Correcting Clinical Facts- Abnormal Primitive Reflexes in Behavioural Optometry and Vision TherapyPeter Blythe, PhD Sally Goddard Blythe, MSc Chester, United Kingdom
- December 9, 2019
- Posted by: INPP USA
- Category: INPP
As early as 1969, the role of retained or residual primitive reflexes was discovered, by one of the authors of this paper (Blythe), to play a significant role in specific learning difficulties, agoraphobia and panic disorder. At the same time, a protocol for neuro-diagnostic assessment based on standard medical tests was devised to detect the presence of aberrant reflexes (neuromotor immaturity) in older children and adults, and developmental movement programmes were devised to inhibit and integrate aberrant reflexes. This system, now known as The INPP Method, has been shown in peer reviewed journals to bring about remission of presenting difficulties both educational and medico-psychological.
Evidence has emerged showing that a number of behavioural optometrists and practitioners of vision therapy are using clinically unknown diagnostic procedures to test for the presence of aberrant reflexes, misinterpreting obser- vations during the assessment of primitive reflexes, and applying clinically unproven reflex inhibition programmes without a clear understanding of the developmental basis for some of the exercises used in relation to primitive re- flexes. These failures appear to be the result of inadequate and misleading training which is being communicated to others through various publications, training courses, seminars, and information given out to patients and families of patients. This viewpoint article highlights some of the issues involved.
assessment, primitive reflexes, reflex inhibition, remediation, theory, training
In 1995 an article, “The role of primitive reflexes in the development of the visual system,”1 written by one of the au- thors (Goddard), was published in the Journal of Behavioral Optometry. Since that time the authors have been made aware of an increasing body of incorrect information concerning the assessment, interpretation, and remediation of primitive re- flexes appearing in publications and training materials dis- seminated amongst practitioners of vision therapy and behav- ioural optometry.
It is not possible to produce an exhaustive list of all exam- ples as the distribution appears to have been widespread from disparate sources over a number of years, and has spilled over to and from other professions. Some examples, which are listed in two sections below, provide evidence that a problem exists, and that there is a need for rigorous academic review of the literature being produced for the purposes of training, assessment, and remediation of primitive reflexes amongst practitioners of behavioural optometry and vision therapy to insure the integrity of the profession and to safeguard patients.
Section 1 lists errors which relate to the administration of test procedures for the assessment of primitive and postural reflexes and the interpretation of the function of primitive reflexes in normal development, followed by factual clinical comments.
Section 2 lists examples of distorted interpretation or po- tential misuse of existing methods for remediation of aberrant reflexes, followed by factual clinical comments.
Section 1. Examples of errors in test procedures and interpretations
Two publications produced for optometrists advocate use of test procedures designed to elicit “soft signs” of neurologi- cal dysfunction to identify signs of abnormal primitive and postural reflexes. These are described in the first publication2 as:
- Walking with the feet turning in (pigeon toed)
- Walking with the feet turning out (Charley Chaplin position;
and in the second publication3 as:
- The “Duck” Walk (walking with the feet turning out)
- The“Pigeon” Walk (walking with the feet turning in).
In the first publication, under the heading “Clinical Picture if Sustained,” it is said that if in the above test procedures “any movement of the feet triggers an obligatory movement of the arms” (vertical synkinesis (VS)), such signs are “pos- sibly caused by the amphibian, labyrinthine or Moro reflex.”
In the second publication, the “Duck” walk is described as a definitive test for the Moro reflex.
“Moro Reflex Testing Procedure
You will be determining if the reflex is present or not present
Test Part 1: Duck Walk
Instruct the participant to stand with toes turned outward (heels pointing towards each other) and walk forwards 10 steps. Then walk backward 10 steps.
If the reflex is present, you will observe one of the following. Please check the item as it occurs when testing:
- Inability to turn feet outward
- Any movement of the upper body such as bending forward
- Movement in hands and arms, such as arms turning outward
- Rotation of the hips or upper body, forward posture or an unbalanced posture
- Awkward extension of upper body
- Walking in a stiff or unnatural motion, inability to walk smoothly
If the reflex is not present, you will observe that the partici- pant will effortlessly turn feet outward; the participant will walk forward and backward smoothly while the upper body remains relaxed and hands remain at sides.”
