Retained Reflexes related to Learning Difficulties



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Did you know that there are 70 known primary reflexes? Here at Optometric Physicians, Nashville Vision Therapy Center, we concentrate on the primary reflexes that are known to affect educational progress. From previous posts we have learned what primitive reflexes are, and how the reflexes become retained. Today we will explain briefly what these reflexes do and how they cause interference when they are retained.

 First up: Asymmetrical Tonic Neck Reflex (ATNR)

The ATNR reflex is noticed before 6 months of age when a baby turns its head to one side and the limbs on that side straighten then the limbs on the other side bend or flex. ATNR should be switched off at six months of age. The retention of this reflex causes the most interference with a child’s learning process. It is responsible for problems with:

• Handwriting - Problems with handwriting is the most obvious casualty of the retained ATNR. Each time a child turns his head to look at the page, his arm will want to extend and the fingers will want to open. Holding and working a pen or pencil for any length of time will require enormous effort. This leads to very heavy pencil grip and tension in the body. All the energy is now going into the writing and distracts attention from the writing content. Some children learn to compensate with an immature pencil grip. Writing may slope in different directions from one side of the page to the other so the child may rotate the page as much as 90 degrees when writing in an attempt to “accommodate” the effect of ATNR.
• Reading - This deals with eye tracking difficulties. When reading some things you might notice is the eyes do not move smoothly from one side of the page to the other, and they often jump. This results in loosing your place, loss of accuracy, which  then leads to poor comprehension.
• Mixed Laterality – Child may use left foot, right hand, left ear or child may use left and right hands interchangeably for the same task. The effect of mixed laterality can be failure to send information to the most efficient centre of the brain for that skill. Competition between 2 centres may occur, which is very like two people trying to drive the same car.

Symmetrical Tonic Neck Reflex (STNR)

This reflex allows the baby to straighten its arms and bend its legs when it looks up. The STNR reflex is present in normal development for a relatively short time span and is normally lost at 8 months after birth. If it is not lost, it can affect a child’s ability to crawl on hands and knees. Crawling is a major developmental milestone, as a baby crawls, as well as looking ahead, babies also learn hand-eye coordination from the movement of the hands.  Later on this ability will be essential for being able to read without losing the words at the middle of the line and to visually follow the moving hand when writing. The focusing distance and hand-eye coordination skills used in the act of crawling are at the same distance that the child will eventually use when reading and writing.

Other symptoms of retained STNR include:

• Poor posture
• Poor hand-eye coordination
• Clumsiness
• Slow at copying from board 

Moro Reflex:
The Moro Reflex should disappear at 2-4 months and should be replaced by the adult “Startle” reflex. The Moro reflex is a response to unexpected changes within the infant’s environment and acts as the infants’ “fight of flight” response. The prolonged retention of this reflex can be highly disruptive to a child’s development.


Symptoms of a retained Moro Reflex include:

• Poor coordination (particularly during ball games) – which leads to poor sequencing and memory skills
• Balance problems
• Motion sickness
• Sensitivity to bright lights
• Difficulty reading black print on white paper
• Tires easily under fluorescent lights
• Dislike of loud noises
• Easily distracted
• Allergies and lower immunity
• Dislike of change- child may be clingy or shy

Tonic Labyrinthine Reflex (TLR)
The TLR is the opposite of STNR; when a baby looks up TLR causes the baby to straighten it’s legs and arms, likewise when the head goes down the limbs fold in. This reflex should be fully present from the time of birth to 4 months old. It is active during the birthing process. It is linked to balance and muscle tone. If this reflex persists it will disrupt balance and gross motor skills. 
        Symptoms of this retained reflex can include:

• Poor posture
• Tendency to walk forward on toes
• Weak at ball skills
• Poor articulation

Spinal Galant Reflex:
This reflex is present at birth, and should disappear by the time the baby is 9 months old. The Spinal Galant Reflex provides the opportunity to experience a change from whole body movements to same side (homolateral) movements.  The Spinal Galant Reflex emerges at 20 weeks in utero, is actively present at birth, and should be integrated by the time the baby is 3 to 9 months of age. The Spinal Galant Reflex is present when a baby is placed in a prone position (on their stomach) and stimulation is placed to one side of the spine, the hip on the side of the stimulus will flex (curl toward that side).  This reflex helps the baby to work its way down the birth canal during the birthing process, and also allows the fetus to hear and feel the sound vibrations in the womb.The Spinal Galant Reflex is important in the development of hearing and auditory processing, as well as helping to achieve balance when the child is creeping and crawling.  If persists, the child experiences :

• Restlessness
• Fidgeting
• Inability to sit still
• Bedwetting
• A tendency to dislike tight clothing
• Poor concentration and short term memory

It is great to be educated on all these reflexes. The great news is we can do several different exercises to improve all the above areas. We now know that with retained reflexes it can hinder your child's educational progress. Let's work together, build up these reflexes and improve your child life!

