Why do OTs test reflexes like the ATNR and tonic labyrinthine, and what do we actually do with what we find? This episode reframes reflexes as a window, not a target: the same way a neurologist reads them for the integrity of the system, not as the shiny thing to fix. Tracy makes the case that a reflex you can provoke is just an adaptation, and the real question is always, why is this here, discrimination, or modulation? It closes with a remarkable case that sets up the next episode.
Prompted by re-listening to the posture episode and by OT friends asking about reflexes, Cory opens up a question paediatric OTs wrestle with: why do we test the ATNR and tonic labyrinthine in our clinical observations, and how does that relate to treatment? The group draws the line between their functional lens, what does posture let this person do in the world, and a pure reflex-integration or retraining approach. Tracy lays out the Ayres clinical-reasoning flow, from occupational outcomes on one side back to the sensory and motor systems, vestibular, proprioceptive, somatosensory, that give rise to anti-gravity and bilateral control, and adds the crucial twist: the postural system is also state-dependent. So a reflex showing up might be a discrimination issue, or it might be modulation, protective activation when a child does not feel safe, and the treatment for each is completely different. The repeated discipline: do not grab the shiny thing, pause and ask, why is this here?
They go deep on what Ayres was really after, the same thing a neurologist looks for, the integrity of processing, by reading the pattern, not the product. A provoked reflex is just an adaptation; the real question is the adaptive response to it. When you turn a child’s head in the ATNR test, do they collapse, or does a postural adjustment correct the course through righting reactions and equilibrium responses? When the correction is missing, Ayres says you are not seeing sufficient activation of the system, so the problem is not the reflex, it is the lack of response, and the treatment is vestibular-proprioceptive work for righting and equilibrium, not reflex integration. Tracy brings it to life with an 18-year-old autistic woman who had not leaned over for a decade; intensive vestibular intervention over about four months gave her freedom of movement, she now loves Disney cruises. They explore cognitive override, how higher-cognition kids lock out instead of collapsing, why that is so fatiguing, and Tracy’s own stand-up-paddleboarding humility. It sets up Episode 17 on that four-month treatment in detail.
Lightly edited for readability. Speaker labels and chapter markers match the published episode.
Cory: Hello, wonderful women. I weirdly was re-listening to our second episode on posture, and it is such a strange experience re-listening to our episodes, it feels like I am listening as if I am not part of it, and I am learning. As I did, I had questions about what we were talking about. For people who did not listen to that episode, we talked about a 12-year-old boy who came into the clinic for a handwriting assessment. I did not do any further treatment with him, I just collected information and provided recommendations. I had done a bunch of clinical observations and some standardised testing and had data to talk about in relation to the postural system. I had some thoughts about what we discussed, and some listeners had questions about the treatment strategies we talked about at the end, particularly around extension and upright posture and how to maintain that through treatment. I have also had discussions recently with some OT friends wondering about the reflex part of this, because in our clinical observations we often test for ATNR, I did a tonic labyrinthine test, and they are reflex-based tests. So there is a lot of wondering around why we do those tests, how they relate to treatment, and then some people talk about reflex integration. I do not really know anything about that, I have not done any training on it, but it comes up. Shall we flesh that out today?
Michelle: I would love to talk about that. It is often one of the places people tend to start. When you have new therapists working in paeds, they seem to get a handle on posture, and perhaps moving into planning, a little easier than some other concepts, so it is a topic lots of paediatric OTs talk about. We should know this stuff really well, particularly how we might look at it differently to a physio, or a chiropractor, or someone who comes with a reflex retraining or integration approach, rather than our more functional one. I come at it much more functionally, what does posture offer, and what is a lack of posture impacting on, rather than a pure, I want you to be upright just because that is good posture and will avoid scoliosis. How it allows function.
