however , the studies examining developing children have shown specific patterns mainly characterized by the girls earlier brain maturation compared with that of boys.14 at this time , as far as we are aware , there is no reported study that has assessed whether adhd symptoms are related to persistence of the primitive reflexes in medication - nave children with a focus on sex - specific assessment . as such ,
in the study reported here we examined the extent to which the persistence of the primitive atnr and stnr is related to adhd symptoms in 35 medication - nave girls of school age ( 811 years ) .
data on 35 girls ( mean age 9.51 , standard deviation [ sd ] = 1.01 , age range 811 years ) with adhd diagnosed according to diagnostic and statistical manual of mental disorders : fourth edition ( dsm - iv ) criteria characterizing their primitive reflexes and psychometric measures of adhd symptoms were collected .
all the patients were medication nave and their assessment was done before starting any treatment .
the adhd diagnosis was combined hyperactive - inattentive subtype with occurrence of adhd - based learning difficulties and , in a few cases , episodic enuresis .
exclusion criteria were other child psychiatric and neurological disorders , including conduct disorder , alcohol or drug dependency , substance abuse , and/or previous exposure to stimulant medication .
recruitment was based on consecutive visits of the untreated patients to the clinic , and the control group was recruited using school advertisements .
the control group of 30 girls without adhd ( mean age 9.83 , sd = 0.98 , age range 811 years ) fulfilled the same exclusion criteria .
parents of all the participants gave written informed consent and the research was approved by the charles university first faculty of medicine ethical committee within the framework of collaboration with the elspac project , the project of the center for neuropsychiatric research of traumatic stress , and the msm0021620849 project at charles university .
the measurement of primitive reflexes was done twice by two independent examiners and the results of the two measurements averaged .
we measured atnr using the schilder test.15 atnr presents as the tonic reflex response that occurs in newborns ; it normally vanishes at around 3 months of age . in the schilder test
, the subject stands with their feet together and the arms held straight out at shoulder level and height but with the hands relaxed at the wrists . in the test
when i turn your head , i want you keep your arms straight out in front of you , as they are now .
this means your arms remain in the same position , and only your head moves .
 then the tester slowly rotates the subject s head until the chin is parallel with the shoulder , pauses for 10 seconds , then returns the head to the midline and again pauses for 10 seconds .
typical indicators of the atnr include movement of the extended arms in the same direction as the head turn , dropping of the arms , or swaying and loss of balance .
it was scored as follows : 0 = no response ( the arms remained straight out in front ) ; 1 = slight movement of the arms up to 20 to the same side as the head is turned or slight dropping of the arms ; 2 = movement of the arms up to 45 as the head is turned or marked dropping of the arms ; 3 = arm movement greater than 45 either to the side or down , swaying or loss of balance may occur .
purdue reflex test.16 this reflex emerges at 68 months of life and is inhibited at between 9 and 11 months . in the bender 
purdue test , the subject is instructed to maintain four point kneeling  table  position and to slowly move the head to look down as between the thighs .
the position is held for up to 5 seconds and then the head is slowly moved upward as if looking at the ceiling .
typical indicators of the reflex are any bending of the arms due to head flexion and/or raising of the feet , straightening of the arms and flexion of the knees as a result of head extension , any bending of the arms due to head flexion and/or raising of the feet , and straightening of the arms and flexion of the knees due to head extension .
the test was scored as follows : 0 = no response ; 1 = tremor in one or both arms or slight hip movement ; 2 = movement of the elbow on either side and/or definite , movement in the hips , or arching of the back ; 3 = bending of the arms on head flexion or movement of the bottom back on head extension ; 4 = bending of the arms to the floor , or movement of the bottom back onto the ankles , so that the subject is sitting in the cat position .
a frequently used measure of adhd symptoms is the conners parent questionnaire ( cpq).17 the cpq is 93-item scale of symptoms that are most commonly associated with behavioral disorders and related to children and adolescents ( aged 317 years ) , and can measure treatment changes and outcome assessment purposes .
the questionnaire enables a total score to be calculated as well as scores for subscales based on the factor structure of the questionnaire : i conduct problems ( items 39 , 40 , 41 , 47 , 48 , 51 , and 69 ) ; ii anxiety ( items 811 , 42 , 43 , and 64 ) ; iii impulsivity - hyperactivity ( items 78 , 8084 , 89 , and 90 ) ; iv learning problems ( items 45 , 62 , 63 , 67 ) ; v psychosomatic difficulties ( items 6 and 2124 ) ; vi perfectionism ( items 3 and 7678 ) ; vii antisocial behavior ( items 7173 and 75 ) ; and viii muscular tension ( items 1214 and 36 ) .
