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lntroduction
f,ere can be many reasons why a child fails to attain competence in literacy and
fI grapho-motor skills, many of which are addressed by services within the edu-
catlon system and initiatives to support development in the early years. Nevertheless,
there remain a signif icant percentage of children whose mastery of basic skills falls below
expected levels at the end of primary education (Ofsted 2010) with children from poorer
backgrounds being at a particular disadvantage (Goodman and Gregg 2010). one area
that has not received sufficient attention in recent years is developmental and physical
"readiness" for formal education.
Readiness for school requires much more than a child simply reaching the chro-
nological age required for school entry. To perform well in an educational environment,
a child needs to be able to: sit still; pay attention; use a writing instrument, and to control
a series of eye movements, which are necessary to follow a line of print without the eyes
"jumping" or losing their place on the page. These are physical abilities, which
are linked
to the development and maturation of motor skills and postural controt. Growth and phy-
sical development are as important to education as they are to the field of developmental
medicine but have been largely overlooked by the educational system in United Kingdom
since the phasing out of routine developmental tests for all children which used to be
carried out by the school doctor at rising 5 years of age.
The disappearance of developmental testing of all children in the United Kingdom
was the result of two changes in the administration of the whole area of special needs
in education: Firstly, in the i980s responsibility for special needs was handed over from
the Department of Health to the Department of Education. This meant that responsibility
for the assessment of children's physical development moved from the domain of Medi-
cine to that of the Educational Psychologist and teachers trained in speclal educational
needs. While the testing of children's cognitive abilities was secure, testing of chilclren's
physical developmental status was no longer carried out as a matter of routine. Secondly,
in the words of a retired paediatrician, 'in the 1980s we entered an era of evidence based
medicine when it became necessary to provide a proven remedy for any problems that
were detected as a result of routine testing - at that time we did not have the resources
or a standard method to offer - and the routine developmental testing of every child was
phased out' (Paynter 2004).
121
One of the outcomes of these changes has been that children who are delayed
in specific aspects of thelr physical development but who do not present with a medical
probl"r simply'sllp through the net' of services which should be in place to identify prob-
lems and provide appropriate remedial intervention or educational support
ln vlew of the increasing number of children who appear to fall into this category,
it was decided to monitor the introduction of a developmental test battery and physical
remediation programme which has been investigated in several other schools.
1zit
functioning and visual-perceptual performance. lndividual
remedial programmes using
physical movements designed to stimulate, integrate and inhibit specific
reflexes are pre-
scribed on the basis of the child's individual refle-x profile. rh"
o"",ir"pr"ental movements
are carried out at home every day under parental supervision
tor approximately one year.
The child's progress is monitored at 8 weekly reviews
through tr,e course of the year and
the exercise programme adjusted accordingly.
One of the shortcomings of the method has been that
only a relativeiy small num-
ber of children can access such detailed evaluation and
individual supervision. lt was in
answer to this problem, that the INPP Test Battery and Developmental
Exercise program-
me for Children in Schools was compiled (GoddaiO
Atytne tgSb).
The INPP Test Battery for Schoots
123
7i
results in extension of the arms and flexion in the legs. lf this is present in the school-aged
child it can affect posture when sitting or standing, the abillty to sit still, and the muscle
tone and coordination needed for activities such as learning to swim and do forward rolls.
Other researchers have found a link between retention of the STNB and Attention Deficit
Hyperactivity Disorder (ADHD) (O'Dell and Cook 1996) and problems with speed and ac-
curacy of copying (Blythe and McGlown 1979).
The Tonic Labyrinthine Reflex (TLR) affects both vestibular and proprioceptive fun-
ctioning, because movement of the head forwards or backwards through the mid-plane
induces f lexion or extension of muscle groups throughout the body. lf the TLR remains, it
can interfere with the development of head-righting reflexes, which are essential for the
maintenance of proper head alignment in relation to body position, upright head and body
posture and centres involved in the control of eye movements (De Ouiros and Schrager
1978, Kohen-Raz 1986)
Previous studies involving more than 000 children in mainstream schools in the
'1
United Kingdom have indicated that a total score of >25ok on tests forthe ATNR, STNR
and TLR is linked to educational under-achievement (North Eastern Education and Library
Board Report 2004, Goddard Blythe 2005)
Teachers in these studies were encouraged to carry out additional measures
of educational attainment on basic skills such as reading, writing, spelling and maths
(SATS) and use of the Draw a Person Test (Aston lndex) at the beginning and the end of
the programme.