Tracy: So many layers. Maybe we start with a basic clinical reasoning flow, using the wisdom of Dr Ayres and the classic Ayres flow chart. It is organised left to right, where on the right-hand side you have the occupational outcomes, what your upright, engaged life, moving about the world, needs from your body in terms of how your postural-ocular system serves you as an agent of interaction. Then we track that back to the elements that give rise to anti-gravity control, bilateral control and movement capacity, and those are grounded back in the sensory and motor systems. Does something like that work for you both as a basic organiser?
Cory: I am picturing the table in Sensory Integration: Theory and Practice, third edition, the table where one side is modulation-based and one side is discrimination-based, which is the postural side, and they start with the nervous system and move out into more functional pieces, to the endpoint, upright control of gravity with ease and fluidity. Is that what you are picturing?
Tracy: That is one way of thinking about it, and we should talk about it, because for me it brings up something we need to integrate into our thinking. Let me get specific. Are we ready to get juicy with something?
Michelle: Yes, we are.
Tracy: In the traditional way of thinking about this from an Ayres perspective, what you are referencing is the current chart Shelly Lane and Anita Bundy use, where you start with the nervous system in the middle, and to the right you are looking at sensory discrimination and perceptual functions. So much of Dr Ayres’ early work talked about how somatosensory processing, in particular vestibular processing and the body-based proprioceptors, give rise to our sensory-motor control. So postural systems derive from sensory-motor systems, and they are based in vestibular functions. In the Ayres tradition you are looking at a sensory discrimination base to the ability to have postural control, bilateral control and balance. But the thing I want to pause and say is that our postural system is also a reflection of our modulation and our state, it is state-dependent. If you tend to hang out in arousal states that are not really typical, you will see it in the postural system. If you have children who are in more activation because they have to be protective of themselves, you will see protective postures and activation of the postural system in that direction. So whenever we see differences in postural systems, we cannot just think through the sensory discrimination lens, the right-hand side of the chart, we have to think more broadly and wonder, where is this coming from? Because how we treat it ends up entirely dependent on that question. Because that is not always evident, sometimes people treat the thing that is most evident. So say we have a child whose basic reflexes are still showing up in typical movement patterns. For certain treatment approaches, that becomes this really shiny thing, oh my goodness, we need to integrate that reflex. But if you back up, if you are in protective defence, you will have potentiation of reflexes to help you be stronger, to fend off whatever threat is perceived. So for modulation reasons we will see reflex potentiation, and the treatment is not to integrate the reflex, it is to get the person into a state of safety. By the same logic, if you see the reflex and wonder whether it is there to give anti-gravity assistance because of weakness or reduced muscle tone, or because they have not sufficiently activated neck righting and equilibrium responses, the treatment is not reflex integration, it is to work on the postural function itself, or the vestibular function underlying it. So it is always important not to go for the shiny thing, but to pause and ask, why is this here?
Michelle: I love that you started with the person, what does their body need to do for them, because for me that is the root of this, going back to the macro of who is this person and the system they are working from, and how does that impact their posture. It is a system, rather than their discrete postural or reflex capacities looking like this. If we get stuck on, oh, they are over-responding to auditory and tactile and not processing vestibular well, we are never going to get anywhere, because that is not the root issue, the root is the modulation piece. Starting bigger helps you see the wood for the trees, and see the reflexes as an outcome rather than the root.
Cory: Let me clarify to see if I am understanding. Say you notice something, maybe a reflex, and let me give something concrete. In my example in the posture episode I did a tonic labyrinthine test, and I had a clear outcome that it was not integrated, he tipped his head backwards and had autonomic responses, eye fluttering, was trying to recruit the visual and proprioceptive systems by collapsing into flexion to support himself. So I could go multiple directions. I could say, that reflex is not integrated, and work purely on integrating that specific thing, which is grabbing the shiny thing. But what you are saying is that if I step back and look at him holistically, I can think about how the sensations are integrating and organising his body to manage that situation, and how that impacts his function day to day, and then the modulation element, because when his head tipped back he became clearly distressed, which is not just a discrimination function, it is a state and arousal issue. State impacts posture and posture impacts state, bidirectionally. So I need to think about all those things in a session, and work on it in a way that is not just targeting the reflex. Have I summed that correctly?
