ESTERIOTIPIAS

Una de mis amigas, hija de una amiga bien querida desde siempre, me mando una pregunta sobre este complejo tema.  Mis colegas ya tiene menos informacion que ella.   La respuesta va a ser en ingles (mejor que en espanol....para mi)

http://youtu.be/8tv7hI8RtwQ

Stereotypies non Autistic

Resumen de los movimientos incluidos en este padecimiento

EN ESPANOL:
(mi amiga va a ayudar con la traduccion)

Background

Stereotypies are repetitive, purposeless actions that are most commonly seen in childhood. Stereotypies do not have a clear definition due to the wide range of possible stereotyped behaviors and the overlap with other movement or behavioral disorders.^[1]

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) strictly defines a stereotypy as a repetitive, nonfunctional motor disorder that interferes with normal activities or results in injury. It must persist for more than 4 weeks and not be due to another medical condition, drugs, or a developmental disorder.^[2]

However, some definitions of stereotypies are extremely broad, and it is therefore helpful to classify them to distinguish between the different movements. Three categories are proposed.^[3]

• Common stereotypies are by far the most frequent type and comprise habits, such as nail-biting and bruxism.
• Complex motor stereotypies are the second main type, and these consist of various repetitive limb movements.
• Head nodding is a separate stereotypy that shares some characteristics with complex motor stereotypies.

Complex motor stereotypies and head nodding fulfill the DSM-IV-TR criteria and are the focus of this review.

Complex motor stereotypies are further subdivided into primary or secondary. Primary stereotypies occur in otherwise developmentally normal children and usually remain stable or regress. Secondary stereotypies are those that occur in conjunction with a neurologic or behavior disorder. They are seen in autism, mental retardation, Tourette syndrome, and rare neurodevelopmental syndromes, such as Rett syndrome. In older children they may be associated with schizophrenia, obsessive-compulsive disorder, or early-onset neurodegenerative diseases.

Other involuntary movements that may present similarly to stereotypies include tics and automatisms. Tics are by far the most common misdiagnosis. Complex motor tics are also repetitive, involuntary actions. However, they usually have a later age of onset, greater variability in movements and rhythms, and are briefer. More importantly, unlike tics, stereotypies are not associated with premonitory urges and subsequent relief from those urges.

Voluntary repetitive movements mimicking stereotypies include attention deficit hyperactivity disorder (ADHD), mannerisms, and compulsions. ADHD tends to be characterized by more generalized and restless actions than stereotypies. Mannerisms are rarely continual and accompany a normal activity. Compulsions comprise repeated ritualistic movements to relieve anxiety or fear, and may occur with tics and stereotypies.

For common stereotypies, the mechanisms are unclear and also dependent on the specific type. For example, head banging may develop from frustration and temper tantrums in early childhood. In contrast, thumb sucking develops as a physiological action in early infancy, but may persist due to reinforcement from its comforting effect.

Research on the mechanisms of complex motor stereotypies has been from 2 different approaches. Psychogenic hypotheses aim to explain the cause of stereotypies from a behavioral standpoint and are discussed later. Neurobiological hypotheses look at the structural and molecular basis for stereotypies.

Anatomically, the basal ganglia is implicated in stereotypic disorders.^[4] In monkeys, stereotypies are correlated to neuronal activity in the striatum, especially the putamen. Intrastriatal injection of amphetamine, which increases dopamine levels, causes stereotypies in rodents.^[5] In humans, case reports of stereotyped movements have spontaneously emerged after lesions of the putamen, orbitofrontal cortex, or thalamus. A volumetric MRI study in children with complex motor stereotypies has shown a reduction in the size of the caudate nuclei and also in frontal white matter.^[6] Precise localization within the basal ganglia and corticostriatal circuitry is yet to be elucidated.

