Classic Reflex Hierarchy and Reflexes

Classic Reflex Hierarchy & Dynamic Systems Theory
The Classic Reflex Hierarchy is a model of motor development influenced by the maturationists' theory of child
development. These researchers believe that normal motor development was attributed to the refinement of cortical networking in
the central nervous system (CNS). This intricate system results in the emergence of higher levels of control over lower level reflexes.
Arnold Gesell and Myrtle McGraw, two well-known maturationists, viewed motor development as a product of genetics rather than
a product of experience. Based on the maturationists' theory, the Classic Reflex Hierarchal model emerged. According to this model,
the infant's spinal cord reflexes must develop fully before development of brainstem reflexes can begin. This process of
development progresses to the midbrain and finally to the cortical level, where voluntary control such as walking, reaching and
other highly skilled activities are refined.
The Dynamic Systems Theory model perceives locomotion as an emergent property of various interacting processes
including, sensory, perceptual, motor, respiratory, cardiac, and anatomical systems. According to this model, motor development
systems have self organizing properties, thus the systems can spontaneously form patterns that arise from the interaction of the
different parts of the system. With the self organizing property, there is no need for the nervous system to provide instructions or
plans to achieve coordinated actions. The Dynamic Systems model stresses that actions will always occur within specific contexts.
Therefore, a given neural code will produce different behavioral outcomes based on the contributions from the other systems
involved. More specifically, a child learns to adapt the original movement to the demands of the task and the environment in which
the movement occurs.
Spinal Cord Level

Spinal cord reflexes are mediated by Deiters' nucleus located in the lower one-third of the pons. It coordinates muscles of
the extremities in patterns of either extension or flexion.
Flexor Withdrawal
 Onset: Birth
 Integration: 1-2 months
 Test Position: Supine with head in mid position and lower extremities extended
 Stimulus: Noxious stimulus to the sole of the foot to be tested
 Response: Uncontrolled flexion of hip, knee, dorsiflexion of foot, and extension of toes of stimulated lower extremity
 Significance: An asymmetrical response may indicate injury to that side of the brain or injury to peripheral nerve supply.
Failure to obtain or late persistence may indicate general depression of the CNS or sensory motor depression.
Crossed Extension
 Onset: Birth
 Test Position: Supine with head in mid position and one lower extremity held in extension
 Stimulus: Noxious stimulus to sole of one foot while holding that extremity extended
 Response: Contralateral leg first flexes then extends, adducts and inwardly rotates with extension and splaying of toes
 Significance: An asymmetrical response may suggest injury to one side of the brain or asymmetric injury to peripheral nerve
supply. Failure to obtain or late persistence may indicate general depression of the CNS or sensory motor depression.
Extensor Thrust
 Onset: Birth
 Test Position: Supine with head in mid position, one lower extremity extended and one flexed
 Stimulus: Noxious stimulus to the sole of the foot of the flexed lower extremity
 Response: Extension of stimulated lower extremity
 Significance: Asymmetry may indicate insult to one side of the brain or asymmetric injury to peripheral nerve supply. Failure
to obtain or late persistence may indicate general depression of the CNS or sensory motor depression.
Brainstem Level
Brainstem reflexes, also referred to as static postural reflexes, are mediated by areas from Dieters' nuclei to the red nuclei
located at the most caudal level of the basal ganglia. The brainstem effects changes in the distribution of muscle tone throughout
the body in response to changes of head position and body in space by stimulus of the labyrinths, or in the head in relation to the
body by stimulus of proprioceptors of neck muscles.
Asymmetric Tonic Neck Reflex (ATNR)

