Testing for retained primitive reflexes involves a series of simple physical maneuvers, each designed to provoke a specific involuntary movement pattern that should have disappeared in infancy. A practitioner places the child (or adult) in a particular position, introduces a stimulus like turning the head or stroking the spine, and watches for telltale motor responses that indicate the reflex is still active. Scoring is typically done on a graded scale, and the results can point toward underlying neurodevelopmental concerns that might otherwise go unrecognized.
Why These Reflexes Matter Beyond Infancy
Primitive reflexes are automatic movement patterns controlled by the brainstem. They emerge in utero or shortly after birth and serve survival purposes: rooting helps a newborn find the breast, the Moro reflex triggers a startle-and-grasp response, and the asymmetric tonic neck reflex helps with birth canal passage. In typical development, higher brain centers gradually suppress these reflexes during the first year or so of life, replacing them with voluntary, coordinated movement.
When that suppression does not fully happen, the reflexes persist in a weakened or partial form. A growing body of research links this persistence to neurodevelopmental challenges including learning disabilities, attention difficulties, sensory processing differences, and motor coordination problems.1The Journal for Nurse Practitioners. Persistent Primitive Reflex and Developmental Delay in the School-Aged Child Children with special needs have been found to show substantially higher primitive reflex activity alongside lower motor skill scores compared to typically developing peers, with a strong negative correlation between reflex persistence and motor performance.2Physikalische Medizin, Rehabilitationsmedizin, Kurortmedizin. The Relationship Between Motor Skills and Primitive Reflexes in Children with Special Needs The underlying idea is that cortical maturation can be uneven, leading to patchy suppression of brainstem-level reflexes and resulting inconsistencies in functional skills.3Journal of Paediatrics and Child Health. Evaluating Primitive Reflexes in Early Childhood as a Potential Biomarker for Developmental Disabilities
The Reflexes That Get Tested Most Often
Not every primitive reflex is routinely assessed for retention. Clinical and educational screening programs tend to focus on a core group, and a recently validated assessment scale identifies seven dimensions that together capture the most clinically relevant retained reflexes: the Moro reflex, asymmetric tonic neck reflex (ATNR), symmetric tonic neck reflex (STNR), tonic labyrinthine reflex (TLR), spinal Galant reflex, spinal Perez reflex, and Landau reflex.4PubMed Central. Development of the children’s primitive reflex integration assessment scale Each has its own test procedure and its own implications when found to be active past the expected age.
How Each Reflex Is Tested
Moro Reflex
The Moro is the classic startle reflex. In infants, it is triggered by a sudden sensation of falling or a loud sound. To test for retention in an older child, the examiner typically has the child stand with feet together and eyes closed, then gently tips the child backward by pressing on the upper back or shoulders. Alternatively, the child lies face-up and the examiner drops the head slightly below the level of the spine. A retained Moro produces a visible startle: arms fling outward with fingers spread, sometimes followed by the arms pulling back in. In older children the response may be subtler, showing up as exaggerated flinching, a catch in the breath, or a visible tensing of the arms and shoulders in response to unexpected stimuli. This reflex normally integrates by about four months of age, so any clear response in a school-age child is considered significant.
Asymmetric Tonic Neck Reflex
The ATNR is sometimes called the “fencer’s reflex” because of the posture it produces. The standard test has the child get on hands and knees, keeping arms straight. The examiner slowly turns the child’s head to one side and holds it there for several seconds, then repeats on the other side. A retained ATNR causes the arm on the face side to straighten and the arm on the skull side to bend, sometimes causing the child to collapse onto the bent arm. An alternate standing version has the child extend both arms forward with eyes closed while the examiner rotates the head; retained reflex shows as involuntary arm drift or bending. This reflex is one of the most studied because of its links to handwriting problems, reading difficulties, and attention issues.5PubMed. Asymmetric tonic neck reflex and symptoms of attention deficit and hyperactivity disorder in children
Symmetric Tonic Neck Reflex
The STNR test also uses the hands-and-knees position. The examiner slowly flexes the child’s head downward (chin toward chest) and then extends it upward (looking at the ceiling). When the STNR is retained, flexing the head down causes the arms to bend and the legs to straighten, while extending the head up causes the arms to straighten and the legs to bend. You might see the child’s bottom rise when the head drops, or their elbows buckle when they look up. This reflex normally integrates around nine to eleven months and is thought to play a role in the transition from crawling to standing. Persistence has been specifically associated with attention and balance difficulties in boys.6PubMed Central. Disinhibition of Primitive Reflexes in Attention Deficit and Hyperactivity Disorder: Insight Into Specific Mechanisms in Girls and Boys
Tonic Labyrinthine Reflex
The TLR is tied to head position relative to gravity and affects whole-body muscle tone. Testing is done in two directions. For the forward component, the child stands with feet together and eyes closed, then slowly tilts the head forward. A retained response causes the body to curl inward, with shoulders rounding and balance shifting to the toes. For the backward component, the head is tilted back, and a retained reflex causes the body to stiffen and sway backward, sometimes with the child going up on tiptoe or losing balance entirely. The TLR is closely linked to balance and spatial orientation, and children who retain it often struggle with posture and coordination.