Tracy: Absolutely. And the beautiful thing about occupational therapy is that while you approach it from that deeper understanding of discrimination and modulation, you do it in a way related to what he wants to do with his body in the world, and how he will find the motivation and engagement to make use of the sensation. Every time we come back to Dr Ayres’ core definition, the organization of sensation for use, there is that thread: if I tip my head back and my vestibular activation is not giving me what I need to make use of the world, I get overwhelmed and a little scared, and then I pull into a more primitive pattern to even try to make sense of it, which further restricts my freedom to do what I want. So all the time we are seeing the full dynamic system in action, and if we get too stuck treating any one part, or if we do not treat the whole of it, we will miss it.
Cory: That is so helpful. So why did Dr Ayres have reflexes in her clinical observations? She obviously saw them as important, and they let us gain insight into what is going on for the child, but can we unpack why she had that in there and what she meant for us to glean from it?
Tracy: Most versions of the Ayres Clinical Observations have some degree of reflex testing. Before I answer, I want to mention: if you go to a neurologist, they do an assessment because you have some complaint, and one of the things in a standard neurological assessment is that they look at reflex integration, because the way your body moves in these prototypical patterns is a reflection of the integrity of processing in the system. Integrity of processing is a bit of a spin on integration. Dr Ayres talked about how poorly integrated postural and ocular mechanisms are an important window into understanding what is happening in processing in general. So she was interested not so much in the product, is there the presentation of a reflex when you provoke it, because most of the tests provoke the reflex on purpose. If you see the reflex in a strong pattern, that is the product. What she really wanted us to look at was the pattern, what is happening to bring about that adaptive function, because a postural reflex is just an adaptation, a response to a stimulus. How is it supporting me, bringing a level of support to maintain anti-gravity control or body alignment? Or do I not have the activation that lets me easily handle that stressor? So I see the reflex as a partner in the dynamic system that allows me to maintain anti-gravity control, because often if you are in an anti-gravity position and then you stress it, you collapse, or you see an intensity of response that misaligns the whole system and moves you out of a functional pattern. The pattern itself is what you are looking at, the big picture, and you are wondering, why is the postural system not sufficiently able to respond? Is it because when I move in a rotational pattern, my mix of stability holding patterns and mobility movement patterns is getting out of synchrony? And where does synchrony, the relationship of my midline to my movement patterns, come from? It turns out it comes from the vestibular-proprioceptive apparatus. So it is often a reflection of underlying processing, and it could be the discriminative processing or the modulation processing. It always opens that question, is it discrimination or modulation?
Michelle: I kind of see it as, we have often already seen it through the way they walk in or sit down and participate, even before we start clinical observations. I have already got an assessment, oh, it is your postural system and the sensory functions that underlie it. I see the bits that fall out of it, including their reflexes, as their unique way of trying to be adaptive when they do not have those functions working well. Sometimes you see the reflexes really strongly, other times their adaptive way to manage the lack of posture, stability and regulation is a refusal, they just say, I am not going to do it, so you do not get to see the reflexes because they will not do it. But for me it is their best shot at being adaptive, and sometimes when they agree to do the thing, you do see the reflex happen, and that is how their body is trying to compensate for a lack of something else. Am I putting that together okay?
Tracy: You absolutely are putting it together, and the wonder and lack of certainty in your voice is really because we are talking in generalities right now. When you land it, when you are with a child and feeling that experience of being with them, you tune in to their lack of awareness of their body in space. When you put them on a movable surface and they become uncertain, how do I maintain my balance when this thing is moving me, you get a clearer, tacit sense of it, because they lose their body schema and awareness, and it does not stay with them as the surface starts to move. You would feel it, name it, identify it, because it becomes concrete in the moment. Versus the child who is terrified of anything unpredictable, where the experience was more based on fear of unpredictability, which could come from their body or from the world. You start to identify that based on who this child is and what experience they are having. So you have totally got it, it is just easier to land with a case than in a conceptual way.