 Onset: Birth-2 months
 Test Position: Supine with head in mid position and upper and lower extremities extended
 Stimulus: Active or passive lateral rotation of head
 Response: Upper and lower extremities on face side are extended while the upper and lower extremities on skull side are
flexed. Spine is curved with convexity toward face side.
 Significance: Integrates as neck righting reactions appear. Integrates for child to roll over adequately. Integrates before
adequate prehension and feeding take place. Integrates before child has unsupported sitting balance. Asymmetry may
indicate insult to one side of the brain or to peripheral nerve supply. Late persistence may indicate general depression of
the CNS or sensory motor dysfunction. Reflex assists with initial eye-hand regard. May lead to skeletal deformities including
scoliosis, hip subluxation, hip dislocation, inability to grasp and regard an object at the same time, inability to balance well
enough to walk, and associated behavior problems. Response is never totally obligatory in a normal child. This reflex may
interfere with feeding, visual tracking, mid-line use of hands, bilateral hand use, rolling, and development of creeping and
crawling.
Symmetric Tonic Neck Reflex (STNR)

 Onset: 4-6 months
 Test Position: Quadruped or prone over examiner's lap
 Stimulus: Head flexed or extended
 Response: Head flexed: upper extremities flexed and lower extremities extended. Head extended: upper extremities
extended and lower extremities flexed.
 Significance: The integration of STNR is seen when the child can lift the buttocks from the heels without flexing the head
and upper limbs. If strong, it may prevent reciprocal creeping. This reflex may interfere with the ability to prop on forearms
in prone position, attaining and maintaining quadruped position, creeping reciprocally, sitting balance when looking around,
and the ability to look at an object in hand.
Tonic Labrythine Reflex Prone & Supine (TLR-P & TLR-S) - These reflexes only expose themselves if atypical
 Onset: Birth
 Integration: 6 months
 Test Position: Supine or prone
 Stimulus: Stimulation of labyrinth in inner ear reflected in head position (flexion or extension) and/or body position (prone
or supine)
 Response: Supine: head extension, extremities are held in extension. Prone: head flexion, extremities held in flexion
 Significance: This reflex may interfere with the ability to initiate rolling, the ability to prop on elbows with extended hips
when prone, and the ability to flex trunk and hips to come to sitting position from supine. It may cause full body extension,
which may interfere with balance in sitting or standing. If strong, it may prevent further motor development, i.e.: in supine,
it may interfere with foot to mouth play and flexion against gravity.
Positive Supporting
 Onset: Birth
 Test Position: Support child in vertical position with hands under arms and around chest
 Stimulus: Weight on balls of feet causing stretching of intrinsic foot muscles
 Response: Co-contraction of lower extremity flexors and extensors
 Significance: Initially needed for upright standing and walking. Asymmetry may indicate insult to one side of the brain. This
reflex may interfere with standing and walking, balance reactions and weight shift in standing, and may lead to contractures
of ankles into plantarflexion.
Negative Supporting
 Test Position: Support child in vertical position with hands under arms and around chest
 Stimulus: Weight bearing in standing
 Response: Alternate flexion and extension of hips and knees. Child tends to jump or beat floor first with one foot and then
the other. Attempts by the elicitor to propel child along result in dragging of feet.
 Significance: May interfere with weight bearing, standing, and walking.
Associated Reactions
 Onset: Birth-3 months
 Integration: 8-9 years
 Test Position: Supine, sitting, or standing
 Stimulus: Resisted voluntary movement in any part of the body
 Response: Involuntary movement in a resting extremity
 Significance: Lack of dissociation and refinement of muscle activity may be a sign of increased tone occurring with
movement. This reflex may interfere with isolated movement and refinement of motor control.
Midbrain: Automatic Movement Reactions

Automatic movement reactions are a group of responses that are reactions produced by changes in position of the head in space or
in relation to the body.
Moro
 Onset: Birth
 Test Position: Supported sitting in a semi-reclined position
 Stimulus: Support child's head and shoulders with hand, then allow head to drop back 20°-30° with respect to the trunk.
 Response: Abduction of upper extremities with extension of elbows, wrists, and fingers followed by adduction of arms at
the shoulders and flexion of the elbows (Child may cry)
 Significance: Asymmetry may indicate insult to one side of the brain or to nerve supply. Failure to obtain or late persistence
may indicate general depression of the CNS or sensory motor depression. Moro differs from the startle reaction because it
consists of a flexor movement only. Involved in breaking up predominant flexion postures at birth. Integrates before sitting
and prior to presence of protective and tilting reactions. Should be universally present in normal full term children.
Asymmetry may be due to Erb's Palsy or clavicular fracture. This reaction may interfere with balance reactions and
protective responses in sitting, eye hand coordination, and visual tracking.
Landau
 Test Position: Prone suspension
 Stimulus: Child in space: may raise and lower child to elicit response
 Response: Extension of entire trunk and pelvis so an upward concavity is observed
 Significance: Helps break up predominant flexor pattern seen at birth and promotes extension. Absence may be due to
motor weakness. Only observed in children with strong labyrinthine righting reflex on the head.
Protective Extensor Thrust (Parachute Reaction): Prone

