Persistence of primitive reflexes and associated problems in children

Abstract

During the development of the fetus a series of reflexes called primitive reflexes are formed which are involuntary, stereotyped, first and dominant forms of movements during intrauterine life and the first year after birth. Reflexes are of great importance for survival and development, caused by external stimuli and controlled by the brainstem and nervous system, such as messages that are quickly transmitted from the brainstem to the muscles to perform a specific function. At the beginning they are necessary for the nutrition, survival, protection of the newborn , and later in life they are important for the process of learning, communication, emotions , motivation. In typical development, primary reflexes are naturally inhibited in particular order during the first year; they are displaced by substitutional reflexes called postu-ral reflexes. Postural reflexes are more mature models of motor responses that coordinate balance, coordination and senso-motor development. Retained primitive reflexes can cause developmental delays that are associated with disorders such as ADHD, autism, learning difficulties, cerebral palsy, dyslexia, dystonia, behaviour disorders and sensory processing disorders. Routine testing of primitive reflexes helps determine the causes of disharmo-nic development, behavioural problems or learning difficulties, and the use of the reflex integration methods leads to a significant improvement of the condition.

Full text

Olivera RASHIKJ-CANEVSKA UDK: 159.922-053.2
Monika MIHAJLOVSKA Original research article
PERSISTENCE OF PRIMITIVE REFLEXES AND ASSOCIATED
PROBLEMS IN CHILDREN
Abstract
During the development of the fetus a series of reflexes called primitive re-
flexes are formed which are involuntary, stereotyped, first and dominant forms of
movements during intrauterine life and the first year after birth. Reflexes are of
great importance for survival and development, caused by external stimuli and con-
trolled by the brainstem and nervous system, such as messages that are quickly tran-
smitted from the brainstem to the muscles to perform a specific function. At the be-
ginning they are necessary for the nutrition, survival, protection of the new-born,
and later in life they are important for the process of learning, communication, emo-
tions, motivation.
In typical development, primary reflexes are naturally inhibited in particular
order during the first year; they are displaced by substitutional reflexes called postu-
ral reflexes. Postural reflexes are more mature models of motor responses that coor-
dinate balance, coordination and senso-motor development. Retained primitive refle-
xes can cause developmental delays that are associated with disorders such as
ADHD, autism, learning difficulties, cerebral palsy, dyslexia, dystonia, behaviour
disorders and sensory processing disorders.
Routine testing of primitive reflexes helps determine the causes of disharmo-
nic development, behavioural problems or learning difficulties, and the use of the ref-
lex integration methods leads to a significant improvement of the condition.
Keywords: PRIMITIVE REFLEXES, INTEGRATION, PERSISTENCE, MORO REFLEX,
ASYMMETRIC TONIC NECK REFLEX, SPINAL GALANT REFLEX
Introduction
During the last 4 months of the prenatal life and the first 4 months af-
ter delivery, the human movement repertoire includes reflex movements
that are involuntary, stereotyped responses to certain stimulations. The baby
is born with over than 70 instinctive reflexes, and many of them appear sub-
cortical, more precisely originate from the regions below the brain cortex le-
vel, indicating that the reflex movements occurred without direct involve-
ment of the higher brain centres (Чичевска Јованова, Рашиќ Цаневска,
2013; Payne, Isaacs, 2012).

514 FACULTÉ DE PHILOSOPHIE SKOPJE
Primitive reflexes help the brain development. The movements define
the schemes of neuronal networks and myelination of the neuronal path-
ways that allow connection of the different brain regions which will later be
important for the learning process, behaviour, communication and emo-
tions. Primitive reflexes play a developmental role, preparing the neonate to
move against gravity, gradually leading to voluntary movement by the pro-
cess of integration during the first months of life. Mature responses in a
child’s psychomotor progress can only occur if the central nervous system it-
self has reached maturity. The process consists of the transition from a brain
stem reflex response to a cortically controlled response. The process is actu-
ally transition from brainstem reflexes to the cortical controlled responses
(Goddard, 2002).
When the most sophisticated brain centres begin to develop, primiti-
ve reflexes become an obstacle and need to be integrated. The integration
means inhibition or transformation of the reflex by the higher centres of neu-
ronal control, so that the pattern of responses is no longer stereotypical. The
integration of primitive reflexes leads to the development of the postural re-
flexes, which are controlled by the middle brain and should remain present
during hole our lives. The postural reflexes aim to help the baby deal with
the requirements of the environment based on gravity and provide the basis
for controlling balance, behaviour and voluntary movement (Goddard, 2014;
Fiorentino, 1980).
Although the time of appearance and disappearance of the reflexes in
children is various, knowledge of the normal frame for the reflex occurrence
and loss is of a particular importance. Most of the primitive reflexes should
be integrated during the first year of life, but if the baby fails to inhibit pri-
mitive reflexes in appropriate time, his motor development will delay same
as the brain development (Blomberg and Dempsey, 2011). Their persistence
is proof for the structural abnormalities or immaturity of the central nervous
system, and is often found in a combination with the absent or insufficient
developed postural reflexes. Early form of infantile movements are signifi-
cant for assessment of the neuronal maturity of the new-born and greater de-
viation from the normal time frame indicates the existence of the neuronal
immaturity and dysfunction (Malina, Bouchard, Bar-Or, 2004).
There are many factors causing unintegration of the primitive refle-
xes, but most prevalent are (Goddard, 2017): caesarean, brain damage dur-
ing the labour, prematurity and low birth weight, shock or big stress during
the pregnancy, illness during the first year of live, substance/alcohol/toxic
material abuse during the pregnancy, insufficient stimulation and tummy
positioning, which helps the development of neck and shoulders muscles,
lack of the time spent in free movements on the floor, stressful environment,
inappropriate food. The reflexes integrated during the childhood can be acti-
vated again as a result of trauma, stress or injury.

