Essay

The Primitive Reflexes: Considerations in the Infant

Samuel A. Berne, OD
Private Practice, Santa Fe, NM

ABSTRACT self direct themselves through treatment programs that

The primitive reflexes are a set of movement patterns will provide them with the opportunity to integrate the
in the newborn that emerge during the prenatal period. reflexes. Infants and developmentally delayed toddlers
These primitive reflexes are present at birth and provide do not have the opportunity to follow these activities
an indication of the neurological development of the secondary to their lack of development. Therefore, an
newborn. The reflexes are movements that are automatic integration program can be initiated that can include
and do not require thinking. The reflexes help in the activities in which the caregiver or therapist can move the
birthing process; they help the newborn adjust to its new infant through the activities as needed. This can provide
environment outside the womb; and help to build a an opportunity for the infant to develop more
foundation for motor and cognitive skills. appropriately and within the developmental sequence.
The reflexes involve changes in the level and
KEY WORDS
distribution of tone which primarily can affect posture
Asymmetrical Tonic Neck, Moro, Spinal Galant,
and movement. These reflexes along with postural
Symmetrical Tonic Neck Reflexes, Tonic Labyrinthine
control are basic developmental patterns. They are
integrated and modified into the more complex patterns INTRODUCTION
which lead to voluntary movement and skills. These are During the prenatal period, a set of reflexes emerge
integrated by the higher centers of the brain. Lack of that are referred to as the primitive reflexes. These
integration of these primitive reflexes can lead to poor reflexes originate in the brainstem, are present at birth
eye movements and poor fixation from far to near. In and provide an indication of the neurological
addition, one may have difficulty with visual development of the newborn. They help the newborn
coordination, hand-eye coordination and visual memory. integrate the overwhelming amount of stimuli the young
When an infant is delayed in the integration of these child receives once they leave the mother’s womb and
reflexes, developmentally appropriate treatment plans are crucial for the baby’s survival in the first few weeks.
should be considered. Traditionally older children can As the child matures, the higher brain centers inhibit
the primitive reflexes so more advanced movement
Correspondence regarding this essay can be e-mailed to patterns can develop. The reflexes are integrated in a
[email protected] or sent to Dr. Samuel A. Berne 227 E. sequential fashion from 6-12 months. This assimilation
Palace Ave Suite G, Santa Fe, NM 87501. All statements are the allows more sophisticated neural organization to
author’s personal opinion and may not reflect the opinions of the
College of Optometrists in Vision Development, Optometry and
increase, which then allows the infant control of
Vision Development or any institution or organization to which he intentional responses. If these reflexes are retained
may be affiliated. Copyright 2006 College of Optometrists in Vision beyond 6-12 months post birth, they can interfere with
Development. cortical processing as well as impede normal
development.
An abbreviated version of this paper was previously published as
Berne SA. The primitive survival reflexes. J Optom Vis Dev Sally Goddard’s work found that the persistence of
2003;34(Summer):83-85 these reflexes can lead to neuro-developmental delays.
She defines a neuro-developmental delay as a significant
Berne SA. The primitive reflexes: Treatment considerations in the immaturity in the performance of the nervous system as
infant. Optom Vis Dev 2006:37(3):139-145.

