Friday, 20 April 2012

Reflex integration and autism


In my last blogpost, I looked at the implications of autism being viewed primarily as a disorder of interpersonal relatedness.  I noted that taking this view gives us an explanation as to why the triad of impairments occur together - because good social interaction, communication and flexibility of thought and imagination all develop as a result of the interpersonal experiences and communication shared by child and caregiver in the early years.
One of my readers asked an excellent question in response to the blogpost:
'How does all this fit in with reflex integration that so successfully helped my autistic son?'
I responded by saying that I don't feel I have sufficient expertise to answer that question, but I know a woman who does.  I'm handing you over now to my good friend and colleague Claire, who very kindly gave a detailed response that I have decided to feature as a blogpost, rather than hiding it away in the 'comments' section.
Claire's response
Hi Motivatedmum
I’ve just qualified as a neurodevelopmental therapist (INPP) so am delighted to hear that a reflex integration programme made a real difference for your child.  It would be interesting to hear more about which programme you followed and what differences it has made for him.
I’ll attempt to answer your question about how this might fit in with Zoe’s post about autism potentially being reversible if you work on what Peter Hobson describes as a disorder of interpersonal relatedness.  But please bear in mind I’m hypothesizing based on what we know about autism and neurological development.
I think Peter Hobson accurately describes what happens developmentally in all those on the autistic spectrum.  In simple terms the guided participation relationship between the child and the caregiver breaks down resulting in the range of symptoms/behaviours we broadly recognise as “autism”.    This clearly occurs in every case of autism.  Outside the scope of Hobson’s work though is the question of why this relationship breaks down.  And the answer to that is that there are doubtless a number of 'reasons' – 'reasons' that we may later come to recognise as the different 'causes' of the various phenotypes of autism. 
Zoe highlighted a couple of potential 'causes' in her post – the absence of vision which is key in developing  the infant/caregiver relationship and the absence of a “caregiver” in cases like the Romanian orphans.    The latter is somewhat different to autism as the breakdown in the relationship occurs on the caregiver side of the equation.  In autism and a subset of (not all) visually impaired infants the breakdown occurs because of disordered functioning on the part of the infant. 
Of course there are many other reasons for this relationship breakdown.  Based on what we know now we are likely to identify other causes in atypical immune responses, environmental “toxins”, atypical sensory functioning etc.   Theoretically once we are able to identify and address the specific cause of someone’s autism we can “cure” it – if I can use that term without being pilloried.  So, for instance, if visual impairment lies at the heart of an individual’s autism restoring sight would “cure” the autism – but only, of course, if the “cure” is applied at developmentally the right time.    In the case of vision the right time developmentally would be no later than the time of birth as vision plays a critical role in the development of the interpersonal relationship from that moment. 
If vision is restored later in life or at the point when the visually impaired infant learns to use other sensory systems (auditory/tactile etc) to develop the interpersonal relationship his/her development will already be seriously delayed and/or disordered.    One of Zoe’s points is that approaches like RDI that work on establishing the interpersonal relationship can be used effectively in either case (ie either if the cause of autism is addressed later in development or even if the cause is never addressed). 
As for reflexes specifically  and how this fits in I think that the issues an effective reflex integration programme addresses are potentially involved in one or more “causes” of autism.    There is a “blueprint” for the development of our reflexes.    Deviation from that blueprint can result in a whole range of cognitive, physical, communication, social, emotional, sensory dysfunctions.  In simple terms the stages of reflex development that we go through – before birth and in those very early months – entrain the many functions of the brain that need to happen “automatically” if we are to function effectively and efficiently.   So for instance typical reflex development leads to a fully functioning visual system (ability to fixate, to track across a page, to follow a moving object visually, to switch from near to far vision, to switch attention from one object to another, to block out peripheral visual input and focus until such time as you need to take in peripheral input etc etc).   These are all skills that should happen automatically.  In cases where the typical reflex development has not occurred much of the brain’s energy will go towards performing what should be automatic, thus reducing the capacity and the ability to perform higherfunctioning “thinking” skills like academic skills, executive functions, problem solving etc.   This creates a very stressed neurological system and a very stressed individual.  A person with such visual problems will not be able to recognise “patterns” and make sense of visual input, they will be drawn to non significant objects/ people in their environment, they will not be able to deal with new situations .  If you want to examine one specific aspect (why aren’t autistic infants addicted to facial gazing) it is likely they may not be able to fixate (so how could they be addicted to faces as is necessary), they are likely to be drawn to visual movement (hence look at mouths that move more than eyes etc). 
The problems associated with  vision are similar to all the other senses (auditory/tactile/proprioceptive /vestibular ) but I don’t have space to expand here.   
So clearly if such problems lie at the heart of an individual's autism, addressing reflex development is key.  But, in addition, using  an approach like RDI to help to re-establish a more typical developmental trajectory as underpinned by interpersonal relationships is also important. 
I’m not sure if that helps at all.  Let me know!
End of Claire's response
If anyone would like to know more about reflex integration and development and how movement feeds the brain's development, Claire has kindly offered to write a follow-up blogpost to explore this in more detail.
Click this link for more information on INPP and how to find a Practitioner.
And a big thanks to Claire for her guest post :)

