Primitive Reflex Integration Case Studies

10-year-old with Autism and ADHD shows gains in motor function, sitting still, and toileting

This OT used the tools from the Brain and Sensory Foundations First Level and Second Level courses to help her son with Autism and ADHD improve his: handwriting, compliance, and ease of falling asleep; plus the ability to exercise, sit still, and use the bathroom independently.

Submitted by Melanie Elliot, Occupational Therapist

Eric is a boy aged 10 years with a diagnosis of ASD and ADHD. He is medicated for his ADHD on school days only. Eric has an IEP in school and receives some of his tuition in small groups. He currently attends a mainstream, state school.

Eric constantly walks on his toes. As his mother I have tried to provide additional vestibular and proprioceptive input over the years including a Lycra sheet for his bed, weighted vests, compressions clothing, Hokki stools of in-seat movement, air-filled seat cushions and deep pressure with a therapy ball etc. I have also encouraged and facilitated activities such as trampolining, cycling and swimming i.e. any activity against resistance to name but a few. His toe walking is less obvious after a family hike or cycling but these activities do not result in lasting change. He has also received a block of physiotherapy to help with his toe walking and to ensure that he maintains a full range of motion in his ankle. He will consciously try very hard when going into school to walk flat footed but this is also not lasting.

Eric has a lot of overflow movements in his mouth when writing/drawing or completing any fine motor activity. He also struggles with lip closure when drinking from a cup or a bottle and chewing his food. He has always backwashed when drinking. I have asked several Speech and Language Therapists for support with this but to no avail.

Sleep was a huge issue when Eric was little. He did not start sleeping through the night until he was 3 and a half and even then, he would wake and bounce on his bed. This happens but less frequently now. However, the ability to fall asleep is still very tricky and we have pushed back bed time till 9:15pm so that we have an hour for bath, movements, reading and bed. We have a pretty rigid bed time routine but there are still many days when he “cannot turn his brain off”.

Eric has always struggled with his fine motor skills and although he has always been given fidgets to play with and supported in playing with Lego etc., he continues to find this difficult. He has always struggled with mid line crossing and when we mowed a figure 8 into our lawn, one of us had to stand in the middle to make sure he crossed over – left to his own devices, he would run around the outside of the figure 8.

Left right discrimination is poor and Eric will swap his cutlery around in his hands day to day. He can cut with a knife and fork, but has been slow to learn and is still very much a conscious task and not automatic. Eric has always struggled to achieve full independence in toileting for bowel movements. It seemed to be a combination of inattention, not wanting to miss out and inadequate sensation. Eric engages in a great deal of flapping and jumping especially when he needs to discharge energy or when he is particularly excited.

I started with the rhythmic movements and the Brain Tune Ups [from the Brain and Sensory Foundations course] as they seemed the best place to start in laying down a foundation for reflex integration. I wanted to help him achieve better sleep in the first instance and help nurture his attention and focus. Rhythmic movements would help with this regulation piece. Having also discovered in the research cited that children with ADHD frequently lack rhythm, the rhythmic movements were the perfect place to start introducing rhythm and smooth movement to Eric.

I then progressed to TLR [Tonic Labyrinthine Reflex], Fear Paralysis and Moro [from the Brain and Sensory Foundations course]. I remembered from a lecture that these 3 reflexes were foundational for regulation of the autonomic nervous system and other reflexes and I wanted to start by regulating Eric and achieving a good foundation, knowing that I would have to gradually work on integrating all his reflexes. Because soiling of underwear was so stressful, I then targeted the Spinal Galant. The [playful] exercise for this one was also easy and fun so it was a win-win situation. At this point I started introducing ATNR [Asymmetrical Tonic Neck Reflex] head movements into the Rhythmic Movements. He found this very hard and I was surprised to see how hard the visual tracking was for him.

Next, I chose the hand and foot reflexes specifically with his handwriting and toe walking in mind. He loved these and they are quick and easy to do so it gave us both a bit of a boost. I am now working on Head Righting and starting on the Brain and Sensory Foundations Second Level reflexes. I have been very interested in learning about the Foot Tendon Guard response and feel very optimistic about incorporating this. The relationship between muscle tension and anxiety was fascinating to me.

We try to do some game on our tummies once a day but it really depends on what is going on, on the day. He finds being on his tummy harder than I had ever realized. So grateful to be learning so much and to have these tools.

Compliance and willingness to participate have always presented significant obstacles to any intervention I or anyone else has ever tried to do with Eric – pencils skills he flat refused to do; he would not do any exercises as part of a sensory diet; most things I introduced were rejected e.g. weighted vest, hokki stool, lycra, weighted pencils and angled writing surface etc. I even tried a play based, child led approach (DIR Floortime) which he enjoyed but even in this space he refused to engage in challenging tasks. He is very self-aware in many ways, for example in one particular Floortime session, I asked him to write down all the names of his pirates so that we could do a role call. He responded without hesitation with a ‘No thank you, you do it.’

When embarking on this course, I presented the exercises as a project that mom was doing to learn new skills for work. This lasted 2 days. I then sat down with him and showed him the case studies on the website. I was SHOCKED and delighted that he agreed. His compliance was a bit hit and miss at first, but increasingly he is an active participant and this in itself was a significant shift. We have a long journey ahead of us, I realize my son has many unintegrated reflexes and the added issue of a dual diagnosis. I am currently doing the Brain and Sensory Foundations Second Level course as I need more tools. I will gradually work my way through all the reflexes.

Positive changes so far, enough for Eric to notice too:

• He no longer backwashes when drinking and has slightly better lip closure.
• He can and does sit still to do his homework–he even does his homework without me sitting next to him, taking more responsibility for his own work.
• His handwriting has improved.
• He actually enjoyed our recent family bike ride and seemed so much more at ease in the seat.
• Accidental soiling of his underwear is very rare these days and I no longer have to prompt him to go to the toilet, now being independent in doing this for himself.
• He is falling asleep more quickly than before.

We have a long way to go, but we have definitely noticed that he is more cooperative in general. Prior to starting this course, he was so avoidant of tasks, requests and challenges. He would simply refuse and it would take time and energy to get him to participate in everything other than activities of his choosing. He now is able to transition between self-selected and adult selected tasks more easily.

I have learned that the integration of these reflexes is not a case of simply working through the reflexes in a linear fashion. The reflexes are so intertwined and interconnected that the approach has to be highly individual. Being observant is key to helping navigate whether or not something is working. I have learned that the games are a vital part of the process and not an optional extra. And that even at 10 years of age, he will still play games on his tummy.

Time doing these movements: May – June and October currently on going
15 min 5x/week, with breaks (holidays, visitors etc), for a total of about 29 hours (1hr, 15 min/week)

(Edited, emphasis added)