Volume 37/Number 3/2006 139

validated by a group of retained primitive and postural advanced motor and cognitive tasks can be undertaken.
reflexes in a child above three and one-half years of age. Depending on the degree of abnormal reflex activity, this
According to Goddard, such a group of aberrant reflexes poor organization of nerve fibers can affect the
is accompanied by problems with control of body functioning of gross motor and fine motor coordination.
orientation, gross and fine muscle coordination, visual These aberrant reflexes can also interfere with the
tracking skills and visual-perceptual skills.1 development of normal sensory perception, cognition
The visual system is intimately involved in the and audition. The primitive reflexes are essential for
transition from primitive reflexes to cortical control of learning. If these reflexes are retained beyond the first
movement patterns. In 2001, Bein-Wierzbinski year of life, many of the advanced cognitive and motor
completed a research project supporting the relationship systems will be underdeveloped or inefficient despite
between the visual system and the primitive reflexes. sufficient intellectual ability. It is as if later skills remain
Her findings involved a study of 52 elementary school tied to an earlier stage of maturity and instead of
children in Germany. She had investigated whether becoming automatic, can only be mastered through
disturbances in oculo-motor skill and visual perception consistent effort on the conscious level.1
could be corrected by means of an appropriate motor For example, visually tracking an object, shaping
training program which focused on primitive reflexes letters with the mouth or holding a pencil require the
and early motor development. All of the children were intentional control of the muscles. When an unconscious
examined for abnormal reflexes with the eye movements reflex interferes with an intentional movement pattern,
being assessed using an infra-red computerized eye the performance will generally not be smooth or
tracking instrument. One half of the children who had coordinated. Once a retained reflex is integrated, the
persistent reflexes were given a reflex stimulation/ performance can then become an automatic learned skill.
integration program. The other half were examined both Learning occurs when basic physical skills such as
at the beginning and end of the program but were not balance and interweaving of both sides of the body
included in any training. Her results showed improvement (right-left coordination and upper-lower body
in oculo-motor functioning and reading skills as coordination) become automatic. In order for the motor
anomalous reflexes were integrated. Oculo-motor deficits skill to become automatic, it has to be learned beyond the
continued to persist in the control group. mechanical level. To learn a motor skill beyond this level
In a study conducted by Ten Hoopen, it was noted requires the patient to feel the body while doing the
that if vision therapy was postponed until a child had at movement. It also requires the patient to develop better
least six months treatment with a reflex integration self- awareness, and ultimately become his own
program, in many cases, the vision therapy was not “error-detecting” system.2 This reciprocal interweaving
required after the reflexes had integrated. In those cases is vital in the development of orientation.3 If the child
where persistent oculo-motor problems remained, the does not develop automatic motor control, a parent may
time needed in vision therapy was halved.1 observe behaviors such as reversals in writing and
Sally Goddard has also reported that oculo-motor reading, poor attention and clumsiness.1,4 Although a
and visual perceptual problems can be associated with a child may demonstrate good potential intelligence,
retained moro reflex. She found that poor ocular pursuit further development may not occur until the delay is
movements (especially at midline) are linked to a addressed. Part of addressing the developmental delays
retained asymmetrical tonic neck reflex. She has also is learning to integrate the reflexes.
determined that oculo- motor dysfunctions, spatial
Testing
problems and visual-perceptual difficulties occur with a
Sally Goddard recommends a testing protocol of the
retained labyrinthine reflex. And finally, her work has
primitive reflexes. This identification process
determined that struggles with hand-eye coordination
determines what reflexes have been retained versus
and poor near far focusing skills are related to a retained
integrated.1 When any of the primitive reflexes persist
symmetrical tonic reflex.1
beyond the time that they should be no longer be
Considerations of development exhibited, the diagnostic assessment suggests that they
Integrating these primitive survival reflexes helps have not been integrated. Therefore, one expects that
the infant to learn the critical processes of movement. there will be interference in the general and specific
There has been some controversy whether the reflexes motor skills of the child.2,5-7 Athletes who still have the
become integrated or inhibited within the person. I primitive survival reflexes can become proficient with a
believe that when the reflexes become integrated, certain specific motor movement but may not have the
attention is shifted from basic motor systems so that more ability to develop more efficient movement patterns.1

