Stereotypic movement disorder in typically developing children

Treatment of stereotypic movement disorder in children

Motor stereotypies are repetitive and rhythmic movements with a fixed pattern that can manifest in some typically developing children. The period of onset that is usually in early childhood (e.g. before 3 years of age) and the behaviors can persist into adulthood for most affected individuals. While motor stereotypies have long been associated with children with autism spectrum disorder (ASD) or intellectual disability (ID), these behaviors can in fact present in individuals who are otherwise typical in their development. Unfortunately there is a scarcity of research on stereotypies in children without developmental disabilities and no clear answers as to what causes the manifestation of these behaviors in some children.

Stereotypies can be primary, in that they appear to be purely physiological, or secondary, meaning that they are present in association with another neurological condition. This article will focus on the occurrence of primary stereotypies in otherwise typically developing children. Primary stereotypies can be classified as being either common or complex. Common stereotypies exist in approximately 20% of children and consist of behaviors such as pencil tapping, hair twisting, nail biting, etc. Complex stereotypies can include a variety and combination of motor mannerisms such as flapping, waving, wringing hands, contorting face, etc. These are estimated to affect 3-4% of children in the U.S. Stereotypies can occur when the child is engrossed in an activity, when bored, stressed, excited or tired. Unlike tics, there is no urge prior to engaging in the motor stereotypy to serve as a predictive mechanism. Children with complex motor stereotypies often present with other disorders such as attention-deficit/hyperactivity (ADHD), obsessive-compulsive disorder (OCD), or Tourett’s disorder.

Both biological and psychological factors are hypothesized to contribute to the etiology of these movements. Psychological factors may include the movements being executed as part of obsessive-compulsive or anxiety-related behaviors, or channeling of thoughts from excess capabilities into movements. However, there is much more evidence for a biological basis to the symptoms. Evidence for the biological abnormalities underlying this disorder come from studies showing neurochemical abnormalities that exist when motor stereotypies are present. The cortical-striatal-thalamo-cortical (CSTC) brain circuit is thought to be involved in the expression of motor stereotypies. Several brain regions are also believe to be involved as studies have found difference in the neural activation and structures of certain brain regions in individuals who present with stereotypies. There is evidence of a genetic component in the disorder in combination with environmental influences. Environments lacking sufficient sensory input or overstimulating environments may contribute to the presence or exacerbation of stereotypies.

There is no established pharmacological treatment for motor stereotypies as there have been no formal studies of the effect of medications for stereotypies in typically developing children. Behavioral therapy which specifically focuses on habit reversal and differential reinforcement of other or incompatible behaviors has some evidence for effectiveness in treating primary complex motor stereotypies.  Therapy requires the active participation of the child who must have the cognitive capacity to understand and follow treatment guidelines. A parent-guided DVD intervention has recently been developed at Johns Hopkins University that focuses on suppressing complex motor stereotypies through behavioral therapy methods. Children are encouraged to exhibit the stereotypic movement intentionally to raise awareness of the behaviors and they are rewarded by parents during intervals when the stereotypic behaviors do not occur. This intervention was found to be beneficial and significantly reduced scores on all motor stereotypy screening scales.

Treatment is most likely to be successful when the child is cooperative and motivated, regardless of type of stereotypy present. The treatment package should incorporate habit reversal with differential reinforcement of competing responses, relaxation training, and self-monitoring. Habit reversal training consists of: 1) awareness training where the child learns to voluntarily exhibit the target behavior in order to become more aware of when it is occurring and 2) competing response training where the child learns to inhibit the target behavior by demonstrating another behavior that is incompatible with it.

Therapy consists of daily practice that begins with the child voluntarily exhibiting the stereotypic movements for 30 seconds followed by a 1-minute rest period. Parents provide feedback to the child to help him or her more closely approximate the target behavior in front of a full-length mirror. Parents also collect data on a daily basis regarding the occurrence of the stereotypic behavior and rank the severity level as mild, moderate, or severe.  In the next phase of treatment parents and children are asked to select two 10-minute periods a day based on the initial data collected where the child will practice not exhibiting the behavior. Parents would praise and reinforce the child every few minutes when the child is successful in not exhibiting the stereotypy. Parents take data on instances of stereotypy occurring during these 10-minute periods. The initial habit reversal training phase of treatment continues to be practiced on a daily basis as well. Over time, parents are asked to increase the frequency of practice session to four per day, increase the length of each session from 10 to 20 minutes, and to include additional/tangible reinforcers for successful trials where no stereotypies were exhibited.

In summary, behavioral treatment can significantly reduce the symptoms of stereotyped movement disorders and this treatment modality can be implemented by parents under the direction of a therapist with knowledge and expertise regarding this disorders. Implementation of the treatment package is intensive in that it demands the availability of a caregiver to commit to daily basis of habit reversal training. Supporting children to incorporate regular relaxation exercises and mindfulness based practices can also help to reduce the overall arousal level of the nervous system and increase self-awareness. Readers who are interested in talking to their children about motor stereotypies should check out Motor Stereotypies and You as an informative resource on this subject.

The first building blocks of communication

Promoting your child’s communication skills is the single most effective means of improving behaviors, play, and socialization. Children who can communicate their needs, wants, likes, and dislikes, are much less likely to cry, scream, or protest. While most parents recognize the value of promoting communication skills, many are unaware of the multitude of ways to shape these skills long before children use intelligible speech. Communication is so much more than the sounds and words we use. Coordinated eye gaze, facial expressions, gestures, and postures are all integral aspects of communication and lay the foundation for the vocal parts of communication that follow. Long before the use of words, children learn that they can influence others, share in experiences, and meet their needs through the use of sounds, expressions, and gestures.

To improve communication skills, begin by shaping the natural gestures that kids use and transforming them into communicative gestures. In order to work on this skill, begin an activity with your child that involves a motor component. For instance, offer them a desired object but hold it slightly out of reach so that your child has to extend their hand to grab for it. Alternatively, you could hold out a highly desired and a neutral or non-preferred item and wait for your child to reach for the one they want, or push away the one they don’t want. It is important to wait for the child to initiate communication in any shape or form (i.e. reaching, vocalizing, smiling, making eye contact with you, etc.), and to avoid guessing the child’s wants and rushing to fulfillment.  As soon as you seen a communicative overture, such as a smile along with eye contact, treat it as if your child just told you exactly what they wanted, and give it to them along with an enthusiastic narration.

When my daughter was 8 months old, she would flap her arms up and down when excited; in a manner I have seen so many other babies do. We used to play a game where I would stand her in front of me on the bed, holding her under her arms. I would bounce her up and down twice and then wait. If she flapped her arms and looked at me with a smile, I cheerfully said “you want more!” and gave her a few more bounces. I would stop and wait for another communication from her and then excitedly verbalize “MORE” while giving her additional bounces. This game could go on long after my arms were tired from bouncing her. What she seemed to enjoy most about it, was not the bouncing itself, but the power of being able to communicate something to me that I subsequently responded to. I noticed that the laughter and excited flailing of her arms only occurred when we played the game of “communicating,” but not when I simply sat behind her and bounced her up and down with no feedback from her. Over time, the game shifted from her flailing her arms to my teaching her to bring her hands together, and eventually to signing “more.” Before long, she verbalized “more” as one of her first sets of words.

As we reinforce each instance of a child initiating communication, we are strengthening their understanding of the power of this communication to meet their needs. Waiting for a child to communicate a need, and suppressing the desire to rush in and give them exactly what we know they want, teaches them the fundamentals to get their needs met no matter where or with whom they are interacting.