Stereotypes of Infancy and Childhood

Childhood habits appear in many different forms. Many people engage in some degree of habit like behavior in their lifetime. For example, habits can range from seemingly benign behaviors, such as nail biting or foot tapping, to more noticeable physically damaging behaviors, such as teeth grinding and hair pulling. 

 
 
Habit disorders, now subsumed under the diagnostic term stereotypic movement disorder, consist of repetitive, seemingly driven, and nonfunctional motor behaviors that interfere with normal activities or that result in bodily injury. Fortunately, many childhood habits are benign, they are considered a normal part of development, they do not meet the criteria for a disorder, and they typically remit untreated. 
 
 
Common Stereotypes
 
 
  • Thumb sucking: Thumb sucking is an oral habit that involves mouthing of the thumb. Other fingers or the hand may also be involved.
  • Nail biting: Nail biting consists of biting on or chewing the nails of the hand.
  • Nose picking: Nose picking is the insertion of a finger into a nostril and may involve the removal of nasal discharge. Older children and adults are most likely to pick their nose in private, whereas young children may commonly do this in public view. 
  • Bruxism: is the forcible gnashing, grinding, clicking, or clenching of teeth. Nocturnal bruxism occurs during sleep, and the child is usually unaware of the problem. Episodes are typically brief, lasting 8-9 seconds, with audible grinding noises. Diurnal (daytime) bruxism is primarily associated with clenching of the teeth and generally does not produce audible noises. Diurnal bruxism is related to other oral habits, such as nail biting or lip chewing. 
  • Breath-holding spells: A breath-holding spell is a paroxysmal event in which a child stops breathing at end-expiration after crying, typically because of pain or anger. The crying may be brief or prolonged. A simple breath-holding spell results when the child becomes apneic (cyanotic or pale) but then takes a deep breath. Spells with loss of consciousness and muscle tone are classified by the child's color during the event. Cyanotic spells typically have an emotional precipitant (eg, anger, frustration), and with breath holding, the child progresses from cyanotic to apneic. The child may then become limp and lose consciousness. The spell typically lasts less than 1 minute. Pallid spells are generally observed in response to pain, and the child quickly becomes apneic and pale. 
  • Head banging: Head banging is the rhythmic hitting of the head (usually the frontal or parietal region) against a solid surface. In children who are developmentally normal, it usually lasts less than 15 minutes but can last hours. A high frequency of up to 60-80 hits per minute is common. It can be associated with temper tantrums, tension, or stress. Head banging can also develop as a sleep ritual if the head banging occurs as the child falls asleep. 
  • Body rocking or rhythmic movements: Body rocking usually involves a forward and backward rhythmic swaying of the trunk at the hips, generally from a sitting or quadruped position. The intensity may be gentle, or it may be forceful enough to move the child's crib or bed. This behavior typically occurs when children are alone in their cribs or beds. Most episodes last less than 15 minutes but may persist up to 30 minutes. Rhythmic or stereotypic behaviors include repetitive nonfunctional motor movements, such as hand flapping or shaking, self-biting, or hitting one's own body. 
 
 
The age of onset and resolution of habit behaviors may be delayed in children with developmental disabilities.
 
 
Mortality/Morbidity
 
 
Because childhood habits take various forms, a wide range of mortality and morbidity profiles exist. Mortality is extremely rare.
 
 
  • All habits have the potential to produce social stigmatization and distress depending on the environmental context in which they occur. 
  • Although the range of physical sequel varies greatly, serious medical complications are rare.
  • Some habit disorders may not directly cause the child observable physical damage. Instead, they may result in impairment in social functioning. Stigmatization resulting from the habit can cause the child considerable distress, humiliation, social rejection, academic problems, feelings of shame and guilt, discomfort in social activities, and depression or anxiety. 

 

History
 
 
The history consists of reports of observed specific behaviors associated with the individual habit. Intensity, severity, and duration may be variable. Habit behaviors may be present for a long time before consultation is sought. Complaints at the time of presentation for evaluation and/or treatment may be either physical or psychological sequel of the habit. 
 
 
Physical
 
 
Most childhood habits are benign and have no specific observable physical signs. However, when physical signs are present, they are typically non-pathologic and often previously unnoticed. In severe cases, physical evidence of a habit may be related to an associated injury or physical squeal of the specific behavior the child engages in.
 
 
  • Thumb sucking: Thumb and digit sucking continued beyond age 4-5 years can result in dental problems, especially malocclusion, mucosal trauma, decreased alveolar bone growth, and abnormal growth of facial bones. These children also have an increased risk of accidental ingestions and pica. Thumb callous and skin breakdown may occur. Deformities of the fingers and thumbs and paronychia occur relatively infrequently. 
  • Nail biting: This can be associated with extremely short fingernails, paronychia, oral herpes, herpetic whitlow, damaged dentition, apical root resorption, fractures to the incisors, and gingivitis. 
  • Nose picking: Epistaxis is the most common complication. In rare cases, complications include perforation of the nasal septum or infection. 
  • Bruxism: This can result in chronic dental pain, dental fractures, wearing down of dental enamel, thermal hypersensitivity of the teeth, hypermobility of the teeth, injury to the periodontium, and pulpits. Dysfunction of the temporomandibular joint and recurrent headaches may also occur. 
  • Breath-holding spells: Injury may result from a fall secondary to loss of consciousness and muscle tone. In some cases, a child may have a seizure secondary to the breath holding. 
  • Head banging: Physical or intracranial injuries rarely result, even with forceful head banging. Head banging may cause callus formation, abrasions, and contusions at the site of the banging. Risk for injury is increased in children with bleeding disorders. Skull fractures, eye injuries, and dental injuries have rarely been reported. 
  • Body rocking and rhythmic movements: In rare cases, self-injurious rhythmic movements may occur and result in various associated physical injuries. 
 
 
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 member’s 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. Behaviour 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 habit like behaviors. Therefore, a functional behavioral assessment by a psychologist can help determine the types of activities that may co-occur with or exacerbate habit like 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 behavioural therapy may be required to attain optimal treatment outcome. When pharmacotherapy is considered, psychologists and medical physicians, such as child and adolescent psychiatrists or behavioral pediatricians, must work in consultation. 
 
 
 Prognosis
 
 
  • Most childhood habits that do not involve self-injury are benign and remit without intervention. 
  • When a habit persists and interferes with daily functioning, intervention is warranted.
  • The prognosis for reducing and eliminating habit disorders is typically good.
  • Treatment research shows that behavioral intervention can reduce the habit behavior by 90%.
  • A child with breath-holding spells does not have an increased risk of seizures but does have an increased risk of syncopal episodes as an adult. 
  • Data about habit behaviors as markers for increased emotional stress, anxiety, or behavior problems are inconsistent.

 

 

 

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