Dopaminergic pathways appear to mediate complex motor stereotypies.^[7] In the treatment of Parkinson disease, patients on high doses of levodopa sometimes perform repetitive, purposeless actions, known as punding. In addition, levels of plasma homovanillic acid, a dopamine metabolite, are reduced in adults with stereotypies.^[8] Studies in rodents have shown that administration of dopamine can produce repetitive behaviors such as sniffing or head bobbing.^[1] From investigating the effect of selective dopamine agonists, D₂ dopamine receptors are known to be important in enhancing stereotypies.^[5]

United States

Data on the prevalence of stereotypies are limited, especially internationally, and this varies according to the exact definition used by the researchers. Nevertheless, habits or common stereotypies are thought to occur in up to two-thirds of infants. In children, 20-50% display them.^[9]

Thumb and hand sucking are seen in 17-59% of children younger than 15 years. Approximately 10% of developmentally normal infants exhibit head banging. Body rocking is seen in 6-19% of children younger than 3 years.^[10] Nail biting has a prevalence of more than 60% in 8-year-olds in one study and is the most common stereotype in school-age children and college students. Trichotillomania is present in 1% of college students, although chronic hair pulling is reported in up to 13%.^[11] Bruxism has a prevalence of 8% worldwide.^[12]

The prevalence of primary complex motor stereotypies is unknown, but it may be as high as 3-4% of preschool children in the United States.^[13]

Secondary stereotypies are of course determined by the associated disorder. Rett syndrome and autism each occur in 1 in 20,000 live births. In Rett syndrome, all affected children have hand stereotypies. In autism, more than 60% of preschool children show stereotypies. In contrast, they are seen in only 25% of nonautistic children of a similar mental ability.^[14]

Mortality/Morbidity

Mortality has not been reported as a direct result of stereotypies.

Stereotypic movements can lead to social stigmatization of the child by peers. There may be embarrassment or anxiety in the child or the parents.

Self-injurious stereotypies are unusual in developmentally normal children, although they occur in up to 40% of children with autism.^[15] They include hand biting, severe trichotillomania, and self-hitting.

Race

There are no known racial differences in the frequency of stereotypies.

Sex

Many common stereotypies show no predilection for either sex. Amongst the different types, thumb sucking, nail biting, and bruxism are slightly more common in females. Head banging is more common in males.

Overall, complex motor stereotypies are nearly twice as likely to occur in males as in females. The increased prevalence of conditions such as autism or mental retardation in males is a confounding factor, but even in primary stereotypies, males are more likely to be affected.

Age

Common stereotypies occur within different age groups. Thumb or hand sucking occurs in early infancy. Head banging usually begins at around 9 months of age, and may last up to 3 years. Body rocking develops in the first year of life, usually as a transient phenomenon during gross motor development. Nail biting begins much later, at the age of 4 years. It has peak prevalence between 8 and 11 years, but still persists in 28% of 18-year-olds. Bruxism and trichotillomania begin in later childhood, although they are less common.

More than 80% of complex motor stereotypies begin before 2 years of age, with a peak incidence at 6 months of age.^{[16, 17]} Another 10% begin in the following year. The outcome is variable, and approximately a third show resolution or improvement of stereotypies. Mostly this happens in the first year but may take 10 years or longer; 60% proceed to have stable stereotypies, and a minority have worsening of their stereotypies.

Complex motor stereotypies may comprise flapping, waving, opening and closing of a fist, finger wiggling, or wrist flexion and extension. They can be primary or secondary, and the main concern for parents and professionals is that they are the manifestation of an underlying disorder. No clinical features enable differentiation of stereotypies between normally developing children and those with autism or developmental delay.

In both groups, the movements can last for more than a minute, and can occur multiple times in a day. In autism, they tend to occur for a longer duration overall.^[18] The movements can be associated with other clinical features. These include skin picking, mouth opening, facial grimacing, and involuntary noises.

The most common trigger is excitement or being happy. Concentration on a task, tiredness, and anxiety are also triggers. More than one trigger is present in most children. In most cases, movements cease if the child is distracted, for example by calling out his or her name. Movements also do not occur in sleep.

