, and learning. It is
commonly found in children with ADHD, ASD, developmental delays, and emotional
dysregulation. Integration techniques must be multisensory and consistent, targeting both motor
and sensory systems for optimal effect.
 Spinal Galant Reflex

Overview

The Spinal Galant Reflex is a primitive reflex that supports movement during birth and plays a
role in the development of trunk rotation, hip mobility, and postural control. It is stimulated by
tactile input along the spine and facilitates coordinated spinal movement necessary for crawling
and walking.

●​ Function: Facilitates spinal and hip development; supports movement during birth and
contributes to early locomotion patterns​

●​ Emergence: Around 20 weeks gestation​

●​ Integration: By 6 months of age​

Symptoms if Retained

A retained Spinal Galant Reflex may interfere with attention, posture, and sensory processing.
Common signs include:

●​ Poor sitting posture and constant fidgeting​

●​ Scoliosis, especially if reflex is retained on one side​

●​ Hypersensitivity to clothing or touch in the waist/lower back region​

●​ Inability to sit still, frequent movement during seated tasks​

 ●​ Bedwetting (enuresis), even beyond typical toileting age​

●​ Delayed speech, grammar, and spelling development​

●​ Difficulty with complex gross motor tasks (e.g., skipping, climbing)​

Retention of this reflex may result in the child being easily distracted by constant internal
sensory input, disrupting focus and classroom participation.

Assessment

Procedure:

●​ With the child in prone (lying on the stomach), use a finger to gently stroke one side of
the spine from the sacrum upward toward the neck.​

Positive Response:

●​ Lateral flexion or arching of the trunk toward the stimulated side​

●​ Lifting of the hip or shoulder​

●​ Reaction may be stronger on one side​

Integration Exercises and Intervention Strategies

Advanced Beanbag Crunch Toss:

1.​ Have the child sit on a BOSU ball or soft surface with feet on the floor​

2.​ Slightly lean back while twisting to pick up a beanbag on one side​

3.​ Twist to place it on the opposite side​

4.​ Repeat, alternating sides for 10 repetitions​

Sit-Walk (Bottom Scoot):

●​ Child sits with legs extended and arms crossed​

●​ Scoots forward across the floor using alternating hip movements​

●​ Avoid use of hands for assistance​

Snow Angels (Prone):

●​ Lie face-up with legs extended and arms at sides​

●​ Inhale and move arms and legs outward along the ground in a sweeping motion​

●​ Exhale and return to starting position​

●​ Repeat 10 times daily​

Additional Strategies:
 ●​ Movement transitions (e.g., supine to sit)​

●​ Sensory stimulation: Brushing, tapping, or stroking the back with textured materials​

●​ Proprioceptive training: Joint compressions and weight-bearing activities​

Simon Says Activities:

●​ “Slither like a snake”​

●​ “Roll like a log”​

These mimic spinal rotation and full-body coordination.​

Clinical Relevance

The Spinal Galant Reflex is frequently linked to attention and regulation difficulties due to
persistent lower back sensory reactivity. It is especially relevant in children who have trouble
sitting still, have difficulty with toileting, or present with posture-related concerns like scoliosis.
Targeted sensory and motor interventions can aid in integration, improving focus, postural
control, and self-regulation.

.
Symmetrical Tonic Neck Reflex (STNR)

Overview

The STNR is a transitional, positioning reflex—not a true primitive reflex—that supports the
infant's ability to transition from lying to crawling. It divides the body into upper and lower halves
and is elicited by head flexion and extension. The reflex prepares the body for crawling by
coordinating movement between the head, arms, and legs.

●​ Function: Supports postural transitions; helps develop quadruped position and prepares
for crawling​

●​ Emergence: 6–9 months of age​

●​ Integration: By 11 months of age​

Symptoms if Retained

A retained STNR can significantly impact postural control, functional mobility, and classroom
participation:

●​ Poor posture (slouching, leaning on arms at desk)​

●​ Difficulty sitting still (constant fidgeting or swaying)​

●​ Challenges in crawling or skipping crawling phase​

 ●​ "Monkey walking" or walking on fingers and toes​

●​ Difficulty with visual tracking and reading​

●​ Trouble with cross-legged sitting​

●​ Poor upper trunk and scapular stability​

●​ Delayed gross motor milestones and poor coordination​

●​ Attention deficits and reduced classroom engagement​

Assessment

Position:​
The child is placed in a quadruped position (on hands and knees)

Procedure:

1.​ Flex the child's head downward (chin to chest) and hold for 5 seconds​

2.​ Extend the head upward (look at the ceiling) and hold for 5 seconds.​

3.​ Repeat the sequence three times. ​

 4.​ Observe for changes in arm/leg posture, shifting weight, or balance loss​

Positive Signs:

