Atypical Behaviors

1. Habits/Self-Stimulatory behavior
   1. Key Points of Habits/Self-Stimulatory behavior
      1. Stereotypic Movement Disorder
      2. Bruxism
      3. Thumb and Finger Sucking
      4. Head rolling and nodding
      5. Lip Biting and Sucking
      6. Body Rocking
      7. Head Banging
      8. Breathholding Spells
      9. Hyper/hypo Ventilation Syndrome
      10. Habit Cough
      11. Nail Biting
      12. Skin Picking
   2. CLINICAL GUIDES FOR Habits/Self-Stimulatory Behavior (See Clinical Algorithm)
      1. Assessment
      2. Thumb and finger sucking
      3. Habit cough
   3. Definitions Of Habits/Self-Stimulatory behavior
      1. Variations
      2. Problems
      3. Disorders
   4. Differential Diagnosis / Comorbid Conditions of Habits/Self-Stimulatory behavior
   5. Management of Habits/Self-Stimulatory behavior
      1. General Guidelines for Habit Reversal
      2. Stereotypic Movement Disorder
      3. Bruxism
      4. Thumb and finger sucking
      5. Head rolling and nodding
      6. Lip biting and sucking
      7. Body Rocking
      8. Head banging
      9. Breathholding Spells
      10. Hyper/hypo ventilation syndrome
      11. Habit cough
      12. Nail biting
      13. Skin picking
2. Repetitive behavior Disorders
   1. Key Points of Repetitive behavior Disorders
      1. Trichotillomania
      2. Tics
      3. Tourette's Syndrome
   2. Clinical Guides for Repetitive behavior Diosders (See Clinical Guide Algorithm)
   3. Definitions of Repetitive Behavior Disorders
      1. Disorders
   4. Differential Diagnosis / Comorbid Conditions Of repetitive Behavior disorders
   5. Management of Repetitive Behaviors Disorders
3. Resources for Parents
4. References

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• Habits: Habit behavior has been described as "repetitive" or stereotyped behaviors that have negative physical (i.e., tissue damage) or social (i.e., embarrassment, social stigma) effects for the individual"(Miltenberger et al., 1998, p.448). Many habits during childhood are brief and self-remitting, however occasionally medical treatment is sought when habits become stigmatizing or self-injurious. Most severe habit behavior occurs in mentally retarded, blind or deaf children who use it as a means of self-stimulation.
  Habit behavior has been described as "repetitive" or stereotyped behaviors that have negative physical (i.e., tissue damage) or social (i.e., embarrassment, social stigma) effects for the individual"(Miltenberger et al., 1998, p.448). Many habits during childhood are brief and self-remitting, however occasionally medical treatment is sought when habits become stigmatizing or self-injurious. Most severe habit behavior occurs in mentally retarded, blind or deaf children who use it as a means of self-stimulation.
• Behaviors may be stigmatizing: may occur to the exclusion of more adaptive behaviors and may result in self injury
  may occur to the exclusion of more adaptive behaviors and may result in self injury
• Self-injurious behaviors are wide ranging: repeated wetting and rubbing of hands in the mouth, causing skin maceration, biting or picking skin resulting in open lesions that can become infected, violent banging of the head or other body parts against hard surfaces leading to fractures, retinal detachment, intracranial hemorrhages, death.
  repeated wetting and rubbing of hands in the mouth, causing skin maceration, biting or picking skin resulting in open lesions that can become infected, violent banging of the head or other body parts against hard surfaces leading to fractures, retinal detachment, intracranial hemorrhages, death.
• Low levels of environmental stimulation: Predictable reactions of caretakers may reinforce stereotypic movements and self injurious behavior. For example, if the behavior gets attention, gets the individual access to materials or activities that may be otherwise restricted, or when caretakers remove task demands.
  Predictable reactions of caretakers may reinforce stereotypic movements and self injurious behavior. For example, if the behavior gets attention, gets the individual access to materials or activities that may be otherwise restricted, or when caretakers remove task demands.
• biological: alterations in neurotransmitters contribute to SIB. Dopamine deficiency early in development thought to cause SIB in individuals with Lesch-Nyhan syndrome (Schroeder et al., 2001). Hypothesis: SIB may release endogenous opiates and this maintains the behavior.
  alterations in neurotransmitters contribute to SIB. Dopamine deficiency early in development thought to cause SIB in individuals with Lesch-Nyhan syndrome (Schroeder et al., 2001). Hypothesis: SIB may release endogenous opiates and this maintains the behavior.
