Primitive Reflex Integration Case Studies

Submitted by K.O., Occupational Therapist

Robby is a six-year-old first grade student diagnosed with Autism. He is enrolled in our Autism program in a public elementary school which utilizes an ABA approach. Robby’s was a full term baby who reportedly met his developmental milestones until approximately 15 months per parent report. Robby is non- verbal, which affects his ability to communicate his needs or frustration. He is being introduced to PECS symbols to choose items that he wants in order to request, including toys, foods, all done and more from an array of two. Typically, Robby will point or take an adult by the hand and bring them over to get a preferred item. He will whine or protest when he does not get these items or when he is not able to tell others his wants and needs. Robby is beginning to make more sound vocalizations that include early developing sounds. Robby continues to demonstrated limited understanding of concepts receptively, including the identification of objects related to school and home environments and food. While Robby makes frequent eye contact as a means of requesting to adults, he does not consistently look in response to his name (about 50%).

Robby requires frequent sensory input to be comfortable and productive during his school day to regulate his body and his attention, including tactile, deep pressure/proprioceptive and oral input. He benefits from wearing a weighted vest and compression belt to provide this input to increase his ability to participate in seated tasks for educational and therapeutic activities. He frequently becomes physically dysregulated and seeks movement by running and yelling. Robby benefits from scheduled times to wear the vest and compression belt as well as other sensory activities to increase his participation and transitions between tasks. When his body is regulated and demonstrating a calm level of arousal Robby is able to sit and participate in fine motor or visual motor tasks for 2-3 minutes with consistent assistance. He demonstrates difficulty sustaining visual attention for visual motor and bilateral tasks and sustaining a 4 finger grasp on tools and manipulatives. He currently mouths non-edibles when upset/frustrated (intense chewing) or seeks to explore something orally. Robby is able to accept an appropriate oral motor tool to chew in most situations when he is seeking input by chewing inappropriate items in his environment. Robby exhibits several interfering behaviors which impact his ability to function in the classroom. He seeks out consistent sensory input (squeezes, ball being rolled over him) and is on a 30 minute fixed interval schedule with the weighted vest. He has limited body and safety awareness, and may run away from an adult or flop to the ground when distressed.

He demonstrates rigidity with regards to his schedule or preconceived notions of how things are “supposed to go”. When frustrated, Robby may flop to the floor, scream or cry and run in circles he can be very difficult to redirect. These tantrum behaviors average about four to five times a day.

Robby participates in routine gross motor tasks each day to help support motor planning development. He is able to follow 1 step tasks with repetition and physical assistance. For example, he is able to jump on the trampoline for varying repetitions but at times needs the motor plan demonstrated or physical assistance to initiate these movement opportunities.

Robby’s schedule is 5 days a week of 20 minutes of 6 varied motor stations that incorporate appropriate developmental movements and directed play activities. He is also seen twice per week for visual perceptual motor/fine motor tasks for a total of 40 minutes in all. He has the opportunity to participate passively in RMT exercises 5 days a week but has had a series of very slow introduction to the basic rhythmic movements due to his overall poor tolerance for touch.

I began very slowly introducing rhythmic movements to Robby as his touch tolerance was very low. We began with whole body deep pressure and slowly introduced the rhythmic movement [from the Brain and Sensory Foundations course] in side lying of shoulders and hips. Robby could tolerate about 3-5 seconds and then roll onto his stomach where rhythmic movement of hips was introduced for a few seconds. We were able to introduce this method for 2-3 times a week as tolerated. Robby would then be introduced to a gross motor task such as using a riding car with his feet or jumping on the trampoline as these were tasks that he could motor plan and tolerate without periods of intense crying or screaming. He would ride to the motor room in a wagon using edibles to help maintain a sitting position. I felt that if we could proceed with a slow introduction he could greatly benefit as he was one of the most dysregulated children I have worked with in many, many years. Robby’s home situation is not one where I felt I could achieve any carryover of these movements.

After about three months Robby slowly began to develop tolerance a few times a week of deep pressure followed by 4 initial rhythmic movements for about 10-15 seconds. I started to incorporate opportunities to hug a large therapy ball as he lay over it to increase his body awareness. Also, hand reflex integration activities as tolerated during session to increase his grasp ability.

Now after six months Robby at this time is now tolerating about 1 minute of the each of the 4 basic rhythmic movements and is active in doing the windshield wipers leg movements with a touch cue. He approaches the mat and will lay down making eye contact consistently about 4 days a week. I have continued to expand his developmental movements/play activities each week/month to include tasks such as crawling through a cloth tunnel pushing a ball, sitting and scooting on a scooter board using his feet for movement as well as maintaining his grasp on a hoop to pull him about 20 feet at a time. He is now able to lie prone on a wedge and use large tweezers to pick up pompoms and release into a basket. We have been able to decrease Robby’s use of compression wrap and weighted vest to once per day.  

The changes we have seen in Robby this school year have been tremendous!

Robby is now able to sit at a table and work on concepts and fine motor activities for up to 30 minutes four to five times a day with periodic movement breaks. He is waving Hello and Good bye to familiar people. He is able to use a picture schedule to help anticipate his daily routine. He is vocalizing much of the day in a modulated volume making sing song noises, developmental sounds and uses approximately five words appropriately. Word use includes Hi, Bye, Go, Eat, No. He is able to sign all done and make an approximation of the words which he uses consistently. Robby is able to sit for circle time and listen to a story, he enjoys listening to music, he engages in “chase games” with staff coming towards making a go sound and looking for engagement. He is able to participate fully in motor group each day with cues for familiar motor tasks such as crawling through the tunnel, rolling a ball to another, jumping on the trampoline, using scooter boards, hippity hops, jumping with theraband holding the ends with both hands to name a few activities . The demonstration of new motor tasks enables him to engage in those activities, he is able to tolerate touch from familiar adults. This has facilitated a number of self-help skills such as buttoning buttons, zipping zippers and snapping snaps on his clothes and backpack. Robby used his finger for all eating at the beginning of the school year. He is now able to use a fork and spoon for foods such as macaroni and cheese, yogurt, etc. He has an upright posture and can wear his backpack to   walk down the hall. Robby is happy and smiling throughout most days. He anticipates his routine now and will follow simple commands such as “come here”, “sit down”, and “time to work”. Robby still chews many items but primarily it is now contained to chew toys and his back pack straps. At school, we have seen a significant decrease in his “tantrum behaviors “this has reduced to about once a week or less at this time. Robby is now able to wait in a noisy cafeteria to ride his bus home each day with a small group of children either sitting on a bench or in the wagon.

Parents report that Robby is much more settled at home and will engage in building tasks and cause effect toys at home. He is now on a more regular sleep schedule and they were able to take a vacation for the first time which involved “beach time”.

Overall I believe the combination of rhythmic movements, developmental activities and consistent approach each day have greatly contributed to Robby’s progress this year. He is a happy, smiling boy now most days!

[edited for clarity]