Abstract

The Asymmetrical Tonic Neck Reflex (ATNR) is a primitive, brainstem-mediated reflex that emerges prenatally and typically integrates in early infancy. Appropriate integration supports early postural control, midline awareness, and the foundations of eye–hand coordination. When the ATNR persists beyond infancy, studies associate it with fine- and gross-motor challenges, oculomotor (eye movement) inefficiencies, attention and reading difficulties, and higher rates of retained reflexes in certain neurodevelopmental conditions (e.g., ADHD, ASD). This review summarizes ATNR development and purpose, functional impact when poorly integrated, common co-occurring diagnoses, and proposed contributing factors to retention. It also outlines practical next steps for parents considering pediatric occupational therapy evaluation.^8,4,6,5,7

Keywords: ATNR reflex; primitive reflexes; child development; fine motor skills; gross motor skills; oculomotor control; reading; ADHD; autism; pediatric occupational therapy

What is the ATNR?

Primitive reflexes are automatic motor responses originating in the brainstem that support survival and early neurodevelopment. They normally become inhibited as cortical control matures in the first months of life.⁸ The ATNR — often called the “fencer’s posture” — links head rotation with extension of the arm and leg on the face side and flexion on the skull side. It typically appears late in gestation and is expected to integrate during early infancy, making way for voluntary, symmetrical movement and bilateral coordination.

What does ATNR do in healthy development?

Functionally, ATNR helps the infant practice coupling head movement with limb activation, laying groundwork for midline awareness, early reaching, eye–hand coordination, and later skills like crossing midline and handwriting.⁸ It supports transitional postures and the shift from reflex-driven movement to volitional control as corticospinal pathways mature. In short: ATNR is a temporary “training wheel” that should fade as higher-level control emerges.

What happens when ATNR doesn’t integrate?

1) Motor development (fine and gross)

Multiple studies show that higher levels of retained primitive reflexes, including ATNR, correlate with lower motor efficiency in otherwise healthy children.⁴ Findings include clumsiness, immature bilateral coordination, and reduced fine-motor precision affecting tool use and handwriting.

2) Vision (oculomotor control and reading)

A retained ATNR is associated with midline-crossing difficulty and inefficient eye movements. Research links reflex persistence — particularly ATNR — with poorer core literacy skills and reading performance.⁶ Emerging work also shows changes in eye-movement performance in children evaluated before and after reflex-inhibition therapies, suggesting a relationship between primitive reflex status and oculomotor control.²

3) Attention and self-regulation

In clinical samples, persistent primitive reflexes (including ATNR) have been associated with ADHD symptoms⁵ and, in broader analyses, with attention and balance deficits — showing sex-specific patterns for ATNR and STNR.¹ These are correlational findings; they do not prove causation, but they help explain why some children with attention challenges also show retained reflexes on screening.

ATNR and neurodevelopmental diagnoses

Retained primitive reflexes are reported more frequently in certain neurodevelopmental conditions. Reviews in autism spectrum disorder (ASD) describe close relationships between retained reflexes and cognitive and motor function, and discuss the potential for change when reflex activity decreases.⁷ Reflex persistence is also frequently studied in ADHD cohorts^5,1 and has been described in children with coordination and learning difficulties.⁶

What might cause ATNR to persist?

The most robust medical literature ties persistent primitive reflexes to central nervous system immaturity or injury (e.g., in cerebral palsy) and uses reflexes as part of neurologic examinations.⁹ Occupational therapy clinical sources propose additional perinatal and environmental contributors — such as cesarean or assisted delivery, limited tummy time, early walking with minimal crawling, chronic ear infections, or head injury — but rigorous causal evidence is limited, and these should be viewed as hypotheses that warrant further study.^9,3

How pediatric OT screens for and treats retained ATNR

Screening

Pediatric OTs observe posture, crossing midline, handwriting mechanics, and oculomotor skills, then perform simple head-turn tests for ATNR while the child is in stable positions. Findings are interpreted alongside functional goals — not in isolation.⁸

Intervention

Therapy plans emphasize functional, play-based activities that build postural control, bilateral coordination, eye–hand coordination, and self-regulation. Reflex-reduction activities (e.g., rhythmic movement patterns) may be included as preparatory methods, but clinical goals remain occupation-centered — reading, dressing, classroom participation, and the daily skills that matter to a child’s life.

Evidence note

The evidence base linking reflex-integration techniques to broad academic or behavioral outcomes is evolving. Parents should expect individualized treatment plans with measurable, functional outcomes rather than reflex scores alone.

Limitations of the current evidence

• Many studies are cross-sectional (correlational). They show associations, not causation.
• Sample sizes can be small, with variable protocols for reflex testing across studies.
• While some interventional studies and clinical reports describe improvements in motor and oculomotor function alongside decreased reflex activity, high-quality randomized controlled trials remain limited.
• Professional guidance from AOTA emphasizes function-focused care and careful interpretation of reflex findings within comprehensive, family-centered practice.

Practical next steps for families

1. Talk with your pediatrician and request an OT referral if concerns persist about handwriting, reading endurance, motor coordination, or self-regulation.
2. Schedule a pediatric OT evaluation. Ask that screening include posture and core strength, bilateral coordination, oculomotor skills, and — if appropriate — primitive reflexes including ATNR.
3. Focus on function at home: tummy time for infants; cross-lateral play (crawling, climbing), ball games, drawing and coloring, and calm-body routines (deep pressure, heavy work) for older children.
4. Track what matters to your child: fewer meltdowns during homework, improved stamina for writing, smoother ball skills, or easier page tracking.

Frequently asked questions about ATNR

Conclusion

ATNR is a normal, temporary building block of infant development. When it lingers, it may be one factor among many that makes schoolwork, sports, or attention harder. Evidence-based pediatric OT looks at how ATNR relates to your child’s real-life goals — and then uses targeted, playful, and family-centered strategies to build the skills that matter most.^8,4,6,5,7