140 Optometry and Vision Development

Lack of integration of these reflexes can also lead to response to external
vision problems.5 In cases with persistent primitive stimuli which is
reflexes, the expectation is that eye movements are poor pe rc e ive d a s a
and fixation from near to far is difficult.1 Visual threat. One of the
coordination, hand-eye coordination and visual memory coping mechanisms
may be below expected levels. Our visual function is to this stress is an
intimately influenced by our brain processes. If the over stimulation of
primitive reflexes are still persistent then some of the the sympa the tic
cortical processing is not available for higher level nervous system. If
information processing. If the primitive reflexes remain the stress is chronic,
a powerful force and have not been integrated, one ma y se e a n
encouragement of the postural reflexes alone will rarely alpha omega pupil
influence related transformation in the areas of fine motor re sponse a nd a Figure 3. Moro Reflex-Response Position
control, oculo-motor performance and academic constriction in the
performance. Although motor training programs may functional visual
help develop postural control, these programs fall short fields. 1 , 8 , 9 The
in helping a child integrate the retained primitive arousal system in
reflexes.1 the brain and the
There are five primitive survival reflexes that most neurological
affect visual motor development. They are: Moro Reflex, muscle tone may
Tonic Labyrinthine Reflex (TLR), Spinal Galant Reflex also be affected in
(SG), Asymmetrical Tonic Neck Reflex (ATNR) and the body. Chronic
Symmetrical Tonic Neck Reflex (STNR).5 stre ss c a n a lso
affect the glandular
Moro Reflex
func tions a nd
This reflex emerges at 9 weeks in utero. It should be
digestive system.
integrated by 2-4 months post-natally. The moro reflex is
The re fore a Figure 4. Moro Reflex-Positive Response
an involuntary reflex to threat. It is a survival mechanism
re ta ine d Moro (arms move outward).
that is composed of
reflex can cause
a series of rapid
biochemical and nutritional imbalances.1 One specific
movements of the
problem is the higher incidence of ear and throat
arms upward away
infections that lead to lower immunity and allergies.1
from the body. A
A persistent Moro reflex depletes energy and can
retai ned Moro
cause fatigue and mood swings. The Moro reflex is the
reflex can cause
earliest primitive reflex to emerge and forms a strong
vestibular (inner
foundation for future life experiences.
ear) re la te d
Figure 1. Moro Reflex-Starting Position for problems such as Tonic Labyrinthine Reflex (TLR)
Infant
poor balance, and This reflex emerges at 16 weeks in utero. It should be
coordination. It can integrated at approximately 4 months postnatally. There
also lead to poor is a gradual progression of integration from 6 weeks up to
visual control of eye 3 years after birth. The TLR is stimulated by the
movements tha t vestibular
may c a use syste m. This
information reflex is initiated
p r o c e s s i n g in response to the
problems . A he a d moving
retained moro reflex ba c kw a rds or
can cause a person forwards, below
t o experie nc e a or a bove the
hypersensitivity to le ve l of the
light, sound, and spine. This head
Figure 2. Moro Reflex-Starting Position
temperature—a control is crucial Figure 5. Tonic Labyrinthine Reflex-Starting
Position