 Integration: Lifelong
 Test Position: Prone suspension
 Stimulus: Child moved forward toward the ground in head first position
 Response: Upper extremities extend and abduct, elbows, wrists, and fingers extend and spread as if to break the fall.
 Significance: This protective response is needed for quadruped and for supported sitting. Asymmetry may indicate insult to
one side of the brain.
Protective Extension: Upper Extremity
 Onset: Lateral: 6-11 months; Posterior: 9-12 months; Anterior: 4 months.
 Test Position: Sitting in tailor position
 Stimulus: Push gently either laterally, posteriorly, or anteriorly
 Response: Laterally: Abduction of opposite side upper and lower extremities with extension of elbow, wrist, and fingers.
Posteriorly: Posterior extension of upper extremities. Frequently, an element of trunk rotation comes in and reaction is
seen in one upper extremity only. Anteriorly: Anterior extension of upper extremities.
 Significance: It creates a new base of support when center of gravity is shifted beyond base of support.
Protective Extension: Lower Extremity

 Onset: 4 months
 Test Position: Support child in vertical position with hands under arms and around chest.
 Stimulus: Child is suddenly lowered 2-3 feet when held upright.
 Response: Child's legs suddenly extend and spread and feet rotate slightly outward.
 Significance: Creates a new base of support when center of gravity is shifted beyond base of support.
Automatic (Primitive) Stepping

 Onset: 37 weeks gestation
 Test Position: Support infant in vertical position with hands around arms and chest.
 Stimulus: Infant is suspended upright and slightly forward so that the soles of the feet touch the surface.
 Response: Rhythmical reciprocal stepping movements.
 Significance: Primitive reflexes that persist may suggest insult to CNS and may signify CNS immaturity.
Midbrain Level
Righting reactions are integrated at the midbrain level above the red nuclei, not including the cortex. Righting reactions interact
with each other and work toward establishing normal head and body relationship in space and with each other. The reflexes are first
to develop after birth and reach maximal concerted effect at approximately the ages of 10-12 months. The response usually
decreases around the fifth year as cortical control increases. Combined actions allow the child to roll over, sit up, and get into
quadruped position.
Neck Righting on Body

 Onset: Birth
 Test Position: Supine
 Stimulus: Head is rotated to one side
 Response: Child rolls nonsegmentally in the same direction the head was turned
 Significance: This reaction is needed for the child to roll from supine to sidelying. It may persist in some children until they
are able to rise straight from supine rather than rolling. Asymmetry may indicate insult to one side of the brain.
Body Righting on Head

 Onset: Birth
 Stimulus: One hip is flexed and adducted over the pelvis
 Response: Child rolls segmentally in the same direction to which hip was adducted
 Significance: Asymmetry may indicate insult to one side of the brain. This reaction directly modifies the neck righting reflex.
It is important in the acquisition of sitting, quadruped, and standing.
Optical Righting Acting on Head

 Onset: Prone: 1-2 months; Supine: 6 months; Vertical: 6-8 months
 Test Position: Prone, supine, or vertical
 Stimulus: Child held in space in prone, supine, or vertical (The additional stimulus needed for the vertical test position is
tilting of the child to the right or left)
 Response: Head rights to normal position: face vertical and mouth horizontal
 Significance: Allows the head to orientate to gravity and realign in an upright position.
Labyrinthine Righting Acting on Head: Vertical