Spinal Galant Reflex
This one is tested with the child lying face-down or on hands and knees. The examiner lightly strokes along one side of the spine, about an inch from the midline, from the shoulder blade area down toward the hip. A retained spinal Galant causes the hip on the stroked side to swing toward the stimulus, and sometimes the whole trunk curves. The test is repeated on the other side. When this reflex persists, children often cannot sit still, are bothered by tight waistbands or labels in clothing, and may have bedwetting issues that seem unconnected to bladder control.
Spinal Perez Reflex
Less commonly discussed but included in newer assessment scales, the spinal Perez is tested by running a finger or light pressure along the midline of the spine from the base upward toward the neck while the child is on hands and knees. A retained response produces extension of the spine (arching the back), sometimes accompanied by a cry or visible discomfort. In infants this reflex can trigger urination, and its persistence beyond infancy is associated with general spinal tension and hypersensitivity along the back.
Landau Reflex
The Landau is typically tested in younger children by supporting the child horizontally in the air, face down. A normal Landau response causes the child to arch the back and lift the head and legs. When the head is passively flexed downward, the child should curl into flexion. Abnormal persistence or absence of this reflex can indicate problems with trunk control and postural tone. In older children, modified versions of the test may be used on a therapy ball or similar support.
Scoring and Interpreting What You See
Most testing protocols use a graded scale rather than a simple present-or-absent judgment. The widely used approach developed by Sally Goddard Blythe rates each reflex on a scale from zero to four: zero means no response at all, one indicates a barely detectable twitch or movement, two shows a clear but partial response, three means the response is obviously present and affects posture, and four represents a fully retained reflex that looks much like what you would see in an infant. Scores of two or above on any single reflex are generally considered clinically meaningful and worth investigating further.
No single retained reflex in isolation tells the whole story. Practitioners typically look at the overall profile across all tested reflexes, noting which are retained and how strongly. A child who shows mild residual ATNR and nothing else is in a very different situation from one who shows moderate-to-strong retention across four or five reflexes. The pattern matters as much as the individual scores.
Formal Assessment Batteries
While individual reflex tests can be performed by anyone who knows the procedures, several structured assessment batteries bring standardization to the process. The INPP (Institute for Neuro-Physiological Psychology) test battery, developed by Sally Goddard Blythe, is one of the most established. It examines the presence of unintegrated primary reflexes in children alongside psychomotor skills, with particular attention to balance and coordination.7Pielęgniarstwo i Zdrowie Publiczne Nursing and Public Health. Psychomotor disorders assesment in 4–6 year-old children with INPP test battery The full clinical version includes a detailed developmental history questionnaire and takes roughly an hour to administer.
A more recently developed tool, the Children’s Primitive Reflex Integration Measurement Scale (CPRIMS), covers the seven reflexes described above across seventeen items and has shown strong reliability in validation studies.4PubMed Central. Development of the children’s primitive reflex integration assessment scale Having a validated scale matters because it reduces the subjectivity inherent in watching for subtle movement patterns. Two different examiners using the same structured tool are more likely to agree on what they see than two examiners working from memory of what each reflex should look like.