11 comments:

  1. I ran into reflex issues when my son could not monitor external monitoring in the later stages of RDI. He could monitor in close proximity and if there was little movement, but if an interaction became more dynamic, he could not keep up. It was then I thought he must have an underlying visual problem and a visit to a developmental optometrist revealed he had numerous visual issues. Looking into the recommended vision therapy, I noticed there was a reflex component and so I decided to research it. It seems to me that RDI in regard to brain reorganization is primarily dealing with the cortex, the last area of the brain to develop. That's fine if the foundation is strong - the development of the medulla, pons and midbrain. For my son there are deficits in each of these areas, specially in regards to vision, and without the foundation being strong, I am guessing RDI cannot adequately build the "interpersonal relatedness" house. I'm hoping through reflex integration we can have a firm foundation to have continued success with RDI. I'd love to hear more from Claire! -Kimberly

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  2. Hi Kimberly

    That is a very interesting insight and I think this may speak to why some kids don't seem to progress or get stuck in RDI when they get to a certain level and also why it is so difficult for some kids to engage in RDI type experiences in the first place. The latter set of children may be so focused on dealing with their sensory environment and/or problems created by retained/un-integrated reflexes that they haven't got room for anything else.
    What you have written has made something stand out very starkly for me - that RDI is dealing with the development of the pre-frontal cortex (and its ability to dampen down the emotional responses from the amygdala) but it doesn't seem to take into account the brain bits that are developmentally (and physically?) in the middle of these two areas (you describe the medulla, pons and midbrain). So now I am thinking, what external process or processes is/are involved in the development of these brain areas? And of course, looking at it through the lens of typical development means that it doesn't make sense to miss out any areas of brain development. So do we need to be asking what comes before the PFC in brain development (which, as you say, is the last and most sophisticated area of the brain to develop), and how is this developed? Can you tell us any more re what you know about the development of the medulla, pons and midbrain? I'd also be very keen to hear about what impact reflex integration has on your son's ability to benefit from continued RDI.

    Thank you to Kimberly and Claire, who have fitted another piece of the puzzle into place for me.

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    Replies
    1. Hi Kimberley
      I think Dr Gutstein used to refer to “obstacles” that impeded the progress of RDI programmes. Issues such as you describe clearly fall into that category.
      I agree with you that RDI works principally at the cortical level of the brain and that neuronal connections in the cortex are made at a developmentally later stage. As you suggest, reflex development is involved in the development of the “lower” parts of the brain – including the brainstem and cerebellum and limbic system. These systems are involved in getting on with what should be “automatic” functions like balance, co-ordination, sensory modulation, emotional regulation.
      Just to give a couple of examples to illustrate – though please bear in mind that it is always somewhat artificial when you extract elements from a complex, interdependent system! Firstly you mentioned your son’s problems with vision. Reflex development is directly associated with the development of all the visual skills I wrote about previously – fixating, tracking, shifting from near to far vision etc. For instance if the Moro reflex is not inhibited at the typical age of 2 to 4 months the infant will continue to be drawn to movement and light in his/her peripheral vision. . If the ATNR reflex is not inhibited by about 6 months tracking across the midline will be very difficult. IF the STNR reflex is not inhibited to allow the infant to crawl properly accommodation (switching from near to far vision) will not be learnt as it should.
      As a second example – returning to the Moro reflex – if this is not inhibited at the appropriate stage that light and movement in peripheral vision (amongst other stimuli) will continue to cause a startle reaction. The infant may develop all sorts of coping strategies. You may see “body armouring” – ie being rigid and tense to prevent responding physically to constant stimuli that startles. In your son it may be that – and this is just one suggestion – that he has learnt to narrow his field of vision because he is so distracted and disturbed by his peripheral vision. In other words he is trying to reduce his exposure to the anxiety caused by specific visual stimuli that triggers the startle reaction. The startle reaction involved in the moro reflex is very different to the adult startle reflex. In the adult something causes them to startle but then they pause, orientate to assess the significance of the stimuli (ie is it dangerous, unpleasant, important) then either ignore it or take appropriate action. In young infants or people where the moro is still active the reaction is an emotional one. The cortex does not immediately kick in and say I don’t’ need to worry about that its not important. Clearly, in autistic children, the cortex often/always kicks in later but it is too late as the intense emotional response (and sometimes “impulsive” or automatic response) has already taken place and the memory laid down that that stimuli creates a very unpleasant response that is to be avoided at all costs.
      If you look up Joseph le Doux who writes about the “emotional brain” he essentially summaries mental wellbeing (like “emotional regulation” in autism)as being about the connection between the cortex (thinking brain) and the lower parts of the brain (like the amygdala). In a healthy well regulated system sensory stimuli is sent to the cortex for analysis so that the emotional response and the course of action taken is in proportion to the significance of the sensory stimuli. In our children the connection from lower to higher brain is too weak and/or too slow – so you get an unregulated emotional response and an impulsive course of action. Hence you can see how important it is that reflex development enables the lower brain to function automatically, thus putting in place the foundations for the development of the cortical brain and the effective interaction betweent the two.