• Increased SIB may occur in association with menstruation, otitis media, fatigue and allergies: as these could decrease one's tolerance for task demands or frustration and alter the likelihood of a specific event triggering SIB.
  as these could decrease one's tolerance for task demands or frustration and alter the likelihood of a specific event triggering SIB.
• Nocturnal bruxism produces audible grinding sounds: brief (8-9sec) episodes and during night of sleep an average of 42 seconds of bruxing occurs (Attanasio, 1991)
  brief (8-9sec) episodes and during night of sleep an average of 42 seconds of bruxing occurs (Attanasio, 1991)
• Diurnal bruxism associated with clenching of teeth and no audible sounds: Also associated other oral habits such as nail-biting or lip-biting or chewing objects.
  Also associated other oral habits such as nail-biting or lip-biting or chewing objects.
• Most common sign is abnormal wearing of teeth: But hypermobility of teeth, injury to the periodontium, fractured teeth and pulpitis also occur.
  But hypermobility of teeth, injury to the periodontium, fractured teeth and pulpitis also occur.
• Probably multifactorial with dental occlusion problems and psychological factors: Emotional stress such as frustration, anger, anxiety, fear, unpleasant life events (Vanderas 1995)
  Emotional stress such as frustration, anger, anxiety, fear, unpleasant life events (Vanderas 1995)
• Can be adaptive and help to soothe child: As it provides stimulation to delay onset of boredom during periods of low stimulation when the child may be restless, tired, upset or about to fall asleep.
  As it provides stimulation to delay onset of boredom during periods of low stimulation when the child may be restless, tired, upset or about to fall asleep.
• May increase during illness: often in combination with a transitional 'lovie' object.
  often in combination with a transitional 'lovie' object.
• Malocclusion can self correct if sucking is stopped: but longer the habit lasts, less self-correction. Common cause of paronychia in children
  but longer the habit lasts, less self-correction. Common cause of paronychia in children
• sequelae: Thumb suckers rated by peers as less intelligent, happy, attractive, likeable or fun, and less desireable as friend
  Thumb suckers rated by peers as less intelligent, happy, attractive, likeable or fun, and less desireable as friend
• Initially associated with eruption of teeth: 5 mos at 6-7 years.
  5 mos at 6-7 years.
• Associated with lack of environmental stimulation: In children with developmental disabilities and with visual impairments
  In children with developmental disabilities and with visual impairments
• no significant functional impairment or stigmatization: although caregivers may fear mental retardation or autism
  although caregivers may fear mental retardation or autism
• Repetitive hitting of head against solid object: often at rates of 60-80x/min; persistence less than 15 min to 3-4 hours/episode
  often at rates of 60-80x/min; persistence less than 15 min to 3-4 hours/episode
• Can occur in multiple positions: on hands and knees, sitting, prone, supine
  on hands and knees, sitting, prone, supine
• Often accompanied by other motor rhythms: E.g., thumb sucking, blanket holding. During banging child does not seem to experience pain or discomfort but appears relaxed.
  E.g., thumb sucking, blanket holding. During banging child does not seem to experience pain or discomfort but appears relaxed.
• Head banging may lead to physical injury: in some developmentally abnormal children e.g. autistic, profound MR, (bruises, cataracts) but in most children head banging does not result in intracranial injury
  in some developmentally abnormal children e.g. autistic, profound MR, (bruises, cataracts) but in most children head banging does not result in intracranial injury
• but most stop by 4 years: some continue into adulthood; 9% who head bang after 3 are still head banging at 7 years (Abe, Oda and Amotoni, 1984)
  some continue into adulthood; 9% who head bang after 3 are still head banging at 7 years (Abe, Oda and Amotoni, 1984)
• some type of aggravation: frustration, anger, fear, minor injury
  frustration, anger, fear, minor injury
• cyanotic: Cyanotic spells are more common and related to abnormality in respiratory regulation that leads to prolonged expiratory apnea
  Cyanotic spells are more common and related to abnormality in respiratory regulation that leads to prolonged expiratory apnea
• pallid: Pallid spells related to an overactive vagal response leading to bradycardia or asystole.
  Pallid spells related to an overactive vagal response leading to bradycardia or asystole.
• Onset typically between 6-18 mos: Recent study indicated as many as 15% of cases had an onset younger than 6 months (DeMario, 2001).
  Recent study indicated as many as 15% of cases had an onset younger than 6 months (DeMario, 2001).
