Developmental Reflex
- Is a critical tool in evaluating a
typical infant or an infant or child
with a disability
- Primitive and tonic reflexes are
present during infancy as a stage in
normal development and become
integrated by the CNS at an early
age
- Persistent reflexes/ obligatory
reflexes beyond the expected age of
development or appearing in adult
patients following brain injury ->
neurological involvement: Stroke,
TBI, UMN signs
Reflex
- Immediate involuntary response
evoked by a given stimulus
- All reflex responses are involuntary
and are not cognitive nor actively
set off
Primitive Reflexes
- A group of motor reflexes found in
newborn babies
- Develop in utero and share the
characteristics of being present at
birth in a full-term, healthy baby
- Mediated or arise from the
brainstem
- Controlled at the level of the
brainstem and spinal cord
- While the CNS matures, the reflexes
are integrated and suppressed
between 3 and 6 months of age.
- Obligatory primitive reflexes, a
reflex that a child cannot move out
of are never normal and indicate a
CNS problem.
- Primitive reflexes are replaced by
postural reactions at approximately
2 months of age.
Asymmetry of Primitive Reflexes
- Considered abnormal
- Hemiplegia
- Peripheral nerve injury (brachial
plexus injury)
- Underlying stroke
Newborn Reflexes
- Grasp Reflex, Plantar grasp, Moro
reflex, Rooting reflex, Sucking reflex,
Babinski reflex, Crawling reflex,
Stepping reflex, Tonic neck reflex
(fencing reflex)
Examination of Primitive Reflexes/
Spinal
Flexor Withdrawal
- Stimulus: sharp, quick pressure to
palm or sole (UE, LE)
- Response: withdrawal of
stimulated extremity
- Onset to Integration: 28 weeks
AOG (age of gestation) to months
Crossed Extension
- Stimulus: same stimulus but on sole
of foot only. Sharp pressure on sole
of feet
- Response: withdrawal of
stimulated LE and extension of
opposite LE
- Onset to Integration: 28 weeks
AOG (age of gestation) to months
- Persistence such as in CP children,
negatively impacts gait and balance
while walking.
Traction or Pull to Sit
- Stimulus: pull infant to sitting from
supine
- Response: UE will flex
- Onset to Integration: 28 weeks
AOG (age of gestation) to months
Moro Reflex
- Stimulus: sudden neck extension
- Response: shoulder flexion and
abduction, elbow extension FFD
(fixed flexed deformity) by shoulder
adduction, elbow flexion
- Onset to Integration: 28 weeks
AOG (age of gestation) to months
- the only one of the primitive
reflexes which can be triggered by
all the senses.
- When activated, the Moro reflex
causes the baby to throw his arms
open and away from his body
(extension and abduction) and his
hands open. His legs also abduct but
not quite so markedly.
- Exaggerated in CP patients and
patients with other neurological
injuries. Patients may have poor
balance when sitting.
- PERSISTENCE: hypersensitive to
sensory input. Constantly alert and
on guard against his little body
which can trip him into exaggerated
reactions to certain stimuli.
Vestibular hypersensitivity (motion
sickness, intolerance of fairground
rides, poor coordination particularly
with hand/eye movements and
balance insecurity). Visual-
perceptual problems • poor reaction
to light
Examination of Primitive Reflexes/
Spinal
Startle Reflex
- Stimulus: loud noise, sudden light,
cold stimulus
- Response: sudden jerk of body
- Onset to Integration: birth to
persists
- Others: persists
Grasp Reflex: Palmar and Plantar
- Stimulus: pressure against palm or
sole
- Response: grasping of objects and
curling of toes
- Onset to Integration: PALMAR:
birth to 4-6 months. PLANTAR: birth
to 9 months
- Others: if delayed, make cause
delayed ambulation
Galant Reflex
- Stimulus: sharp stroke to
paravertebral line
- Response: lateral trunk flexion
towards stimulated side
- Onset to Integration: birth to 3
months
- Others: possible scoliosis
- Elicited by holding the baby in
ventral suspension. Then pulling
your finger down the lateral side of
the back muscles at one side. The
spine and torso will curve towards
the side where the fingers are.
- PERSISTENCE BEYOND NORMAL
AGE
- can affect the child’s ability to sit
- may indicate presence of scoliosis
- unable to sit still and may appear
to have ‘ants in his pants
- will fidget, squirm and not remain
quietly in one position
- may dislike labels in his clothes,
belts, anything round his waist
and be hypersensitive to all
clothing round his middle
- Distractibility, as a result of the
unwanted sensations above,
means that this child may have a
poor attention and concentration
span.
- As he dislikes sitting, he may
prefer to work on the floor on his
tummy.
- Nocturnal enuresis or bed-wetting
 - Absence: may mean sensory loss
such as when there is
myelomeningocele.
Asymmetrical Tonic Neck Reflex
Rooting Reflex
- Stimulus: stroke of perioral region
- Response: head turning with mouth
opening
- Onset to Integration: birth to 2
months
- Persistence: drooling,
hypersensitivity around the mouth.
Poor fine muscle control of the
internal and external mouth area
may lead to problems with correct
and full articulation needed for
speech. The tongue position may be
too far forward making, swallowing
and chewing difficult resulting in
poor control of food in the mouth
and dribbling.
Sucking Reflex
- PERSISTENCE: The sucking of
fingers, thumb and clothes may
continue if this reflex is retained. An
immature swallow pattern may lead
to problems with the correct
development of the palate. Poor
control of muscles around the
mouth may result in speech and
articulation issues.
Examination of Tonic Reflexes/
Brainstem
Positive Support Reflex
- Stimulus: contact to ball of foot in
upright standing
- Response: rigid extension of LE
- Onset to Integration: birth to 6
months
- Others: interfere in ambulation
- Elicited when placing weight on the
sole of the foot or pressure is given
against the sole of the foot resulting
in extension of legs
- Stimulus: head rotation