1?,il
Activate movements are used for 2 weeks, then moved up in a step by step se-
quence through a progressive and developmental 36 week structure. The extra activity
extensions provided can be introduced at a speed to suit the class. Every gth week there
is provision f or the pupils to create their own programme from their favourites or their own
original movement ideas.
Two lndependent projects were undertaken:
- The Northumberland project involved four primary schools. No pre-selection of
participants was made in this study.
- small study at St John's Primary School in Berkshire with 2 children whose
A '1
reading age was identif ied as being lower than their chronological age
Aims
The pilot project undertaken by teachers in 4 schools in Northumberland was car-
ried out to investigate:
1. ls there evidence of persistent primitive reflexes in children in mainstream
schools in this sample?
ls there a relationship between immature reflexes and lower performance on
the'Draw a Person'Test? (The Draw a Person Test provides an indication of
non-verbal cog nitive performance)
3. ls the INPP Programme for Schools effective in reducing the incidence of ab-
normal reflexes?
4. ls there a cross-over from improvement in reflex status to improvements in
drawing, reading and SATS results?
Ethics
Parents of all participants were contacted by letter explaining the aims of the pro-
iect and requestlng permission for their child to be included in the project. The project
was supervised in all schools by Ruth Marlee, Behaviour Support Service Schools and
Family Support Division, Children's Services Directorate Northumberland County Council,
Hepscott Park, Morpeth, Northumberland.
The Activate programme was included because teachers were unwilling to wit-
hhold intervention f rom a control group, who might potentiaily have benefited f rom a daily
intervention programme. Teachers were also unwilling to select specific children for inclu-
sion in either group. For this reason, two intervention groups were included ln the study
without pre-selection and there was no control group.
Method
Testing and supervision of the INPP exercise programme was carried out by class
teachers who had attended an INPP approved one day training course in how to admini-
ster the INPP test battery and exercise programme. lnter-test reliability was checked by
Ruth Marlee who had received additional training from INPP All testing and supervision of
the programme, data collection and statlstical analysis were carried out independently of
INPP and the final results were submitted to INPP for writing up.
The INPP one day training course instructs teachers how to:
1. Administer a simple test battery to assess developmental maturity of :
- Balance
- Coordination
- 3 primitive reflexes
lAS
2. Supervise a dally programme of exercises (10 minutes per day) with individual
groups or whole classes of children over the course of one academic year.
Participants
187 children from 4 schools took part in the INPP exercise programme over the
course of one academic year. Of these:
- 25 children aged 4- 6 years were assessed using the INPP test battery for yo-
unger children at the beginning and end of the year. Thls group participated in
the INPP Programme.
- 52 children aged 7 - 8 years were assessed using the INPP test battery for chil-
dren from 7 years at the beginning and end of the programme. Of these,
- 21 children participated in the INPP Developmental Programme every day under
teacher supervision for one academic year
- 21 children participated in a general programme (Activate) of daily exerclses for
one academlc year.
- All pupils following
the 7+ programme were in parallel classes in the same
school. They followed the same curriculum in every aspect other than the exer-
cise programmes. Five pupils had Statements of Special Educational Need and
were referred to the Behaviour Support Service before the first assessment
using The INPP Test Battery. All f ive pupils followed the INPP programme
Data was recorded for the following tests prior to implementing the exercise pro'
grammes and at the conclusion of the programmes:
- Asymmetrical Tonic Neck Reflex
- Symmetrical Tonic Neck Reflex
- Tonic Labyrinthine Reflex
- Draw a Person Test (Aston lndex based on the Harris-Goodenough 1963, Draw
a Person Test)
- scores for reading, writing and ma{hs for the 7 + year old group
SATS
- Reading and spelling for the 4 - 6 year old group
The results were submitted for independent statistical analysis.
Results
1. ls neurological dysfunction (measured by retained reflex scores) present in chil
dren in mainstream schools in this sample?
Yes. ln this sample 88.5 % of children in the 7-8 year old group and 40ok of childrer
in the 4-O year old group were had a total score of >25ok on tests for the ATNR, STNF
and TLR.
2. ls there a relationship between retained reflexes (neurological score) and poore,
scores on the Draw a Person test?
Yes: there is a significant correlation between neurological scores and mental agt
measured by the Draw a Person test. Children who score higher on the neurological score
perform less well on the Draw a Person test (r : -0.215, p : 0.048).
