Prevalence of nail biting and its association with mental health in a community sample of children

Dermoscopic Nail Disorders in School-Going Children

Introduction The majority of nail diseases in children are comparable to those in adults, while there are some physiological changes that start to happen around this age and go away over a few years. These conditions could be symptoms of infections and systemic illnesses. Pediatric nail disorders are typically easy to diagnose clinically, although there are occasionally conditions that masquerade as juvenile nail problems. Dermoscopy has grown in favour as a rapid, easy, non-invasive clinical procedure for examining nail diseases. This study aims to assess dermoscopic findings of child nail diseases. Methods A prospective analysis was conducted for seven months between January and July, 2022, at PNS Shifa Hospital, Karachi, Pakistan. A total of 180 patients who presented in the outpatient department with any dermatological complaint underwent thorough history and examination. Special emphasis was given to clinical and dermoscopic examinations of nails. Data analysis enclosed descriptive and inferential statistics. The quantitative data was presented with help of mean and standard deviation, while the qualitative data was presented with help of frequency and percentage tables. Chi-square test was applied to compare nail findings diagnosed on clinical examination and dermoscopic examination. Results The mean age of study subjects was 9.4±3.2 years and ranged between five years and 18 years. The most common nail changes were hand eczema (n=41, 23%) followed by nail changes due to nutritional disorders (n=38, 21%), anaemia (n=34, 19%) and habit tic deformity (n=31, 17.2%). Conclusions Clinical evaluation is crucial for nail disease diagnosis. Dermoscopy of nails can help with the final diagnosis of nail disease and confirm clinical diagnoses. Also, it aids in the management of nail illnesses by providing a clearer picture of pathology and nail structure.

Association between Child Abuse and Poor Oral Habits in Mongolian Adolescents

(1) This study aimed to investigate the association between child abuse and oral habits in adolescents in Mongolia. (2) A cross-sectional survey was conducted with children and their caregivers in Ulaanbaatar, Mongolia. Parents of 770 children enrolled in two public schools in Ulaanbaatar, Mongolia, completed questionnaires regarding the physical and psychological abuse that their children were subjected to and the presence of poor oral habits (biting nails/lips/pens and bruxism). Multivariable Poisson regression models were fitted with adjustment for age, gender, age of the mother, parental education, family income level, birth order, and living status with grandparents. (3) Biting nails/lips/pens and bruxism were reported by 39.0% and 17.5% of the respondents, respectively. Biting nails/lips/pens was significantly associated with physical abuse but was not significantly associated with psychological abuse (prevalence ratio, PR [95% confidence interval, CI]: 1.44 [1.07-1.95] and 1.34 [0.98-1.83], respectively). However, bruxism was not associated with physical or psychological abuse (PR [95% CI]: 1.16 [0.77-1.77] and 1.04 [0.68-1.61], respectively). (4) Child abuse was associated with biting habits among Mongolian adolescents.

Update on Diagnosis and Management of Onychophagia and Onychotillomania

Onychophagia (nail biting) and onychotillomania (nail picking) are chronic nail conditions categorized as body-focused repetitive behavior (BFRB) disorders. Due to a limited awareness of their clinical presentations, embarrassment on the part of patients, and/or comorbid psychiatric conditions, these conditions are frequently underrecognized and misdiagnosed. This article reviews the prevalence, etiology, diagnostic criteria, historical and physical exam findings, and treatment options for these conditions. The PubMed/MEDLINE database was searched for relevant articles. Onychophagia and onychotillomania are complex disorders necessitating a detailed patient history and physical examination and a multidisciplinary treatment approach for successful diagnosis and management. Due to the dearth of clinical trials for treatment of nail biting and nail picking, large clinical trials are necessary to establish standardized therapies.

A Hierarchical Personality Approach Toward a Fuller Understanding of Onychophagia and Compulsive Buying

PURPOSE

Employing a hierarchical model of personality, prior research suggests that cardinal traits such as conscientiousness and agreeability predict central traits such as materialism and need for arousal that in turn impact surface traits such as onychophagia and compulsive buying. More research is needed to explore additional central traits and their effect on onychophagia and compulsive buying. Thus, the goal of the current research is to examine how another central trait-negative perfectionism-impacts onychophagia and compulsive buying.

DESIGN/METHODOLOGY/APPROACH

A survey was administered both online and face-to-face resulting in a sample of 634 subjects of which 391 were individuals with onychophagia. Through a multi-group analysis, a causal model was tested to identify personality traits and their relationship with compulsive buying.