Other secondary stereotypies

Atypical gazing at objects or fingers has been described in children with autism.^[14] These have been termed complex visual stereotypies and appear to occur only as secondary stereotypies. Abnormal pacing, running, or skipping have also been considered to be secondary stereotypies. Again, they are strongly associated with autism rather than other disorders.^[14]

Head nodding

Head nodding has slightly different characteristics than complex motor stereotypies of the limbs. It comprises a regular rhythmical movement of the head and neck, which is either up-and-down, side-to-side, or shoulder-to-shoulder. It has an earlier age of onset, and episodes occur more than once a day. Head nodding is unlikely to be associated with a family history, unlike other forms. Also, in most cases it regresses in later childhood.

Common stereotypies

The range of habits or common stereotypies is described below in chronological order. These rarely require medical attention. In some children, a natural progression is seen. This begins with thumb or hand sucking, then body rocking and head banging, and later still, with nail biting and foot or finger tapping.

• Thumb or hand sucking is first seen in utero, and is the earliest common stereotypy.^[19] Hand sucking rarely persists beyond infancy. Thumb sucking is not usually associated with medical sequelae unless it persists beyond the age of 4. It can then lead to dental malocclusion, digital deformities, temporomandibular disorders, and social stigmatization.
• Head banging is the repeated action of hitting the head against a wall or the bed when lying. It often occurs during teething, ear infections, and temper tantrums. Head banging may cause abrasions and callus formation, but only rarely does it lead to fractures or more serious injury.
• Body rocking is a rhythmic side-to-side or to-and-fro rocking of the body. It is usually seen just before sleeping or after waking.
• Nail biting is the most common stereotypy of later childhood. It leads to shortened, irregular fingernails that may be aesthetically unpleasant. It also predisposes to paronychia and herpetic whitlow. Again, the behavior is increased with anxiety and stress.
• Trichotillomania is the repeated plucking of scalp or body hair leading to clinically significant hair loss. Most sufferers have no other comorbidities, but it is related to body dysmorphic disorders, personality disorders, and eating disorders.^[11] The most common sites, in order of decreasing frequency, are scalp, eyelashes, eyebrows, and pubic hair.
• Bruxism is the act of grinding teeth and/or clenching the jaw. It can happen subconsciously at night as well as during the day. Complications include mechanical wear, teeth fractures, temporomandibular disorder pain, headache, and neck pain.^[12]

Other movements

The presence of other stereotypies, tics, or obsessive tendencies should also be sought in the history since they are associated in more than one third of children with complex motor stereotypies.

Developmental history

A birth and developmental history should always be taken. This includes pregnancy, gestation, delivery, and developmental milestones. These may identify underlying disorders and so are essential to differentiate primary and secondary complex motor stereotypies. In autism, children show limited social and communication skills and a restricted range of activities. Interestingly, even children with primary stereotypies may have mild language delay despite normal intelligence.^[20]

Family history

A comprehensive family history is important because 25% of children have at least 1 affected family member.^[16] This should also include asking about the presence of other developmental and movement disorders.

Drug history

Although drugs are rarely implicated, clinicians should be aware that chronic neuroleptic drug use can lead to stereotypies, usually as part of a tardive dyskinesia. Amphetamine poisoning in children has been reported to cause self-injurious stereotypies, including head banging and hand biting.

Physical examination is guided by the history and types of stereotypies present. In most cases no physical findings are apparent, except for the movements themselves. One must look for other movement disorders, such as tics or chorea. Sensory and motor examination identify underlying pathology. Blindness, deafness, hemiparesis, and cerebral palsy are causes of secondary stereotypies.

After weeks of waiting, today was our appointment for Olivia at Children’s Hospital with a Pediatric Neurologist.