3. Do children in the 7 -Byear old INPP group have a greater reduction in retainec
reflexes (measured by neurological score) than those in the Activate group?
Yes: Figure 2 shows that children in the INPP group show a significantly greate
reduction in reflexes than those in the Activate group (F:9.68, p:0.003).
4. Do children in the 7 -8year old INPP group have a greater increase in score fo
mental age on the Draw a Person Test than those in the Active group?
No: while both groups improved their score, there is no statistically significan
difference between children in the INPP group and those in the Active group (F:0.82
p:0.37).
r26
o 100 r- -- -..-.'
E
E
6
g3-6years
o
ffi=
o
qt r7-Syears
G
o
o
(,
o-
1 >250k <250h
Reflexes Reflexes
g3-6Years 40 60
885 11 .5
r7-SYears
Abnormal reflex score
Figure l. Percentage of sample scores of >25o/o an tests far retained reflexes in both age groups
45
40
35
30 EAssessment 1
25
20 lAssessment 2
15
10
5
o
and Trme 2
Figure 2. Reflex scores for INPP and Acttvate groups at Time
1
25
20
15 I Assessment 1
lAssessment 2
10
0
^A,ctive
5.Dochildreninthel- syearoldlNPPgrouphaveagreaterincreaseinSATre-
ading score than those in the Activate group?
from Time 1 to Time
No: while Uotf", giorp, inlprou"i thelr SAT reading scores
2 (F(1,50):28.00, p <.bot), there was no evidence that the
in:rel:-e-Yt::t:11::?,t
ir: i-#;;;o in# t";ln" Activate sroup (F (1,50) : see Fisure 1)
1.05, non-sisnificant'
,27
E
.s
12
Figure 4' Mean sAT reading scores of the Acttvate ancl lNpp groups at times I and 2
5 Do children in the 7 - B year old INPP group have a greater increase in SAT wri-
ting scores than those in the Activate group?
No: while both groups improved their SAT writing scores from Time 1 to Time
2. (F( 1,50)-12J3, p: .001), there was no evidence that the increase was greater for
the INPP group than for the Activate group (F (,],50) - .35, non-signifjcant, see Figure 2).
o
q,
o
o
o
E
ts INPP
=
o r Actinte
F
o
; 0
Time'1 llme 2
G
g INPP 11.187 12.871
o
I Actirate '10.9 13.15
Time
Figure 5. Mean sAT writrng scores of the Activate anc! lNpp groups at times I and 2
5. Do children in the 7 - 8 year old INPP group have a greater increase in SAT maths
scores than those in the Activate group?
No: while both groups improved their sAT maths scores from Time 1 to Time
2 (F(1,50):25.21 , p <.001), there was no evidence that the increase was greater for
the INPP group than for the Activate group (F (1,50) : .001 , non-significant, see Figure 3).
l2a
o
9. nn.
o
3,u
E
(t,
13.5 E INPP
FIJ r Actiwte
'a 12.5
'; 12
llme 1 llme 2
l!
$ a INPP 12.968 14.25
Time
Figure 6. Mean SAT maths scores of the Activate and INPP groups at times 7 and 2
Figure 7. Mean Astan lndex draw a man mental age score at Time 1 and Trme 2
a tcb
The St John's Sehool Proiect
Aims
1. To investigate whether abnormal ref lexes were present in a group of 6 children
in Key Stage 2 who had been identified as under-achieving in reading, spelling
and writing. These children were not classified as having a Specific Learning
Diff iculty.
2. To investigate whether The INPP Developmental Exercise Programme for Chll-
dren in Schools wlth SpeclalNeeds was effective in reducing scores on tests
for abnormal reflexes.
3 To compare the reading progress of 6 children in the INPP group to 6 children
identified with reading disabilities who did not participate in a daily movement
programme.
Participants
The Special Educatlonal Needs Coordinator identified 6 children of similar age from
key Stage 2, where concerns had been raised by teachers that the children experienced
difficulties with reading skills, writing including spelling and hand writing.
Following the completion of the INPP programme, the school compared gains in
reading ages of a similar age group of 6 children from within Key stage 2 using the Salford
Reading Test results from September 2006 and September 2001 .
Method
Reading ages using the Salford Sentence Reading Testwere identified atthe start,
after 3 terms and finally at the end of the 4th term programme. The Salford Sentence Re-
ading Test demands a range of strategies to be employed bythe child from initial sounds
and blends to segmenting and use of syllables. Sequencing, memory and organisational
skills all being required to decode the unfamillar words.
