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Reflex Reaction

Normal Until

Stimulus

Response

Negative Effects

3 months

Introduce a finger into mouth

Sucking action of lips and jaw

Rooting

3 months

Touch baby s cheek

Head turns toward stimulus

Interferes with - Oral-motor


development, Optical
righting/visual tracking/social
interaction
Interferes with - Oral-motor
development, development
of midline control of head,
Optical righting/visual
tracking/social interaction

Cardinal Points

2 months

Sucking

(1) Touch corner of mouth


(2) Centre of upper lip is
stimulated
(3) Centre bottom lip is
stroked

(1) Bottom lip lowers on


same side and tongue moves
towards point of stimulation.
When finger slides away, the
head turns to follow.
(2) Lip elevates, tongue
moves towards place
stimulated. If finger slides
along oronasal groove, then
the head extends.
(3) Lip is lowered and tongue
directed to site of
stimulation. If finger moves
towards chin, the mandible is
lowered and head flexes.

Grasp

3 months

Press finger or other suitable


object into palm from ulnar
side

Fingers flex and grip object.


(Head in midline during this
test.)

Hand opening

1 month

Stroke ulnar border of palm


and little finger

Automatic opening of hand

Foot Grasp

9 months

Press sole of foot behind the


toes

Grasping response of feet

Placing

Remains

Bring the anterior aspect of


foot or hand against the edge
of a table

Child lifts limb up to step


onto table

Primary walking

2 months

Hold baby upright and tip


forwards, sole of foot presses

Initiates reciprocal flexion

Interferes with - ability to


grasp and release objects
voluntarily, weight bearing on
open hand for propping,
crawling, and protective
responses
Interferes with development
of hand function
Interferes with - ability to
stand with feet flat on
surface, balance
reactions/weight shifting in
standing

Interferes with - standing and


walking, balance reactions

(automatic walk:
reflex stepping)

against table

and extension of legs

and weight shifting in


standing, development of
smooth/coordinated
reciprocal movements of
lower extremities
Interferes with - development
of sitting balance, can lead to
scoliosis

Galants trunk
incurvation

2 months

Stroke back lateral to the


spine

Flexion of trunk towards side


of stimulus

Automatic sitting

2 months

Pressure is placed on the


thighs and the head is held in
flexion. Supine position.

Child pulls to sitting from


supine

Moro

06 months

Baby supine and back of


head is supported above
table. Drop head backwards;
also associated with loud
noise

Abduction and extension of


arms. Hands open. This
phase is followed by
adduction of the arms as if in
an embrace

Interferes with - balance


reactions in sitting, protection
responses in sitting, eyehand coordination/visual
tracking

Startle

Remains

Obtained by sudden loud


noise or tapping the sternum

Elbow is flexed (not extended


as in the Moro reflex) and the
hand remains closed

Interferes with - sitting


balance, protective responses
in sitting, eye-hand
coordination/visual tracking,
social interaction/attention

Landau

From3 months to 2.5 years,


strong at 10 months

Child held in ventral


suspension, lift head

The head, spine and legs


extend. Extend arms at
shoulders

Interferes with development


of protective responses

When the head is depressed


The hip, knees and elbows
flex

Flexor withdrawal

2 months

Supine; head mid-position,


legs extendedstimulate sole
of foot

Uncontrolled flexion response


of stimulated leg (do not
confuse with response to
tickling)

Extensor thrust

2 months

Supine; head, mid-position,


one leg extended, opposite
leg flexed stimulate sole of
flexed leg

Uncontrolled extension of
stimulated leg (do not
confuse with response to
tickling)

Crossed extension

2 months

Supine; head, mid-position;


legs extended stimulate
medial surface of one leg by
tapping

Opposite leg adducts,


extends, internally rotates
and foot plantarflexes
(typical scissor position)

Interferes with ability to


stand with feet flat on the
surface, balance reaction and
weight shifting in standing

Asymmetrical tonic
neck (ATNR)
reaction

6 months, usually
pathological

Patient supine; head in midposition; arms and legs


extended turn head to one
side

Extension of arm and leg on


face side, or increase in
extensor tone; flexion of arm
and leg on skull side or
increase in flexor tone

Interferes with - feeding,


visual tracking, midline use of
hands, bilateral hand use,
rolling, development of
crawling, can lead to skeletal
deformities (e.g. scoliosis, hip
subluxation, hip dislocation)