●​ Bending of elbows and shifting weight backward when head flexes​

●​ Arm straightening and leg bending when head extends​

●​ Postural instability or difficulty maintaining quadruped position​

Integration Exercises and Intervention Strategies

Cat-Cow Stretch:

1.​ Child on hands and knees​

2.​ Arch back and look up (inhale)​

3.​ Round back and tuck chin to chest (exhale)​

4.​ Repeat for 10 slow cycles​

5.​ Improves coordination of head and trunk movement​

Prone on Elbows Play:

●​ Weight-bearing through upper trunk to improve scapular and core stability​

●​ Engage with toys or puzzles while prone​

Wedge/Peanut Ball Movement Transitions:

 ●​ Supine to side lying, side lying to prone​

●​ Encourages controlled movement and righting reactions​

Visual Tracking Activities:

●​ Follow lighted or high-contrast objects through full visual field​

●​ Enhances coordination of eye movements with head and trunk control​

Rolling and Crawling Practice:

●​ Encourage rolling both directions​

●​ Crawl through tunnels or over uneven surfaces to strengthen postural control​

Monkey Walk or Bear Walk (modified):

●​ Crawling with elevated hips and bent elbows​

●​ Helps in separating upper and lower body movement patterns​

Proprioceptive and Vestibular Training:

●​ Swinging in linear paths, bouncing on therapy balls, or walking balance beams​

●​ Helps regulate arousal and postural readiness for seated tasks​

Clinical Relevance

STNR is crucial for establishing the foundation for posture and crawling. When retained, it often
leads to poor classroom sitting behavior, clumsiness, attention challenges, and visual-motor
integration difficulties. Integrating this reflex helps children stabilize their core, improve reading
and desk work posture, and participate more fully in functional tasks.
Palmar Grasp Reflex

Overview

The palmar grasp reflex is a primitive reflex seen in newborns in response to tactile stimulation
of the palm. It enables early grasping and is essential for developing the hand’s sensory-motor
connection. This reflex integrates early in infancy to allow voluntary grasp and fine motor
control.

●​ Function: Supports early grasp and sensory-motor connection between hand and brain​

●​ Emergence: Birth​

●​ Integration: By 3–4 months of age​

Symptoms if Retained

If the palmar reflex persists beyond the typical integration window, it can interfere with fine motor
development and cause hypersensitivity.

●​ Difficulty with voluntary release of objects (e.g., dropping, transferring items)​

●​ Clumsy or immature grasp patterns (e.g., tight or fisted grip)​

●​ Delays in fine motor tasks such as buttoning, writing, or using utensils​

●​ Tactile defensiveness or aversion to touching varied textures​

●​ Poor bilateral hand coordination​

 ●​ Increased muscle tone in the hand or forearm​

Assessment

Procedure:

●​ Ask the child to stand with elbows bent and palms facing upward, away from the body​

●​ Using your finger, gently stroke from the web space between the thumb and index finger
down toward the base of the palm (heel of hand)​

Positive Response:

●​ Involuntary closing of the fingers or thumb​

●​ Flexion at the wrist or elbow​

●​ Difficulty maintaining an open hand posture​

Integration Exercises and Intervention Strategies

Rubber Ball Squeeze:

 ●​ Use a medium-resistance ball​

●​ Instruct the child to squeeze and release repeatedly, 10–20 times daily​

●​ Helps normalize grip strength and facilitates voluntary release​

Sensory Stimulation:

●​ Apply various textures (e.g., cotton, silk, rough cloth) to the palm​

●​ Brush or stroke from distal to proximal palm (2x/second, 10 reps, 3–5 sets)​

●​ Provide 30-second breaks between sets​

●​ Helps reduce tactile defensiveness and normalize tone​

Weight-Bearing Activities:

●​ Have the child bear weight on extended arms in prone or quadruped​

●​ Activities include prone on a therapy ball, animal walks, or wall push-ups​

●​ Enhances proprioceptive input and hand stability​

Bimanual Coordination Tasks:

●​ Transfer small objects from one hand to the other​

●​ Activities such as scooping, threading, or play with tongs​

●​ Promotes refined motor control and integration of bilateral hand use​

Fine Motor Games:

 ●​ Theraputty: Pressing, pulling, rolling​

●​ Clapping games and rhythmic tapping​

●​ Pegboard or pop beads for precision grasp/release​

Clinical Relevance

A retained palmar grasp reflex interferes with functional independence in daily tasks like
handwriting, dressing, or feeding. Children with sensory defensiveness or immature hand
function may benefit from targeted interventions to desensitize the palm, promote volitional
grasp and release, and improve bimanual coordination. Consistent sensory-motor input
supports reflex integration and neuromuscular reeducation.
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