2014 POTA Conference Presentation Handout

1. Neurodevelopment
Child Development, Reflex Retention
and the Impact on Learning
POTA ANNUAL CONFERENCE
NOVEMBER 1, 2014
Presented by
Jenni fer Doyle, MA OTR/L & Karen Gual t ier i , MS OTR/L

2. 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

3. 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 Training
and Handwriting Without Tears.

4. Developmental Milestones
➢ Lifting head
➢ Rolling
➢ Crawling
➢ Sitting unsupported
➢ Pulling to stand
➢ Cruising
➢Walking

5. 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.

6. 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

7. 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

8. 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.

9. 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

10. 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

11. 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.

12. 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.

13. 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.

14. 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.

15. 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

16. 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

17. 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).

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. 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.

25. Effects of Retained ATNR
 Problems with handwriting
 Difficulties with reading
 Mixed laterality
 Difficulty or inability to cross midline

26. 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.

27. 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.

28. 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.

29. 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

30. 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.

31. 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.

32. 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.

33. Spinal Galant Reflex
• Integrated response: No movement of the
back with touch.
• Retained response includes movement of
the hip towards the stimulation.

34. 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

35. 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).

36. 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

37. 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

38. 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

39. 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

40. 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.

41. Physical Observations …
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

42. 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)

43. 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

44. 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 Quadraped
position on mat …crawl towards
parent or therapist while parent or
therapist applies gentle resistance to
shoulders while letting child move
forward.

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

46. Intervention Strategies

47. 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

49. Rhythmic Movement
• The cerebellum is the brain structure
responsible for providing timing and grading
of movements for efficient and accurate
motor output.

50. 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.

51. 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

52. 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

53. 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.

54. Questions?
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KARENG@BETHLEHEMPEDIATRIC.COM
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