(This fall, I noticed Olivia wasexperiencing what I thought were facial tics. Our doctor sent us to a Pediatrician, who ordered an EEG, which led to our appointment today with a Pediatric Neurologist. Earlier this week,I posted about her worsening symptoms.)

The Diagnosis

The Pediatric Neurologist believes that Olivia is experiencing stereotypy.

Until yesterday, I had never heard the term stereoytpy. But, a reader actually emailed me yesterday after reading my post about Olivia’s tics, (or what I assumed were tics,) and told me that her daughter had the same symptoms and was diagnosed by a Pediatric Neurologist with stereotypy. She wrote to tell me not to worry, that stereotypy can occur in healthy children.

Here is how Wikipedia defines Stereotypy:

A stereotypy (pronounced /ˈstɛriː.ɵtаɪpi/) is a repetitive or ritualistic movement, posture, or utterance, found in patients with mental retardation, autism spectrum disorders, tardive dyskinesia and stereotypic movement disorder. Stereotypies may be simple movements such as body rocking, or complex, such as self-caressing, crossing and uncrossing of legs, and marching in place.[1] Several causes have been hypothesized for stereotypy, and several treatment options are available.[2]

Stereotypy is sometimes called stimming in autism, under the hypothesis that it self-stimulates one or more senses.[3] Related terms include punding and tweaking to describe repetitive behavior that is a side effect of some drugs.[4]

Distinction from tics:

Like tics, stereotypies are patterned and periodic, and are made worse by fatigue, stress, and anxiety. Unlike tics, stereotypies usually begin before the age of three, involve more of the body, are more rhythmic and less random, and are associated more with engrossment in another activity rather than premonitory urges. Examples of early tics are things like blinking and throat clearing, while arm flapping is a more common stereotypy. Stereotypies do not have the ever-changing, waxing and waning nature of tics, and can remain constant for years. Tics are usually suppressible for brief periods; in contrast, children rarely consciously attempt to control a stereotypy, although they can be distracted from one.[5]

Proposed causes:

There are several possible explanations for stereotypy, and different stereotyped behaviors may have different explanations. A popular explanation is stimming, which hypothesizes that a particular stereotyped behavior has a function related to sensory input. Other explanations include hypotheses that stereotypy discharges tension or expresses frustration, that it communicates a need for attention or reinforcement or sensory stimulation, that it is learned or neuropathological or some combination of the two, or that it is normal behavior with no particular explanation needed.[3]

excerpt from Wikipedia

The doctor assured us that while stereotypy does present in children with other disorders such as autism, it is also common in typically developing children. (Her own daughter experienced stereotypy.)

She said that as Olivia gets older, she may learn to inhibit her stereotypies and do them more when she is alone. She may stop doing them altogether.

Now what?

The neurologist is referring Olivia to a pediatric psychiatrist who specializes in stereotypy, tics and Tourette’s, as well as ADHD, etc.

I am glad that we will be able to receive some sort of follow up care. Neurology doesn’t treat stereotypy and considers it benign.

I am so grateful that my daughter doesn’t require medication or treatment! But, considering our family history, I do prefer to have her receive some sort of longer term follow up with a specialist. (Olivia’s brother Jackson has ADHD, ODD and Anxiety, and one of Olivia’s cousins is on the Autism Spectrum.)

I just prefer to stay as educated and aware of what my children are experiencing as possible. Even if there isn’t anything I “can do,” knowledge just makes me feel better.

I have been reading tonight about stereotypy, and indeed it does seem to occur often in developmentally healthy children.

Here is an excerpt from an informative article I found and it describes how stereotypies can affect children who do not have mental retardation or pervasive developmental disorders:

“…The stereotypies seen in these children were associated especially with periods of engrossment such as when playing a game or participating in an activity, but also at times of excitement, stress, fatigue, and boredom. They usually lasted in the range of seconds to minutes (but could go on for hours in some cases) and appeared many times per day. In practically all cases, the stereotypies could be suppressed by sensory stimuli or distraction…

Stereotypies usually develop in early life, mostly before 2 years of age, whereas tics begin to occur in children at age 6 7 years. Unlike tics, which rapidly change from one thing to another (blinks, grimaces, twists, shrugs), stereotypies are prolonged episodes of the same iterated movement.

