eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics
Childhood Habit Behaviors and Stereotypic Movement Disorder: Treatment & Medication
Updated: Jan 26, 2010
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Treating childhood habits that do not interfere with everyday functioning is often unnecessary because many habits remit spontaneously over time. However, if the habit is causing the child and/or family members distress, social isolation, or physical injury, a therapeutic intervention may be required.
If the physical examination reveals bodily damage from a habit behavior, focus on treating the specific injury and reducing or eliminating the immediate physical harm the child may be inflicting on himself or herself. At this time, consultation with a developmental-behavioral pediatrician, child psychologist, and/or child psychiatrist may be indicated.
Dental occlusal splints are occasionally used in the treatment of oral destructive habits. Splints do not eliminate but do help reduce the frequency of bruxism.
Helmets may be required for children with severe and persistent head banging, particularly those with clinically significant developmental disabilities.
Consultations
Consultation with a developmental-behavioral pediatrician, child psychologist, and/or child psychiatrist may be indicated.
Behavior therapy is the mainstay in the treatment for children with habit behaviors. Effective behavioral therapies for habits include the following:
- Habit reversal: This is the most consistently effective way to treat presenting habits in children because of its brevity, immediacy, efficacy, durability, flexibility, and consistency.
- Relaxation training
- Self-monitoring
- Reinforcement
- Nocturnal biofeedback (bruxism)
- Competing responses
- Use of bitter-tasting substances (nail biting)
- Negative practice
- Use of aversive-tasting substance (thumb sucking)
Activity
Although no specific activity limitations are needed when treating a child with a habit disorder, some situations and contexts may perpetuate habitlike behaviors. Therefore, a functional behavioral assessment by a psychologist can help determine the types of activities that may co-occur with or exacerbate habitlike behaviors.
Medication
Most common habits in children that require treatment can be substantially improved with behavioral interventions, without the use of medication. However, in some cases, medication in addition to behavioral treatments may be required to attain optimal treatment outcomes. When pharmacotherapy is considered, psychologists and medical physicians, such as child and adolescent psychiatrists or behavioral pediatricians, must work in consultation.
Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with antidepressants in the pediatric population.
In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most selective serotonin (5HT) reuptake inhibitors (SSRIs) are not suitable for use by persons younger than 18 years for treatment of depressive illness. After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.
In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and therefore could not be definitively linked to drug treatment.
However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants. This is the largest study to date to address this issue.
Currently, evidence does not exist to associate obsessive-compulsive disorder (OCD) and other anxiety disorders treated with SSRIs with an increased risk of suicide.
Although few drug studies of the many habits and habit disorders in children and adults have been performed, medications commonly used to treat other disorders (eg, tics, trichotillomania, obsessive-compulsive disorder) may also be useful when pharmacotherapy for childhood habit is indicated.
SSRIs and tricyclic antidepressants have shown some efficacy in reducing the frequency and intensity of some repetitive behaviors. SSRIs may be preferred over tricyclic antidepressants because of their milder adverse-effect profiles. Other isolated successes have also been reported with traditional and newer neuroleptics, but their adverse-effect profiles make them second-line medications.
SSRIs
These are antidepressant agents chemically unrelated to the tricyclic, tetracyclic, or other available antidepressants. Inhibits CNS neuronal uptake of 5HT. They may also have a weak effect on norepinephrine and dopamine neuronal reuptake.
SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse-effect profile of SSRIs is less prominent than that of other agents, they promote compliance. SSRIs do not have the risk of cardiac arrhythmia associated with tricyclic antidepressants. The risk of arrhythmia is especially pertinent in overdose, and a suicide risk must always be considered when a child or adolescent with a mood disorder is being treated.
Fluoxetine (Prozac)
Selectively inhibits presynaptic 5HT reuptake with minimal or no effect in reuptake of norepinephrine or dopamine. Approved for obsessive-compulsive disorder in children >8 y.
Adult
20-80 mg/d PO
Pediatric
<8 years: Not established
8-18 years: 10 mg PO qd initially; may uptitrate; not to exceed 20-30 mg/d for lighter children and 60 mg/d for heavier children or adolescents
Increases toxicity of diazepam and trazodone by decreasing clearance; interacts with many drugs due to inhibition of cytochrome P450 (CYP) 2C9, CYP2C19, CYP2D6, CYP3A4; also increases toxicity of MAOIs and highly protein-bound drugs; 5HT syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergics at least 2 wk before SSRI therapy
Documented hypersensitivity; monoamine oxidase inhibitor (MAOI) use within 2 wk; coadministration with thioridazine
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hepatic impairment and history of seizures; MAOIs should be discontinued at least 14 d before start of therapy; FDA recently recommended that all antidepressants should be used with caution in children and adolescents because of an association with increased suicidal ideation
Sertraline (Zoloft)
Selectively inhibits presynaptic 5HT reuptake. Approved for obsessive-compulsive disorder in children >6 y.