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The primitive reflexes can be divided in three groups – multisensory
reflex, primitive reflexes of positioning and primitive tactile reflexes. Beca-
use of the huge number of reflexes, we will mention some of them.
Multisensory reflex – Moro reflex, the only one of the primitive re-
flexes that can be triggered by all senses: positioning of the head (vestibular),
tactile, visual, audible, olfactory and movement factors, such as baby kicking
or sneezing. It is an involuntary reaction to a treat. Sudden movements of
the head in the vertical plane, or movements of the head back and forth, ca-
use the appearance of this reflex. The reaction is fast extension of the limbs,
deep inhalation, followed by the limb contraction and cry. This is perfectly
normal reaction from about 9 weeks after the conception to about 12 weeks
after birth, presents a reaction of potential threat and occurs as a result of the
nerve/muscle stimulation and the release of the stress hormones adrenaline
and cortisol. If this reflex reaction maintains longer than the normal period
for inhibition, the persons are constantly exposed to the higher concentrate-
ons of the stress hormones, hypersensitivity can be seen, inappropriate reac-
tion to small treats, hard focusing on objects, and they more prefer periph-
eral seeing than the central seeing area and have problem in the small detail
discrimination. The same effect can impact the hearing, these persons have
difficulties in concentration to the verbal messages by ignoring the back-
ground noises (Walker, 2013). Other symptoms related to the retained Moro
reflex are: mood swings, sudden changes in the behaviour (aggressive and
impulsive), visual problems, learning difficulties in reading/writing, strong
light hypersensitivity, panic attacks, depression, attention deficits, texture
hypersensitivity, ADHD, Asperger syndrome, autistic behaviour, emotional
and social immaturity, coordination and balance problems. The instinctive
reactions to stimuli cause problems in the long-term memory. Retained Mo-
ro reflex is often case in persons with intellectual disability without motor
impairment, including people with Down syndrome, athetoid cerebral pal-
sy, and sometime in persons with spastic cerebral palsy (Чичевска Јованова,
Рашиќ Цаневска, 2013; Iiyama, Miyajima, Hoshika, 2002).
Spinal Galant reflex appear around the 20 gestational week and
should be inhibited around the sixth month after the birth. It is tested when
the child is laying on the stomach or when holding down the face. In the
new-born, stroking the low back on one side of the spine will result in side
flexion of the lumbar (low back) spine away from that side, with raising of
the hip on the same side, stimulation of the both sides of the spine simulta-
neously upward from the pelvis to the neck causes flexion of the limbs, ex-
tension of the head and urination (Mejashki-Boshnjaк, 2008). This reflex
helps the baby develop its vestibular system and along with the asymmetric
tonic neck reflex helps the baby in the process of birth, it also contributes to
the development of the range of movements of the hips needed for crawling
and walking. Persistence of the gallant reflex can cause hypersensitivity to