- Response: jaw or face limb
extension skull limb flexion. The
child assumes a “fencing” position.
The arm and leg on the side of the
skull remain in flexion, while the
arm and the leg on the face side
extend
- Onset to Integration: birth to 4-6
months
- Others: rolling, hand to mouth
activities, grasping
- Elicited by turning the head to one
side
- Persistence: Difficulty in visual
pursuits (tracking). Impaired
development bilateral hand function
(midline), writing problems,
dyslexia. Asymmetry & deformities
(spine/limbs) or even hip dysplasia
(subluxation) Impaired
development in prone (crawling).
Hand-eye coordination difficulties.
Problems with Balance (gait
problems, standing, sitting)
- DIFFICULTY CROSSING THE
MIDLINE: difficulties in:
manipulating an object with both
hands and passing the object
between hands which may not be
learnt properly:
- writing and reading are
compromised
- Visual-perceptual difficulties, such
a symmetrical presentation of
figures or symbols on a page, may
be seen.
- POOR VISUAL-MOTOR
INTEGRATION – hand-eye
coordination.
- AWKWARDNESS or a slightly
different way of moving in
 comparison to his peers may
cause the ATNR child angst.
- COGNITIVE EFFECTS A child with
an ATNR may be very capable
orally in the classroom but, when
writing is required or under
stress, such as in an exam, he may
well appear to ‘let himself down’
or perform below the level
expected of him.
Symmetrical Toni Neck Reflex
- Stimulus: Flexion of cervical neck
and UE; extension of cervical neck
and UE
- Response: flexion of UE; extension
of LE; extension of UE; flexion of LE.
forward head flexion producing
flexion of the upper extremities and
extension of the lower extremities
while extension of the head will
produce extension of the upper
extremities and flexion of the lower
extremities.
- Onset to Integration: 4-6 months
to 8-12 months. Not present at birth
- Others: quadruped position,
creeping with hands and knees
- normally emerges during the first
year of an infant's life and is
diminished by the age of 8-12
months
- bridging or transitional brainstem
reflex that is necessary for a baby to
transition from lying on the floor to
quadruped crawling or walking.
- tested by placing the child in
quadruped position on the floor and
passively flexing the head forward
and then extending it backwards
- Persistence: Posture - head
position will still affect the tone of
the upper and lower body
differently. When walking, the gait
may have simian/monkey-like
quality. In standing, the posture is
slouched with shoulders rounded
and the chin forward. In sitting on
the floor, a child may adopt a ‘W’
position. Problems with sitting o
Problems with concentration and
attention (fidgety and unable to sit
still). Problems with vision
(accommodation and vertical
tracking): Difficulty in catching a
ball, copying from the blackboard or
white board, trouble assessing
height such as walking onto a
descending escalator or when
standing on the edge of a diving
board or cliff.
- Messy eater
- Problems with swimming
Tonic Labyrinthine Reflex
- Stimulus: Prone and supine
- Response: flexor and extensor tone
- Onset to Integration: birth to 6
months
- Others: rolling (increase in extensor
tone). Best position is to side lie
- Present in newborns
- tilting the head back while lying on
the back causes the back to stiffen
and even arch backwards, the legs
to straighten, stiffen, and push
together, the toes to point, the arms
to bend at the elbows and wrists,
and the hands to become fisted or
the fingers to curl.
- To activate the TLR (flexion), the
baby’s head is brought to his chest.
His arms bend into his body and his
hips flex and knees bend, as his legs
are drawn into his tummy
- PERSISTENCE:
- beyond the first six months of life
- developmental delays and/or
neurological abnormalities
- may hinder functional activities
such as rolling, bringing the hands
 together, or even bringing the
hands to the mouth
- can cause serious damage to the
growing child's joints and bones,
causing the head of the femur to
partially slip out of the
acetabulum (subluxation) or
dislocation.
- VESTIBULAR EFFECTS - motion
sickness, poor balance, visual
perception problems (the ability
to correctly interpret information
received through sight). Issues
with spatial concepts (complex
cognitive skills which allows a
child, for example, to know: right
from left, up/down, on/in, was
from saw, how to fill a sheet of
paper with information). Specific
visual problems: lack of near-
point convergence and figure
ground effect (the ability to work
out which is the object and which
the background). Poor sequencing
skills and a poor concept of time.
- EFFECTS ON TONE- TLR in
flexion or forwards may cause
hypotonus – lower than normal
tone which can manifest as
weakness, poor posture and
slumping. A retained TLR in
extension may cause hypertonus/
increased tone and presents as the
lack of smooth movement or toe
walking.
Associated Reaction Reflex
- Stimulus: resisted voluntary
movement
- Response: involuntary movement
of resting extremity
- Onset to Integration: birth to 34
months, 8-9 years
Examination of Cortical Reflexes/
Midbrain
Body Righting on Body (BOB) Reflex
- Stimulus: passively rotate UT or LT
segment
- Response: body segment not
rotated will follow to align the body
- Onset to Integration: 4-6 months
to 5 years
- body-on-body reflex
- appears at about seven months of
age
- response of the body to pressure
stimulation
- The body will right itself
independently of the head.
- It plays a role in helping the child to
move from sitting to standing.
Body on Head (BOH) Reflex
- Stimulus: prone or supine
- Response: PRONE: head will orient
on vertical position. SUPINE: head
will orient in vertical position
- Onset to Integration: birth to 2
months to 5 y/o
Body on Head (BOH) Reflex
- Stimulus: tilt the body
 - Response: head orient in vertical
position
- Onset to Integration: birth to 2
months to persists
- Others: persists