People with a tic disorder often will stop their tics during engrossing activities, but individuals with stereotypies often will start their repetitive movements during such periods. Distraction usually interrupts stereotypies but not tics.

Many of the children in the study had a comorbidity, including ADHD (15%), obsessive-compulsive disorder or obsessive-compulsive behavior (20%), tics (13%), learning disability (4%), or had an early language or motor developmental delay that resolved itself (12%).

The biologic basis for stereotypies remains unclear, although some evidence suggest that there is a dysfunction in the circuitry between the cortex and the striatum, Dr. Singer said (Pediatr. Neurol. 2005;32:109-12).

If a child’s stereotypy doesn’t interfere with his activity, Dr. Singer said that he doesn’t recommend any particular therapy…”

excerpt from BNET Today.com

Relief

I didn’t expect to leave the hospital feeling relieved. Going in, I felt hopeless.

Watching my daughter get lost in repetitive movements, her body clenched and her face contorted, is incredibly upsetting. It interrupts her constantly throughout her day and some episodes go on and on.

But knowing that these episodes are not damaging her brain, that they aren’t seizures and I didn’t leave the hospital with a prescription for medication, is such a relief.

Life isn’t perfect. Life isn’t typical. We all have our unique challenges, experiences and blessings.

As difficult as it is to watch my daughter clench and contort her face and her body, even as I hold her or we walk down the street, I am trying to have peace that this is just part of the plan the Lord has for her life.

I need to have faith and let Olivia thrive in the life God has planned for her.

THANK YOU again for all your loving support! Your comments, messages and prayers mean so much to us!!!

UPDATE ON OLIVIA

Olivia is now four years old. She is a happy, energetic, and extremely friendly little girl who keeps us in constant laughter.

Olivia still has her stereotypies. They have not lessened — she still experiences them regularly and is now aware that she has them. There are certain situations and stimuli that always brings on her stereotypic movements, such as driving in a car, waiting in a line up, being in the shower or getting out of the bath/shower, and getting bored. Stress and fatigue do seem to make them worse, but are not as much of a factor as the stimulation around her.

I can “call her out” of a stereotypy by calling her name firmly. She will then “come back” and look at me as if she just came from another place. But, unless I continue to hold her hand and engage her, she will immediately go back into her stereotypic movements.

Olivia will sometimes go for an hour or more and not have any stereotypic movements, but at other times they are far more frequent.

It isn’t easy to watch my daughter struggle with stereotypic movement disorder. It is hard when people stare at her, kids and adults alike, confused by what they are seeing, or ask me if she is special needs.

But, even though I feel a slight panic sometimes when I see my daughter “go away” into a place I don’t understand as she experiences her stereotypies, I constantly thank God. My daughter is alive. She is not experiencing seizures or anything that is hurting her. She is happy. She is here. And I am so very very grateful.

If your child is experiencing stereotypic movements or tics, please don’t despair. Yes, it is hard. I know the pain and panic I felt when I first realized something was going on with Olivia. We want the best for our children. We want to keep them from all suffering.

But we can’t. Life sometimes hurts. And a diagnosis of stereotypy or tics??? Well — it isn’t the end of their world or yours. As Julia’s cousin told Olivia, it is just a part of who she is.

Written by Janice, co-founder of 5 Minutes for Mom.

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Tagged as: Olivia, stereotypy, tics

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Janice is co-founder of 5 Minutes For Mom. Along with her twin sister Susan and their mother Joan, Janice also owns two online toy stores -- one specializing in Ride on Toys and the other in Rocking Horses. Janice has a spunky little girl and a rambunctious boy who love to make it difficult for her to work from home.

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