• Group of symptoms: That may be caused by overbreathing include: dizziness, paresthesias, blurred vision, chest pain, palpitations, dry mouth, muscle spasms, headache, confusion, hallucinations and feeling of impending doom (Evans, 1995)
  That may be caused by overbreathing include: dizziness, paresthesias, blurred vision, chest pain, palpitations, dry mouth, muscle spasms, headache, confusion, hallucinations and feeling of impending doom (Evans, 1995)
• Hyperventilation decreases cerebral blood flow: may account for dizziness, visual changes, headache and confusion
  may account for dizziness, visual changes, headache and confusion
• Occasionally associated with other behavioral or emotional problems: Usually school problems
  Usually school problems
• Results in damage to cuticle, roughness of the nail's free edge, bleeding, paronychia and infection: (in cases of oral herpes, development of herpetic whitlow on the bitten finger)
  (in cases of oral herpes, development of herpetic whitlow on the bitten finger)
• In severe cases, nail-biting may be harmful to dentition: resulting in apical root resorption, fractures in the edges of the incisors and gingivitis
  resulting in apical root resorption, fractures in the edges of the incisors and gingivitis
• Generates antagonism between children and parents: rarely requires tx
  rarely requires tx
• No sex difference before 10: 20% both sexes in college, then boys more commonly
  20% both sexes in college, then boys more commonly
• Nose picking may begin in association with rhinorrhea: resulting from colds or allergies, or may begin in association with nasal irritation or itchiness
  resulting from colds or allergies, or may begin in association with nasal irritation or itchiness
• Common complication is epistaxis: less commonly causes infections or perforation of the nasal septum
  less commonly causes infections or perforation of the nasal septum
• Individual may also pick at their skin: or at scabs resulting in excoriations and infections
  or at scabs resulting in excoriations and infections
• Stereotypic movement disorder: Motor behavior that is repetitive, often seemingly driven and nonfunctional. Behavior clearly associated with social dysfunction and stigmatization
  Motor behavior that is repetitive, often seemingly driven and nonfunctional. Behavior clearly associated with social dysfunction and stigmatization
• Spasmus nutans, salaam spasms: Especially with head rolling and nodding
  Especially with head rolling and nodding
• Other medical conditions: Seizures, cardiac arrhythmias, brainstem tumors or malformations, asthma, thyrotoxicosis, salicylate ingestion, pneumonia, metabolic abnormality, cardiac arrhythmia, or neurologic disorders. Anemia may increase frequency of breath holding spells.
  Seizures, cardiac arrhythmias, brainstem tumors or malformations, asthma, thyrotoxicosis, salicylate ingestion, pneumonia, metabolic abnormality, cardiac arrhythmia, or neurologic disorders. Anemia may increase frequency of breath holding spells.
• Habit Reversal: First reported by Azrin & Nunn (1973) and more recently described in detail by Miltenberger et al. (1998).
  First reported by Azrin & Nunn (1973) and more recently described in detail by Miltenberger et al. (1998).
• Teach the individual a competing response to engage in when they feel as if they are about to engage in the habit: Often habit behavior is maintained by the consequence of the habit-that is, either tension reduction or sensory stimulation (Miltenberger et al., 1998). Replacing the habit behavior with a more socially acceptable and less physically harmful behavior is critical. A competing response is one that uses the same muscle group as the habit and thus prevents the habit behavior from occurring. Holding the CR for 1-3 minustes has shown to be effective over the short and long term (Twohig & Woods, 2001).
  Often habit behavior is maintained by the consequence of the habit-that is, either tension reduction or sensory stimulation (Miltenberger et al., 1998). Replacing the habit behavior with a more socially acceptable and less physically harmful behavior is critical. A competing response is one that uses the same muscle group as the habit and thus prevents the habit behavior from occurring. Holding the CR for 1-3 minustes has shown to be effective over the short and long term (Twohig & Woods, 2001).
• sustain compliance/motivation and facilitate generalization: For children, social support is particularly important for treatment success (Miltenberger et al., 1998).
  For children, social support is particularly important for treatment success (Miltenberger et al., 1998).
• Child motivation and a high level of cooperation between child and parents increases success: If either or both of these are not present, then address these issues first before attempting habit reversal.
  If either or both of these are not present, then address these issues first before attempting habit reversal.
• environmental stimulation: (Guess and Carr 1991). However high levels of stimulation may produce anxiety, stress or frustration, which may increase repetitive behaviors.
  (Guess and Carr 1991). However high levels of stimulation may produce anxiety, stress or frustration, which may increase repetitive behaviors.
• Evaluate the potential communicative role of the SIB.: A behavior analyst may be needed to conduct a functional analysis of the behavior (Steege et al 1989).
  A behavior analyst may be needed to conduct a functional analysis of the behavior (Steege et al 1989).