A reflex is an involuntary muscle reaction to a specific type of stimulation in which certain sensations or movements are known to produce specific muscular responses.4 Recognised standard tests with defined observations and criteria have been developed and established to assess the presence of re- flexes in the neonate5 and in the older child.6
The Moro Reflex
The Moro reflex is elicited by any movement which sud- denly moves the head in relation to the spine. It can be pro- duced by the head and neck muscles participating in a gener- alised startle reflex,7 as in the manoeuvre described by Moro.8 It is primarily a vestibular reflex, which is elicited in the neo- nate by slapping the mattress or by lifting the child from the supine position, and letting the head fall back onto a padded surface.9
This reaction occurs in the infant before head-righting re- flexes and muscle tone to support posture have developed, and is a reaction to sudden stimulation of the labyrinth or the auditory system. As far as we are aware, there is no evidence to suggest that altering position of the feet (as in the Duck and Pigeon Walks) elicits the Moro reflex.
Observations listed under the tests for the Duck and Pigeon Walks may offer “soft signs” of neurological dysfunction, but these soft signs do not afford hard evidence of aberrant re- flexes. There can be many reasons for these soft signs – age,10 orthopaedic structure, impairment of the later-developing inhibitory mechanisms responsible for mirror movements,11 complexity of the movement, order of presentation, familiar- ity of the task, and lateralization with the non-dominant side exhibiting more overflow,12 – for the appearance of vertical synkinesis (VS) on various tests for soft signs of neurological dysfunction. Some authors considered VS to be a secondary event linked to interhemispheric interaction in the functional organization of motor acts.13 Execution of useless move- ment during performance of motor activity and/or sleep may represent an expression of the slow maturation of structures responsible for achieving basic levels of inhibitory control,
which is reflected in the performance of complex tasks.14 It cannot be assumed that such signs elicited when altering po- sition of the feet are a direct result of either retained Moro or Tonic Labyrinthine Reflexes or an absent or under-developed Amphibian Reflex as described above without additional sup- porting evidence from other recognised tests to assess the sta- tus of each reflex.
In the second publication, the author states that the Moro reflex helps the infant “to hold the correct vertical and hori- zontal positions of the head for the first two months of life.”3
Contrary to the statement made above, the Moro reflex is a reaction to loss of head control in the first 2 – 4 months of life. The Moro reflex gradually recedes as a result of maturation in the central nervous system (CNS) as head righting reactions and centres involved in the development of muscle tone and postural control mature.
Under symptoms of the Moro reflex the same author lists,
“weakened adrenal glands.”3 No evidence or references to support this statement are provided.
Factual Clinical Comment
Goddard15-17 described how the continued presence of the Moro reflex in an older child can be associated with an exag- gerated startle reaction, which can result in hypersensitivity in one or several sensory channels. This in turn may cause the child to over-react to certain stimuli, increasing activity in the sympathetic division of the autonomic nervous system and increasing the demand for production of adrenaline and cortisol. Such demand on the adrenal system could, in theory, compromise regulation of stress hormones normally reserved to respond to extreme stress and to support the functioning of the immune system. This process is not the same as having
“weakened adrenal glands.”3
In a description of a test procedure for the Asymmetrical Tonic Neck Reflex (ATNR), the tester is instructed to place the subject “with hand and knees on the floor in a creeping position and head hanging downward,” and then to “rotate head right and left.”2
A description of the ATNR states that, “It not only assists in the birthing process but also is reinforced and activated by it. This twisting motion is the first experience of the infant to understand coordination of both sides of the body together. Many researchers believe that this is a contributing factor as to why children requiring forceps delivery or born by Caesar- ean section are at higher risk of experiencing developmental delays.”3 The same author goes on to state that, “one of the biggest factors that cause reflexes to be retained is a trau- matic birthing process,” but does not provide evidence to support this assertion of a direct link between traumatic birth and retained reflexes.
Also in relation to the ATNR it is stated, “crawling and creeping are extremely important in the integration of the ATNR at the appropriate time, and children who stand and walk without these intermediate movements often experience a retained ATNR.”3
Asymmetrical Tonic Neck Reflex
The ATNR is elicited in the neonate as a result of head rotation to either side. A. Jean Ayres developed an addition- al test for assessing the continued presence of the ATNR in older children using the quadruped position.18 For this test, the head should be held level with the spine. By placing the subject in the quadruped position with “head hanging down- ward,” this procedure could also elicit the Symmetrical Tonic Neck Reflex (STNR) in flexion, causing the arms to flex even if the ATNR is not present,19 resulting in a false “positive” result for the ATNR.
Goddard15 suggested that the ATNR may a play a part in the normal birth process by lending flexibility to the shoulders and the hips as the baby gradually works its way down the birth canal. It is a quantum leap from this suggestion to state that, “this twisting motion is the first experience of the infant to understand coordination of both sides of the body togeth- er,” or that “many researchers believe that this is a contrib- uting factor as to why children requiring forceps delivery or born by Caesarean section are at higher risk of experiencing developmental delays,” without either providing references to substantiate these statements or making it clear that they are the conjecture of the author.