Volume 37/Number 3/2006 141

for later postural reflexes that involve neurological tone
and balance. When the infant learns to lift his head using
his neck muscles, he has begun to understand how to
work with the forces of gravity. When the infant’s head
movement becomes automatic, an integration of the
Tonic Labyrinthine Reflex (TLR) is observed. If the TLR
lingers, this may lead to poor balance, low muscle tone,
and poor eye movement control. This can further lead
toward difficulties in information processing problems.1
Spinal Galant Reflex
This reflex is first seen at 20 weeks in utero. It should
be integrated postnatally by nine months. The reflex is Figure 6. Spinal Galant-Starting Figure 7. Spinal Galant-Positive via
seen when the baby is placed on its stomach, a finger Position hip moving outward
lightly stimulating one side of the back near the spine
resulting in a rotation of the hip on the side of the
experience. This may be
response. The spinal galant reflex is used in the birthing
one reason why some
process by helping the baby work its way down the birth
children who are born by
canal. It also enables the fetus to hear and feel the sound
c a e sa re a n se c tion or
vibrations in the aquatic environment in the womb. If the
require forceps delivery are
spinal galant reflex lingers beyond the 9 month postnatal
in jeopardy of becoming
period, the reflex may interfere with the ability for the
developmentally delayed.1
child to control his bladder. This can be seen as
Without experiencing the
bedwetting in the child beyond the age of 5. In adults, if
tw isting the y do not
the reflex is still present in adult, some studies suggest
directly learn the right-left
that that it can lead to irritable bowel syndrome.1
and upper body-lower body
Commonly seen behaviors in school-aged children
coordination that is needed Figure 8. ATNR
include fidgeting in their seat, squirming, wiggling or Quadruped-Starting Position
for developing the
difficulty sitting still. Children with a persistent spinal
interweaving
gallant reflex don’t like clothing to fit tightly around the
patterns of crawling,
waist. A persistent Spinal Galant Reflex competes for the
w a lking a nd
child’s attention and short-term memory because the
skipping. The
child is distracted by movement initiated by the reflex.
ATNR is important
This reflex can also interfere with the development of
in the development
one’s orientation.
of a c tivitie s
The Asymmetrical Tonic Neck Reflex (ATNR) re quiring the
The reflex develops at 18 weeks in utero and is integration of both
postnatally integrated by 6 months of life. The ATNR sides of the body. Figure 9. ATNR Supine-Starting
reflex is demonstrated by moving the baby’s head to one Thus the ATNR can Position-note no arm extension
side and seeing an automatic extension of the arm and leg lead to problems of
on the side that the head is turned while the opposite arm balance- orientation both mentally and physically and
and leg are in a flexion posture. In utero, the ATNR helps lead to confusion while using both sides of the body
the fetus move the head from side to side while swinging together. A retained ATNR may also interfere with
the arms and kicking the legs. This pattern helps develop symmetrical release of both eyes while moving from near
the muscle tone and the vestibular (inner ear) system. to far. Tracking will also be impaired, with later effects
This reflex is also needed at birth so that the fetus can upon reading, writing and spelling.1
help rotate itself through the birth canal. This movement
Symmetrical Tonic Neck Reflex (STNR)
pattern is the infant’s first experience in understanding
The STNR reflex presents at 6-9 months of life.1 It
the coordination of both sides of the body together
should be integrated at 9-11 months postnatally. This
(reciprocal interweaving). This is done in a twisting
reflex helps the infant learn to rise up on hands and knees
action and is why children taken by Cesarean section are
and experience the force of gravity. This reflex is
at a higher risk for developmental delay. The ATNR not
displayed when the infant while on his knees, lifts and
only supports the birth process, but is strengthened by the
142 Optometry and Vision Development
 extends his head which Substantial delay in head control, sitting, crawling
causes the legs to flex and Poor muscle tone
the arms to straighten. If Cholic, frequent ear infections
this reflex lingers too long Abnormal response to vaccinations
it will interfere with the 4. Optometric Findings
infant’s ability to learn Strabismus/ amblyopia
creeping and crawling. Anything over 2 diopters (non-cycloplegia) of
This is vital as this is the hyperopia, myopia, astigmatism
first opportunity for the
Motor guidance program
vestibular, proprioceptive
If the infant shows the need for reflex integration
and visual systems to
activities, they are prescribed an Infant Motor Guidance
integrat e i nforma tion
Program. In this program, the difference between
duri ng move me nt. 1
working with an infant versus a child three years of age
Creeping is an essential
Figure 10. STNR-Starting and older is that the parent/therapist will make the
Position aspect of visua l
movements for the infant as opposed to the child making
development as it helps the
the movements himself. I recommend both mom and dad
eyes to cross midline on the body. As the infant begins to
make the movement patterns on the infant together. The
creep from one hand to another, this helps the infant with
benefits of applying an Infant Motor Guidance Program
the control of eye movement patterns to cross the midline
short term is to assist the infant to continue along the
of the body. Later when the child is learning to read, they
normal sequence of development. The long term
need to have the skill of moving the eyes across the
benefits of applying an Infant Motor Guidance Program
middle of the page without losing their place. Studies
are to reduce developmental motor delays with children
have shown that children who don’t learn to creep and
diagnosed later on along the ADD-Autism spectrum of
crawl have a higher incidence of reading and learning
disorders. Another long-term benefit would be more
problems.10
efficient visual skills and visual processing abilities. No
Treatment of infants contraindications have been found if applying the Infant
The early use of treatment for infants is based on four Motor Guidance Program The Motor Guidance program
factors. is done in the following manner. Spend five minutes
1. Abnormal developmental landmarks during gestation. twice a day for one month on each reflex. After the
This period includes a history from the embryonic month, continue to the next reflex movement pattern
phase (the first eight weeks of pregnancy) through the until all five reflex patterns have been integrated. The
third trimester. Some other factors in this history best times to apply the movement patters are upon
include the mother’s activity level, her overall health waking and before sleep.
and nutrition, and her stress levels during the
Moro Reflex Exercise
pregnancy. Any abnormal findings can create a risk
Starfish
factor that the primitive reflexes may not integrate
1. Infant lies on her back in the crib. Use a blanket and
normally.
pillows under infant’s back so that her back is in a 20
2.The Birth Process: The newborn endures the labor,
degree inclined position. Support her head with your
delivery, and post-delivery. The fetal head may be a
hands.
battering ram when used to dilate the birth canal.
2. Start in the “Starfish “ position. The arms and legs are
There can be shock to the fetus even in a normal birth.
spread out in a loose, relaxed position. In other words,
These initial experiences are the first imprint the
the legs and arms are open. Hold the head slightly
newborn has to deal with when leaving the womb.
back.
Fetal distress, Breech, Forceps, Vacuum Extraction,
3. In a synchronized movement, move the arms and legs
and C-section are all risk factors that can affect the
in towards each other until they reach a fetal position
development of the primitive reflexes.
with arms and legs drawn into chest. Move the head so
3. Infant Movement Patterns that may signal a problem
the chin can touch the chest.
with normal reflex development:
4. Stay in this fetal position for two seconds and then
The infant stiffens when picked up
slowly move the arms and legs back to the “Starfish”
Tends to startle when touched or crib is jostled.
position. Pause two seconds in the “Starfish” position
Hates being bathed, dressed, changed
as well. The movement should be safe and relaxed.
May be difficult to feed, does not suck well.
The left leg and left arm cross over the right leg and
Volume 37/Number 3/2006 143
Figure 11. Moro Reflex Diagram Figure 12. Tonic Labyrinth Reflex Diagram