• SIB may be so severe that medication may be necessary.: Neuroleptic medications are most frequently used. Research ongoing in the use of other medications such as opiate antagonists, serotonin-reuptake inhibitors and beta-blockers. Also for some individuals, naltrexone has been useful.
  Neuroleptic medications are most frequently used. Research ongoing in the use of other medications such as opiate antagonists, serotonin-reuptake inhibitors and beta-blockers. Also for some individuals, naltrexone has been useful.
• psychological therapies: relaxation exercise, self hypnosis
  relaxation exercise, self hypnosis
• physical therapy: Exercises, heat applications, ultrasound and transcutaneous electric stimulation
  Exercises, heat applications, ultrasound and transcutaneous electric stimulation
• Dental problems: Seek a dental evaluation if teeth are affected. Oral appliances may be needed.
  Seek a dental evaluation if teeth are affected. Oral appliances may be needed.
• positive reinforcement: Such as praise and tangible rewards. Also Manicures are often a good motivator for girls.
  Such as praise and tangible rewards. Also Manicures are often a good motivator for girls.
• negative reinforcement: such as bitter tasting nail polish, sock or gloves over hand (Friman and Leibowitz 1990)
  such as bitter tasting nail polish, sock or gloves over hand (Friman and Leibowitz 1990)
• If child motivated use a combination of positive and negative reinforcement: Give consequence each time sucking is noted and reward child every day (or half-day) child goes with out sucking. Simple rewards like stickers are appropriate.
  Give consequence each time sucking is noted and reward child every day (or half-day) child goes with out sucking. Simple rewards like stickers are appropriate.
• Reassure parents: no brain damage will occur and usually not a sign of emotional disturbance or developmental disability
  no brain damage will occur and usually not a sign of emotional disturbance or developmental disability
• Ignore behavior: particularly when occurs during tantrums. If banging occurs mainly during tantrums, manage these
  particularly when occurs during tantrums. If banging occurs mainly during tantrums, manage these
• do little: and may exaggerate habit
  and may exaggerate habit
• In children with developmental disabilities: If head banging severe and persistent: consultation with behavioral psychologist specializing in developmentally disabled children. Pharmacologic treatments (phenothiazines, haldol) and helmets might be used
  If head banging severe and persistent: consultation with behavioral psychologist specializing in developmentally disabled children. Pharmacologic treatments (phenothiazines, haldol) and helmets might be used
• Demystify and reassure parents.: that spells are not harmful and child will begin breathing after losing consciousness.
  that spells are not harmful and child will begin breathing after losing consciousness.
• Treat with iron if anemic.: May be useful even if the child is not anemic (Daoud et al., 1997)
  May be useful even if the child is not anemic (Daoud et al., 1997)
• Atropine can decrease the frequency of spells: in cases of frequent and severe (with seizures) pallid breath-holding spells (McWilliam and Stephenson, 1984)
  in cases of frequent and severe (with seizures) pallid breath-holding spells (McWilliam and Stephenson, 1984)
• Parents who remain fearful of events may try to prevent child from experiencing pain, fear, minor injury, anger or frustration, may restrict activities, may provide attention when child has tantrum.: These behaviors may reinforce tantrums and spells. If reassurance and demystification do not change parents behavior may need referral to mental health professional.
  These behaviors may reinforce tantrums and spells. If reassurance and demystification do not change parents behavior may need referral to mental health professional.
• behavioral treatments are recommended: namely brief suggestive therapy (Lokshin et al., 1991; Lavigne et al ., 1991); Irwin et al. (2006) also mention self-hypnosis, behavioral therapy, speech therapy techniques and wrapping a bedsheet around the child's chest.
  namely brief suggestive therapy (Lokshin et al., 1991; Lavigne et al ., 1991); Irwin et al. (2006) also mention self-hypnosis, behavioral therapy, speech therapy techniques and wrapping a bedsheet around the child's chest.
• Avoid punishments: Nagging or ridicule as these can worsen behavior
  Nagging or ridicule as these can worsen behavior
• Habit reversal yields effective and long lasting results: With an adult sample, 19% nail growth at 5 month follow-up for HR group vs. 0% growth for placebo control group.
  With an adult sample, 19% nail growth at 5 month follow-up for HR group vs. 0% growth for placebo control group.
• Treatments rarely indicted in young children: because behaviors tend to decrease
  because behaviors tend to decrease
• Combination of normal behaviors deliberately designed to facilitate motor and ego development that become exaggerated or modified because of psychosocial issues or secondary pleasure.: May occur especially in children with disabilities where the behavior relieves the child's discomforts, frustrations, or unsatisfied needs, or alleviates monotony from isolation or perceptual disability. Catecholamines or indolamines can serve as underlying neurotransmitters. Repetitive behaviors or stereotypes are commonly found in mentally retarded children, those with development emotional or physical disorders and also normal children. They do not necessarily cause significant functional impairment.