In a study which analysed responses from parents who had completed the Institute for Neuro-Physiological Psychology (INPP) Developmental Screening Questionnaire about their child, Goddard and Hyland found that problems during the birth process were only one of a cluster of factors in early development which could contribute to developmental delay later on. They went further and stated that problems during the birth process were also present in the developmental his- tory of some children who did not experience developmental delay.20
The statement which says, “crawling and creeping are ex- tremely important in the integration of the ATNR at the appro- priate time, and children who stand and walk without these intermediate movements often experience a retained ATNR” is ambiguous, as it is inhibition of the ATNR (circa 6 months of age), which is important for a child to be able to progress through subsequent stages of crawling and creeping.
Under a section entitled “Overview of the Tonic Labyrin- thine Reflex (TLR)” it says, “It (the TLR) aids in the inte- gration of the vestibular, proprioceptive and visual systems, and is also needed in preparation for rolling over, crawling, standing, and walking.”3
The TLR is elicited by change in the position of the head in space, which stimulates the otolithic organs of the two labyrinths. Bobath explained that as the labyrinths are fixed within the head, it is the position of the head itself which determines the distribution of hypertonus throughout the af- fected parts.21 The TLR is not elicited as a result of alteration of foot position (unless the head position is also adjusted) as suggested in earlier citations of descriptions of the Duck and Pigeon Walks; neither is it “also needed in preparation for rolling over, crawling, standing, and walking.” On the con- trary, continued presence of the TLR in its crude state will interfere with the ability to roll, crawl, stand, and walk.
In a poster, “Optometric Correlates of Developmental De- lay in a Population of Patients with Learning Difficulties,”22
published online, the original version showed photographs of test procedures for five primitive reflexes in which the first two illustrations described, “Assessment of the Strauss reflex response for the underlying Tonic Labyrinthine Reflex (TLR).” The issue was reported to the author and a correc- tion was made immediately, as it was admitted to be a simple mistake in labelling.
The Tonic Labyrinthine Reflex and Strauss Reflex
The test procedure shown for the TLR in the original online document22 is also a test for assessing presence of the Landau reflex. Used in isolation, the test as shown does not provide clear evidence of a retained Tonic Labyrinthine reflex.
It should also be noted that the Strauss and Tonic Labyrin- thine reflexes are separate reflexes, which are distinct reac- tions to different stimuli.
The Strauss Reflex
The Strauss reflex is a startle response elicited by a sud- den or unexpected stimulus. The original films of Strauss23 and Landis and Hunt24 show a difference between the fright (startle) reaction and the Unklammerung reflex described by Moro. According to Landis and Hunt, the startle reaction is originally a flexor reaction while the Moro clasping reflex is an extensor reaction. Clarke25 observed that the Moro reflex is the first to appear in the course of development. Later some features of this reaction disappear and extension becomes flexion, as in the startle reaction. While Hunt26 observed that both reactions can be elicited in the newborn during the course of normal development, as the Moro reflex is inhib- ited, the more mature “startle” response, sometimes referred to as the “Strauss” reflex, takes over. There is no recognised test for both the Tonic Labyrinthine and Strauss reflexes to- gether. The photograph used in the original article is not a test for the Strauss reflex.
The description of the Duck and Pigeon Walks previously cited2 stated that these procedures could also elicit possible signs of the amphibian or labyrinthine reflex.
The Amphibian Reflex
The Amphibian reflex is a postural reaction which devel- ops in the infant from about 4 months of age. It is elicited by elevating the pelvis on one side when lying in the prone or su- pine positions. It enables the infant to use one quadrant of the body independently of the other three, and in the prone posi- tion, is a precursor to commando style crawling. Recognised tests for the assessment of the amphibian reflex in the prone position are available.27 It cannot be assumed that signs of VS elicited in the upper body when carrying out either the Duck or Pigeon Walks are the result of an absent amphibian reflex.
The unqualified statement, “possibly caused by the am- phibian, labyrinthine or Moro reflex” does not make it clear that it is the absence of the amphibian reflex in a child above the age of 6 to 8 months which provides an indication of neu- romotor immaturity. When referring to the “labyrinthine” reflex, no distinction is made between the TLR and the Laby- rinthine Head Righting Reflex. This distinction is crucial be- cause the continued presence of the former in a child above 3½ years of age is abnormal, while the absence of the latter in an older child is a sign of neuromotor immaturity.