516 FACULTÉ DE PHILOSOPHIE SKOPJE
the waist area (denial labels and wearing belt), the child will not be able to
sit still, constantly turn from side to side and cannot stand still in one positi-
on. As a result of the previous symptoms can be noticed attention and con-
centration problems, enuresis nocturne, scoliosis (if the reflex remained only
on the one side of the body), hyperactivity (especially if it wears tight upper
clothing or with the back touches the back of stool), postural problems, slow
and irregular development of speech, grammar and spelling, problems in
walking and performing complex leg activities (Integrated Learning Strate-
gies, 2016).
Primitive reflex of positioning – Asymmetric tonic neck reflex
(ATNR) is initiated when the head is turn to the left or right on a horizontal
plane. It is activated by the labyrinth in the inner ear and the reaction con-
sists of extension of the limbs at the same side where the face faces, and flex-
ion of the limbs on the opposite side. The eyes are also controlled by this re-
flex; they are directed toward the extended arm. It appears approximately 18
weeks after gestation, this is a period when the mother becomes aware of the
baby movements in the uterus. The baby uses ATNR for its repositioning in
the uterus, as a reaction to the changed position of the mother. ATNR should
be present at birth; it should help the baby to cross the birth channel. This re-
flex usually integrates at the age of 6 months. The asymmetric tonic neck re-
flex is responsible for the development of the muscle tone of the baby, hemi-
sphere domination of the brain, binocular sight, listening with both ears, de-
velopment of eye-hand coordination (Walker, 2013). A child with retained
ATNR may manifest one or more problems. It is always forced to follow the
scheme of this reflex, which can be frustrating for the child and to impact its
complete physical development. In these children can be noticed that they
are not able to roll or to crawl military, because retained ATNR prevents ro-
tation of the head and flexion of the same side of the body. Retained ATNR
results in homolog movement – both hands are used together to pull the
body forward, and the legs can only be pulled out together or symmetri-
cally. The balance is also affected – when the child is standing he will feel
unstable and uncertain, unless his head stands steady in the centre line. The
difficulty to cross the middle line causes various problems, the child may
manifest problems when manipulating objects with both hands, while read-
ing or writing, the child may not develop dominant lateralization. They also
may present difficulties in visual perception, such as symmetrical presentati-
on of figures or symbols on the paper, poor visiomotor integration, eye-hand
coordination, which will affect his reading and writing. Because of the previ-
ously mentioned problems in reading and writing, retained ATNR is also as-
sociated with dyslexia. When this reflex is not integrated can affect also the
binocular seeing and the child has reduced ability to see with both eyes in
the same time, almost always manifests strabismus. These problems often
lead to poor reading skills, inability to follow the line, inability for reading if

ANNUAIRE 517
there are many rows on the page, writing difficulties, very strong grip, bad
balance and coordination in walking, running, driving rollers, mirror writ-
ing of letters and numbers, poor depth perception, eating disorders (God-
dard, 2014).
Symmetric tonic neck reflex (STNR) is reflex that is difficult to cate-
gorize. In fact, it is not real primitive reflex because it is not present at birth,
nor is it a postural reflex because it should not be retained during life, it is
positioning reflex and the last ones appears. It appears between the 6th and
the 9th month and should disappear until the 11th month, it is stimulated
with the flexion and extension of the head, and causes response dividing the
body on two halves (from the waist upward and from the waist down), thus
two opposite patterns of movements occur on the upper and lower half of
the body. When the chin is raised, the arms extend and the legs flexed and
vice versa will come when the chin is lowered down. Signs of an retained
STWR is a late occurrence or no occurrence of crawling, improper holding of
the body, sloping shoulders, bent knees, flexion in the hips, monkey walking
- the right hand moves forward with the right leg and vice versa, walking on
the fingers, constant swaying and movement when sitting, tends to rely on
the table when sitting on a chair due to the decreased muscle tone, especially
the spinal muscles, attention and concentration problems, reading problems,
writing difficulties, poor memory, clumsiness, and so on (Walker, 2013).
Methodology of the research
The goal of the research was determination of the persistence of pri-
mitive reflexes in preschool children, period of most intensive development.
The study included 60 children aged 3-5 years, 30 girls, 10 of whom were 3
years old, eight were 4 years old and twelve were 5 years old. There were
also 30 males, six on the age of 3 years, eleven at age of 4 and thirteen at age
of 5. For the examination of the primitive reflexes Sally Goddard test was
used, and were assessed Moro reflex, palmar reflex, plantar reflex, seeking
reflex, spinal gallant reflex, tonic labyrinth reflex, asymmetric tonic neck re-
flex and symmetric tonic neck reflex. In 3 years old children tests for the
tonic labyrinth reflex were harder to use, so we changed with the test pro-
posed by the Integrated Learning Strategies, from Utah, USA. The scoring
was adapted to our needs and standards, 0 was meaning that here is no pre-
sence of the reflex, 1 was meaning easy reaction of the reflex stimulation and
2 was meaning retained reflex. Each reflex was examined up to 5 times if we
noticed presence of the reflex in the child or the response was ambiguous, in
order to obtain best positive answers.