Baseline assessments were carried out on the INPP group before and after the pro-
gramme using The INPP Developmental Test Battery for Schools.
Both the INPP group and the comparison group received the same spelling in
tervention programme and individualised handwriting support, but the comparison group
did not take part in the INPP exercise programme.
Results
1. Are abnormal reflexes present in a group of 6 children identified with under-
-achievement in reading, spelling and writing?
Yes: everychildinthelNPPgrouphadatotal score oI>25o/o ontesisfortheATNR,
STNR and TLR.
2. ls there a reduction in reflex scores in the INPP group between Time 1 and
fime 2?
Yes: the reflex scores of all children in the INPP group decreased between Timel
and Time2.
3. Do children in the INPP group have a greater increase in reading scores than
those in the comparison group?
Yes: F(1,10) : 34.40, p <.001 (see Figure n)
Discussion
Northumberland Proiect
- Retained primitive reflexes were present in children in mainstream schools in
the No(humberland sample. Previous research (North Eastern Education and Library
{3$
Board 2004), which had examlned a sample of 663 children in mainstream schools in Nort-
hern lreland had found total scores aI >25o/o on tests for the ATNR. STNR and TLR in 48%
of children aged 5 - 6 years and 35% of children age 8 - 9 years. The Northumberland
sample f ound scores ol >25ok on the three ref lexes were present in 40% of children aged
4 - 6 years and 88.5% in 7 - B year olds. The discrepancy in the proportion of children
identified with neuro-motor immaturity between these two studies carried out at different
times shows considerable variation in the incidence of residual reflexes across studies
and may reflect other factors such as differences in socio-economic grouping. However.
ail studies cited have shown lmmature reflexes to be presen't in a significant percentage
of children in nrainstream schools.
10
o
a-
o
(JA
ov w Comparison
5
154
r INPP
(!^
OJ
t
2
1
0
Sept.2006 Nov.2007
Time
Figure 8. Mean reading scores af the INPP and comparison groups at ttmes 1 and 2
Primitive reflexes and motor skills at key stages in development provide indications
of neuro-motor maturation and of a child's developmental readiness in terms of the phy-
sical skills needed to support performance on cognitive tasks, ln view of these findings
developmental testing of all children to evaluate prrmitive reflex status could help to iden-
tify children who are at risk of under-achieving as a result of immature motor skills. These
tests could be conducted at the time of school entry and repeated at key slages during
education to identify children who would benefit from physical intervention programmes.
- There is a significant correlation between neurological scores and mental age
measured by the Draw a Person test. The Draw a Person test provides one measure
of non-verbal cognitive performance. While many educational measures focus on verbal
skills, non-verbal skills are necessary to support operations in space, body awareness and
social skills. lt is thought that the non-verbal aspects of language contribute up to 90%
to ef{ective communication. Children who have immature non-verbal skills tend to find it
difficult to read the body language of others and react appropriately, which can affect how
they lnteract in social situations. lmmature body language can also influence how children
communicate and behave.
- Children in the 7 - 8 year old INPP group had significantly greater reduction in ab-
normal reflexes than children in theActlvate group. These results reflectthose reported in
earlier studies (Goddard Blythe 2005) which revealed a similar effect on abnormal reflexes
when a general physical exercise programme was compared to the INPP developmental
r32
followed the INPP school programme but who had received the same educational support
in reading, writing and spelling. This may be linked to improvements in the controi of
the oculo-motor skills needed to support reading, which previous studies have indicated
improve when primitive ref lexes are inhibited.
When the progress of both groups of children over the 3 term period from Sep-
tember to September was compared using the Salford data available, the INPP gr..up
made an average gain of 22.5 monlhs in reading compared to a gain of 8.5 months iir the
comparison group.
The numbers in this sample were small and therefore any inferences derived froni
the results should be treated with caution. However, the difference in reading improve-
ment in the experimental group suggests a link between maturation in neuro-motor si..tus
and improvement in reading ln this sample.
Conclusions
lf the findings of these two projects are representative of children in the gen.'ra1
populatlon, they suggest that neuro-motor immaturity is present in a significant percenta-
ge of children in mainstream schools in the United Kingdom. Furthermore, many of tlrese
chlldren are ones who are not identified as having either specific learning difficulties or de'
velopmental immaturity and therefore tend to 'slip through the net' of services which sho-
uld be in place to identify underlying problems and provide effective remedial interverrt trrr.
