Approach Considerations
Childhood habits that do not interfere with everyday functioning often do not require any treatment, because many of them will remit spontaneously over time. However, if the habit is causing the child or family members substantial 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, 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.
Pharmacologic therapy for stereotypies is only considered after behavioral assessment and interventions have been tried.
Behavioral Therapy
Behavior therapy is the mainstay of treatment for children with habit behaviors. However, mixed results have sometimes been noted with common stereotypies. [15, 17, 26] Interventions can be directed at the antecedents or the consequences of the behavior. [27] For example, gloves or adhesive plasters can remove the antecedent stimulus for thumb sucking.
Effective behavioral therapies for habits include the following:
-
Habit reversal with differential reinforcement - This is a common strategy in which the child is made aware of the stimulus and is taught to make a competing response that is physically incompatible with the stereotypy (eg, in thumb sucking, having the child fold his or her arms when the stereotypy occurs); because of its brevity, immediacy, efficacy, durability, flexibility, and consistency, it is the most consistently effective way to treat presenting habits in children
-
Relaxation training
-
Self-monitoring
-
Reinforcement
-
Nocturnal biofeedback (for bruxism)
-
Competing responses
-
Use of bitter-tasting substances (for nail biting)
-
Negative practice
-
Use of aversive-tasting substances (for thumb sucking)
In complex motor stereotypies, behavioral methods have yielded variable results. [28] Significant improvement has been shown in primary complex motor stereotypies after 1 year. However, a clear improvement has not been confirmed for secondary stereotypies.
Overall, behavioral methods are most successful when patients are cooperative and motivated, regardless of the type of stereotypy present.
Pharmacologic Therapy
Most common habits in children that require treatment can be substantially improved by means of behavioral interventions, without the use of medication. However, in some cases, pharmacotherapy may have to be added to behavioral therapy in order 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.
Although few pharmacologic 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, and obsessive-compulsive disorder) may also be useful when pharmacotherapy for habit behaviors or stereotypic movement disorders is indicated.
Studies involving SSRIs have shown promising evidence of decrease in repetitive or stereotyped behavior (specifically secondary to autism spectrum disorders). Fluoxetine (one of the oldest and most well-studied SSRIs) was shown to be particularly effective in scientific research, although sample size remained a limiting factor. [29]
Clomipramine, a tricyclic antidepressant, was one of the first antidepressants studied and found to have efficacy in treatment of stereotypy, [30] although it should be used with caution given its adverse side effect profile.
Mood stabilizers such as Depakote also have some limited evidence in reduction of repetitive behavior. [31]
Typical and atypical antipsychotics have been increasingly studied, with atypicals often being preferred due to lower risk of inducing extrapyramidal symptoms (EPS) or tardive dyskinesias (TD). Risperidone and aripiprazole have been especially promising in reducing self-injury behavior specifically in patients with autism spectrum disorder (ASD). [32, 33]
Naltrexone, an opioid antagonist, is believed to block the euphoria from self-injurious behaviors and other stereotypies. It has been shown to reduce the frequency of stereotypies in children with autism. [34, 35]
Some more recent evidence has been published in support of atomoxetine, a non-stimulant psychotropic, having secondary effects to include decrease in stereotyped behavior. [36]
Again, evidence supporting these claims remains limited due to small sample size, are have been frequently deemed “promising but lacking sufficient evidence.” In addition, most studies have been conducted in scenarios where stereotypies are secondary to another developmental disorder.
Special considerations with antidepressants
Physicians considering the use of antidepressants to treat pediatric patients are advised to be aware of the following information and use appropriate caution.
In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of depressive illness. After review, the MHRA decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except in the case of fluoxetine, 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 medications in pediatric patients. The FDA 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 medication treatment.
A 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. To date, this is the largest study to address this issue.
The currently available evidence does not indicate that the use of SSRIs to treat obsessive-compulsive disorder and other anxiety disorders is associated with an increased risk of suicide.
Consultations
A developmental-behavioral pediatrician, a child psychologist, or a child psychiatrist should be consulted for further assessment and possible treatment modalities as indicated.
For self-injurious stereotypies, a behavioral therapist should be consulted. For secondary stereotypies, the involvement of developmental pediatricians, pediatric neurologists, and psychiatrists may be appropriate, depending on the cause of the disorder.