Cory: When you started, Tracy, you talked about Dr Ayres looking at the reflexes to glean something about integration, and I thought it was interesting that neurologists do this too. So it is not like we are doing some woo-woo thing, we are trying to understand the nervous system so we can piece it to function, which is what we do as paediatric OTs, glean something from the nervous system to understand how it is impacting occupational performance. So we do an ATNR test, you get a kid on all fours, make sure they do not lock their elbows out, gently turn their head to one side, and see whether the postural system can sustain alignment. That is a stress on the system. If I stressed it and saw the reflex, are you saying that is helpful because they cannot integrate that stress, so the body does the function that helps it most, which is to collapse and pull in?
Tracy: Yes, or it could be that when you move the head out of midline alignment, you get a differential firing pattern in the neck musculature that fuels what happens below. That is partly a vestibular signal, and also a matching of the neck proprioceptors. When you get mis-signalling between the neck proprioceptors, what the body is trying to do, and the vestibular system, moving into a collapse is protective, it is, what is happening, I do not know how to maintain myself here. As that differential firing happens, trying to come back to, where is my base of stability, a collapse is the closest thing to that, the adaptation is, let me come back to my most primitive pattern and resort what is going on, where should I find strength, what position do you want me to be in. It is also interesting because, once we are out of baby crawling life, we are not in four-point with the head turned very often, it is not a super adaptive position, especially when you get really asymmetrical in your firing pattern. But your logic is right about the adaptation. Then also, if you have a higher ability to recruit assistance against gravity, what should happen is a weight shift to the opposite side that holds the integrity, because that is where crawling comes from. So instead of going to collapse, I should find my strength. What we are looking at is not just whether the collapse happens, but what is the adaptive response to the collapse, are they working actively against it or allowing it? In a person who does not evince the big reflex, you see a little collapse but then a postural adjustment that corrects the course. When you do not see that postural adjustment, that is when Dr Ayres suggests you are not seeing sufficient activation of the system itself. So again, the problem is not the reflex, it is the lack of sufficient response.
Cory: Let me clarify the neurological piece. For the child with the big reflex, when I turn their head, it relates to the vestibular organs on each side of the head firing into the postural system, and because each organ gets different stimulus when I turn the head, the postural system activates asymmetrically, one side differently to the other to maintain position. But if I have not organised and integrated that with the proprioceptors of the neck and body, then to manage it I have to pull in the reflex. Whereas if I can integrate that difference, moving my head, the asymmetrical firing of the vestibular system, with the proprioceptors of the neck and body, I can make the adjustment to manage that stress.
Tracy: That is exactly right. At a higher level it also tells you the treatment approach Dr Ayres suggested is pretty accurate still, because when you see this difficulty, what you want to do is create a vestibular-proprioceptive opportunity to work on pulling for righting reactions and equilibrium responses, the higher-level integration above the reflex, so the reflex can be made use of appropriately and does not have to garner all the attention. The righting and equilibrium responses are really what postural adaptation is all about, the balance of stability and mobility within the context of righting and equilibrium. In those responses you get this beautiful weight shifting, you pull into alignment, you get gradations of rotational responses around the midline, balancing and maintaining alignment so your body can keep doing what it wants, keep moving or holding on or reaching, anywhere from the eyes to the head to the trunk to the extremities. You see the same beautiful orchestration of stability and mobility whether you are reaching with the eyes or trying to pick up a little piece of lint off the floor without falling over.