Who Should Perform the Testing
One of the practical questions parents face is figuring out who actually does this kind of assessment. The answer depends partly on where you live and what services are available. Pediatric occupational therapists and physiotherapists with training in neurodevelopmental approaches are the most common professionals to conduct formal reflex assessments. Some developmental optometrists include primitive reflex screening as part of their evaluations, particularly when reading and visual tracking are concerns.
Nurse practitioners can perform basic primitive reflex checks during routine examinations, complementing standard developmental screening tools.1The Journal for Nurse Practitioners. Persistent Primitive Reflex and Developmental Delay in the School-Aged Child Pediatricians, however, vary widely in how much attention they give to retained reflexes beyond the newborn period. Many standard well-child visits do not include primitive reflex testing after the first year, so if you suspect retained reflexes in an older child, you may need to request a specific referral or seek out a practitioner who specializes in this area.
Some parents learn to perform informal screening at home using instructions from INPP-trained practitioners or published guides. These home checks can be useful as a first step, but interpreting the results accurately takes experience. A child who is anxious or self-conscious during testing may tense up in ways that mimic a retained reflex response, and a genuinely retained reflex can look mild enough to miss if you have not seen many examples. Home screening works best as a reason to seek professional evaluation, not as a substitute for one.
Conditions Linked to Retained Primitive Reflexes
Testing does not happen in a vacuum. Parents and practitioners usually pursue reflex assessment because a child is already struggling with something, and research has connected retained reflexes to several overlapping areas of difficulty.
Attention and hyperactivity symptoms have a particularly well-documented connection. Studies have found that ADHD symptoms are closely linked to persisting ATNR, suggesting that some attention difficulties may reflect compensation for unfinished developmental stages in reflex integration.5PubMed. Asymmetric tonic neck reflex and symptoms of attention deficit and hyperactivity disorder in children The connection also appears to differ by sex: persistent ATNR is more strongly associated with ADHD symptoms and balance deficits in girls, while persistent STNR shows a stronger link in boys.6PubMed Central. Disinhibition of Primitive Reflexes in Attention Deficit and Hyperactivity Disorder: Insight Into Specific Mechanisms in Girls and Boys
Motor coordination and fine motor skills are also affected. The strong negative correlation between reflex persistence and motor skill performance found in children with special needs is especially pronounced in balance and fine motor domains.2Physikalische Medizin, Rehabilitationsmedizin, Kurortmedizin. The Relationship Between Motor Skills and Primitive Reflexes in Children with Special Needs This makes intuitive sense: if turning your head involuntarily affects your arm tone because of a retained ATNR, handwriting is going to be harder than it needs to be.
Reading difficulties have been explored in connection with ATNR specifically. In one study, an intervention program designed to replicate primary reflex movements produced a significant decrease in persistent ATNR levels in the experimental group, while control and placebo groups showed no meaningful change.8The Lancet. Effect of replicating primary reflex movements on the reading and motor performance of children with reading difficulties The Lancet publishing that study lent some credibility to the field, though the sample was small and replication has been limited.
Autism spectrum disorder is another area where retained primitive reflexes appear at elevated rates. Research supports a close relationship between retained reflexes and both cognitive and motor function in autistic individuals, with some evidence suggesting that working to inhibit those reflexes can lead to positive changes.9PubMed Central. Retained Primitive Reflexes and Potential for Intervention in Autistic Spectrum Disorders
What Happens After Testing
Finding retained reflexes is only useful if it leads somewhere. The main therapeutic approach involves reflex integration programs: structured movement exercises that mimic the developmental movements which would naturally suppress each reflex. These programs typically involve daily exercises performed at home over several months, with periodic reassessment to track progress.
The INPP method, for example, prescribes a specific sequence of movements tailored to whichever reflexes are found to be retained. The child performs these movements for about ten minutes a day, and the program usually runs for twelve to eighteen months. Other approaches, such as the Masgutova Neurosensorimotor Reflex Integration (MNRI) method, use hands-on techniques performed by a trained practitioner combined with home exercises.
