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Over the next several days, I want to take a closer look at Primitive Reflexes. Not simply what they are or how we test for them, but what they may actually tell us about the person sitting in front of us. It’s a topic I have spent a significant amount of time reading and learning about, and one I have even been fortunate enough to teach on in recent years.

We will look at the Moro, Tonic Labyrinthine (TLR), Asymmetrical Tonic Neck (ATNR), Symmetrical Tonic Neck (STNR), and Spinal Galant (SG) reflexes, along with head-righting reactions. We will explore where each comes from, what purpose it serves during development, how the reflexes interact with one another, and what the research currently tells us about retained primitive reflexes. Most importantly for those of us working in vision therapy, we will look at how each may interact with visual development and what can happen to these systems following a traumatic brain injury.

But before we start breaking down individual reflexes, I think we need to establish something important:

A retained primitive reflex is a clinical observation, not a psychiatric diagnosis, nor is it a sign of an underlying emotional imbalance.

Vision Therapists spend a tremendous amount of time observing people, often much more time than many other providers. We notice how someone sits, how they move, and how they respond when something becomes difficult. We notice the child who becomes frustrated very quickly, the patient who seems unusually sensitive to movement or noise, or the person who becomes overwhelmed when we increase the visual or vestibular demand of an activity. It can be easy to look at those behaviors, find a retained primitive reflex, and begin connecting the dots. Moro equals anxiety. ATNR equals poor attention. STNR equals difficulty sitting still.

But the nervous system is rarely that simple.

A retained primitive reflex may give us useful information about neurological development and regulation. It may even help us understand why something that appears easy from the outside requires considerably more effort for the patient experiencing it, but it doesn’t give us a diagnosis.

What If the Patient Really Is Working Harder?

Think about a child you have met who cannot seem to sit still while reading. We might see poor attention, difficulty maintaining posture, challenges with stabilizing the head, eyes moving inefficiently, and even vestibular information competing with visual information. These ideas are important, and they inevitably lead to a question:

What if sensory stimulation that barely registers for another child is extraordinarily distracting to this child?

Now ask that same child to sit still, read, comprehend, remember what they have read, and answer questions. By the time we see the behavior, their nervous system may already be working incredibly hard. That doesn’t mean a retained reflex explains the behavior. It means increased knowledge of primitive reflexes may help us ask a better question:

How much effort is this nervous system using to accomplish something that should eventually become automatic?

That is a very different way of looking at the patient.

The Physical and Emotional Sides Aren’t Always Separate

Often times, there is talk about physical function and emotional function as though they belong in completely different conversations, but the nervous system doesn’t necessarily work that way. Vision interacts with vestibular processing. Vestibular processing interacts with posture. Posture interacts with proprioception. Sensory processing influences arousal. Arousal influences attention. Attention influences performance. And performance, particularly repeated difficulty or failure, can influence frustration, confidence, anxiety, and how someone feels about themselves. That does not mean there is a straight line to be drawn between a primitive reflex and an emotional condition.

We cannot say:

Retained reflex = anxiety

Retained reflex = depression

Nor should Primitive Reflex findings be used to predict who will develop a mental-health condition; the research simply doesn’t support that. However, we also shouldn’t ignore what the patient is telling us simply because we can explain some of what we’re seeing neurologically.

When Something Bigger Walks Into the Therapy Room

Vision Therapy creates an interesting relationship with patients. We may work with someone one-on-one every week for months. We see them when they’re successful. We see them struggle. We watch them become frustrated, adapt, improve, and sometimes become overwhelmed.

And people talk to us.

Sometimes they tell us things that have very little to do with convergence, accommodation, eye movements, or primitive reflexes. Occasionally, what we hear may go beyond normal frustration. We may see significant anxiety, emotional dysregulation, hopelessness, or a level of distress that deserves attention. If a patient with a retained Moro reflex appears extraordinarily anxious, for example, our conclusion should not automatically be:

“That’s the Moro.”

Instead, we should be asking:

What am I actually seeing?

The retained reflex may tell us something about neurological reactivity. The behavior may tell us something about how the patient is responding to that experience, and what the patient actually says may tell us something entirely different. Those are three separate pieces of information.

As Vision Therapists, we should not even try to diagnose the psychological piece: that isn’t our role. But we do need to recognize when something has moved outside our scope and needs to be brought to the attention of the supervising doctor, a parent or guardian when appropriate, or another qualified healthcare professional. Understanding our scope also means recognizing when a patient may need something beyond what we can provide, and knowing when it is appropriate to refer them to another professional who can help.

And Then There Is Brain Injury

Traumatic brain injury makes this conversation even more interesting. We commonly say that primitive reflexes become “integrated” during development. Neurologically, it may be more useful to think of them as becoming increasingly inhibited and regulated by higher levels of the nervous system. That distinction matters after an injury.

A person may have developed normally and functioned perfectly well for decades. Then a concussion or other brain injury disrupts systems involving vision, vestibular processing, proprioception, balance, eye movements, accommodation, convergence, sensory tolerance, attention, autonomic regulation, or emotional regulation. Suddenly, things that once happened automatically require effort. Primitive patterns may become more apparent.

Rather than simply saying: “The reflex came back,” perhaps the better question is: “Has the injury reduced the nervous system’s ability to regulate a response that was previously under effective higher-level control?”

We don’t have all of those answers yet, which is part of what makes this subject so interesting.

Over the Next Several Days

Throughout this series, we are going to look at what we know, and be equally honest about what we don’t know. Some relationships involving primitive reflexes are well supported by research, while others are emerging. Some make neurological sense but remain largely theoretical, and some things commonly repeated about retained primitive reflexes simply haven’t been adequately demonstrated in the scientific literature.

That doesn’t make primitive reflexes less important. It just means we need to be thoughtful about what they can, and cannot, tell us. Ultimately, the goal shouldn’t simply be to determine whether a reflex is present or absent. The goal should be to use that information to ask better questions about the person sitting in front of us.

What is their nervous system experiencing? How is that affecting vision, posture, movement, attention, and behavior? How much effort are they using to accomplish something that should be automatic? And when what we’re seeing extends beyond our expertise, do we recognize it?

Remember, a retained primitive reflex is a clinical observation, not a psychiatric diagnosis or a sign of emotional imbalance, but sometimes that clinical observation reminds us of the importance of looking a little more carefully at the whole person.

Next, we’ll start with one of the earliest and perhaps most fascinating of these responses: the Moro Reflex.