Primitive Reflex Integration Case Studies

Submitted by Theresa Williams OTR/L

David is a 19-year-old male diagnosed with autism and ADHD inattentive type. He had been home schooled for most of his education and was nearing the point of graduation. David expressed a desire to continue his education at the collegiate level, however his mother had concerns regarding his lack of social awareness, emotional ability, and poor sleep/wake patterns. She requested an occupational therapy evaluation to address limitations in executive functions and social engagement.

Upon evaluation, David presented with a positive fear paralysis reflex noted by constant pacing (chronic stress response), frequent attempts to control or manipulate the environment and testing situation, and rapid breathing with reliance on parent for reassurance (anxiety) during transitions and formal testing. He also presented with a positive TLR [Tonic Labyrinthine Reflex] elicited by flexion and extension of the head and neck in standing.

David had slight alteration of balance and locking of the knees with eyes open, and a near loss of balance with a step backward when eyes were closed.

It was determined that due to his extreme anxiety secondary to FPR [Fear Paralysis Reflex], initial treatment recommendations should be carried out at home with his mother present and facilitating. David and his parent were instructed in the four rhythmic movements [from the Brain and Sensory Foundations course]. Since David was unable to achieve a smooth movement pattern actively, passive movements were recommended with parent facilitation. He was resistant to touch; however, he could perform the movements in parallel with his parent simultaneously with the visual demonstration.

Recommendations were to continue with the passive movements daily for up to 5-10 minutes 2x/day for the next two weeks. Parent was encouraged to keep a log of any negative responses and was instructed to go slowly at David’s level of tolerance for the movement.

After completing two weeks of rhythmic movement, David returned to the clinic. He reported that he really enjoyed some of the movements. He did not “like” back slides because it rubbed his head and back too much, but he “got used to it”.

It was also noted that David was able to stand still (no repetitive pacing) and accept verbal and demonstration instructions from the therapist. His mother reported that it took approximately one week of slow progression, but he now tolerated about 20 min per day of rhythmic movement. During this session, David was instructed in both [the Brain Tune up] and the supportive re-patterning sequence to further aid with integration of the FPR but was unable to perform the eye movements because he felt dizzy. This most likely reason for this was due to the unintegrated TLR. He was encouraged to continue with the passive rhythmic movements with his parent and to perform [the Brain Tune up] and supportive re-patterning without eye movements for the next two weeks.

The following weeks consisted of OT sessions every 2 weeks followed by ongoing home recommendations. After about 10 weeks of intervention, David was able to carry on a conversation with the therapist without evidence of anxiety or stress. He asked appropriate questions and was able to demonstrate the four rhythmic movements actively with good control, speed, and accuracy. It would appear that his fear paralysis response was less intrusive, and he was ready to address some of the TLR integration recommendations. David tolerated TLR isometrics, but had some difficulty grading the force of head isometrics initially. Parent was encouraged to perform TLR isometrics using her hand so that she could cue David as to the appropriate amount of force applied.

Weekly OT sessions were now tolerated with direct intervention from the OTR. TLR integration activities were conducted in the office including play-based activities and sustained prone positioning during board games and puzzles. David was able to perform [the Brain Tune up] and supportive re-patterning with the eye movements without report of feeling dizzy. His mother reported that David no longer fell asleep during the day and he had a more typical night time sleep/wake cycle sleeping from 10pm to 9am. (Previously he would fall asleep at 10pm, sleep for a few hours, wake to play video games for a few hours, and return to sleep until about 11 in the morning. He would then nap during the middle of the day.) She also reported that he was on task for academics and his piano teacher reported improvements in David’s ability to keep pace with a metronome. These changes were not “expected” by the parent and she was extremely pleased that she was seeing functional improvements after so many years without change.

David’s mother agreed to allow him to enroll in one online class through the community college. At one point, David was required to attend office hours with the professor. A 5-step Balance was implemented to assist him with success during this encounter. David set a goal of completing the conference with his professor without his parent present. He practiced role playing this interaction in the clinic with the therapist and with the office receptionist (a less familiar person). This elicited some shortening of breath, but David was able to utilize mitigation techniques [from the  Brain and Sensory Foundations course] to reduce his anxiety.

He then performed a supportive re-patterning sequence while in standing with therapist giving demonstration of activities as needed. Fortunately, only the initial puppet march required cues, most likely due to the lingering anxiety from the encounter with the receptionist. Finally, David verbalized that he would be able to meet with his professor alone without his parent present.

Prior to his actual conference, David was encouraged by his mother to perform his rhythmic movements and [the Brain Tune up]. While driving to the campus he engaged in positive self-talk and practiced what he would say. His mother reported that when David returned to the car after his conference, he breathed a sigh of relief and gave her a hug (something he had not done in a very long time).

David expressed a desire to continue working with OT to decrease other reflexes which have also been identified as non-integrated. This includes continued work with his TLR, as well as addressing the STNR [Symmetrical Tonic Neck Reflex] and spinal galant reflexes. STNR and Spinal Galant reflexes were previously not addressed due to his heightened anxiety and resistance to touch. At the time of this writing, David continues to attend his college class and is planning to enroll in a class and a lab in the next semester. OT intervention is scheduled to continue on a weekly basis as needed.

[Edited for length and clarity, emphasis added]