the symptoms are rated on a four - point likert scale ( from 0 to 3 ) by either one or both parents of the child . for statistical evaluation of scores of the measures of atnr , stnr , and adhd symptoms ,
nonparametric analyses were preferred because cpq , atnr , and stnr data do not have normal distribution .
all the methods of statistical evaluation were performed using the software package statistica ( v 6 ; statsoft inc , tulsa , ok , usa ) .
data on 35 girls ( mean age 9.51 , standard deviation [ sd ] = 1.01 , age range 811 years ) with adhd diagnosed according to diagnostic and statistical manual of mental disorders : fourth edition ( dsm - iv ) criteria characterizing their primitive reflexes and psychometric measures of adhd symptoms were collected .
all the patients were medication nave and their assessment was done before starting any treatment .
the adhd diagnosis was combined hyperactive - inattentive subtype with occurrence of adhd - based learning difficulties and , in a few cases , episodic enuresis .
exclusion criteria were other child psychiatric and neurological disorders , including conduct disorder , alcohol or drug dependency , substance abuse , and/or previous exposure to stimulant medication .
recruitment was based on consecutive visits of the untreated patients to the clinic , and the control group was recruited using school advertisements .
the control group of 30 girls without adhd ( mean age 9.83 , sd = 0.98 , age range 811 years ) fulfilled the same exclusion criteria .
parents of all the participants gave written informed consent and the research was approved by the charles university first faculty of medicine ethical committee within the framework of collaboration with the elspac project , the project of the center for neuropsychiatric research of traumatic stress , and the msm0021620849 project at charles university .
the measurement of primitive reflexes was done twice by two independent examiners and the results of the two measurements averaged .
we measured atnr using the schilder test.15 atnr presents as the tonic reflex response that occurs in newborns ; it normally vanishes at around 3 months of age . in the schilder test
, the subject stands with their feet together and the arms held straight out at shoulder level and height but with the hands relaxed at the wrists . in the test
when i turn your head , i want you keep your arms straight out in front of you , as they are now .
this means your arms remain in the same position , and only your head moves .
 then the tester slowly rotates the subject s head until the chin is parallel with the shoulder , pauses for 10 seconds , then returns the head to the midline and again pauses for 10 seconds .
typical indicators of the atnr include movement of the extended arms in the same direction as the head turn , dropping of the arms , or swaying and loss of balance .
it was scored as follows : 0 = no response ( the arms remained straight out in front ) ; 1 = slight movement of the arms up to 20 to the same side as the head is turned or slight dropping of the arms ; 2 = movement of the arms up to 45 as the head is turned or marked dropping of the arms ; 3 = arm movement greater than 45 either to the side or down , swaying or loss of balance may occur .
purdue reflex test.16 this reflex emerges at 68 months of life and is inhibited at between 9 and 11 months . in the bender 
purdue test , the subject is instructed to maintain four point kneeling  table  position and to slowly move the head to look down as between the thighs .
the position is held for up to 5 seconds and then the head is slowly moved upward as if looking at the ceiling .
typical indicators of the reflex are any bending of the arms due to head flexion and/or raising of the feet , straightening of the arms and flexion of the knees as a result of head extension , any bending of the arms due to head flexion and/or raising of the feet , and straightening of the arms and flexion of the knees due to head extension .
the test was scored as follows : 0 = no response ; 1 = tremor in one or both arms or slight hip movement ; 2 = movement of the elbow on either side and/or definite , movement in the hips , or arching of the back ; 3 = bending of the arms on head flexion or movement of the bottom back on head extension ; 4 = bending of the arms to the floor , or movement of the bottom back onto the ankles , so that the subject is sitting in the cat position .
we measured atnr using the schilder test.15 atnr presents as the tonic reflex response that occurs in newborns ; it normally vanishes at around 3 months of age . in the schilder test
, the subject stands with their feet together and the arms held straight out at shoulder level and height but with the hands relaxed at the wrists . in the test
when i turn your head , i want you keep your arms straight out in front of you , as they are now .
this means your arms remain in the same position , and only your head moves .