RESULTS

Results showed that onychophagia was affected by other obsessive-compulsive disorders-particularly trichotillomania, and excoriation disorder, which significantly increased the likelihood that the participant was a compulsive buyer.

Onychophagia as a clinical symptom: A pilot study of physicians and literature review

Although onychophagia is a medical condition and is associated with poorer health, there are no guidelines for assessment or treatment. The purpose of this study was to investigate the clinical aspects of nail biting from doctors' points of view, to estimate the prevalence of onychophagia among physicians, and to review the literature on and treatment methods for onychophagia. Twenty-four percent of doctors reported nail-biting periods during their lifetimes, and 2% of them remained active nail biters. A total of 64.4% of doctors see nail biting in their practices, and 60.6% never or only on request ask patients about nail biting and examine their nails. Family doctors and pediatricians ask their patients about nail biting most often. Attitudes and opinions on the treatment of nail biting are undefined and vary. Doctors reported usually treating nail-biting patients by referring them to another specialist or offering special nail polish. There is a need to improve physicians' knowledge of nail-biting treatment methods, but a lack of studies evaluating the clinical aspects of onychophagia and its relation to mental health and emotion dysregulation. Further research is needed. Clinical attitudes toward nail biting could be more precise in training and medical practice.

Onychophagia: detailed clinical characteristics

BACKGROUND

Onychophagia is a common disorder affecting 20% to 30% of the general population. It is defined as habitual nail biting and can cause various changes in the nail units. However, to date, there has been a paucity of data focusing on nail deformities related to onychophagia. This study was performed to investigate the clinical characteristics of onychophagia in Korea.

METHODS

This study included 53 patients with onychophagia who visited the Pusan National University Hospital (Busan and Yangsan) over a 10-year period (2011-2020). We retrospectively reviewed medical records and clinical and dermoscopic photographs.

RESULTS

All 10 fingernails were affected in 37.7% of the patients. The left thumbnail was the most predominantly affected site (81.1%). Clinical findings showed that short nails with ragged distal borders were the most common presentation (100.0%), followed by generalized or patchy rough areas (50.9%), linear and pinpoint hemorrhage (32.1%), longitudinal melanonychia (30.2%), transverse groove (28.3%), brittleness (28.3%), macrolunula (24.5%), washboard nail (13.2%), and pterygium (3.8%). Of the patients, 88.7% had periungual complications, such as periungual exfoliation (77.4%), absent or ragged cuticle (52.8%), hyponychial hyperkeratosis (37.7%), and paronychia (15.1%).

CONCLUSIONS

Although onychophagia is a common disorder, its clinical characteristics have not been reported in the literature. The results of this study may be helpful in managing patients with onychophagia.

Childhood neurodevelopmental markers and risk of premature mortality: Follow-up to age 60-65 years in the Aberdeen Children of the 1950s study

Background

Individual neurodevelopmental disorders are associated with premature mortality. Little is known about the association between multiple neurodevelopmental markers and premature mortality at a population level. The ESSENCE (Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations) approach considers multiple neurodevelopmental parameters, assessing several markers in parallel that cluster, rather than considering individual diagnostic categories in isolation.

Objectives

To determine whether childhood neurodevelopmental markers, including reduced intellectual functioning, are associated with all-cause premature mortality.

Methods and procedures

In a general population cohort study (n = 12,150) with longitudinal follow up from childhood to middle age, Cox proportional hazard models were used to study the associations between childhood neurodevelopmental markers (Rutter B scale and IQ) and premature all-cause mortality.

Outcomes and results

The cognitive measures and 21 of the 26 Rutter B items were significantly associated with premature mortality in bivariate analyses with hazard ratios from 1.24 (95% CI 1.05–1.47) to 2.25 (95% CI 1.78–2.90). In the final adjusted model, neurodevelopmental markers suggestive of several domains including hyperactivity, conduct problems and intellectual impairment were positively associated with premature mortality and improved prediction of premature mortality.

Conclusions

A wide range of neurodevelopmental markers, including childhood IQ, were found to predict premature mortality in a large general population cohort with longitudinal follow up to 60–65 years of age.

Implications

These findings highlight the importance of a holistic assessment of children with neurodevelopmental markers that addresses a range of neurodevelopmental conditions. Our findings could open the door to a shift in child public mental health focus, where multiple and/or cumulative markers of neurodevelopmental conditions alert clinicians to the need for early intervention. This could lead to a reduction in the risk of broad health outcomes at a population level.