What Causes Reflexes to Be Retained?

I have been doing a lot of research on Primitive Reflexes. I have so many great articles that have helped me understand each reflex and how to implement them into our office.  From Visual Dynamix inc. , I found this great article on what causes reflexes to be retained. Take a look!

What Causes Reflexes to Be Retained?

There are a number of different reasons why primitive reflexes fail to integrate.  One of the biggest factors that cause reflexes to be retained is a traumatic birthing process.  This includes prolonged or premature birth, breach position, births involving forceps or suction, and emergency Caesareans.  The general increase in Caesarean section births may also be a contributing factor to the increased incidence of retained primitive reflexes since some of the reflexes are stimulated by the process of passing through the birth canal during natural childbirth.  The reflexes involved in aiding the birthing process are more likely to still be ‘present’ at a later age with children that were born via Caesarian section. 

Societal factors can also come into play such as not allowing babies to spend enough time lying on their stomachs (tummy time) due to the fear of Sudden Infant Death Syndrome (SIDS).  *It is important to follow the advice of your pediatrician regarding SIDS. 

Another societal factor that can cause reflexes to be retained is the lack of exploration of the infant’s space and world during the creeping and crawling stage.  If an infant spends a great deal of time in a car seat, stroller, crib, or other confining environment it is more likely that the primitive reflexes will be retained past the typical timeline.

Doing “too much, too fast” can also be detrimental to the developmental process.  As a child develops they gain more and more control over their physical body. 

Children progress from lying on their back, to rolling over onto their stomach, to creeping, to crawling, and eventually to walking.  Some parents will comment, “My child was very fast to develop!  He was walking very early!”  Unfortunately, the child who spends little time crawling can miss out on some valuable developmental experiences for visual-spatial development. 

It is very important that we first gain mastery of our environment from the ground as this stage of development strengthens our muscular system and sets in place the building blocks for higher-level coordination and spatial awareness.  

What are Primative Reflexes?

When a child starts Vision Therapy we test their primitive reflexes and we integrate reflex exercises into our vision therapy plan. A lot of my parents ask questions like,  "What are primitive reflexes?",  and "How does this relate to the visual system?". For the next couple blogs we will go over all those questions.

First, primitive reflexes are the basic reflexes we are born with.

Take for example an infant child. When the child’s head is turned to one side, both his leg and arm automatically turn in the same direction. This is known as the Asymmetric Tonic Neck Reflex. As another example, when an infant is stroked on the lower back, his side muscles automatically contract performing what is known as the Spinal Galant Reflex. Lastly, when an infant is startled, he opens his eyes, throws his head back, and spreads his hands wide for what is called the Moro Reflex.  

Through these basic concepts physicians can determine the development of the infant based on the progression of their primitive reflexes.   

Ideally, the child’s primitive reflexes develop accordingly as he or she ages and advances in development. The body naturally integrates itself with the reflex or inhibits the reflex depending on the developmental stage. 

It is crucial that the body moves through these developmental stages and primitive reflexes according to nature’s plan. When the body fails to initiate, integrate, or inhibit these reflexes, the system automatically locks down in the developmental stage it is in. 

This “lock down” can restrain maturation of the body’s neural systems and possibly lead to learning disabilities that range from mild to severe.  

Next week we will talk about how retained reflexes have the potential to cultivate learning disabilities. Stay tuned!

Let Your Children Explore and Play!

Vision development in children is a very important part of child development which influences fine motor development, gross motor development, and visual perceptual development.  Good visual development in children is necessary for proper brain maturation, and, many cognitive stages of child development may be delayed and learning problems could arise if proper vision development has not occurred.

So what can parents to encourage good visual development in their preschoolers?