Tracy: The reason this is so critically important to life function: I am thinking of a woman who was about 18 when she was referred to me, who has a diagnosis of autism, with a lot of restrictions in her cognitive and language skills, a pretty complicated profile. She was referred because she had moved into a high school program with a goal for more independence in daily living skills, in particular things like picking up her shoes and putting them on. She could not lean over, and it turned out, when I met with her mom, that since she was about seven or eight she had stopped ever leaning over. For more than a decade, leaning over to get out of bed, into the bathtub, to do toileting, she was so restricted she would not do any of them, so rigid, fixed and held in her posture. People had been doing all these behavioural interventions to get her to lean over and pick up her shoes for a reward of some Skittles, but everyone was missing that this was all based back in her vestibular system and the integrity of her ability to make use of her postural system. This relates to a listener’s question about how long you have to treat these sensory-based issues to support posture. In this case I did a really intensive, vestibularly focused intervention, she came in several times a week, I worked with her quite intensively, and gave her parents a home program. Within about four months she suddenly started to find delight in moving her head through space, and a few months later she just automatically understood that the space above her in standing and the space down by her feet were all available to her. That discovery came from the integrity of the vestibular system supporting her posture. It did not come from training her to bend over and pick up her shoes, but it allowed her the freedom to do that. This is a person who was pretty restricted in lots of her skill sets, but she found so much joy. Her most favourite thing in the world now is to go on a cruise, which she could not do before because she could not enjoy that kind of movement. It changed everything for the whole family, they go on Disney cruises now. The vestibular system can restrict you so much that you really cannot move, cannot find the freedom to bend over, nor get on a boat.
Michelle: That is so wonderful that they met with you and you changed their trajectory, a beautiful case to illustrate getting the intervention right and understanding the lack of integration at the root, rather than the other approaches that were not landing for her. I am fascinated that you mentioned she had lower cognitive capacities, but there was a knowing that this is not working for me and I am going to avoid this, and it did not matter the lure, whatever her currency or special interests, painted big and bright. She still had a knowing, when my head does this I do not feel safe, and I am not going to do that for the bright shiny things, for decades. That is of interest to me, and it was my question earlier, that this is all pretty automatic, we are not necessarily thinking about it. The opposite is where we see kids with more cognitive function who go around it, who anticipate, maybe really subconsciously, that when Michelle is going to tilt my head again in the ATNR example, there is a locking, whoa, this does not work out well for me, I am not going to collapse, I will lock out instead. With a really good eye we can still spot that, but it gets harder when they have high cognitive capacity and have worked out ways to get around it, so you do not see the full, complete reflex, you see it start and then they move out of it or laterally shift and lock elbows so they do not collapse. Can you talk about that automation, that a reflex is just that arc, that there is not necessarily conscious control of this, particularly for your beautiful lady?
Tracy: Absolutely. It is this low-level pattern that is just a pure reflex, it really does have that quality. But because it is not happening in the peripheral nervous system where we think of other reflexes, like stepping on a tack, where it goes to the spinal cord and comes straight back and you pull your foot away, or a patellar stimulus where you see the little reflex arc in the leg, these deeper postural reflexes are integrated through the sensory-motor circuitry, so there are lots of other influences on them. Just like you said, Michelle, if somebody is, every time I am in this position and turn my head, this thing happens, so I am going to super avoid it. I have a friend who is an OT but has worked for a long time as a driving coach for people with all kinds of issues, head injuries, or living with some neurodiversity, who want to learn to drive. She hears this story all the time, the hardest part is when I am holding the steering wheel and have to look all the way behind me to my left or right, and I pull on the steering wheel, it is a reflex, that is the ATNR kicking in, as soon as I turn my head I know I am going to turn the wheel. So there are all these strategies to do what you described, getting really stiff and saying, I am not going to let that happen, I am not going to collapse. We can override it through the activation patterns we pull into our new plan, but then we become really inefficient. You both do lots of finesse things with your bodies. I try, but I am less competent in some ways. In the last year I have been trying stand-up paddleboarding, which is a riot, and really hard, because the surface is so unstable.