Neuro-motor immaturity is linked to lower performance on the Draw a Person IDAP)
Test in this sample. The DAP provides an indication of non-verbal cognitive performerrce,
which plays an important part in supporting many aspects of learning and behaviour'
The progress of children aged 4 -6 years following the INPP programme in tests
for neuro-motor maturityand reading and spelling suggest a possible llnk between ne'Ltro-
-motor maturity and educational attainment. This should not be conf used with educatiorral
potential or intelligence but raises questions as to whether children with immature nrotor
skills tend to under-achieve at school. lf such children are already performing at or close
to their chronological age, under-achievement is often not identified and they are sirrrply
assumed to be performing 'as well as can be expected'.
Discrepancy between ability and performance tends to result in frustration, ullich
may then be acted out in behaviour. The observation that 5 children referred to the Btrha-
vioural Support Service before the first assessment, were removed from the referral list
after one term using the INPP programme, suggests that improvement in neuro-r'lrotof
skills may also have a beneficial effect on behaviour A study involvlng larger nunrLrets
would need to be carried out to support this observation.
The f indings raise a question as to whether routine testing of neuro-motor nrattrrily
at key stages in education ln the future could help to identify children who are at rtsk o{
under-achieving as a consequence of immature motor skills, so that effective physical arrd
remedial intervention programmes could be implemented.
This observation is supported by the results from the small sample at St Jolrrr's
School, where children had been identified as under-performing in reading, writing rrrrd
spelling and maths, but had not been classified as having Specific Learning DifficLrltics
As the neuro-motor skills of this group matured, reading performance also improved irrdi-
cating a possible relationship between the two.
Children in both intervention groups (INPP and Activate) in the Northumbt:tlattil
study showed improvement on all measures over time. ln the older group, childrt'rr irr
the INPP group had greater reduction of primitive reflexes than the Activate group bLtl
there was no significant difference between the two intervention groups in attainmcttt otr
educational measures. This suggests that both the daily physical intervention prollrallr-
mes were of benefit but that uslng a specific movement programmes such as The INPP
f33
Programme may be more effective when addressing specific developmental needs such
as the retention of primltive reflexes in the school-aged child.
It is recommended that a {ollow-up study involving larger numbers and a control
group be carried out to see if the above findings can be replicated.
References
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Abstract
Two independent pro.jects were undertaken with 64 children in schools jn Northum-
berland and 6 children in Berkshire to investigate whether; a) retention of three primitive
reflexes (indicators of neuro-motor immaturity) was present in children in mainstream
primary schools in the United Kingdom; b) there was a link between immature motor
skills and lower performance in reading, writing, spelling, maths and drawing; c) retained
primitive reflexes responded to a developmental movement programme (The lNpp pro-
gramrne for Schools)
88.5% of children age 7-8 years and 4Oo/o of children age 4-6 years in the Nort-
humberland sample had residual primitive reflexes. Higher scores on tests for retajned
primitive reflexes correlated with lower performance on the Draw a Person test. Children
in the INPP group showed a significantly greater decrease in scores for abnormal reflexes
than children who participated in a general movement programme.
Six chiJdren who followed the INPP Programme in the Berkshire sample had signi-
ficant decrease in abnormal reflexes and improvements on the Salford Sentence Reading
Test compared to six children who did not take part in The lNpp programme.
Acknowledgements
To the staff, children and parents from ali schools that participated
in the independent studies in England.
Ruth Marlee, Behaviour support Service Schools and Family Support Division,
Children's Services Directorate Northumberland County Council,
Hepscott Park, Morpeth, Northumberland.
Jill Mckay (Head teacher) Choppington First School.
Eastgate. Choppington. NE62 5RR.
Linda Brett (Head teacher), Anne Douglas, Red Row First School,
Red Row. Morpeth. NE61 bAU
Mick Spencer (Head teacher) Jennifer stewart, Ashington central First School,
Milburn Road, Ashingron. NE63 9Lp
Elizabeth Brown (Head teacher) Ruth yule, penny Derries, The Grove School,
Grove Gardens, Berwick on Tweed. TDl b 2EN
Jenny Fry (NDT INPP Licentiate), former Headteacher
Angharad Brackstone (Headteacher), Graeme Buick, pam Edwards, st John's School,
Orts Road, Reading. Berkshire.
Dr Mike Boulton, Department of psychology,
University of Chester for statjstical analysis and advice.
Declaration of interest:
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