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  3. Hi Zoe,

    As shared with you, Im an RDI parent for 2 years and got stuck in RDI due to my son's motor and sensory issues.

    Last year, I saw nice improvements in my child's awareness of body in space, muscle tone and vision after using HANDLE, however I could not find resources to help me see while.
    I started MNRI about half a year ago and noticed the stabilisation of my child's arousal, his sleeping, longer attention, better cognition and observation of his surrounding, better get "ready to participate in guiding relationship". Ive added in some Moro, ATNR, balance board, pendulum,infinity eight 2 weeks ago and I am seeing my son better"communicates" with gestures and vocals, which I'm extremely excited about.

    Reading reflex books by Sally and Masgutova, I find it so true with my son when I relate to his "retained" reflexes and all the difficulties hes been facing since birth. Moro is a very true example.

    I believe that RDI consultants with reflex integration practice will be of great help to children with co-occuring conditions.

    Best wishes
    Ha

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  4. Does anyone know the difference between MNRI and Neurological Reorganization?

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  5. What is the evidence for retained primitive reflexes and the "exercises" that are prescribed to integrate them? I'm a pediatric OT, and while in theory it all sounds legitimate and interesting, I've had a hard time finding independent research on these matters, especially which exercises are supposed to integrate the reflexes and why. I've also seen these theories criticized.

    It was difficult to find any research on the methods for determining why a child has a "residual" reflex, who developed the clinical "tests" since they differed from tests performed on infants, or why certain "exercises" are supposed to "fix" these reflexes.

    Does it all just come down to poor coordination and praxis, which, to be honest, so many kids with learning disabilities and other developmental delays have? My thought was that all the "positive" reflex signs were simply examples of poor disassociation between left and right and upper limbs/lower limbs, as well as between the eyes and head---all of which are simply issues of praxis and coordination, right? Is it possible that since reflexes are supposed to help us develop voluntary movement, some people don't develop voluntary movement as well as others--but can we really call these issues poorly integrated reflexes, or simply state that the children are poorly coordinated?

    I just want to be able to be honest and forthcoming with my patients' families, and I want to be able to show them the evidence if need be.

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  6. Zoe and I have been discussing emotional and social development in autism and in her most recent post about this http://is.gd/DSizCO Zoe mentioned that previous guest posts on her blog had commented on other developmental milestones delayed or absent in autistic children. Having read Claire's post above, it occurred to me that some of the points Zoe and I had differed over might be the result of us having different concepts of child development itself. I want to comment on three things Claire said that illustrate this point; genetic blueprints, the role of reflexes in development, and how there can be different possible causes for variations within development.

    I'm aware that Zoe is busy and can't reply at the moment, but I wondered if Claire might want to get back to me. My reply to Claire is in three parts. Sorry it's so long, but this is a complex topic.