  May occur especially in children with disabilities where the behavior relieves the child's discomforts, frustrations, or unsatisfied needs, or alleviates monotony from isolation or perceptual disability. Catecholamines or indolamines can serve as underlying neurotransmitters. Repetitive behaviors or stereotypes are commonly found in mentally retarded children, those with development emotional or physical disorders and also normal children. They do not necessarily cause significant functional impairment.
• General medical or neurological conditions: multiple sclerosis, post viral encephalitis, head injury, Sydenham chorea, Huntington chorea, Lesch-Nyhan syndrome
  multiple sclerosis, post viral encephalitis, head injury, Sydenham chorea, Huntington chorea, Lesch-Nyhan syndrome
• Sensory impairments: occur with increased frequency in children with hearing impairments, visual impairments
  occur with increased frequency in children with hearing impairments, visual impairments
• Medications: seizure medication, hypnotics, anxiolytics
  seizure medication, hypnotics, anxiolytics
• Developmental disorders: mental retardation, pervasive developmental disorder
  mental retardation, pervasive developmental disorder
• Psychiatric disorders: obsessive-compulsive disorder, schizophrenia
  obsessive-compulsive disorder, schizophrenia
• Normal during periods of isolation, boredom, fatigue.: Can be distracted from behaviors. Most are transient, require only support and guidance to reduce stress.
  Can be distracted from behaviors. Most are transient, require only support and guidance to reduce stress.
• evaluation: Treat if development impaired or threatened, self-esteem suffering, child teased or excluded, physical harm results, family not tolerating symptom
  Treat if development impaired or threatened, self-esteem suffering, child teased or excluded, physical harm results, family not tolerating symptom
• behaviors: In otherwise developmentally normal children stereotypic movement called blindisms may occur. These include: raising, flapping, swinging hands, pressing on eye, putting fingers into eye sockets, rubbing eyelids - performed rhythmically; (2) Deaf individuals: knee shaking with vocal sounds (3) Children with MR and blindness: repetitive partial body movements, swaying of upper body, flapping of hands; (4) Children with MR and deafness: whole body actions, stereotyped walking and wandering with vocal sounds. (3) Children with autism: stereotyped walking, bizarre patterns of motility: whirling, darting, sidewalking, lunging, hand flapping, head banging, body rocking palilalia - repetition of meaningless words.
  In otherwise developmentally normal children stereotypic movement called blindisms may occur. These include: raising, flapping, swinging hands, pressing on eye, putting fingers into eye sockets, rubbing eyelids - performed rhythmically; (2) Deaf individuals: knee shaking with vocal sounds (3) Children with MR and blindness: repetitive partial body movements, swaying of upper body, flapping of hands; (4) Children with MR and deafness: whole body actions, stereotyped walking and wandering with vocal sounds. (3) Children with autism: stereotyped walking, bizarre patterns of motility: whirling, darting, sidewalking, lunging, hand flapping, head banging, body rocking palilalia - repetition of meaningless words.
• Biological factors: Infant studies show rhythmical patterns are nearly universal (90-100% of infants) and occur with distinctive developmental progression. For instance: 1) Hand, finger and thumbsucking: mean age of onset at birth; 2) Foot kicking begins 2-3 months of age; 3) Object banging and body rocking begin about 6 months of age; and, 4) Hand clapping begins about 7-8 months of age. 5) These behaviors may represent intrinsic movement patterns generated by the developing nervous system (Thelen, 1979). Infants also show startle responses, sobbing episodes, gentle lip movements, erections, transient smiles and twitches; yet, most of these do not persist. However, spontaneous rhythmical mouthing persists up to 6 months of age and can reappear in those who suffer CNS insults. The basal ganglia, frontal lobes and dopamine neurotransmitter systems are implicated in etiology of some repetitive behaviors. A variety of brain injuries and alterations of neurotransmitters produce repetitive behaviors and may be explained by linkages between these systems.
  Infant studies show rhythmical patterns are nearly universal (90-100% of infants) and occur with distinctive developmental progression. For instance: 1) Hand, finger and thumbsucking: mean age of onset at birth; 2) Foot kicking begins 2-3 months of age; 3) Object banging and body rocking begin about 6 months of age; and, 4) Hand clapping begins about 7-8 months of age. 5) These behaviors may represent intrinsic movement patterns generated by the developing nervous system (Thelen, 1979). Infants also show startle responses, sobbing episodes, gentle lip movements, erections, transient smiles and twitches; yet, most of these do not persist. However, spontaneous rhythmical mouthing persists up to 6 months of age and can reappear in those who suffer CNS insults. The basal ganglia, frontal lobes and dopamine neurotransmitter systems are implicated in etiology of some repetitive behaviors. A variety of brain injuries and alterations of neurotransmitters produce repetitive behaviors and may be explained by linkages between these systems.