Labyrinthine Reflex

- Stimulus: tilt the body with eyes

covered
- Response: head orient in vertical
position
- Onset to Integration: birth to 3
months
Protective Reflex
- Stimulus: displaced COG
- Response: abduction and extension
of extremities to support and
protect body from falling
- Onset to Integration: ARM: 4-6
months. LEG: 6-9 months
- Others: persists
- used in order to protect themselves
from a loss of balance.
- 5-6 months
- While holding the infant in a vertical
(upright) position in space with
your hands around the infant’s
waist, plunge the child downward
towards flat surface.
- Results in the child extending his or
her head, extending the arms and
fingers outward as to protect the
child from falling. The child blocks
the fall by taking weight into his or
her arms.
- used in order to protect themselves
from a loss of balance.
- 7-8 months
- While the child is sitting with legs
out in front, push the child on his or
her shoulder hard enough to cause
the child to lose his balance.
- Results in the child reaching out
with his arm on the side opposite
the push force with extension of the
elbow, wrist, fingers to catch himself
from falling to his side. The child
blocks his fall by taking weight into
his open palm and fingers.
- used in order to protect themselves
from a loss of balance.
- 9-10 months
- While the child is sitting with her
legs out in front, push the child
backwards hard enough to cause the
child to lose her balance over her
base of support.
- Results in the child extending her
arms out backwards to protect
 herself from falling. The child blocks
her fall by taking weight onto her
extended arms.
Equilibrium Reaction (Platform) Reflex
- Stimulus: displaced COG
- Response: UPWARD SIDE: trunk
curvature with abduction and
extension of extremities
- Onset to Integration: PRONE: 6
months. SUPINE/ SITTING: 7-8
months. QUADRUPED: 9-12 months.
STANDING: 12-21 months
- Others: persists
- subconscious but, unlike a reflex
response, their movement response
is event specific and unique to each
situation
- the last of the developmental motor
reflexes to mature.
- mediated/found in the cortex and
are controlled together with the
cerebellum to allow fine-tuned,
responsive and protective
movement.
Neck Righting Reflex
- Stimulus: turn the infants head in
supine position
- Response: body log roll on same
side
- Onset to Integration: 4-6 months
to 5 years
- first of the righting reflexes to
appear
- present at birth in a normal full-
term baby and strongest at about
three months of age
- triggered by stretching of the neck
muscles when there is rotation of
the head or movement of the
cervical/neck spine
- With the baby in supine/on his back,
if the head is turned to one side, the
whole body will follow, in what is
called a log roll, until it is brought
into alignment with the head.
Landau Reflex
- Develops by 4 to 5 months of age
- infant is suspended by the
examiner’s hand in the prone
position, the head will extend above
the plane of the trunk. The trunk is
straight and the legs are extended so
the baby is opposing gravity.
- When the examiner pushes the head
into flexion, the legs drop into
flexion. When the head is released,
the head and legs will return to the
extended position.
- The development of postural
reflexes is essential for independent
sitting and walking.
 Silverskiold Test
Phelp’s Test
- used to identify isolated
gastrocnemius contracture
associated with several foot and
ankle pathologies
- measures the dorsiflexion (DF) of
the foot at the ankle joint (AJ) with
knee extended & flexed to 90
degrees
- considered positive when DF at the
AJ is greater with knee flexed than
extended.
- performed with the patient seated
or in supine

Galeazzi Test

- Allis sign
- used to assess for hip dislocation,
primarily in order to test for
developmental dysplasia of the hip.
- performed by flexing an infant’s
knees when they are lying down so
that the feet touch the surface and
the ankles touch the buttocks.
- If the knees are not level then the
test is positive, indicating a potential
congenital hip malformation