Evidence for these interventions is growing but still modest in scale. A case study using the reflex integration approach on a child with developmental delay showed significant improvement in ATNR integration after twenty days of therapy, along with moderate gains in gross motor function and attainment of previously unmet milestones.10PubMed. Effectiveness of Reflex Integration Approach on Asymmetric Tonic Neck Reflex in a Child With Developmental Delay-A Case Study In children with spastic cerebral palsy, both reflex integration and play therapy improved functionality, though play therapy showed a slight edge for self-care, cognition, and gross motor function.11Bulletin of Faculty of Physical Therapy. Effectiveness of reflex integration approach and play therapy on functionality in patients with spastic cerebral palsy The honest take is that the evidence base consists mostly of small trials and case studies rather than large randomized controlled trials, so the strength of the claims should be weighed accordingly.
Where the Science Stands on Reliability
Retained primitive reflex testing occupies an interesting position. It has genuine research support, published in peer-reviewed journals including some high-profile ones, yet it has not been fully embraced by mainstream pediatric medicine. Part of the reason is methodological: many studies in this field are small, and the testing itself relies on clinical observation rather than objective measurement like a blood test or brain scan. Two trained examiners may disagree on whether a given response is a “two” or a “three” on the rating scale, and anxiety, fatigue, or unfamiliarity with the testing situation can all influence a child’s performance.
Another challenge is that retained reflexes tend to co-occur with conditions that already have established diagnostic pathways. A child with ADHD, dyslexia, or autism already has access to a range of interventions, and it can be difficult to isolate what retained reflex integration therapy adds beyond what those interventions provide. The field would benefit enormously from larger, well-controlled trials that compare reflex integration programs to active control conditions rather than no-treatment controls.
That said, the testing itself carries virtually no risk. It involves putting a child in natural positions and watching how they move. The worst-case outcome of testing is a false positive that leads to unnecessary exercises, which themselves are gentle movement sequences unlikely to cause harm. For a child who is struggling and not responding fully to conventional approaches, checking for retained reflexes is a reasonable additional avenue to explore.
Frontal Release Signs in Adults
Retained primitive reflexes are not exclusively a pediatric concern. In adult neurology, the reappearance of certain primitive reflexes is known as “frontal release signs” and is associated with degenerative brain conditions. The grasp reflex, snout reflex, and palmomental reflex are among those tested. Their emergence in older adults reflects diffuse cerebral dysfunction and frontal lobe changes that weaken the cortical suppression of brainstem activity.12Srpski arhiv za celokupno lekarstvo. Primitive reflexes in developing and adult brain – from intellectual disability to dementia
Testing for frontal release signs is straightforward and done at the bedside. The grasp reflex is tested by stroking the patient’s palm; an involuntary grasp that the patient cannot easily release is positive. The snout reflex is triggered by tapping the upper lip and watching for a puckering response. The palmomental reflex involves stroking the thenar eminence (the fleshy part of the palm near the thumb) and watching for a twitch of the chin muscle on the same side.
These signs carry clinical weight. In a cohort of cognitively intact research participants, those who tested positive for frontal release signs had roughly twice the risk of progressing to dementia compared to those who were negative: about a quarter of the positive group developed dementia versus about 15% of the negative group.13JAMA Network Open. Frontal Release Signs and Future Decline in Research Participants With Intact Cognition The finding is provocative because these individuals appeared cognitively normal at the time of testing, suggesting that frontal release signs may serve as an early warning marker. A single positive sign on its own is not diagnostic of anything, since some frontal release signs can appear in healthy aging, but a cluster of them warrants closer follow-up.
Practical Tips for Parents Considering Testing
If your child is struggling with coordination, attention, reading, or sensory sensitivities and conventional evaluations have not fully explained the picture, asking about retained primitive reflexes is worth the conversation. Look for a practitioner who uses a structured assessment battery rather than informal observation alone, since validated tools produce more reliable results.4PubMed Central. Development of the children’s primitive reflex integration assessment scale Occupational therapists with specific training in reflex integration are a good starting point, and some will offer an initial screening that takes only fifteen to twenty minutes before deciding whether a full evaluation is warranted.
Be wary of practitioners who present retained reflexes as the root cause of all learning and behavioral issues. Reflex retention is one piece of a larger neurodevelopmental picture, and the best outcomes tend to come from approaches that address reflexes alongside other needs rather than in place of them. A child with significant ADHD symptoms, for example, may benefit from both reflex integration exercises and evidence-based ADHD management strategies. The two are not competing explanations; they can be complementary lenses on the same developing brain.