    1/3

    Claire describes the genetic control of reflexes as a 'blueprint'. This term is widely used to describe genetic control, but people use it to mean different things, which is where confusion can creep in. The idea of a genetic 'blueprint' dates back to the very early days of genetic research, when scientists knew that each species had its own unique pattern of chromosomes, and when the structure of genes was often likened to beads on a necklace. It was assumed that human beings shared a specific genetic pattern that unfolded naturally and automatically during development, and that children would develop in the way that was typical for our species, unless there was something 'wrong' with the genes or the environment the child was brought up in.

    As we've learned more about the structure of DNA, we've become aware that the picture is a bit more complicated than that. We now know that each of us has unique DNA. It has a recognisably human pattern, but is unique to each of us. The structure of the DNA can change when between generations when it divides or recombines during reproduction. Genes can be 'switched' on and off by other genes, or by factors in the environment. In addition, each of us occupies a unique environment and has a unique life experience. Although we each develop in a similar way, each of us follows a unique developmental trajectory.

    So the phrase 'typical developmental trajectory' can mean different things. It can describe what happens - 'most children develop in this way', or it can prescribe what should happen - 'all children *should* develop in this way'. I'm not clear which meaning Claire or Zoe are using. The first meaning, the description, is a useful rule of thumb to highlight developmental variations that might cause problems. The second meaning depends on what people involved with the child think is 'typical' development and why they think the child might not be developing 'typically'. It can lead to a child's unique genetic makeup being overlooked, and developmental 'targets' being set when they might not be appropriate for the individual person.


    Sue

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  7. 2/3 Claire then goes on to say that typical reflex development entrains the 'many functions of the brain that need to happen “automatically” if we are to function effectively and efficiently.' I'd agree with that. She then says 'for instance typical reflex development leads to a fully functioning visual system. These are all skills that should happen automatically.'

    Research certainly confirms that reflexes 'kick start' development. However, I think Claire might be giving reflexes more credit than they warrant. Development isn't like a train travelling along a track unless something pretty major occurs to derail it. A healthy baby's development is more like someone who's never seen a motor vehicle before being put in a car with the engine running and having nothing else to do but drive all day. (The novice driver representing the baby's brain and the car representing the rest of the baby's body). Most people in that situation (on a quiet road at least) would become a reasonably competent driver pretty quickly because they would learn through trial-and-error how the car's controls worked, how to avoid bumping into things, and that other drivers kept to one side of the road. They would also end up driving in a very similar way, because their behaviour would be shaped by the way the car functioned and the layout of the road. Because our brains and the rest of our bodies are similar and we all live on planet earth, we tend to follow a similar developmental pathway, but variations in our brains, the rest of our bodies and the environment we grow up in, mean that our developmental trajectory will vary.

    In Claire's example, a problem with a visual reflex might well impair visual development but reflexes aren't the only things involved. Learning, at a preconscious as well as a conscious level, plays a significant role. For example, the visual system can recognise images it's seen before, even if the person being shown the images can't remember them.

    Obviously, there isn't much visual information in the womb, so visual development starts in earnest at birth. The development of a fully-functioning visual system is also dependent on the structure and function of the bits of the body it uses; eyes (which are complex organs in and of themselves), nerves, and neurons and other cells in at least 40 brain areas. That's a lot of bits other than visual reflexes that could potentially vary from the 'typical'.

    The research also suggests that whether some processes end up as automatic depends on the number of times the process is carried out. The more frequently it happens, the more likely it is to become automatic. In other words, the automatic nature of visual skills isn't only down to reflexes either.

    I'm not suggesting that what Claire says about visual development is wrong, just that in a complex system there are going to be alternative explanations that need to be ruled out before you can be sure that one explanation is likely to be the right one.

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  8. 3/3 My last point is linked to the previous one. I wouldn't question the effectiveness of sensory integration exercises, reflex integration interventions or RDI unless I had a good reason to do so, and to date, I don't have a good reason to do so. I'm convinced from my own experience that sensory integration exercises, at least, do *work* in some cases. However, even if such interventions are effective, it doesn't follow that the theory behind them is the only explanation for how they work. For example, in my son's case, I have no doubt that rotating (twizzling, spinning) made a big difference to his stability when he was younger. But an assessment by a vestibular consultant showed that he has specific vestibular impairments - so far we have no evidence that there's a problem with sensory 'integration'. So some of the exercises prescribed by OTs were effective, but not necessarily for the reasons they claimed.

    In Sarah's comment on Claire's post, she asks for evidence for retained primitive reflexes and the "exercises" that are prescribed to integrate them. Like Sarah, I've failed to find good research evidence to support the theories behind these interventions, and I think it's important to avoid being too dogmatic about theories that are actually quite speculative.

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