 Onset: 2.5-6 months
 Test Position: Child held vertically with tester's hands under the arms and around the chest
 Stimulus: Tilt child 30o-40o in lateral, anterior, and posterior direction
 Response: Alignment of the head to vertical with the mouth horizontal
 Significance: This Reaction is needed for head control. It is necessary for bringing the body into an upright position and to
orient in relation to gravity.
Body Righting on Body

 Test Position: Supine, head in mid position, upper and lower extremities extended
 Stimulus: Shoulder or pelvic girdle rotated to one side
 Response: Body segments realign to segment that was rotated
 Significance: Allows pelvic and/or shoulder girdle to realign after rotation.
Cortical Level
The cortical level is mediated by the efficient interaction of cortex, basal ganglia, and cerebellum. Integration/maturation brings
individuals to the bipedal stage of motor development. The reactions occur when muscle tone is normalized and provide body
adaptation in response to changes of the center of gravity in the body.
Equilibrium: Prone
 Onset: 6 months
 Test Position: Prone on tilt board with upper extremities and lower extremities extended
 Stimulus: Tilt board laterally
 Response: Righting of the head and trunk, abduction and extension of upper extremities and lower extremities of the raised
side (muscle shortening), and protective reaction to the opposite side (muscle elongation).
 Significance: A negative or delayed reaction after 6 months may be indicative of delayed reflex maturation.
Equilibrium: Supine
 Onset: 6 months
 Test Position: Supine on tilt board, upper and lower extremities extended
 Response: Righting of the head and trunk, abduction and extension of upper and lower extremities of the raised side, head
rotates with face toward the raised side (muscle shortening), and protective reaction on the opposite side (muscle
elongation).
Equilibrium: Quadruped
 Onset: 8 months
 Test Position: Quadruped
 Response: Righting of the head and trunk toward raised side and abduction and extension of upper and lower extremities
of the raised side (muscle shortening), and protective reaction on the opposite side (muscle elongation).
Equilibrium: Sitting
 Test Position: Seated in tailor on tilt board
 Response: Righting of the head and trunk toward raised side, abduction and extension of upper and lower extremities of
the raised side (muscle shortening), and protective reaction on the opposite side (muscle elongation).
Equilibrium: Tall Kneeling

 Onset: 15 months
 Test Position: Tall kneeling
 Response: Righting of the head and trunk, abduction and extension of upper and lower extremities of the raised side
(muscle shortening), and protective reaction on the opposite side (muscle elongation).
Equilibrium: Standing
 Test Position: Standing; may hold the child by the arm for safety
 Stimulus: Tilt board anterior, posterior, or lateral
 Response: Righting of head or trunk or dorsiflexion of ankles when shifted posteriorly
Non Level Specific
This level is not identified in the Classic Reflex Hierarchy. It contains reflexes, reactions, and responses that do not specifically fall
under the above Classic Reflex Hierarchical categories.
Galant
 Onset: Birth
 Test Position: Prone
 Stimulus: Stroke skin between 12th rib and iliac crest 3cm lateral to spine
 Response: Fleeting lateral flexion of trunk to side of stimulus
 Significance: Long lasting response may lead to scoliosis. Retention may cause considerable delay in the development of
symmetrical stabilization of the trunk and of independence of the head, which are necessary for sitting, standing, or walking.
Placing-Lower Extremities (proprioceptive "legs")

 Onset: Birth
 Test Position: Hold child in a vertical position with your hands under the arms and around the chest; support head of young
children
 Stimulus: Lift child so that the dorsum of one foot presses lightly against a protruding surface like a tabletop or a chair.
 Response: The child's foot is lifted by flexion in knee and hip above table or chair top; leg extends and the foot is placed
squarely on the table or chair top.
 Significance: Asymmetry may indicate insult to one side of the brain. Failure to obtain or late persistence may indicate
general depression of the CNS or sensory motor depression. It may be obtained at any age as a withdrawal response if
traction exerted against foot to point of discomfort.
Placing-Upper Extremities (Proprioceptive "Arms")