Malocclusion trait and the parafunctional effect among young female school students

Extraneous activities of either the mouth, tongue or the jaw comprise the oral parafunctional habits of the stomatognathic system. This denominated habit is expressed through bruxism, digit sucking, nail biting to name a few, have led to hypothesizing the possible relationship of evolution of occluso-facial abnormalities such as malocclusion thereby hindering the conventional developmental process. Hence, the present study aimed to determine the prevalence and the possible relationship of parafunctional oral habits with the types of malocclusions among 12–16 years old females in Jeddah, Saudi Arabia. This cross-sectional study was conducted through questionnaire and clinical examinations, where the sagittal abnormalities within a randomly selected 672 participants who met the eligibility criteria were tabulated and analyzed. A positive history of the presence of parafunctional habit was recorded among all the participants with nasal and mouth breathing [46.6%], nail biting [39.6%] being predominant. 36.4% presented with significantly higher prevalence of bi-maxillary protrusion in mouth breathers while 17.1% with moderate overbite in participants with nail biting habit. Therefore, within the limitations of the present study, the findings do support the literature on the prevalence and the possible association of these habits with the malocclusion development thereby emphasizing on the importance of early recognition, management and prevention of them.

Art of Prevention: The importance of tackling the nail biting habit

Onychophagia, commonly referred to as nail biting, is a chronic condition that is repetitive and compulsive in nature, and generally seen in children and young adults. Multiple factors play a role in the development of nail biting, ranging from genetic components to underlying psychiatric conditions. Complications of chronic, compulsive nail biting range from obvious distortion of the nail bed unit to ungual and oral infection. Dental hygiene is typically less well-maintained in patients with nail-biting disorders, and teeth may become chipped or notched and gums many become inflamed. Treatment of nail biting involves a multidisciplinary team that provides social, psychiatric, dermatologic, and dental care. Treatment ranges from psychotherapy modalities to medication trials of selective serotonin reuptake inhibitors and N-acetylcysteine. Proper nail hygiene remains a mainstay in the prevention of the complications of chronic nail biting. Additional supportive measures include the support of self-motivational novels and television episodes that help children learn coping mechanisms.

Defining Subtypes in Children with Nail Biting: A Latent Profile Analysis of Personality

OBJECTIVE

This study aimed to examine personality profiles and behavioral problems of children with nail biting (NB) to gain insight into the developmental trajectory of pathological NB.

METHODS

681 elementary school students were divided into non NB (n=436), occasional NB (n=173) and frequent NB group (n=72) depending on the frequency of NB reported in Child Behavioral Checklist (CBCL). Children's personality was assessed using the Junior Temperament and Character Inventory (JTCI), and behavioral problems were assessed using the CBCL. Latent Profile Analysis (LPA) was performed using JTCI profiles to classify personalities of the children with NB (belonging to frequent and occasional NB group, n=245).

RESULTS

For subscale scores of CBCL, the total, internalizing, externalizing, anxious/depressed withdrawn/depressed, depression, thought, rule-breaking, and aggressive behavior problems, were most severe in the frequent NB group followed by occasional NB and non NB group. LPA of personality profile in children with NB revealed four classes ('adaptiveness,' 'high reward dependence,' 'low self-directedness,' and 'maldaptiveness'). The four personality classes demonstrated significant group differences in all of the CBCL subscales. Children who showed low self-directedness and cooperativeness and high novelty seeking and harm avoidance personality profiles demonstrated highest tendency for problematic behavior irrespective of the frequency of NB.

CONCLUSION

Children with NB reported significantly more problematic behaviors compared to children without NB. Children with specific personality profile demonstrated higher tendency for problematic behavior irrespective of the frequency of NB. Therefore, accompanying personality profiles should be considered when assessing behavioral problems in children with NB.

Association of oral parafunctional habits with anxiety and the Big-Five Personality Traits in the Saudi adult population

Background

Oral parafunctional habits are related to any abnormal hyperactivity of the oromandibular system. They are prevalent in all societies in varying intensity and have potential physical and psychological implications. The aim of this study was twofold: (1) to determine the prevalence of various types of oral parafunctional habits in the Saudi adult population, and (2) to examine their association with and the level of anxiety and personality factors.

Methods

This cross-sectional study was conducted with an electronic data collection form distributed to the public through social media. The questionnaire comprised of the following: (a) demographic information, (b) the Hamilton Anxiety Rating Scale (HAM-A), (c) the Ten-Item of Big-Five Personality Traits, (d) a list of oral parafunctional habits. Data were analysed using a Pearson’s Chi square and binary logistic regression.