Symmetrical tonic
neck (STNR) reflex

Rare and usually pathological

(1) Patient in quadruped


position or over testers
knees ventroflex the head.
(2) Position as above,
dorsiflex the head

(1) Arms flex or flexor tone


dominates; legs extended or
extensor tone dominates. (2)
Arms extend or extensor tone
dominates; legs flex or flexor
tone dominates

Tonic labyrinth
supine

Pathological

Patient supine; head in midposition; arms and legs


extended. Test stimulus is
the position

Extensor tone dominates


when arms and legs are
passively flexed

Tonic labyrinth
prone Reaction to
prone

3 months

Turn patient prone head in


mid-position. Test stimulus
prone position

Unable to dorsiflex head,


retract shoulders, extend
trunk, arms, legs

Interferes with - ability to


prop arms in prone position,
attaining/maintaining handand-knees position, crawling
reciprocally, sitting balance
when looking around, use of
hands when looks at object in
hands in sitting
Interferes with - ability to
initiate rolling, ability to prop
on elbows with extended hips
when in prone, ability to flex
trunk/hips to come to sitting
position from supine, often
causes full body extension:
which interferes with balance
in sitting or standing
Often causes full body
extension which interferes
with balance in sitting or
standing

Possitive
supporting

3 months

Hold patient in standing


position press down on
soles of feet

Increase of extension in legs.


Plantarflexion, genu
recurvatum may occur

Negative
supporting

35 months

Hold in weight bearing


position

Child sinks astasia

Neck righting

5 months

Supine, rotate head to one


side, actively or passively

Body rotates as a whole in


same direction as the head

Associated
reactions

Pathological

Have patient squeeze an


object (with a hemiplegic,
squeeze with uninvolved
hand)

Clench of other hand or


increase of tone in other
parts of the body. Abnormal
overflow

Interferes with - standing and


walking, balance reactions
and weight shift in standing,
can lead to contractures of
ankles into plantar flexion
Standing and walking
balance reaction and weight
shifting in standing can lead
to contractures of the ankle
to plantar flexion

-Levitt, Sophie. Treatment of Cerebral Palsy and Motor Delay. Fifth Edition.

Age
Newborn

Gross Motor

4 months

7 months

Flexor tone

predominates

In prone, turns head


to side
Automatic reflex
walking
Rounded spine
when held sitting

Head midline

Head held when

pulled to sit

In prone position,
lifts head to 90
and lifts chest
slightly
Turns to supine
Maintains sitting
May lean on arms
Rolls to prone
Bears all weight,
bounces when held
erect

Fine Motor
Adaptive
Hands fisted
Grasp reflex
State-dependent
ability to fix and
follow bright object

Personal/Social
Habituation and
some control of
state

Speech and
Language
Cry
State dependent
quieting and head
turning to rattle or
voice

Cognitive

Hands mostly open


Mid-line hand play
Crude palmar grasp
Fascinated by own
face in mirror

Recognizes bottle

Turns to voice and bell


consistently
Laughs, squeals
Responsive
vocalization
Blows bubbles,
raspberries

Intermediate grasp
Transfer cube from
hand to hand
Bangs objects

Differentiates

between familiar
person and
stranger
Holds bottle
Looks for dropped

Uses single-word and


double-consonant
vowel combinations

Sensorimotor 024
months
Reflex stage

Emotional

Circular reaction, the


interesting result of
an action motivates
its repetition

Basic trust vs. basic


mistrust (first
year)
Normal symbiotic
phasedoes not
differentiate self
and mother

Lap baby,
developing a sense
of basic trust

At 5 months begin
to differentiate
mother and self
individualization
Sense of belonging
to a central person

10 months

Cervical lordosis

Creeps on all fours


Pivots in sitting
Stands
momentarily,
cruises
Slight bow leg
Increased lumbar
lordosis, acute
lumbosacral
angulation
Walks alone, arms
in high guard or
mudguard
Wide base,
excessive knee
and hip flexion
Foot contact on
entire side
Slight valgus of
knees and feet
Pelvic tilt and
rotation
Arms at low guard
Mature supporting
base and heel
strike
Seats self in chair
Walks backward