 Onset: Birth
 Test Position: Hold child in a vertical position with hands under the arms and around the chest; support head of young
children
 Stimulus: Lift child so that the dorsum of one hand lightly presses against a protruding edge like a table top.
 Response: The child's upper extremity flexes and the hand is brought above the table. Upper extremity and wrist extend,
fingers extend and abduct as hand places on the surface (fingers may remain fisted in the newborn, and therefore, only
upper extremity and wrist extend).
 Significance: Asymmetry may indicate insult to one side of the brain. Failure to obtain or late persistence may indicate
general depression of the CNS or sensory motor depression. It may be obtained at any age as a withdrawal response if
traction exerted against hand to point of discomfort.
Traction
 Onset: Birth
 Test Position: Supine with head in mid position
 Stimulus: Grasp forearm and gently pull child up from supine to sitting, stretching shoulder adductors and upper extremity
flexors.
 Response: Flexion of neck, shoulders, elbows, wrists, and fingers
 Significance: Asymmetry may indicate insult to one side of the brain or birth trauma to nerve roots or brachial plexus.
Persistence after 4-5 months may inhibit voluntary reach and grasp.
Rooting
 Onset: Birth
 Test Position: Supine with head in mid position and hands above the chest
 Stimulus: Stroke skin at the corner of the mouth with finger moving laterally toward the cheek, upper lip or lower lip
 Response: Head and tongue turn toward stimulus. Upper lip: opening of mouth and flexion of the head. Lower lip: mouth
opens and the jaw drops
 Significance: Absent in babies particularly depressed by barbiturates. Turning away from the stimulus will occur in satiated
babies. Asymmetry may indicate insult to one side of the brain.
Palmar Grasp
 Onset: Birth
 Test Position: Supine with head in mid position; older child may sit
 Stimulus: Pressure in palm from ulnar side of hand
 Response: Flexion of fingers causing strong grip
 Significance: After development of this reflex, the child will reach and use palmar grasp. Asymmetry may indicate injury to
one side of the brain. Failure to obtain or late persistence may indicate general depression of the CNS or sensory motor
depression. Persistence of this reflex may interfere with the ability to grasp and release objects voluntarily, weight bearing
on an open hand for propping, creeping, and protective responses.
Startle Reflex
 Onset: Birth
 Test Position: Non specific
 Stimulus: Sudden loud or harsh noise
 Response: Sudden extension or abduction of upper extremities, crying occurs
 Significance: Overactive response may indicate sensory sensitivity to auditory stimulus. This reflex may interfere with sitting
balance, protective responses in sitting, eye-hand coordination, visual tracking, social interaction, and attention.
Plantar Grasp
 Onset: Birth
 Test Position: Supine with head in mid position and toes in resting position
 Stimulus: Press thumb against ball of child's foot across metatarsal heads
 Response: Toe flexion: response is stronger with ankle in dorsiflexion
 Significance: An asymmetrical response may suggest an injury to one side of the brain or to the nerve supply. Continued
presence of reflex after 9 months or absence of reflex may indicate general depression of the CNS or sensory motor
depression. This reflex should integrate before the child begins to weight bear. This reflex may interfere with the ability to
stand with feet flat on a surface, balance and weight shifting in standing.
Babinski
 Onset: Birth
 Integration: Unknown
 Stimulus: Noxious stimulus to lateral border of foot continuing across metatarsal heads
 Response: Dorsiflexion of big toe followed by a fan-like spreading of other toes
 Significance: The presence of this reflex past infancy may be indicative of a central nervous system lesion.

Classic Reflex Hierarchy and Reflexes

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Classic Reflex Hierarchy and Reflexes

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Classic Reflex Hierarchy & Dynamic Systems Theory

Spinal Cord Level

Asymmetric Tonic Neck Reflex (ATNR)

Symmetric Tonic Neck Reflex (STNR)

Midbrain: Automatic Movement Reactions

Protective Extensor Thrust (Parachute Reaction): Prone

Protective Extension: Lower Extremity

Automatic (Primitive) Stepping

Neck Righting on Body

Body Righting on Head

Optical Righting Acting on Head

Labyrinthine Righting Acting on Head: Vertical

Body Righting on Body

Equilibrium: Tall Kneeling

Placing-Lower Extremities (proprioceptive "legs")

Placing-Upper Extremities (Proprioceptive "Arms")

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