HABIT DISORDERS

All children have one or more habits, i.e. repetitive pattern of movements, at some point of time. The term habit disorder denotes unusual persistence of some habit/s, which interfere in their physical, emotional and social functioning.

While the list of habit disorders is endless, e.g. head nodding/ banging, body rocking, eye-blinking, throat­clearing, body manipulations, some important ones are discussed here.

Bruxism is one of the commonest habit disorder, 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.

Etiology: Bruxism is usually considered as a tension­discharge activity for the suppressed anger, resentment or anxiety. However, some cases may be associated with: (a) abnormal sleep activity, (b) familial behavior pattern, (c) anal pruritus, e.g. pinworm infestation, and (d) 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: (a) detailed behavioral evaluation for underlying psychological conflicts, (b) behavioral modification via positive reinforcement (rewards), and (c) parental counseling regarding the need for open communication with child. Psychotherapy, e.g. hypnosis and pharmacotherapy, e.g. diazepam is very rarely required.

Thumb-sucking is a common habit among infants and toddlers and most children overgrow it by 3-4 years. Persistence of this habit beyond this age is abnormal.

Etiology: Thumb sucking is usually considered as an indicator of insecurity and anxiety, often associated with (a) emotional neglect, (b) over-disciplined or over- protective rearing, and (c) inherently shy or stubborn behavior.

Clinically, apart from hygiene issues, prolonged thumb­sucking may lead to significant adverse effects, e.g. (a) dental problems, e.g. malocclusion, periodontitis, (b) nail deformities, e.g. chronic paronychia, (c) speech problems, and (d) recurrent diarrhea or worm infestations.

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

In older children, important steps of management include: (a) psychosocial evaluation and counseling regarding appropriate parent-child relationship, (b) behavioral modification with positive reinforcement, e.g. praising the child's efforts to discard this habit, (c) distractions, e.g. engaging him into other activities at the time of habit activity, and (d) 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.

Nail-biting (Onychophagia) is a common habit in relatively older children, reported in ~30% of school children and even adolescents.

Etiology: Nail-biting too, like thumb-sucking, usually reflects suppressed anxiety and is relatively common in children who had thumb-sucking in early childhood. It is also a tension-discharge behavior, which sometimes borders as compulsion or overlapping obsessive­compulsive disorder. Precipitating factors include emotional stress, lack of self-confidence and self-esteem. Co-morbidities, e.g. enuresis, intellectual disability and attention-deficit hyperactivity disorder are common.

Clinically, nail-biting as base-line habit, is often aggravated during the periods of stress. In long-term, it may lead to acute/chronic paronychia, bleeding and permanent damage/ deformities to nails. Recurrent diarrhea and worm infestations, e.g. enterobiasis and dental problems are also common.

Management includes: (a) emotional support during stressful situations to build the self-confidence of child,

(b) behavioral modification with positive reinforcement, e.g.

(c) distractions, e.g. engaging him in other activities at the time of nail-biting, and (d) treatment of physical complications.

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 presentation: 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, head banging, etc.

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

• Complex vocal tics include repeated use of words/ phrases out of context, 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 tick may change to another after some time.

Diagnosis: Tics need to be differentiated from partial seizures and dyskinetic/dystonic extrapyramidal disorders, on the basis of: (a) changing frequency during stress and sleep, (b) amenability for voluntary control, and

(c) normal EEG.

Tics need to be differentiated from stereotypies, which are classically rhythmic, distractable and persist for long time.

Management: Although no specific management is required for benign ticks, socially distressing habits may require: (a) parental counseling to ignore the symptom, (b) behavioral modification with positive reinforcement, and rarely, (c) drugs, e.g.

Gilles De La Tourette syndrome is a rare but severe tick disorder, 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.: (a) genetic defect, (b) neurobiological abnormality, (c) emotional and environmental stress,

(d) dopaminergic drugs and (e) 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 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.

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

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

Stuttering or stammering is a fluency disorder of speech characterized by difficulty in initiation of some consonants, spasmodic repetition of sounds or syllables or words and pauses or interruptions in speech, known as blocks. Stuttering is common in 2-5 years of age during the phase of rapid language development and resolves spontaneously with advancing age.

Clinically, stuttering denotes unusual hesitancy to speak during the stress or excitement, aggravated when the

child is reminded or corrected while stammering. It is often absent in low-stress settings like playing alone or singing. Many cases develop secondary mannerisms, e.g. blinking of eyes or twitching of facial muscles during speaking, as well as social anxiety and low-self-esteem, avoiding social interactions.

Management includes: (a) reassurance to parents about self-regressing nature of stuttering with age, (b) avoidance of teasing or scolding the young child while stuttering, (c) encouraging loud-reading or speaking in low-stress situations without undue attention, (d) emotional support to anxious child, and (e) speech therapy in older children, if the problem persists. Cognitive behavior therapy may be useful in children with major behavioral issues. Drugs like haloperidol or clonidine may be considered in rare cases of socially or functionally debilitating tics.

Masturbation, i.e. stimulation of one's own genitals to derive the pleasure (also termed as gratification disorder), is common even in preschool children. About 30% of boys and 10% of girls are reported to engage in masturbation by 8 years of age, with incidence increasing to gt;90% by adolescence.

Masturabation is usually a benign habit, sometimes triggered by emotional disturbances, e.g. boredom, agitation or even systemic problems, e.g. abdominal pain or urethral/vaginal irritation. However, compulsive masturbation that interrupts normal activities, engage public displays or lead to development of anxiety or self-guilt, needs intervention.

Management involves reassurance about harmless nature of activity, counseling to avoid such acts in public and maintenance of hygiene, parental education and behavior therapy by experts. Medications are of very limited benefit in these cases.

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