Primitive Reflex Integration Case Studies

Submitted by LW, OTR/L 

ZF is a 4-year-old male with a diagnosis of autism. He was referred for occupational therapy when he was almost 3 years old secondary to sensory processing deficits and fine motor delays. Parent’s primary OT-related concerns at initial evaluation were hyper-responsivity to certain sounds, poor sleep hygiene, and poor self-feeding skills. Other pertinent medical history includes a history of chronic ear infections, and receptive and expressive language delay. Upon evaluation, ZF was found to have hypotonia, lack of coordination, and sensory processing differences including poor interoception and body awareness. His sound sensitivity was quite disabling and limited family routines and outings. He only played with toys if the batteries had been removed and did not tolerate singing, the TV being loud, or the car radio being on. He was easily over-stimulated when in public spaces with various environmental sounds, such as standing in line at the grocery store due to the continuous beeping at check-out and the chatter of nearby customers and employees. Parents noted that ZF did not respond to pain and that he struggled with functional play skills due to poor attention and impulsivity. ZF struggled with falling asleep at night as well as sleeping through the night. He was toilet-trained during the day if taken regularly to the bathroom, otherwise he had decreased awareness of when he needed to toilet and/or be changed. When therapy was started, ZF ran from one thing to another with little interaction or awareness/desire to interact with objects/people. He frequently assumed a protective posture of curling up and covering his eyes and ears when over-stimulated. He only tolerated being seen in a small treatment space with no other children or therapist’s around him.

• I started with rhythmic movements [RMs] [from the Brain and Sensory Foundations course] in supine to see if the motion would help with overall calming so that he could focus on functional tasks. I also thought this was a good starting point because ZF always seems to be in a hyper-alert state. Initially, he only tolerated RM to a count of 5, but always covered his ears and requested “no counting” or “no singing.” I wanted to address his hypo-responsive vestibular system as well as provide input and activation of his cerebellum to see if the rhythm would help with coordination. Over the course of several months, I gradually was able to increase the amount of time ZF tolerated supine RM and was able to introduce and train mom in the other RMs. Parents are now using RMs at home on a regular basis and ZF will now ask for “rocking” and has started “rocking” his baby sister. I am now able to count or sing and on occasion ZF has joined me in counting. The most significant improvement parents have seen since doing the RMs on a consistent basis, is improved sleep. ZF was getting up every couple of hours during the night and is now sleeping through the night.
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• I’ve worked on doing the two-minute brain tune-up [from the Brain and Sensory Foundations course] with ZF as a way to address bilateral coordination, motor planning, and overall readiness for functional activities. Over several sessions I have seen him progress from needing full assist to being able to model a few consecutive cross crawls in sitting. We are still working on cross crawls in standing.
  
  
• We addressed reflex stimulation and integration activities [from the Brain and Sensory Foundations course] as part of each session over the course of several months. I focused primarily on the Fear Paralysis Reflex and Moro reflexes, but have also done activities to address the TLR [TonicLabyrinthine Reflex], ATNR [Asymmetrical Tonic Neck Reflex], and STNR [Symmetrical Tonic Neck Reflex]. I chose to address these reflexes because [I] felt that these retained reflexes were factors contributing to ZF’s hypersensitivity to sounds, overall sensory processing differences, and his inability to focus and attend to functional activities including structured gross and fine motor tasks. ZF does not cross his midline and avoids fine motor and visual motor tasks. When addressing the ATNR, ZF required verbal and/or tactile cues to fully turn his head. After doing some of the integration activities, I noticed that ZF’s visual tracking skills have improved and he is more willing to participate in tabletop visual-motor activities. I found that ZF has become more engaged in therapy sessions, has improved attention and ability to focus, tolerates being in gym with other children and lots of background noise, and most importantly, his parents are now able to take ZF to the store without any meltdowns due to being overwhelmed and overstimulated. I also noticed that ZF is more aware of where sounds are coming from and is better able to filter out noises when focused on fine motor activities at the table. ZF receives speech therapy directly after OT and on days we do a lot of reflex integration work, the speech therapist has noticed that these are ZF’s best days in speech. Lastly, ZF is now noticing and responding to pain and parents have reported that he seems more aware of his emotions and feelings and is initiating play with family members and peers.

I was skeptical about the heart-brain connection, but was pleasantly surprised when I tried it and my sessions, interventions, and outcomes were better. I found the RMs to work the best when ZF was so distracted or unengaged and they were also a way for us to co-regulate. I noticed that when I seemed to be “losing” ZF, that if I did some more RMs with him, I was able to regain his attention and focus.

[Edited, emphasis added]