Under “Observations” for the Spinal Galant reflex, the fol- lowing signs are listed as being indicative of the reflex being retained: “arching of the back; curved toes; participant pull- ing away or bending downward; ticklish or touch sensitive; any motion, even slight, such as movement in the shoulders, back or bending of the arms. This movement may only be one side of the body.”3
Spinal Galant Reflex
The Spinal Galant Reflex in the neonate is a reaction to stimulation of the dorsal skin in the lumbar region at the level of the first lumbar vertebra on one side.28 “When the dorsal skin, near and along the vertebral column, is stroked, the infant forms an arch with his body; the concavity of the arch is directed toward the stimulated area, and by arching in the opposite direction the infant evades stimulus.”29 In other words, the reaction is an outward movement of the hip on the stimulated side. In the neonate, “this response is elicited by stimulating the paravertebral area with the thumb nail or a sewing wheel going caudal from the lower thoracic to the sacral region. Truncal incurvature is elicited with flexion of the hips on the ipsilateral side.”30 This is a specific reaction to the stimulus.
“Arching of the back; curved toes; participant pulling away or bending downward; ticklish or touch sensitive; any motion, even slight, such as movement in the shoulders, back or bending of the arms” could be caused by a number of fac- tors, including tactile sensitivity or being ticklish, and are not a definitive response indicating that the Spinal Galant reflex is present.
Under “STNR Testing Procedure” the following observa- tions are listed:
“Movement of the head is restricted or there is resistance; the head drops or there are tremors in the body; shoulders/neck/ arms are tense.”3
Symmetrical Tonic Neck Reflex
The STNR, “produces symmetrical changes in the distri- bution of muscle tone in the limbs in reflex response to the symmetrical change in the position of the head with relation to the trunk. When the head is tilted back (extended), there occurs a reflex increase in tone of muscle groups which ex- tend (straighten) the elbows, wrist and fingers, and a corre- sponding increase in tone of muscle groups which flex (bend) the hips and knees. On the other hand, when the head is bent forward (flexed), this pattern of muscle tone is reversed.”31
Observations for signs of the STNR when tested in the quadruped position are specifically related to specific chang- es in muscle tone in the arms or the legs in response to flexion or extension of the head. The other signs quoted above are not clear indicators of the STNR being retained.
Section 2. Examples of misinterpretation and inappropriate application of existing methods for the remediation of aberrant primitive reflexes:
Issues 1 & 2
In the preamble to the instructions for the use of an exer- cise called “The Starfish,” it is acknowledged that the exer- cise was “borrowed from Peter Blythe” and that the author had “not been trained in Blythe’s methods.” The author de-
scribes the exercise as: “the child then thrusts both arms and legs apart and leans body and head backward, again for a count of 10. The child then repeats this two-step procedure several times, alternating right over left and left over right.”2
In an essay, “The Primitive Reflexes: Considerations in the Infant,”32 a treatment programme for infants is described rec- ommending use of the “Starfish” exercise for children under 5 years of age.
The “Starfish” exercise developed by Blythe in 1990 and originally named “Fetal Movement,” was devised for use with children over 7 years of age with specific diagnostic criteria following a full diagnostic assessment of all of the primitive and postural reflexes. The movement was only intended to be repeated twice at each session. Because the movement both simulates and stimulates the Moro reflex, over-stimulation or inappropriate use of the movement can result in increased hyper-sensitivity, over-reactivity, emotional regression and increase in symptoms in some subjects.33 Fetal movement was also adapted for use in a school program (Sea Anemone exercise) developed by Goddard Blythe34, 35 in which there are only two repetitions of the movement carried out once a day.
Berne makes no attempt in the essay to define at what age
“The Starfish” or other exercises outlined in the Infant Move- ment Program he describes might be appropriate, nor does he offer age norms for various tests shown to assess the presence of primitive reflexes in children under 7 years of age. For example, figures 8 and 10 in the publication illustrate quad- ruped testing positions for the ATNR and STNR in children considerably younger than 7 years of age. In 1975, Parmenter had found a visible ATNR response when tested in the qua- drupedal position in most normal children through to the third grade.36 In other words, if certain test procedures for reflexes designed for use with older children are used with younger children, the test can yield a false positive result because the test age norm is higher than the chronological age of the child being assessed.
Berne also quotes Goddard as a source to substantiate use of the Infant Movement Program described in the essay. He quotes a statement by Goddard made specifically in the con- text of exercises used as part of The INPP Method, “the re- flex movements are based on a thorough understanding of the primitive reflex sequence of development and normal child maturity.”16 Goddard never recommended the use of the ex- ercises described as part of the Infant Movement Program with this age group, in this context, or without more detailed assessment or further training in the diagnostic techniques and application of exercises which form part of The INPP Method.
