Understanding the Symmetrical Tonic Neck Reflex (STNR)

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Primitive reflexes are present at birth and integrated as a child grows. Reflexes are actions that are executed as a response to a stimulus automatically.

Reflex integration therapy is a treatment that aims to integrate primitive reflexes that should have been integrated (disappeared) at earlier ages. This type of therapy has been shown to be effective in improving function in children with various developmental difficulties. But it is a hotly debated topic in the pediatric therapy world.

When primitive reflexes are not integrated by the proper age they are no longer functional.  They now lead to maladaptive patterns and can lead to difficulties concentrating, difficulties with auditory processing, and coordination issues.

When primitive reflexes are retained we will see limitations in the areas of midline development (ability to use the right hand or foot on the left side of the body and vice versa), coordination, balance, oculomotor dysfunction (movement of the eyes such as tracking an object), posture, and attention.

What does the Symmetrical Tonic Neck (STNR) Reflex look like?

When the STNR is elicited, the baby or child’s head is flexed or bent forwards, the child’s arms to bend and their lower legs to straighten. When the head is extended or bent backward, the child’s arms are straightened, and their legs bend.

What is the Purpose of the Symmetrical Tonic Neck Reflex (STNR)?

The Symmetrical Tonic Neck Reflex helps the child separate arm and leg movement independently from each other. The symmetric tonic neck reflex is commonly referred to as the “crawling reflex” as it helps the child come into a crawling position.

How do you test for a retained STNR reflex?

The STNR can be tested with the child on all 4s in a quadruped, crawling position.  While in this position the therapist moves the child’s head up and downward. Moving the neck through flexion and extension.  And observing the effect on the child’s arms.  The STNR is still present and not integrated if the child’s arms bend when the head is flexed.

When should STNR be integrated?

The STNR reflex is present at birth and typically integrates by 10 months of age.

What are some signs the STNR reflex has not integrated?

With infants, the presence of the STNR may make crawling itself difficult as the child’s arms will want to bend every time he looks down.  

As a child ages, especially to school-age eye-hand coordination is affected by an unintegrated STNR.

Children with unintegrated primitive reflexes have many difficulties which affect their abilities in a classroom and in tabletop tasks. Including:

• difficulty sitting in an upright seated posture
• often slump
• move excessively in their seats
• decreased attention  

Children with retained reflexes often also have difficulty with sensory processing.

What happens if STNR is not integrated?

In my occupational therapy practice, I have seen that children with unintegrated reflexes have difficulty with handwriting because when they look down at the paper, their arms will want to bend. This also makes participation in sports difficult as they are perceived as awkward and clumsy.

Activities and exercises to support the integration of the Symmetrical Tonic Neck Reflex?

What’s next?  How can we help these children integrate and inhibit an unintegrated STNR reflex so they can better participate in occupations? 

The key is to have the child participate in:

• Activities on all 4s such as crawling but looking around with their head up at the same time. Continuing to crawl will encourage the child to keep their arms straight while their head moves up and down.
• Another activity would be to complete an activity on the floor such as a puzzle while in a crawling position.
• I love using the cat yoga pose for STNR integration activities. Using yoga cards makes these activities more fun for the children.

Have other fun ideas to work on the STNR reflex? Leave a comment below!