 then the tester slowly rotates the subject s head until the chin is parallel with the shoulder , pauses for 10 seconds , then returns the head to the midline and again pauses for 10 seconds .
typical indicators of the atnr include movement of the extended arms in the same direction as the head turn , dropping of the arms , or swaying and loss of balance .
it was scored as follows : 0 = no response ( the arms remained straight out in front ) ; 1 = slight movement of the arms up to 20 to the same side as the head is turned or slight dropping of the arms ; 2 = movement of the arms up to 45 as the head is turned or marked dropping of the arms ; 3 = arm movement greater than 45 either to the side or down , swaying or loss of balance may occur .
purdue reflex test.16 this reflex emerges at 68 months of life and is inhibited at between 9 and 11 months . in the bender 
purdue test , the subject is instructed to maintain four point kneeling  table  position and to slowly move the head to look down as between the thighs .
the position is held for up to 5 seconds and then the head is slowly moved upward as if looking at the ceiling .
typical indicators of the reflex are any bending of the arms due to head flexion and/or raising of the feet , straightening of the arms and flexion of the knees as a result of head extension , any bending of the arms due to head flexion and/or raising of the feet , and straightening of the arms and flexion of the knees due to head extension . the test was scored as follows : 0 = no response ; 1 = tremor in one or both arms or slight hip movement ; 2 = movement of the elbow on either side and/or definite , movement in the hips , or arching of the back ; 3 = bending of the arms on head flexion or movement of the bottom back on head extension ; 4 = bending of the arms to the floor , or movement of the bottom back onto the ankles , so that the subject is sitting in the cat position .
a frequently used measure of adhd symptoms is the conners parent questionnaire ( cpq).17 the cpq is 93-item scale of symptoms that are most commonly associated with behavioral disorders and related to children and adolescents ( aged 317 years ) , and can measure treatment changes and outcome assessment purposes .
the questionnaire enables a total score to be calculated as well as scores for subscales based on the factor structure of the questionnaire : i conduct problems ( items 39 , 40 , 41 , 47 , 48 , 51 , and 69 ) ; ii anxiety ( items 811 , 42 , 43 , and 64 ) ; iii impulsivity - hyperactivity ( items 78 , 8084 , 89 , and 90 ) ; iv learning problems ( items 45 , 62 , 63 , 67 ) ; v psychosomatic difficulties ( items 6 and 2124 ) ; vi perfectionism ( items 3 and 7678 ) ; vii antisocial behavior ( items 7173 and 75 ) ; and viii muscular tension ( items 1214 and 36 ) .
the symptoms are rated on a four - point likert scale ( from 0 to 3 ) by either one or both parents of the child .
for statistical evaluation of scores of the measures of atnr , stnr , and adhd symptoms , spearman correlation coefficients were determined and multiple linear regression analysis was undertaken .
nonparametric analyses were preferred because cpq , atnr , and stnr data do not have normal distribution .
all the methods of statistical evaluation were performed using the software package statistica ( v 6 ; statsoft inc , tulsa , ok , usa ) .
adhd symptoms measured by total score of the cpq and its subscales were significantly correlated with atnr and stnr scores ; that is : cpq and atnr , r = 0.64 ; cpq and stnr , r = 0.41 ; ii anxiety and atnr , r = 0.39 ; iii impulsivity - hyperactivity and atnr , r = 0.47 ; iii impulsivity - hyperactivity and stnr , r = 0.40 ; iv learning problems and stnr , r = 0.47 ; and vi perfectionism and atnr , r = 0.44 ( table 1 , figure 1 ) .
spearman rank correlation coefficients with r higher than 0.43 were significant at p < 0.01 , with fisher s z > 0.46 , and spearman rank correlation coefficients with r > 0.33 significant at p < 0.05 , with fisher s z > 0.35 .
these correlations indicate that significant manifestations of adhd symptoms are associated with persisting atnr and stnr responses .
we compared cpq , atnr and stnr scores for the 35 study subjects with those for the 30 control participants .
the control group had no adhd symptoms , and none of this group manifested atnr ( the score was zero in all cases ) , while only one case of stnr response was found with a score of 1 . to analyze effects of atnr and stnr on cpq
, we used a multiple linear regression to determine whether persisting primitive reflexes in their specific interactions are proportionally linked to increased levels of cpq .