In a publication referring to a primitive reflex training pro- gram “Vision Therapy at Home,” it is stated that “The reflex activities included in the program have been proven by re- searchers and thousands of clinicians to be safe, extremely effective……”3
While specific reflex integration programs have been shown to be effective,37-40 the above statement does not make it clear that these programs are not the same as the one being prescribed in the Vision Therapy at Home program. No refer- ence sources are provided to support the assertion that “the reflex activities included in the program” (Vision Therapy at
Home program) “have been proven by researchers and thou- sands of clinicians to be safe, extremely effective ….”3
The examples listed above provide some illustrations of four distinct areas of misinformation:
- Potential misdiagnosis of aberrant reflexes resulting from misapplication and misinterpretation of test procedures not recognised as valid tests for the reflexes described.
- False baseline premise for research based on primitive reflexes resulting from use and interpretation of tests not rec- ognised as valid tests for the primitive reflexes described.
- Use of exercises originally designed for other purposes without training in their original
- Lack of evidence provided to support claims made for specific programs professing to integrate
It is our view that incorrect information concerning the as- sessment and remediation of primitive and postural reflexes is being replicated and distributed to other professionals through various training programs and publications produced for op- tometrists and parents of children receiving vision therapy. Practice based on this erroneous information appears to be spreading amongst practitioners, there may be some cross- contamination to and from other professions, and incorrect information is subsequently being disseminated as part of professional training to others in the field. In the interests of science, education, ethics, professional practice, clinical stan- dards, valid research, and most importantly, providing better patient care in the future, this must be put right.
- Goddard SA. The role of primitive reflexes in the development of the visual system. J Behav Optom 1995;6:2.
- Wachs Visual spatial thinking. In: ICDL Clinical Practice Guidelines. Redefining the Standards of Care for Infants, Children and Families with Special Needs. 2000. www.icdl.com. Last Accessed January 15, 2012.
- Mowbray L. Retained Primitive Reflexes. MN: Visual Dynamix Inc., 2010.
- Infant Reflexes http://www.umm.edu/ency/article/003292. htm#ixzz1pZWr8ZB2. Last Accessed August 23, 2012.
- Illingworth RS. The Development of the Infant and the Young Edinburgh: Churchill Livingstone, 1987.
- Fiorentino MR. Reflex Testing Methods for Evaluating CNS Develop- ment. Springfield, IL: Charles C. Thomas,
- Chesni Y, Saint-Anne Dargassies S. The neurological examination of the infant. London: Medical Advisory Committee of the National Spastics Society,
- Moro E. Originalien. Das erste Trimonen. München: Med Wschr 1918;65:1147.
- Capute AJ, Accardo Developmental Disabilities in Infancy and Child- hood. Baltimore: Paul Brookes Publishing Co., 1991:10.
- Kohen-Raz R. Psychological Aspects of Cognitive Growth. New York: Academic Press,
- Accardo PJ. A Neurodevelopmental Perspective on Specific Learning Difficulties. Baltimore, MD: University Park Press,
- Towen Examination of the Child with Minor Neurological Dys- function. Clinics in Developmental Medicine.71. Philadelphia: JB Lip- pincott Co., 1979.
- Zaytseva NV, Sami Walid M, Berdichevskaia EM. Interhemispheric in- teraction in the motor domain in children with cerebral palsy. Neurology India 2009;57:411-7.
- Ilis-Stošovis D, Nikolis Motor skill performance of children with sen- sory impairments. In: Sittiprapaporn W, ed. Learning Disabilities. Ri- jeka, Croatia: In Tech., 2010.
- Goddard SA. A Teacher’s Window Into the Child’s Mind. Eugene, OR: Fern Ridge Press,
- Goddard Reflexes, Learning and Behaviour. Eugene, OR: Fern Ridge Press, 2005.
- Goddard Blythe SA. Attention, Balance and Coordination. The ABC of Learning Success. Chichester, UK: Wiley-Blackwell,
- Ayres Sensory Integration and Learning Disorders. Los Angeles, CA: Western Psychological Services, 1973.
- Parmenter C. The asymmetric tonic neck reflex in normal first and third grade children. Am J OccupTher 1975;29:463-8.
- Goddard SA, Hyland D. Screening for neurological dysfunction in the specific learning difficulty child. Br J Occup Ther 1998;10:459-64.
- Bobath K. A Neurophysiological Basis for the Treatment of Cerebral Oxford: Blackwell Scientific Publications Ltd., 1984.
- Hurst C. Optometric Correlates of Developmental Delay in a Population with Learning Difficulties. oep.org/ICBOFlash/PostersHurst4.pdf. Last Accessed August 23, 2012.
- Strauss H. Das zusammenschrecken. Journal für Psychologie und Neu- rologie 1929;39:111.
- Landis C, Hunt The Startle Pattern. Cited in: Peiper A. Cerebral function in infancy and childhood. New York: Consultants Bureau, 1963.