• environmental factors: Both high and low level of arousal may increase frequency of repetitive behaviors, as can severe sensory deprivation. Programs to enrich environmental stimulation usually decrease repetitive behaviors in institutionalized children with MR. In first year of life repetitive behaviors are associated with a change in stimuli such as the appearance of caretaker or a nonalert (fussy) state (Thelen 1981). In older children repetitive behaviors appear during periods of low arousal (when child is tired, bored) or during periods of high arousal (when child concentrating, angry or frustrated) (Sallustro and Atwell, 1978; Troster, 1994). Repetitive behaviors can be maintained because of their effects on the environment. In individuals with disability, repetitive behaviors, especially self-injurious behaviors are reinforced by caretakers who respond to the behaviors by providing attention, by allowing individual access to tangible reinforcers or by allowing the individual to avoid undesired activities (Guess and Carr, 1991). Similar factors may reinforce head banging in toddlers, leading to increased rates of head banging during tantrums.
  Both high and low level of arousal may increase frequency of repetitive behaviors, as can severe sensory deprivation. Programs to enrich environmental stimulation usually decrease repetitive behaviors in institutionalized children with MR. In first year of life repetitive behaviors are associated with a change in stimuli such as the appearance of caretaker or a nonalert (fussy) state (Thelen 1981). In older children repetitive behaviors appear during periods of low arousal (when child is tired, bored) or during periods of high arousal (when child concentrating, angry or frustrated) (Sallustro and Atwell, 1978; Troster, 1994). Repetitive behaviors can be maintained because of their effects on the environment. In individuals with disability, repetitive behaviors, especially self-injurious behaviors are reinforced by caretakers who respond to the behaviors by providing attention, by allowing individual access to tangible reinforcers or by allowing the individual to avoid undesired activities (Guess and Carr, 1991). Similar factors may reinforce head banging in toddlers, leading to increased rates of head banging during tantrums.
• regulate overstimulation/understimulation: Stimulus Regulation model of hair-pulling, skin picking, nail biting and similar body focused repetitive behavior (Penzel, 2003).
  Stimulus Regulation model of hair-pulling, skin picking, nail biting and similar body focused repetitive behavior (Penzel, 2003).
• Onset: An early onset type (2-6 years) usually associated with thumbsucking, tends to be outgrown during adolscence before reaching clinical attention. It is thought to be harmless and is sometimes referred to as "baby trich". Clinical practice suggests a wide range of age of onset with outliers possible--anywhere from age 1 through the 50's. (Penzel, 2003).
  An early onset type (2-6 years) usually associated with thumbsucking, tends to be outgrown during adolscence before reaching clinical attention. It is thought to be harmless and is sometimes referred to as "baby trich". Clinical practice suggests a wide range of age of onset with outliers possible--anywhere from age 1 through the 50's. (Penzel, 2003).
• Can involve scalp hair, eyelashes, eyebrows, pubic hair: can be pulled, plucked, twisted off, rubbed or cut off
  can be pulled, plucked, twisted off, rubbed or cut off
• increasing sense of tension before pulling out their hair and a sense of gratification: However many individuals do not report this tension and gratification.
  However many individuals do not report this tension and gratification.
• Hair loss here results in irregular or patchy alopecia, with a migrating loss of hair: with advancing loss on one side and regrowing hair on other side
  with advancing loss on one side and regrowing hair on other side
• When it begins in older children or adolescents: Clinical practice suggests that for most patients there are other co-morbid psychological difficulties. These may include depression, generalized anxiety disorder, alcohol abuse, simple phobias, obsessive-compulsive disorder, social phobia or bulimia (Penzel, 2003, p. 27).
  Clinical practice suggests that for most patients there are other co-morbid psychological difficulties. These may include depression, generalized anxiety disorder, alcohol abuse, simple phobias, obsessive-compulsive disorder, social phobia or bulimia (Penzel, 2003, p. 27).
• about trichophagy: hair that is chewed and swallowed after being picked
  hair that is chewed and swallowed after being picked
• trichobezoar: massive concretion of hair in stomach
  massive concretion of hair in stomach
• psychosocial factors: Such as emotional arousal, stress and conflicts. Also when parents are overwhelmed by the child's tics, they may not be fully available medically or emotionally which can lead to a worsening of tics.