Proper play activities are the most important ways that parents can help encourage good visual development in children.  When a child plays, he or she is strengthening not only his muscles, but also strengthening their perceptions.  They are learning new skills and letting off excess energy.  They are also trying out different solutions to problems and learning how to interact with others.

Good visual play activities allow the child to explore and experience their world with vision driving the action.  This kind of play will build upon and enhance gross motor development, fine motor development, balance, eye movements, body awareness, spatial relationships, visualization skills, and much more.

We know that play affects visual development and visual development affects play.  Motor development and visual perceptual development are interdependent.  If a child experiences delays in motor development, visual perception can be skewed which reduces the child’s ability to explore and learn from the environment.

Remember, when there is a delay in one area of development such as motor development, there is often a delay in other areas as well.  School-aged children with functional visual disorders arising from poor vision development often face a lifetime of learning difficulties and frustration in the classroom and in everyday life. Let you children play and explore the world around them. Below is a great list of toys and games that can improve visual development:

Building toys – Develop eye-hand coordination and visualization/imagination.
1. Building Blocks
2. Legos/Duplos
3. Lincoln Logs
4. Tinker Toys
5. Erector Set

Fine motor skill toys – Develop fine motor skills including visual skills and manual eye-hand coordination.
6. Light Bright
7. Pegboard and Pegs
8. Coloring Books and Crayons
9. Dot-to-Dot Activity Books
10. Finger Paints
11. Playdough/Silly Putty/Modeling Clay
12. Chalkboard (24” x 36”)/Easel
13. Bead Stringing
14. Sewing Cards (craft)
15. Paint or Color By Numbers
16. Sand Art
17. Stencils
18. Bead Craft Kits
19. Models (car, airplane, ships, etc.)

Space perception toys – Develop depth perception and eye-hand coordination.
Within arm’s length:
20. Jumpin’ Monkeys
21. Fishin’ Around
22. Operation
23. Pick-up Sticks
24. KerPlunk
25. Jenga

Beyond arm’s length:
26. Oball (good for kids who aren’t very good at catching)
27. Ball (any kind!)
28. Pitchback
29. Toss Across (tic-tac-toe)
30. Ring Toss
31. Nerf Basketball
32. Dart Games (velcro)
33. Ping Pong

Visual thinking toys and games - Develop visual thinking including visualization, visual memory, form perception, pattern recognition, sequencing and eye tracking skills. These skills are important basics for academics including mathematics, reading and spelling.

34. Color Blocks and 1” Cubes
35. Parquetry Blocks
36. Attribute Blocks
37. Make N Break Game
38. Jigsaw Puzzles
39. Rory’s Story Cubes
40. Card Games (Old Maid, Go Fish, etc.)
41. Dominoes
42. Checkers
43. Chinese Checkers
44. Perplexus
45. Qwirkle
46. Battleship
47. Labyrinth
48. Blokus
49. Connect Four
50. Rush Hour/Rush Hour Jr.
51. Perfection
52. Tactilo
53. Bingo
54. Memory Games
55. Chicken Cha-Cha-Cha
56. Simon Flash
57. Bop It
58. Hyperdash

Balance and Coordination toys and games – Develop large motor skills.
59. Hoppity Hop
60. Jump Ropes
61. Sit and Spin
62. Slip ’n Slide
63. Trampoline
64. Stilts
65. Twister

iPhones, iPads, Nintendo DS...OH MY!

If you are sitting in a waiting room or out shopping, you probably see a lot of children on electronics like an iPhone/iPad or a Nintendo DS to keep them busy. Unfortunately, some of these children may be in danger of future vision problems if these devices are used as a crutch to entertain a child. Now I am not saying children shouldn’t have electronics – as an educational tool, they can do wonders – but what if we could minimized the amount of time they use the device.

When children are very young, their visual systems are still developing. Developing children need to interact with objects in real space. It’s how they develop depth perception, eye teaming, tracking and other visual skills.

Here are a couple tips to avoid vision problems:

• Preschoolers should not play on an iPhone or small screen video game for longer than 15 minutes per day.
• Older children should be limited to 30-60 minutes per day and take breaks every 15 minutes.Both children and adults should try and balance their gaming and computer usage with outdoor activities or sports that include a ball.
• A child should not hold the screen too close to their eyes. Use the Harmon distance, which is the distance from the elbow to the middle knuckle.