- Clarke FM, A developmental study of the bodily reactions of infants to an auditory stimulus. J Genet Psychology 1939;55:415-27.
- Hunt “Body jerk” as a concept describing infant behavior. Genet Psychol 1939;55:215-20.
- Fiorentino MR. Reflex Testing Methods for CNS Development. Spring- field. IL: Charles C Thomas,
- Peiper A. Cerebral function in infancy and early childhood. New York: The International Behavioral Sciences Series. Consultants Bureau,
- Galant S. Der Rückgratreflex. Diss. University of Basel,
- Capute AJ, Accardo Developmental Disabilities in Infancy and Childhood. Baltimore, MD: Paul H. Brookes Publishing Co., 1991.
- Bender ML. The Bender-Purdue Reflex San Rafael, CA: Academic Therapy Publications, 1976.
- Berne SA. The primitive reflexes: Considerations in the infant. Optom Vis Dev 2006;37:139-45
- Blythe INPP Practitioner Supervision Seminar. Chester, UK, 1991.
- Goddard Blythe SA. The INPP developmental test battery and exercise programme for use in Chester, UK: INPP training manual, 1996.
- Goddard Blythe SA. Assessing Neuromotor Readiness for The INPP Developmental Screening Test and School Intervention Pro- gramme. Chichester, UK.: Wiley-Blackwell, 2012.
- Accardo PJ. A Neurodevelopmental Perspective on Specific Learning Disabilities. Baltimore, MD: University Park Press,
- McPhillips M, Hepper P, Mulhern G. Effects of replicating primary re- flex movements in specific reading difficulties in children: A randomised, double-blind, controlled trial. Lancet 2000;355:537-41.
- North Eastern Education and Library Board (NEELB). An evaluation of the pilot INPP movement programme in primary schools in the North Eastern Education and Library Board, Northern Ireland. Final Report. Prepared by Brainbox Research Ltd for the NEELB. 2004;
- Goddard Blythe SA. Releasing educational potential through movement. A summary of individual studies carried out using the INPP Test Battery and Developmental Exercise Programme for use in Schools with Children with Special Needs. Child Care Pract 2005;11:415-32.
- Goddard Blythe SA. Neuromotor maturity as an indicator of develop- mental readiness for education. Report on the use of a neuromotor test battery and developmental movement programme in schools in Northum- berland and Berkshire. In: Kulesza EM, ed. Movement, Vision, Hearing
-The Basis of Learning. Warszawa. Wydawnictwo Adademii Pedagogiki Specjalnej im. Marii Grzegorzewskiej, 2011.
Peter Blythe PhD
Sally Goddard Blythe MSc.
The Institute for Neuro-Physiological Psychology (INPP) 1, Stanley Street
Date submitted for publication: 9 October 2011 Date accepted for publication: 3 March 2012
Dear Dr Taub,
Having been cited in the article “Viewpoint: Correcting Clinical Facts – Abnormal Primitive Reflexes in Behavioural Optometry and Vision Therapy” by Peter Blythe, PhD, and Sally Goddard Blythe, MSc, I felt it would be appropriate to note more about my professional background and the legacy of our understanding of primitive reflexes.
Arnold Gesell, MD, worked with the primitive reflexes 19 years before Mr. Blythe and Ms. Goddard came on the scene. Both Drs. Albert A. Sutton and John Streff had vari- ous discussions with me about Gesell’s exploration into the primitive reflexes. My training with the reflexes came from Catherina Johanneson-Alvegard and her development of the reflex integration program in 1975. (There was and still is a dedicated group of optometrists developing and using the primitive reflex program in Scandinavia.)
Dr. Sutton invited Dr. Lena Rasmussen from Sweden (one of Catherina’s students) and Thorkild Rasmussen from Denmark to teach our first course on the primitive reflexes. Dr. Sutton and I also were interested in Goddard’s work and invited her to the United States to present a course, but she never responded to us.
Adding to this early training, I developed my own protocol for ADD-Autism Spectrum children, TBI and regular adult vision therapy patients, which I call The Berne Method.®
I have treated more than 2,000 patients using this method that combines Craniosacral therapy developed by Dr. John Upledger, Continuum Movement developed by Emilie Con- rad, and the primitive reflex integration developed by Lena and Thorkild Rasmussen. The results have been excellent.