Michelle: Tracy, could you send me some video, please? That will be my bright shiny thing, I will do whatever you want as long as you trade me some video of you on a paddleboard.
Tracy: It is beyond comical, partly because I have really low muscle tone and a large frame, and I find myself having to breathe through, relax, do not hold, do not fix there, allow for the rotation, feel your body in space. I know how the whole system works, so I can coach myself in my head.
Cory: For context, Tracy is tall, so getting on a paddleboard, your centre of gravity over your base of support is very high, so it is even more of a challenge. If you were not more integrated, you would spend the whole time falling off, or be too worried to even get on the board.
Michelle: You are so playful, and you know it is tricky, and you know you have the capacity to do it, you are brave, hopefully doing it with friends who are giggling and co-regulating you. But you have a lot of resources, and it is still taxing on you. So if you found some rapids or ran into reeds or there were suddenly piranhas, all of that would drop off a bit. Some of our kids do not have those resources to pull on to giggle through it.
Cory: So Michelle talked about the kid who can cognitively override it, but because that system should be so automatic, as soon as you have to pull in the cognitive piece it becomes a much more taxing task. That made me think about many of the kiddos we see who are doing pretty well but are so fatigued by the end of the day, and then they fall apart. We do not always know exactly why, but sometimes when you gather more information, it is having to think through almost everything that should often be the automatic piece that supports them to do day-to-day things. That was relevant for the kiddo in the posture episode too, he was asking about having to hold the paper, which is an automatic function when you write, you do not think about it, you just hold it because it is efficient. But if I am holding my postural system up with my arm because I do not have ease and uprightness due to the integrity of the vestibular-proprioceptive somatosensory system, then I have to think about all of those pieces, which makes me tired.
Tracy: It is absolutely true. Is it vestibularly based, is it in the motor patterns, in their muscle tone, in their strength and endurance, in the impact of the vestibular on their strength? All of those are live questions when we are figuring out how to help this person engage and perform and be fully available to do their handwriting in class, or stand-up paddleboarding, or get on and off the swing in the clinic, or climb over us in rough and tumble. The postural system should become pretty automatic. Even in little babies, once they get it, they get it and move to the next stage, they get integrity in prone prop, in the shoulder girdle, and now they can move around in pivot prone, and it is just there and available, and it does not matter that their head is moving. You can pull the reflex in a five-month-old, but it does not influence them too much, because they have all this ability to move around. So when we see it in an eight-year-old or an 18-year-old, you have to ask a lot of questions, from the far left of the grid to the far right and all the way across. It is really about sorting it from each level of processing to the occupational outcome, back and forth over and over again.
Cory: What a wonderful discussion, I have lots to think about. I had a wondering about the treatment process for that wonderful young woman you worked with, Tracy, because I am sure it was very refined. I would love to talk about that next episode, exactly how you came to that end point where she could find herself in space, use the space above and below her, enjoy cruises, all through this process over four months. I think that would be super valuable. Shall we chat about that next time?
Michelle: Love it.
Tracy: Love it, a great idea. Vestibular treatment can feel mysterious, and it is also full of principles, and the nuance of beautiful, engaged, relational treatment, so it will be fun to talk through and learn a little more together.
Cory: Amazing. We will see everybody next time. Thank you, wonderful women. Do not forget to send those videos on, please, Trace. See you, everyone.
And that’s a wrap on today’s episode of Spirited Conversations. We hope this sparks something for you, whether it’s a new clinical idea, a fresh perspective, or just the reminder that you are definitely not alone in this work. If this conversation resonated, we would love for you to share it with anyone on their own learning journey. You can find information about the podcast on our website, and you can join us in the courses and communities the Developmental FX team have put together at developmentalfx.org. And if you’re enjoying listening, please subscribe or leave a review, it genuinely helps more people find us. Until next time, keep the conversations spirited!