right arm, then when the infant repeats the movement can follow the hand until the arm is straight. You may
into fetal position the right leg and right arm cross over need to prompt her with verbal cues. Make sure arm is
each other. lifting as you move it. Once the arm is straight, then move
5. It is very important to move the head and neck all the the arm back until it is straight ahead. Repeat with the left
time. For example, starting in the “Starfish” the head arm while it is lifted moving it in the same manner as the
is back. When moving to the fetal position, the head right arm. When the left arm has returned to being in
moves forward. When moving the “Starfish” the head front, let the arms and hands rest on the floor with the
and neck move back. head down, that is one cycle. Repeat for three cycles.
6. Repeat for five cycles. The key is relaxing the legs and move the arms as slowly
Because the moro reflex is connected to vestibular as you can.
stimulation, at another time, I recommend these
The Spinal Galant Exercise
additional movements to help stimulate and develop
This exercise is similar to angels in the snow. The
the vestibular system:.
position for beginning is both feet together with legs
1. Hold infant in the air so she is facing you. Make eye
straight and arms down to the side while lying on the
contact. Lift her up and down slowly for 20-30
back. In a really slow movement begin moving the arms
seconds.
and legs out like a jumping jack. The arms need to be
2. Rock infant in a rocking chair and change her
stretched and the hands need to touch each other just as
posture when rocking her. She can lie on her
the legs reach their widest position. Then bring arms and
stomach on your knees, she can lie on her back on
legs back to the starting position slowly. Each angel in the
your knees, and she can stand in your lap so her head
snow should last at least 20 seconds. Do three angels to
is resting on your shoulder. Rock for 5-10 minutes.
complete the reflex. (If moving the arms and legs
3. Swing infant in an arcing swing for 20-30 seconds
together is too difficult then break the movements down
and pause for 10 seconds and repeat for a total of
by moving the arms by themselves and the legs by
four cycles.
themselves) (Up and down equals one cycle) Repeat for
Tonic Labyrinth Reflex Exercise three cycles if doing for 20 seconds per angel.
The infant lies on the floor or in her crib on her
Asymmetrical Tonic Neck Reflex Exercise
stomach. Her arms and legs should be relaxed. Lift right
Begin the exercise by lying the infant down on his
arm while looking at the thumb. If she can hold a
stomach face down. Ask him to lie very quietly on the
bright/colored rattle in her hand that makes a sound that
floor or in his crib. Then place his body lying on his left
is even better. Move right hand to the right and see if she