I have found that using the primitive reflex integration pro- gram can be volatile for the patient and must be done with the utmost care and monitoring. Both Continuum and Cra- niosacral soften the survival response that can occur from implementing the reflexes, and the combination of all three modalities can help the person integrate the reflexes. I do use the Starfish activity that I learned from Lena and Thorkild and also use other movement patterns to integrate the Moro reflex, depending on the severity of birth trauma and/or toxic- ity exposure in the gestation, birth and bonding period. As for age, I have worked with pregnant mothers near their delivery as well as early in the infant/toddler period. In terms of test- ing the ATNR, my clinical experience has shown that one can see the reflex in body movement without testing the reflex. I have been able to observe it by applying the 21-point analy- sis, saccadic testing, and paper and pencil testing.
I share Ms. Goddard’s impression that some optometrists might not be applying some of the primitive reflexes in what both of us deem as the appropriate manner. For example the duck or pigeon walk does not show the Moro reflex. I believe it does show how connected the pathway is from cortex to brainstem, which can be useful in understanding a child’s vi- sion development. However, this can and does happen when one is dealing with a complex system. A similar scenario oc-
curs in clinical optometry: A purist of the 21-point analysis or graphical analysis might well be critical of the optometrist who uses his or her experience to modify either method. I am not familiar with Ms. Goddard’s INPP program and do not use it, so I cannot comment on what she is doing in her own reflex program. I think she brings into light the importance of receiving the proper training when implementing a reflex pro- gram. Perhaps we can have a symposium to discuss and share ideas, in the hopes of helping children reach their potential.
Sam Berne, OD, 4 October 2012
Dear Dr Taub,
I write in response to your invitation to comment on the pre-publication copy of a paper by Peter Blythe and Sally Goddard, as my work is discussed within it. The paper also considers the work of Harry Wachs, Lori Mowbray and Sam Berne. I shall primarily limit my reply to the section relat- ing to my work as I expect the others mentioned will also be responding.
I always test my patients for primitive reflex responses as part of my assessment of the patient’s vision and visual pro- cess. The visual process is pervasive in human thought and action. Vision is much more than eyesight, the visual process takes meaning from all sensory input, relates it to previous experience, and then is used to anticipate and direct action. It has been said that the primary purpose of the visual pro- cess is the direction of action. It is the observation, probing, testing and assessing of directed action and performance as a view of the visual process, that informs my examination of the patient.
The learning and development of the visual process is in- tertwined with the development of movement, postural con- trol and perceptual processing skill in the first year of life, and continues thereafter. In 1949 Gesell1 said that “The intimate interdependence of the visual and action systems is nowhere more significantly displayed than in the sequence and trends of child development.”1
Hadders Algra’s2 Theory of Motor Development is based on Edelman’s Neuronal Group Selection Theory3 (NGST) and describes a primary variability of movement patterns, fol- lowed by selection, and then a secondary (adapted) variability of movement patterns. The primary repertoire of movement variability begins in utero and is explored by self generated movements, based on the sensory afferent information. With time and practise, and as the child gains voluntary control, selection of movement patterns takes place, which is age re- lated e.g. reaching and grasping selection takes place at about 4 months, selection for sitting at about 6-7 months. Then that is followed by a repertoire of secondary variability of move- ment patterns as the child practises their selected movement in different situations, e.g., can grasp when sitting, standing, lying, in different directions etc. Selection of movement pat-
terns in the secondary repertoire of movement takes place based on experience. The neurosensory cortical re-entrant pathways provide the reference back to previous experience3 in the visual process that is used in secondary repertoire selec- tion. The mature situation occurs when the child can adapt each movement exactly and efficiently to task specific condi- tions and tasks.
The primitive reflexes are involved with the primary rep- ertoire of movement variability, and remain available in the brainstem as a movement choice within the motor develop- ment hierarchy. Indeed, the Tonic Labyrinthine Reflex (TLR) and Tonic Neck reflexes are used at all times in the uncon- scious control of posture,4 as part of the neural substrate.5 Ca- pute5 has shown that investigations using electromyography have demonstrated the universal persistence of the primitive reflexes into normal adulthood. Gesell1 described the role of the tonic neck reflexes in the development and control of eye movement at length. The understanding and treatment of the motoric basis of visual process learning has been part of op- tometry for over 60 years.
Hadders Algra2 said “The NGST advocates that interven- tion therapies for children with motor dysfunction at an early age should focus on the provision of variable sensorimotor experiences. The latter might be achieved by means of the application of variable postures which counteract the infant’s propensity for stereotyped activity.” This describes the learn- ing of primary movement patterns from the primitive reflexes as part of a motor intervention strategy.
When it comes to making an assessment of primitive re- flexes response the appropriate stimulus is used to elicit the reflex, and observation made to probe whether the patient has the cortical learning to have developed a primary and sec- ondary movement repertoire to that stimulus. It questions whether the cortical learning has been made from the primi- tive reflex to gain voluntary control. If the cortical learning is in place completely then the reflex response will be absent.