  Such as emotional arousal, stress and conflicts. Also when parents are overwhelmed by the child's tics, they may not be fully available medically or emotionally which can lead to a worsening of tics.
• simple motor tics: involve an individual muscle group and include blinking, neck stretching, shrugging, shoulder shrugging, squinting and lip licking
  involve an individual muscle group and include blinking, neck stretching, shrugging, shoulder shrugging, squinting and lip licking
• complex motor tics: involve either a cluster of simple tics or more coordinated pattern of movements - touching, jumping, manipulating clothing or facial grimacing
  involve either a cluster of simple tics or more coordinated pattern of movements - touching, jumping, manipulating clothing or facial grimacing
• simple vocal tics: include grunting, sniffing and throat clearing
  include grunting, sniffing and throat clearing
• complex vocal tics: involve saying works, parts of words, phrases, palilalia (repeating own words), echolalia (repeating other's words)
  involve saying works, parts of words, phrases, palilalia (repeating own words), echolalia (repeating other's words)
• Sensory phenomena may precede tics: an unpleasant feeling described as a pressure, urge, or itch that becomes more bothersome until individual performs the tic. Premonitory sensations most often involve shoulders, palms, abdomen, throat
  an unpleasant feeling described as a pressure, urge, or itch that becomes more bothersome until individual performs the tic. Premonitory sensations most often involve shoulders, palms, abdomen, throat
• Transient tic disorder: Both Transient tic disorder and Chronic tic disorder have either only motor or only vocal tics (less common), but not both. Tics may be single or multiple tics. Onset is during childhood or early adolescence and variation in intensity over weeks or months may occur. The difference is that transient tic disorder has a duration lasting greater than 1 month and less than 1 year while chronic tic disorder has a duration lasting greater than one year.
  Both Transient tic disorder and Chronic tic disorder have either only motor or only vocal tics (less common), but not both. Tics may be single or multiple tics. Onset is during childhood or early adolescence and variation in intensity over weeks or months may occur. The difference is that transient tic disorder has a duration lasting greater than 1 month and less than 1 year while chronic tic disorder has a duration lasting greater than one year.
• Tourette's Syndrome: Tourette's Syndrome is characterized by both motor and vocal tics, either single or multiple, which last for greater than 1 year.
  Tourette's Syndrome is characterized by both motor and vocal tics, either single or multiple, which last for greater than 1 year.
• Course: Attentional and hyperactive problems often precede tics, then motor tics, then vocal tics with ecolalia, echokinesis (repetition of another person's movements) coprolalia (in 40% of cases)
  Attentional and hyperactive problems often precede tics, then motor tics, then vocal tics with ecolalia, echokinesis (repetition of another person's movements) coprolalia (in 40% of cases)
• Usual gradual onset: with one or more episodes of transient tics followed by more persistent motor and vocal tics
  with one or more episodes of transient tics followed by more persistent motor and vocal tics
• Tics usually have waxing and waning course: may be exacerbated by anxiety, stress, excitement, or fatigue
  may be exacerbated by anxiety, stress, excitement, or fatigue
• Impact is largely social not physical: Severity of symptoms is associated with subjective distress and interference with interpersonal relationships and classroom or other activities
  Severity of symptoms is associated with subjective distress and interference with interpersonal relationships and classroom or other activities
• Frequently positive family history for tics: Data is consistent that TS is transmitted in an autosomal dominant manner with OCD being an alternative expression of the TS gene. Males are more likely to have TS, and females to have OCD without tics (Como, 1995).
  Data is consistent that TS is transmitted in an autosomal dominant manner with OCD being an alternative expression of the TS gene. Males are more likely to have TS, and females to have OCD without tics (Como, 1995).
• Has neurological substrate: high incidence of abnormal EEG's and soft signs
  high incidence of abnormal EEG's and soft signs
• Obsessive Compulsive Disorder: In individuals with Tourette's Syndrome 90% experience OC symptoms with 40-50% meeting criteria for OCD.
  In individuals with Tourette's Syndrome 90% experience OC symptoms with 40-50% meeting criteria for OCD.
• ADHD: About 50% of individuals with Tourette's Syndrome also have ADHD, which often predates the onset of tics.
  About 50% of individuals with Tourette's Syndrome also have ADHD, which often predates the onset of tics.
• Stereotypic movement disorder: Motor behavior that is repetitive, often seemingly driven and nonfunctional. Behavior clearly associated with social dysfunction and stigmatization
  Motor behavior that is repetitive, often seemingly driven and nonfunctional. Behavior clearly associated with social dysfunction and stigmatization
• Motor development/functioning disorders: Dystonias, dyskinesias, myoclonic movements and spasms.