Results

The participants reported several parafunctional habits including daily gum chewing (86%), lip/object biting (59%), clenching (45%), nail biting (36%) and grinding (32%). Males were 3 [2.3–3.7] times and younger age groups were 1.5 [1.1–2.0] times more likely to be associated with nail biting compared to their counter groups (adj.P < 0.001 and adj.P = 0.007). Lip/object biting was significantly 1.3 [1.1–1.7] times more prevalent in males (adj.P = 0.015). Participants who reported being extroverts were more likely to be associated with clenching (46.4%) (P = 0.024). An emotionally stable person was significantly less likely to be associated with nail biting (28.4%), grinding (24.9%), clenching (35.8%), and lip/object biting (48.4%) (P < 0.001each). Participants who reported conscientiousness and emotional stability were significantly less associated with TMD (P = 0.007, P < 0.001).

Conclusion

Oral parafunctional habits are highly prevalent in the Saudi adult population in varying degrees. Possible risk factors include males, younger age groups, single people, and being financially constrained.

Pediatric Onychophagia: A Survey-Based Study of Prevalence, Etiologies, and Co-Morbidities

BACKGROUND

Onychophagia, defined as habitual nail biting, is a common disorder affecting 6-45% of the population and is more prevalent in children.

OBJECTIVES

Our primary objective was to determine the prevalence of nail biting in the pediatric population. Secondary objectives were to assess the presence of psychiatric co-morbidities associated with nail biting, and the effect of treatment on nail biting.

METHODS

An anonymous voluntary survey was administered to participants at an outpatient academic pediatric clinic at Weill Cornell Medicine. Age, sex, psychiatric diagnosis, treatment sought, family history, and frequency of nail biting were analyzed across 282 enrolled patients aged 3-21 years. One patient was subsequently excluded due to incomplete data.

RESULTS

Of 281 patients, 101 (37%) reported past or present nail biting lasting more than a month. Median age of onset was 5 years old (range 1-13 years). A significantly higher percentage of biters (18%; 19/104) than non-biters (6%; 11/177) were diagnosed with a psychiatric disorder (p < 0.01). Amongst biters, concurrent fingernail and toenail involvement was much less common (12%; 12/104) than that of fingernails alone (88%; 92/104). However, the ratio of fingernail and toenail biters to fingernail biters alone was greater in those with psychiatric diagnosis (0.36) than without (0.09) (p = 0.07).

CONCLUSIONS

Our study highlights behavioral patterns as well as familial, psychiatric, and other factors associated with pediatric nail biting. Familiarity with such factors, the clinical presentation of onychophagia, and available treatment options may aid in reducing its severity in affected patients and overall prevalence.

A systematic review on the prevalence of conduct disorder in the Middle East

OBJECTIVE

Several epidemiological studies have been done on conduct disorder in the Middle East, but no systematic review has been conducted on this topic. Thus, we aimed at investigating the prevalence of conduct disorder in the Middle East in this systematic review of the literature.

METHODS

We searched all the cross-sectional studies in the scientific databases of PubMed, Scopus, Google Scholar, Index Medicus for the Eastern Mediterranean Region, Islamic World Science Citation Center, and Grey Literature including conference proceedings, and hand searching of key journals from 1995 to the end of 2014. Included studies described the prevalence of conduct disorder prior to age of 18, with any type of random or non-random sampling for at least one gender in the general or school-based populations who resided in Middle Eastern countries. Two reviewers assessed the quality of the included studies independently and extracted the relevant data.

RESULTS

Twenty-four studies were included in this review. Sample sizes varied from 136 to 9636 with the age range of 6-18 years. These studies were conducted in Iran, Turkey, Israel, Cyprus, Egypt, United Arab Emirates, Iraq, Afghanistan, Yemen, and Palestine. Strengths and Difficulties Questionnaire (SDQ) was used in most of the included studies. The prevalence of conduct disorder was reported from 2.4% by diagnostic criteria taken from DSM-IV-TR in Iraq to 32.9% by SDQ in Iran; the prevalence rates ranged from 1 to 29.9% for females and from 3.3 to 34.6% for males. However, the prevalence of conduct disorder was reported 0.34% by the diagnostic instrument of Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime in Iranian children and adolescents.

CONCLUSIONS

The prevalence of conduct disorder in this study was higher than the worldwide prevalence, thus, it seems essential to design preventive and treatment programs for children and adolescents with conduct disorder.