Where there has been incomplete cortical learning from the primitive reflex movement development will be affected and is considered a primary course of delay in achieving motor milestones and performing coordinated movements.6
Impoverished and incomplete motor learning affects, and is affected by, the learning and development of visual skill, and is apparent in all performance and behaviours, e.g., co- ordination, school performance, fine hand control, sports skill, thinking, planning, sequencing, eye movement control. Piaget7 said that highest visual skills – attention, identifica- tion, localisation, apperception, mental synthesis and visu- alisation – are part of abstract thought. In turn abstraction is a high level experience that is a source for the development of intelligence. It follows that the visually directed cortical learning from the primitive reflexes in the first year of life is fundamental to the development of intelligence.
My assessment of a patient involves testing within my op- tometric examination room, and the assessment of primitive reflexes and gross motor skill movement patterns in my vi- sion therapy room. There are many methods of testing for primitive reflex responses, e.g., by Fiorentino8 and Capute,5 not just those recommended by INPP. A lack of learning from the reflexes can be seen in posture, movement and gait when walking on a walking rail; when testing pupil reactions and at other times in the optometric examination of the patient.
A photographic description of the assessments I make for primitive reflexes was shown on the ICBO poster described by Goddard and Blythe as ‘Issue 9’ in their paper. As was pointed out I had a labelling error on my poster, and that has been corrected. But it was just that, a labelling error not an error of thinking. The poster now says, correctly,
Assessment of the Landau reflex response for the underly- ing Tonic Labyrinthine Reflex (TLR). Also, assessment of body awareness, the ability to follow instructions, balance, and core strength and stability.
The Landau reflex follows on from the Tonic Labyrinthine reflex (TLR), and develops as the child learns extensor con- trol from the TLR. As I stated on my poster, I view the Lan- dau reflex response in terms of learning from the TLR, so that where there has been incomplete learning from the TLR the development of the Landau reflex will be incomplete, and the development of the extensor tone will be poor.4
In my practice, testing for any primitive reflex does not take place in isolation, but is viewed as part of the patient’s over- all performance, as described above. Goddard9 states in her book, Reflexes, Learning and Behaviour,. that “the Landau re- flex acts as an inhibitory influence upon the TLR,” but has ne- glected to mention that in this paper, preferring to give a lesson on the Strauss reflex which was the reflex mentioned in the labelling error. The Strauss reflex does not play any part of my assessment of the Landau reflex and learning from the TLR.
I have been working in this way for over 12 years includ- ing motor developmental learning in my Optometric Vision Therapy (OVT) programme, with excellent success. In or- der to reach their full potential, patients need to complete a programme of OVT that includes learning from the primitive reflexes, through gaining the ability to move accurately, au- tomatically and gracefully through space with the eyes, body and mind, as they have for over 60 years.
By coincidence, optometrists may now choose to gain a greater appreciation of both the benefits and limitations of the INPP approach of reflex stimulation and inhibition pro- grammes by attending Goddard and Blythe’s newly launched course for behavioural optometrists.
Yours sincerely, Caroline Hurst, BSc 25 October 2012
- Gesell Vision: It’s Development in Infant and Child. Santa Ana, CA:
Optometric Extension Program Foundation, 1949.
- Hadders-Algra M. The neuronal group selection theory: Promising prin- ciples for understanding and treating developmental motor Dev Med Child Neurol 2000;42:707-15.
- Edelman GM, Tononi A Universe of Consciousness. New York: Basic Books, 2000.
- Magnus R. Cameron prize lectures: On some results of studies in the physiology of posture. Lancet 1926;208:531-6,585-8.
- Capute AJ, Accardo PJ, Vining EPG, Rubenstein JE, et al. Primitive Re- flex Profile, Baltimore, MD: University Park Press,
- Savelsbergh G, Davids K, van der Kamp J, Bennett S. Development of Movement Co-ordination in Children. London, UK: Routledge, 2003:97- 106.
- Piaget J. The Origin of Intelligence in the Child, London. UK: Penguin Books Ltd, England, 1936.
- Fiorentino A Basis for sensorimotor Development – Normal and Ab- normal The Influence of Primitive, Postural Reflexes on the Development and Distribution of Tone. Springfield, Illinois: Charles C Thomas, 1981.
- Goddard S. Reflexes, Learning and Behavior. Eugene, OR: Fern Ridge Press,
Section 1 lists errors which relate to the administration of test procedures for the assessment of primitive and postural reflexes and the interpretation of the function of primitive reflexes in normal development, followed by factual clinical comments.
Section 2 lists examples of distorted interpretation or po- tential misuse of existing methods for remediation of aberrant reflexes, followed by factual clinical comments.