Now we are not saying every child will develop vision problems or computer eye strain if they use a small screen video device.  What we are saying is we need to practice good viewing habits, your child could experience issues such as headaches, eye strain, or possibly develop nearsightedness.

If your child is currently in Vision Therapy and they abuse their time with video games or small electronics, by using these devices too much they could worsen the condition. Your children can still have fun with video games and games on the iPhone or iPad, just be smart and limit their time!

Why are eye exams so important?

Have any of you watched The Doctors show? Check out this video: http://www.thedoctorstv.com/main/home_page?init_type=Feature&init_id=4988

We can learn a lot from this video. This video states how important a comprehesive approach to testing for eye issues. When going to your local eye doctors make sure they are testing more than your child's visual acuity. When we do our comprehensive exams we test for: Alignment of the eyes, binocular depth perception, eye movements necessary for reading (‘tracking’), magnitude and flexibility of accommodation (‘focusing’), visual motor integration and visual perceptual abilities. We stress that vision is more than seeing 20/20.

What I also love about this video is how they state that your child should have an eye exam starting at 6 months! So, make sure your child receives an eye exam before age 1, at 3 years old, and before they enter kindergarten.  After that, if vision is developing on schedule, children should be seen every one to two years as directed by their eye doctor.

Lastly, like this child's teacher noticing her student was looking very closely to her page, look to see if your a child rubbing his or her eyes, avoiding reading, complaining of headaches or eyestrain, it should be a warning sign that more testing is needed.

It’s Not About the Patch

A great article about Amblyopia from the COVD Blog:

Amblyopia, also referred to by the public as “lazy eye”, is a unilateral or less commonly bilateral condition in which the best corrected visual acuity is poorer than 20/20 in the absence of any obvious structural anomalies or ocular disease. Amblyopia is associated with strabismus (an eye turn) and/or anisometropia (difference in refractive status between the eyes).  Amblyopia is the BRAIN’S response to the imperfect and unequal visual input received from the eyes.

Treatment of amblyopia is based on eliminating its most obvious symptom: the reduction in visual acuity.  An amblyopic child cannot read the 20/20 line with the amblyopic eye and this becomes the primary focus of most interventions.  First, children are provided with glasses to neutralize any differences in refractive status between the eyes, then the patching begins.  Patching is a form of penalization.  By penalizing the better seeing eye, the child is forced to use the amblyopic eye, and improvements in visual acuity are measured.   The scientific evidence of the benefits of patching in the treatment of amblyopia is extensive and well-founded.  When evaluating the effectiveness of patching in populations of amblyopic children, most of them show statistically significant improvements in visual acuity….. but not all patients.

At COVD’s annual meeting, Drs. Janna Iyer and Genia Beasley presented a case of a 10 year old girl with amblyopia.  She had been treated with patching and atropine (a pharmacological form of penalization) for YEARS.  She hated the patch and the blur-inducing eye drops and found many ways to “beat the system” and use her better seeing eye.  The visual acuity in the amblyopic eye remained 20/100.  Drs. Iyer and Beasley recommended a paradigm shift.  Instead of focusing on amblyopia as a monocular problem, they began to treat the binocular problem and shifted emphasis to the integration of the visual inputs in the BRAIN from a 3-dimensional world.  Activities designed to use the eyes together in order to make judgements about where things are in space were emphasized.  Activities involving patching and identifying what things are  were significantly reduced.   Her visual acuity improved within weeks of initiating this therapy program.  More important, her academic performance skyrocketed.

Amblyopia is much more than a reduction in visual acuity.  Amblyopic eyes have poor eye movement and focusing skills; the amblyopia causes distortions and difficulty processing spaces between objects.  On any visual task you design, amblyopic eyes will perform slower and with less accuracy.  Even when using both eyes, amblyopic children often do not perform as well as “normal” children.  The consequences of amblyopia are far greater than reduced visual acuity.  Clearly treatment must move beyond the patch to the brain.  Only then will these children begin to demonstrate improvements in their living and learning skills and not just their ability to read the little letters on the doctor’s chart at the end of the examination room.

-Dr. Rochelle Mozlin

Here at Optometric Physicians we have many amblyopic children. Where patching does improve the visual acuity of the amblyopic eye, it shouldn't stop there. That eye still has poor eye tracking and focus abilities, and that is where vision therapy comes in. A combination of patching and vision therapy will improve your child's overall living and learning skills.