144 Optometry and Vision Development

Figure 13. Spinal Galant Diagram Figure 14. Asymmetrical Tonic Neck Reflex Diagram

side with legs and arms in proper position. (See diagram

below)
1. Nose is facing the side the where the arms and legs are
bent. Palms are facing down. Move his head to the
other ear.
2-3. Then move his bent arm down then move his bent leg
down until he becomes straight. When he gets to the
point where he straightens his leg, so that both legs are
straight have him pause with both legs straight for 5
seconds before you begin to roll him to the other side.
The stopping is important.
4–5. Move his straight leg until it bends then move
Figure 15. Symmetrical Tonic Reflex Diagram
straight arm until it bends.
6. Move head to other ear.
7. Move his bent arm down, then bent leg until it There is a continuous movement back and forth for three
straightens. When he gets to the point when he minutes. Try to do between 18-25 cycles during this
straightens his leg, so that both legs are straight have period.
him pause again with both legs straight for 5 seconds
CONCLUSION
before the begin to roll to the other side. The stopping
The primitive reflexes are a set movement patterns
is important.
found in every child. The main purpose of these reflexes
8. Move his straight leg until it is bent
is to help the newborn survive the cold, harsh
9. Move his straight arm until it is bent. At this point you
environment outside the mother’s womb. These reflexes
have completed 1 cycle.
begin developing in-utero and should become integrated
This should be repeated 2 more full cycles. The goal
by the first year of life. If the reflexes are retained or
is to move the arms and legs as slowly as possible. Try to
aberrant, they can represent an impediment in the
relax the body as much as possible.
development of the Central Nervous System. If the
Symmetrical Tonic Neck Reflex Exercise reflexes are tested and found to be persistent beyond the
First, put the infant into a position so she sits on her normal period, a reflex integration program can be
feet and calves. Lower her head and the forehead is started. This program involves specific repetitive
touching her thighs. Straighten the infant’s arms so the movement patterns practiced five to ten minutes per day
ears can just fit through the arms. The arms are always for a period of 4-6 months. In the infant and young
straight during the movement of the body and head as it developmentally delayed child, the patient must be
moves forwards and backwards. Begin by moving the moved through the pattern vs. self guiding them self. The
head and body together (synchronize this movement) reflex movements are based on a thorough understanding
and move the infant as forward as you can (to a crawling of the primitive reflex sequence of development and
position). Then move the infant backwards down to the normal child maturity.1 It should also be noted that many
beginning position with the forehead touching her thighs. of these reflexes can inhibit various activities in the older

Volume 37/Number 3/2006 145

child and when treated appropriately may improve
academic11 and other areas of function.
Acknowledgments
Aspecial thank you goes to Drs. Curtis Baxstrom and
Albert A. Sutton who helped in the editing of this paper.
References
1. Goddard S. Reflexes, learning, and behavior. A window into a child’s
mind. Eugene, OR: Fern Ridge Press, 2005.
2. Berne S. Without Ritalin. Los Angeles, CA: Keats Publishing,
2001:105.
3. Sutton A. Building a visual space world. OEP Curriculum II
1984;1(1):47-78.
4. Blythe SG. Neurological dysfunction as a significant factor in children
with dyslexia. J Behav Optom 2001;12(6):145.
5. Sutton A. The basis for visual development from prenatal through
infancy. J Optom Vis Dev 1996;27(2):80-6.
6. Blythe S. Screening for Neurological Difficulties in the Specific
Learning Difficulty. Br J Occupational Therapy 1998;61(10):459-464.
7. Fiorentino M. Reflex testing methods for evaluating CNS development.
Springfield, IL: Bannerstone House, 1981.
8. Edelman ES. Visual signs of reduced form fields. J Optom Photother
April 2004.
9. Fast D. Syntonic blue book. Ithaca, NY: College of Syntonic
Optometry, 1985.
10. Pavlidis G, Miles T. Dyslexia research and it’s applications to
education. New York: Wiley Publications, 1987.
11. Wahlberg T, Ireland D. Can replicating primary reflex movements
improve reading ability? Optom Vis Dev 2005;36(2):89-91.

146 Optometry and Vision Development