Another mother called, on the verge of tears, expressing concern regarding her four year old son. “He is really struggling in preschool. He has difficulty sitting still and keeping his hands to himself. Sometimes he hits or has trouble sharing toys. He has a hard time with transitions or calming himself when things don’t go as planned. I’m afraid he will not be allowed to return to school.” The emotion could be felt….sadness, hurt, disappointment, anger, frustration…were just a few. I understood. She was at a loss and did not know what to do.

Unfortunately, behavioral concerns are the reason for many of the referrals to our pediatric Occupational Therapy clinic now. So, what’s going on? Many critics say, “Parents should be more strict” or “Take away privileges, like recess. That will make him behave!” Unfortunately, these beliefs often make the situation worse.

Children with negative school behaviors are often misdiagnosed with ADHD and urged to take medication. They are also diagnosed with sensory processing disorder and offered accommodations to help them “make it through the day”. These accommodations can often be helpful, but do not treat the underlying cause of the behavior. Children are often in speech therapy, as well.

After thousands of evaluations of preschool and early elementary children, we have discovered an undeniable link. Children with behavior issues have low scores on developmental motor assessments. This includes children diagnosed with sensory processing disorder, as well.

You’re probably thinking (like most parents), my child is a MONKEY! He runs all over the place, climbs, and is moving all the time!!! His motor skills aren’t delayed. Motor development is more than simply ‘moving’. We look at controlled and precise movements. For example: How does he coordinate both sides of his body to perform jumping jacks? Can he hop on one foot with hands on hips or stand on tip toes for 5 seconds with hands overhead?

At the other end of the continuum is a child who doesn’t like active play, tires quickly and seems to have low endurance and weak muscles. He may lean on you, lie on the floor or fall out of chair occasionally. This shows low muscle tone and muscle weakness, which makes it difficult to hold his body up against gravity.

Can your 3 ½ year old balance on one leg for 5 seconds with her hands on his hips? Can she lie on her tummy and raise straight arms and legs off the ground, like “superman” and hold for 10 seconds? Can she lie on her back, put arms across her chest, bring knees to her arms, and lift forehead to knees for 5 seconds? In order to sit still in school and keep his hands to self, a child first needs to be able to be able to hold body against gravity, balance on one leg and hold body still in all developmental positions. Behavior, gross and fine motor skills and speech and language are directly related.

When a 4-year-old child scores in the 2-3 year age range for motor skills it becomes apparent that it is not for lack of trying or non-compliance, but truly a lack of ability. We cannot expect a child to perform four year old age appropriate skills, such as sitting still for extended periods of time, listening, copying letters and other higher level cognitive tasks when he does not have the foundational developmental skills of a typical three year old.

So those bribes or behavior modification charts you’ve used (I know I did when mine were little!) to try to get him to behave, just don’t work for this behavior or impulsivity. He doesn’t have the reasoning ability of a 4-year old to think… “ If I touch/hit my friend, I won’t get to go to the block center”. This is a higher-level brain function, and developmentally, he is using lower level brain functions.

The Good News!

Just as the behaviors are insight into how his brain in functioning, it means that we can affect and improve development and brain function by offering novel movement exercises and activities. We have found that many children have impaired reflex integration. This sounds like a technical term, but reflexes are simply a part of normal development. They begin in-utero and should be integrated by age three. If they are not integrated, the presence of these reflexes can cause impairment in learning, development, emotional maturity and behavior. After starting reflex integration therapy, in combination with vestibular input, parents and teachers notice dramatic changes in behavior, attention, speech, motor development, balance, coordination and improved processing speed.

Many parents ask, “What caused this”? The answer is unknown. It is possible that it starts in-utero. It is possible to promote reflex integration in infants by allowing them as much time as possible on the floor on their tummies. Infants should spend minimal amount of time in car seats, carriers, bouncers or other play equipment, for proper development to occur.

For whatever reason, some children do not “integrate” these reflexes and the reflexes continue to control their movement patterns. These primitive reflexes occur at the lowest level of the brain, in the brain stem. This is also where basic emotions and behaviors are processed: fear (fight or flight), avoidance, sensory processing and impulse control, just to name a few.

What can you do to determine if your child might have impaired reflex integration?

Ask your child (3 years and older) to be very still and hold these positions “like a statue”. If they have difficulty with any, you should consult with an occupational therapist with training in reflex integration. An evaluation will give you developmental age levels and information regarding your child’s reflex integration.

“Superman position” (Tonic Labyrinthine Reflex –TLR Extension)

This position tests for your child’s ability to hold his body against gravity in extension. He should lie on his tummy on the carpet and raise arms and legs off the ground. Extremities should be straight, thighs not touching the carpet and he should hold very still.


  • Age 3 – 10 seconds
  • Age 4 – 18 seconds
  • Age 5 – 30 seconds
  • Age 6 – 60 seconds
  • Age 7 and older – 90+ seconds

“Egg position” (Tonic Labyrinthine Reflex-TLR Flexion)

This position tests your child’s ability to hold his body against gravity in flexion. He should lie on his back, cross arms across chest with hands by shoulders and bring knees to arms. Then ask him to lift his head/neck so that he is trying to touch his forehead to his knees. Look for shoulder elevation (his shoulders raise up to his ears) or using extension rather than neck and stomach muscles to raise head off the ground. If you observe these, the reflex is not integrated


  •  Age 3 – 5 seconds
  • Age 4 – 10 seconds
  • Age 5 – 25 seconds
  • Age 6 – 46 seconds
  • Age 7 and older – 60+ seconds

“Glider” (Symmetrical Tonic Neck Reflex-STNR Extension)

  • Integrated – If able to rock forward
  • Not integrated – Not able to assume position or rock forward

This position tests your child’s ability to freely move in and out of hip flexion and extension with head and neck raised. Ask your child to get in hands and knees position (like the Cow) or “be still like a puppy dog”. Ask him to raise his head so that he is looking straight ahead and rock forward over his hands. He should not hold his hips in flexed positon, but rather open up so that his back and hips are in a straight line. If his back arches significantly; looks down when rocking over hands or keeps hips bent (like they are stuck in that position as in 2nd picture), then this reflex is not integrated.

If you suspect your child may be struggling with behavior or sensory processing difficulties due to impaired reflex integration, contact an occupational therapist trained in reflex integration.

Debbie O’Connor, MPH, OTR/L
Pediatric Occupational Therapy, LLC Stronger Bodies, Brighter Minds, Happier Lives!

We offer on-site preschool observations and consultations, as well as 1:1 and group occupational therapy services. Contact us to schedule an evaluation or to discuss your child’s needs. (918) 629-3821