Adult
50-200 mg/d PO
Pediatric
<6 years: Not established
>6 years: 25-100 mg/d PO
Inhibits CYP3A3/4, CYP2C9, CYP2C19, and CYP2D6, possibly decreasing clearance of isoenzyme substrates (eg, metoprolol, thioridazine, imipramine, haloperidol, phenytoin, barbiturates, glyburide, warfarin); increases toxicity of MAOIs, diazepam, tolbutamide, and warfarin; 5HT syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergics (eg, anorectics, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan); discontinue other serotonergics at least 2 wk before SSRI therapy
Documented hypersensitivity; MAOI use within 2 wk
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in preexisting seizure disorders and recent myocardial infarction, unstable heart disease, or hepatic or renal impairment; volume depletion or diuretic use may cause hyponatremia (especially in elderly); FDA recently urged that all antidepressants should be used with caution in children and adolescents because of association with increased suicidal ideation; decreased libido possible in male adolescents
Fluvoxamine (Luvox)
Potent selective inhibitor of neuronal 5HT reuptake. Does not notably bind to alpha-adrenergic, histamine, or cholinergic receptors and therefore has fewer adverse effects than tricyclic antidepressants. Many antidepressants available, but SSRIs provide many advantages. MAOIs should be avoided in mood disorders with depressive features; lethal if patient relapses from abstinence and combines them with cocaine. Approved for obsessive-compulsive disorder in children >8 y.
Adult
50-300 mg/d PO
Pediatric
<8 years: Not established
8-17 years: 25 mg PO initially as single dose qhs; increase dose in 25-mg increments q4-7d as tolerated, until maximum therapeutic benefit achieved; divide total daily doses >50 mg into 2 doses; if divided doses not equal, administer large dose qhs; not to exceed 200 mg/d
Risk of a hypertensive crisis increases with coadministration of MAOIs; potentiates effect of triazolam and alprazolam (when taken concurrently, reduce dose by >50%); reduce dose of theophylline by one third and monitor plasma levels if taken concurrently; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity; 5HT syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergics (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergics at least 2 wk before SSRI therapy
Documented hypersensitivity; MAOI use within 2 wk; concurrent administration of terfenadine, astemizole, or cisapride
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in liver dysfunction or cardiovascular disease and history of seizures or suicidal tendencies; FDA recently urged that all antidepressants should be used with caution in children and adolescents because of association with increased suicidal ideation
Tricyclic antidepressant agents
These agents are structurally related to the phenothiazine antipsychotic agents and have 3 major pharmacologic actions in varying degrees: inhibition of the amine pump, sedation, and peripheral and central anticholinergic action. These drugs inhibit the reuptake of norepinephrine or 5HT (ie, 5-hydroxytryptamine) at the presynaptic neuron.
Clomipramine (Anafranil)
Affects 5HT uptake while its metabolite desmethylclomipramine affects norepinephrine uptake. Approved for obsessive-compulsive disorder in children >10 y.
Adult
100-250 mg/d PO
Pediatric
>10 years: 25-200 mg/d PO; not to exceed 3 mg/kg/d
May increase effect of CNS stimulants, CNS depressants, MAOIs, sympathomimetics, alcohol, antipsychotics, benzodiazepines, barbiturates, anticholinergic agents, thyroid medications (cardiac effects), or phenytoin; may decrease effect of clonidine and guanethidine; phenothiazines, methylphenidate, PO contraceptives (estrogen), or marijuana may increase effects; lithium, barbiturates, chloral hydrate, or smoking may decrease effects
Documented hypersensitivity; cardiac conduction abnormalities; concurrent MAOI therapy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In general, not used during pregnancy; caution in seizure disorder (may lower seizure threshold); may exacerbate psychosis; caution in severe cardiopulmonary or renal impairment and those unable to metabolize sorbitol; adults or children with major depressive disorder (MDD) may have worsening of depression and/or emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressants
More on Childhood Habit Behaviors and Stereotypic Movement Disorder |
| Overview: Childhood Habit Behaviors and Stereotypic Movement Disorder |
| Differential Diagnoses & Workup: Childhood Habit Behaviors and Stereotypic Movement Disorder |
 Treatment & Medication: Childhood Habit Behaviors and Stereotypic Movement Disorder |
| Follow-up: Childhood Habit Behaviors and Stereotypic Movement Disorder |
| References |
| Further Reading |
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References
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Keywords
childhood habit behaviors, stereotypic movement disorder, habits, teeth grinding, bruxism, hair pulling, thumb sucking, breath holding, breath-holding spells, stereotypies, nose picking, rocking, nail biting, nailbiting, head banging, headbanging, habitlike behavior