518 FACULTÉ DE PHILOSOPHIE SKOPJE
Result analysis and discussion
In the table number 1 there are results from the examination of the
Moro reflex in 3 preschool groups. According the data this reflex is integra-
ted in 93,4% of male examinees, only two respondents, one 3 years old and
one 4 years old, had small – easy reflex reaction. Complete persistence of the
reflex was nоt noticed in any male respondent. In the female group there
was not observed any reactions of the reflex. Konicarova and Bob (2012) in
their study, where they examined persistence of the primitive reflexes in 20
children with ADHD and 20 children in control group, determinate that the-
re is significantly greater retention of the Moro reflex and spinal gallant re-
flex in children with ADHD, categorized according the DSM10 (hyperactive
behaviour).
Table 1. Analysis of the appearance of Moro reflex
Reflex
Gender Age
012
Total
N%N%N%N / +
ans.
%
Moro
Male
3 4 80 1 20 0 0 2 93.4
410911900
5121000000
Female
3 10 100 0 0 0 0 0 0
481000000
5111000000
In the table 2 we can notice a gradual decrease in the number of chil-
dren with the asymmetric tonic neck reflex retained. In 13% of children aged
3 years there is a small reaction, and there is no complete presence of the re-
flex in any 3 years old child. A small reaction was observed in 5% of children
aged 4 years, and there was not observed complete reaction. In all children
in the group of 5 years the reflex was totally integrated, there was not even
small reaction. There was noticed more prevalent reflex persistence in males
than in females.
Table 2. Analysis of the appearance of Asymmetric tonic neck reflex
Reflex
Gender Age
012
Total
N%N%N%N / +
ans.
%
Male
3 4 80 1 20 0 0 2 93.4
410911900

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ATNR 5 12 100 0 0 0 0
Female
3 9 90 1 10 0 0 1 3.4
481000000
5111000000
In the 3rd table are present the results from the examination of the
spinal gallant reflex. In the 3 years old males there was small reaction only in
one respondent, and there was not complete reaction in any male. Both
groups 4 and 5 years, had two respondents with small reactions, and there
was not complete reflex presence. In the girls, respondents in 3 years old two
had small reaction and one girl had persistence of the reflex. In 4 years old
girls there was not any reflex reaction, and in the group of 5 years old, two
(18%) showed small reaction of the reflex stimulation.
Table 3. Analysis of the appearance of the Spinal gallant reflex
Reflex
Gender
Age
012
Total
N%N%.N %N / +
ans.
%
Spinal
gallant
reflex
Male
3 4 80 1 20 0 0 5 17.8
498221800
5108321700
Female
3 7 70 2 20 1 10 5 17.24
481000000
598221800
Table 4. Analysis of the appearance of the Symmetric tonic neck reflex
Reflex
Gender
Age
012
Total
N%N%N%N / +
ans.
%
STNR
Male
3 4 80 1 20 0 0 4 14.2
410911900
5108321700
Female
3 9 90 1 10 0 0 2 6.8
481000000
510911900
The table number 4 presents the results from the examination of the
symmetric tonic neck reflex. In the male groups of 3 and 4 year old there is
one respondent in each group manifesting small reactions, and there was not

520 FACULTÉ DE PHILOSOPHIE SKOPJE
observed complete reaction. In the group of 5 years old males 2 (17%) had
small reactions. In female respondents two girls, one in 3 years old and one
in 5 years old, had small reflex reaction. In this reflex was also observed
more frequent persistence in males than in females.
Gieysztor, Choińska, and Paprocka-Borowicz (2016) in their study
“Persistence of the primitive reflexes and associated motor problems in heal-
thy preschool children” have noticed that according the psychomotor abili-
ties 9% of the children were in the category of “altered development”, 29%
in “delayed development”, 59% in “normal” and 3% in “very good develop-
ment”. The greater the severity of the reflex, the motor efficiency was lower
(p < 0.05). At the sample of 35 children aged 4-6 years old, most prevalent
was asymmetric tonic neck reflex, in 66% of respondents, and at least preva-
lent was symmetric tonic neck reflex, in 34%. Grzywniak in his research
comparing normal school aged children, among which one group of chil-
dren were orphans, has noticed that 55% of examinees have persistence of
the primitive reflexes on the first or second level, or according our scoring
they have small reactions.
Conclusion
Persistence of the primitive reflexes out of the normal time frame,
even they present in traces are significant and affect normal psychomotor
development of the child. If the staff know normal time frame of the reflexes
and the impact they have on development of healthy children, not only
would they have a faster reaction to their persistence, but they could also
prevent subsequent disorders and consequences.

ANNUAIRE 521
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