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Disorders in children

All children acquire one or more habits at some point of their development. The term disorders in children denotes unusual persistence of habits, which interfere child’s physical, emotional and social functioning. Most of these disorders indicate a physical expression of underlying emotional tension (tension-discharge phenomena).

Althougn the list of disorders in children is endless e.g. head nodding/banging, body rocking, eye-blinking, throat-clearing, body manipulations, some important disorders are discussed here.

Bruxism is one of the commonest disorders, characterized by non-functional repeated grinding of teeth with a high-pitched sound, usually during sleep. Nocturnal bruxism occurs in —15% children, at some time during childhood.

Habit disorders in children

Etiology of disorders in children

Bruxism is usually considered as a tension- discharge activity for child’s unexpressed anger, resentment or anxiety. However, some cases may be associated with abnormal sleep, activity, familial behavior pattern, anal pruritis e.g. pinworm infestation, and neurological diseases e.g. mental retardation or cerebral palsy. No relationship with the dream sequence is established

Management

Bruxism usually subsides spontaneously over time. However, severe cases need detailed behavioral evaluation for underlying psychological conflicts, behavioral modification via positive reinforcement (rewards), and parental counseling regarding the need for open communication with child. Psychotherapy e.g. hypnosis, and pharmacotherapy e.g. diazepam is very rarely required.

Tics are characterized by involuntary, sudden, rapid, recurrent, non-rhythmic or stereotyped motor movements or vocalizations. Tics are more common in school children, though also seen in children as young as 2 years.

Etiology: Tics are usually benign tension-discharge activities, although occasionally seen in psychiatric syndromes, perinatal problems, chorea or encephalitis.

Clinical spectrum of disorders in children: Broadly, tics may be classified as motor or vocal and simple or complex.

Simple motor tics are repetitive, rapid contractions of functionally similar muscle groups e.g. eye-blinking, lip smacking, grimacing, body rocking etc.

Complex motor tics are less common and involve more purposeful or ritualistic behaviors e.g. grooming behaviors, smelling/touching of objects, echopraxia (imitation) and copropraxia (obscene gestures) etc.

Complex vocal tics include out-of-context use of — words/phrases, use of obscene words/phrases, palilalia (repetition of one’s own words), and echolalia (repetition of last words, heard from others).

Generally, tics tend to worsen with emotional stress or parental attention and relieved on distraction or sleep. Multiple tics may be present in the same child or one tic may change to another, after some time.

Diagnosis

Tics need to be differentiated from partial seizures and dyskinetic extra pyramidal disorders in children on the basis of changing frequency during stress and sleep, amenability for voluntary control, and normal EEG.

Management: Although no specific management is required for benign ticks, socially distressing habits may require parental counseling to ignore the symptom, Behavioral modification with positive reinforcement, and rarely, drugs e.g. haloperidol in resistant tics.

Gilles de Ia Tourette syndrome is a rare but severe tic disorders in children, characterized by a motor component e.g. multiple tics and a vocal component e.g. compulsive barking, grunting or shouting obscene words (coprolalia). It is more common in boys (3-4:1) and first- degree relatives of similar cases.

Etiology: Exact etiology is uncertain, though many factors e.g. genetic defect, neurobiological abnormality, emotional and environmental stress, dopaminergic drugs and a pediatric autoimmune neuropsychiatric disorder secondary to streptococcal infection (PANDAS), have been implicated as causative or precipitating events.

Clinical features: Full-blown Gilles de la Tourette syndrome is relatively rare in children than in adults. Usually, the motor component appears first by —7 years of age and almost always precedes the vocal component. Early disorder with only motor component is difficult to distinguish from simple tics, though behavioral, emotional and academic problems are more common in this syndrome.

Diagnosis is largely clinical with no specific diagnostic tests. EEG shows non-specific abnormalities in —80% cases. Verbal scores on psychometric testing are usually low in these cases.

Management includes parental counseling regarding the compulsive nature of behavior, behavior therapy with positive reinforcement, and pharmacotherapy with a dopamine antagonist e.g. haloperidol or pimozide, which may reduce the severity of tics by >50%. Other drugs e.g. clonidine, clonazepam and carbamazepine have been also used.

Prognosis: Gellis de Ia Tourette syndrome persists throughout life, though usually with considerable reduction in symptoms after 10-15 years of diagnosis.

Thumb-sucking! Nail-biting is a common disorders in children in infants & toddlers and most children overgrow it by 3-4 years. Persistence of these habits beyond this age is abnormal and may cause significant adverse effects e.g.

a) dental problems e.g. malocclusion, periodontitis,

b) nail deformities e.g. chronic paronychia,

c) speech problems &

d) recurrent diarrhea and worm infestations.

Etiology: Thumb sucking/nail biting is usually considered as an indicator of suppressed insecurity and anxiety, often associated with emotional neglect, over-disciplined or over-protective rearing and inherently shy or stubborn behavior.

Management: No intervention in disorders in children is required till 4 years of age, except parental counseling. Forcible and overenthusiastic efforts generate more hostility in the child and perpetuation of this habit for a longer time.

In older children, important steps of management of disorders in children include Psychosocial evaluation and counseling regarding appropriate parent-child relationship, behavioral modification with positive reinforcement e.g. praising the child’s efforts to discard this habit, distractions e.g. engaging him into other activities at the time of habit activity, and treatment of physical complications.

Application of bitter substances over thumb/fingers or physical restraints e.g. splinting of hands, may be useful in some cases, though should be avoided.

Check out the below video on disorders in children –

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