14 months

18 months

2 years

Begins running

Walks up and down

stairs alone
Jumps on both feet
in place

3 years

Runs well
Pedals tricycle
Broad jumps
Walks up stairs

Pincer grasp,

mature thumb to
index grasp

Bangs 2 cubes held


in hands

object
Talks to mirror
image
Plays peek-a-boo
Finger feeds

Chews with rotary

movement

Piles 2 cubes
Scribbles
spontaneously
Holds crayon full
length in palm
Casts objects

Emerging hand

dominance

Crude release

Holds crayon butt


end in palm
Dumps raisin from
bottle
spontaneously
Hand dominance is
usual

Builds 8-cube tower


Aligns cubes
horizontally

Imitates vertical line


Places pencil shaft
between thumb
and fingers
Draws with arm and
wrist action
Imitates 3-cube
bridge
Copies circle
Uses overhead

Shouts for attention


Imitates speech
sounds
Waves bye-bye
Uses mama and
dada with meaning
Inhibits behavior to
no

Uses spoon with


Uses single words
over pronation and Understands simple
spilling
commands
Removes a garment

Can retrieve an

object hidden from


view

Differentiates
available behavior
patterns for new
ends, eg, pulls rug
on which is a toy

Imitates housework
Carries, hugs doll

Deinks from cup

neatly

Points to named body


part
Identifies 1 picture
Says no
Jargons

Capable of insight;
problem solving by
mental
combinations, not
physical groping

Pulls on garment

Uses spoon well


Opens door turning

knob
Feeds doll with

bottle or spoon

Toilet training
usually begun

Two-word phrases are


common
Uses verbs

Refers to self by name


Uses me, mine

Follows simple
directions

Preoperational period
2-7 years
Able to evoke an
object or event not
present
Object performance
established
Comprehends
symbols

Most children toilet


trained day and
night
Pours from pitcher

Three-word sentences
are usual
Uses future tense
Asks who, what,

Preoperational period
continues;
Capable of deferred
limitation symbolic

Practicing phase of
separation
individuation,
practices imitating
separations

Rapprochement
phase
individuation;
ambivalence
behavior to
mother
Stage of autonomy
vs. shame and
doubt
Pleasures in control
of muscle and
sphincter

Stages of initiative
vs. guilt 3-5 years
Deals with issue of
genital sexuality

4 years

alternating feet

throw with
anteroposterior arm
and motion
Catches with
extended arms
hugging against
body

Walks down stairs


alternating feet
Hops on 1 foot

Plantar arches

developing
Sits up from supine
position without

rotating

Handles a pencil by
finger and wrist
action, like adults
Copies a cross

Draws a froglike
person with head
and extremities
Throws underhand
Cuts with scissors

5 years

Skips, tiptoes

Balances 10
seconds on each
foot

6 years

Rides bicycle
Roller skates

7 years

Continuing
refinement of skills

Hand dominance
expected
Draws man with
head, body,
extremities
Throws with
diagonal arm and
body rotation
Catches with hand

Prints alphabet;
letter reversals still
acceptable
Mature catch and
throw of ball

Unbutton; washes
and dries hands
and face
Parallel play
Can take turns
Can be reasoned
with
Cooperative play-
sharing and
interacting
Imaginative make-
believe play

Dresses and
undresses w/
supervision

distinguishing front
and back of

clothing and
buttoning
Does simple errands
outside of home

where
Follows prepositional
commands
Gives full name
May stutter; eager
Identifies sex of self
Recognizes 3 colors
Gives connected
accounts of
experience
Asks why, when, how
Uses past tense,
adjectives, and
adverbs
Knows opposite
analogies
Repeats 4 digits

Creative play

Competitive team
play
Uses fork for

stabbing food
Brushes teeth

Self-sufficient in
toileting
Dresses without
supervision except
tying shoelaces

Teacher is important
authority
Uses fork
appropriately
Uses knife for
spreading
Plays table games
Eats with fork and
knife
Combs hair
Is responsible for
grooming

Fluent speech
Misarticulation of
some sounds may
persist
Gives name, age,
address
Define concrete nouns
composition,
classification, use
Follows 3-part
commands
Number concept of 10
Shows mastery of
grammar
Uses proper
articulation

play, drawing of
graphic images,
mental images,
verbal evocation of
event

Period of
concrete
operational
thought 7
years

Stage industry vs,


inferiority 5 years
adolescence

Adjust to the
inorganic
laws of the
tool worls

Stage of industry
vs. inferiority
continues

Molnar GE, Alexander MA. Pediatric Rehabilitation 3rd Edition

adolescence
Capable of
logical
thinking