The effect of psychological state and social support on nail-biting in adolescents: An exploratory study

Nail-biting is one of the most common behavioral problems in children. This study aimed to examine factors affecting nail-biting among adolescents and the effects of psychological state and social support on nail-biting. This cross-sectional study was conducted between January and May of 2014 in seven schools in Istanbul ( N = 724). Data were collected using the Personal Information Form, Brief Symptom Inventory, and Child and Adolescent Social Support Scale. This study found that 48.2% of adolescents in the 11- to 17-years-old age group had a habit of nail-biting. Anxiety, depression, negative self image, somatization, hostility, and three global index scores of adolescents who bit their nails were significantly higher than in those who did not. Social support scores of those who bit their nails were significantly lower than in those who did not in the ‘mother’ and ‘classmates’ subscales and total scores. Psychological state and social support were factors affecting nail-biting among adolescents.

Recurrent digital infections and osteomyelitis in monozygotic twins with congenital analgesia and compulsive onychophagia

Congenital insensitivity to pain is a rare sensory neuropathy that manifests with multiple and recurrent injuries secondary to a lack of negative pain stimuli. When present with compulsive onychophagia, prompt recognition and behavioral management to prevent chronic digital infection or amputation is imperative. We present the case of two 7 year-old monozygotic twins that presented with congenital insensitivity to pain and compulsive onychophagia without directed parental counseling or behavioral modification strategies. The presenting child was noted to have an acute digital felon and osteomyelitis of several distal phalanges, and the sister had a similar history with distal phalangeal amputations. The occurrence of these overlapping disorders in monozygotic twins has not been previously reported, however, patient and parental education with behavioral modifications of injurious and compulsive behavior is the cornerstone of management. In addition, we have provided a review of the diagnosis for clinical differentiation.

Habit Reversal versus Object Manipulation Training for Treating Nail Biting: A Randomized Controlled Clinical Trial

OBJECTIVE

This is a parallel, three group, randomized, controlled clinical trial, with outcomes evaluated up to three months after randomization for children and adolescents with chronic nail biting. The current study investigates the efficacy of habit reversal training (HRT) and compares its effect with object manipulation training (OMT) considering the limitations of the current literature.

METHOD

Ninety one children and adolescents with nail biting were randomly allocated to one of the three groups. The three groups were HRT (n = 30), OMT (n = 30), and wait-list or control group (n = 31). The mean length of nail was considered as the main outcome.

RESULTS

The mean length of the nails after one month in HRT and OMT groups increased compared to the waiting list group (P < 0.001, P < 0.001, respectively). In long term, both OMT and HRT increased the mean length of nails (P < 0.01), but HRT was more effective than OMT (P < 0.021). The parent-reported frequency of nail biting did show similar results as to the mean length of nails assessment in long term. The number of children who completely stopped nail biting in HRT and OMT groups during three months was 8 and 7, respectively. This number was zero during one month for the wait-list group.

CONCLUSION

This trial showed that HRT is more effective than wait-list and OMT in increasing the mean length of nails of children and adolescents in long terms.

Impact of a Healthy Nails Program on Nail-Biting in Turkish Schoolchildren

This study was conducted to examine the effect of a healthy nails program on nail-biting in Turkish schoolchildren. This quasi-experimental study was of pretest–posttest control group design. A total of 50 students of a primary school formed the intervention group, while 53 students from the same school formed the control group. Data were collected with a demographic form, a nail-biting follow-up form, and photographs of the fingernails. It was found that 68.9% of students were biting seven or more of their nails; 46.6% had damaged nail beds. In the intervention group, the rate of the children who were not biting their nails (baseline = 0%, 4th week = 56.0%, 8th week = 64.0%) increased significantly compared to the control group (baseline = 0%, 4th week = 15.1%, 8th week = 18.9%). Outcomes indicate the efficacy of the healthy nails program in reducing the nail-biting problem in schoolchildren.

Nail biting; etiology, consequences and management

Nail biting (NB) is a common, but unresolved, problem in psychiatry, psychology, medicine and dentistry. While it seems that NB is a simple behavior that can be stopped easily, many of the children with NB have already tried to stop it, but they have not been successful. The frustrations due to failed attempt involve others such as parents and siblings. The present review aims at providing an overview of prevalence, co-morbidities, education and counseling, and management for NB. Overall, the reviewed literatures suggest that co-morbidities of psychiatric disorders and other stereotypic behaviors in clinical sample of children with NB is more than 80%, and more than half of the parents suffer from psychiatric disorders mainly depression. Treatment of NB, however, is not as easy as it seems. The management of NB is much more complicated than just focusing on stopping it. Nail biting cannot be managed without considering its co-morbidities, antecedents and consequences. It might be concluded form the reviewed literature that children with NB, parents, siblings, and teachers should be educated about what to do and what not to do about NB. Punishment is not effective. Moreover, clinical randomized controlled trials are required to make available evidence-based behavioral and pharmacologic treatment protocols.