multiple r = 0.60 was found to be statistically significant ( p = 0.0008 ; f = 8.99 ; sequential consistency ( sc ) model = 2,375 ; sc residuals ( resid ) = 4,229 ; processor consistency ( pc ) model = 1187 ; pc resid = 132 ) which enables cpq to be defined as a linear function of two variables : cpq = f(atnr , stnr ) .
recent findings show that a high proportion of children with adhd exhibit motor abnormalities.3,4 according to brain imaging studies , these abnormalities are probably linked to prefrontal cortex deficits that influences attention and executive functions.1820 the abnormalities may also be of cerebellar origin and adhd children in many cases exhibit atrophy in cerebellar regions associated with motor dysfunctions that are most likely linked to inhibitory deficits.3,21,22 disinhibitory processes related to disturbed motor functions are probably also linked to persisting primitive reflexes that were not sufficiently suppressed in later stages of development . according to
some evidence , persisting primitive reflexes may occur in various neuropsychiatric syndromes such as schizophrenia or various forms of dementia5,6,20,23 and have also been observed in patients with dyslexia11,24 and in school - aged children with adhd12,13,25,26 in our previous study on medicated adhd children,13 we found that boys had higher levels of adhd symptoms and that there was little statistically significant difference in persisting primitive atnr between girls and boys .
moreover , studies that have focused on persistent atnr in dyslexia11,24 have not reported differences between girls and boys . in this context , this study represents an important step focused on detailed analysis of adhd children in medication nave conditions .
the results show that persistent atnr and other primitive reflexes that may occur in later age specifically influence adhd symptoms related to hyperactivity due to muscular tension , which also may have specific influence on attentional functions .
taken together recent research predominantly does not take into account differences between adhd girls and boys.27,28 nevertheless several comparisons showed few sex effects in core clinical manifestations of adhd .
in addition , girls compared with boys , have significantly more parent - rated emotional symptoms and more likely they become victims of bullying .
girls and boys have similar levels of coexisting psychiatric and physical health problems , and receive the same types of treatment although fewer girls than boys are referred for adhd treatment.27,28 therefore , research focused on girls with adhd seems to be particularly important and , in the future , detailed comparison of girls and boys may provide particularly important findings and have significant therapeutic implications .
the results of this study support the hypothesis that adhd symptoms are linked to the persisting primitive atnr and stnr in girls .
further data are needed to find specific sex differences and to determine the relationships between adhd symptoms and various primitive reflexes that are possible to assess in school - aged children .
together , our data suggest a hypothesis for future research that adhd symptoms may present a process related to primitive neural mechanisms , such as primitive reflexes , interfering with higher - level brain functions due to insufficiently developed cognitive and motor integration . in this context ,
hughlings jackson s concept may in principle be useful to explain and understand certain developmental changes as a consequence of disturbances between higher and lower levels of cognitive and motor functions during brain processing that might cause processes related to  dissolution  ( or disintegration ) of mental functions.8,12
the preliminary data reported here show that detailed analysis of persisting primitive reflexes in children with developmental disorders and comparisons of differences between girls and boys with adhd and dyslexia may offer important new findings with specific consequences for treatment .
 background and objectivesrecent and historical findings suggest that later - developed functions during brain ontogenesis related to higher levels of cognitive and motor integration tend to replace the older , more primitive , ones , and the persistence of the older functions may be linked to specific neuropsychiatric disorders . 
 currently , there is growing evidence to suggest that persisting primitive reflexes may be related to developmental and neurodegenerative disorders . 
 preliminary data also suggest that persisting primitive reflexes may be specifically linked to attention - deficit and hyperactivity disorder ( adhd).methodsin the study reported here , we tested to what extent the persisting primitive asymmetric tonic neck reflex and symmetric tonic neck reflex are related to adhd symptoms measured by conners parent questionnaire in 35 medication - nave girls of school age ( 811 years ) with adhd . the results were compared with those of a control group of 30 girls of the same age.resultsthis study showed that persisting primitive reflexes are closely linked to adhd symptoms.conclusionthe data suggest that adhd symptoms may be linked to more primitive neural mechanisms interfering with higher brain functions due to insufficiently developed cognitive and motor integration 
 . 
Introduction
Methods
Participants
Measurement of primitive reflexes
ATNR
STNR
Psychometric measure of ADHD symptoms
Statistical analysis
Results
Discussion
Conclusion