  Dystonias, dyskinesias, myoclonic movements and spasms.
• Other medical conditions: e.g., Athetosis, chorea, hemiballismus, iron deficiency, Huntington's Disease, Lesch-Nyhan Syndrome, Wilson's Disease, Sydenhams's choreah, Multiple Sclerosis, post-viral encephalitis.
  e.g., Athetosis, chorea, hemiballismus, iron deficiency, Huntington's Disease, Lesch-Nyhan Syndrome, Wilson's Disease, Sydenhams's choreah, Multiple Sclerosis, post-viral encephalitis.
• Autoimmune disorders: Alopecial areata is an autoimmune skin disease where the immune system attacks hair follicles resulting in partial or total hair loss
  Alopecial areata is an autoimmune skin disease where the immune system attacks hair follicles resulting in partial or total hair loss
• Thyroid or pituitary disorders: Hypo or hyperthyroidism, hypo parathyroidism, hypopituitarism
  Hypo or hyperthyroidism, hypo parathyroidism, hypopituitarism
• Medication: Cytotoxic or anticoagulant, hypervitaminosis A, tx
  Cytotoxic or anticoagulant, hypervitaminosis A, tx
• Other medical conditions: Before diagnosing trichotillomania in individuals who deny hair pulling consider other causes of alopecia such as alopecia areata, male pattern baldness, chronic discoid lupus erythematosus, lichen planopilaris, folliculitis decalvans, pseudopelade, and alopecia mucinosa (DSM-IV, 1994).
  Before diagnosing trichotillomania in individuals who deny hair pulling consider other causes of alopecia such as alopecia areata, male pattern baldness, chronic discoid lupus erythematosus, lichen planopilaris, folliculitis decalvans, pseudopelade, and alopecia mucinosa (DSM-IV, 1994).
• Behavioral treatments have best efficacy: Habit reversal procedure (Azrin, Nunn & Frantz 1980b, Blum, Barone, & Friman, 1993)
  Habit reversal procedure (Azrin, Nunn & Frantz 1980b, Blum, Barone, & Friman, 1993)
• Some interest in antidepressants, particularly fluoxetine (Prozac) and clomipramine (Anafranil): adult studies- mixed results Jaspers, 1996
  adult studies- mixed results Jaspers, 1996
• Habit reversal is helpful: Habit reversal has been shown to be more effective than supportive psychotherapy in the short term and at a 10 month follow-up (Wilhelm et al., 2003).
  Habit reversal has been shown to be more effective than supportive psychotherapy in the short term and at a 10 month follow-up (Wilhelm et al., 2003).
• Determine impact of tics and of comorbid conditions.: Comorbid conditions often have a great impact and treatment should focus on them as well.
  Comorbid conditions often have a great impact and treatment should focus on them as well.
• When to begin treatment for tics: Treatment should start when tics cause significant disruption in motor or speech functions or interfere with social or emotional development or interpersonal relationships.
  Treatment should start when tics cause significant disruption in motor or speech functions or interfere with social or emotional development or interpersonal relationships.
• Neuroleptics: risperidone, haloperidol, pimozide and fluphenazine) most effective but many side effects (sedation, weight gain, dysphoria, anxiety, school phobia, cognitive dulling and extrapyramidal effects. Risk of tardive dyskinesia limits use to most severely affected
  risperidone, haloperidol, pimozide and fluphenazine) most effective but many side effects (sedation, weight gain, dysphoria, anxiety, school phobia, cognitive dulling and extrapyramidal effects. Risk of tardive dyskinesia limits use to most severely affected
• Alpha-2 adrenergic agonists clonodine and guanfacine are less effective, but have fewer side effects (most common is sedation) and no TD.: Useful when ADHD is comorbid. Maximum efficacy after 3-4 weeks but 50-75% show little improvement (Peterson 1996). Rapid discontinuation produce rebound hypertension and worsening tics, thus need to be tapered slowly.
  Useful when ADHD is comorbid. Maximum efficacy after 3-4 weeks but 50-75% show little improvement (Peterson 1996). Rapid discontinuation produce rebound hypertension and worsening tics, thus need to be tapered slowly.
• habit reversal: Habit reversal has been shown to be more effective than supportive psychotherapy in the short term and at a 10 month follow-up (Wilhelm et al., 2003).
  Habit reversal has been shown to be more effective than supportive psychotherapy in the short term and at a 10 month follow-up (Wilhelm et al., 2003).