Co-morbid tics and stereotypies: a systematic literature review

BACKGROUND

Tics and stereotypies are childhood-onset repetitive behaviours that can pose significant diagnostic challenges in clinical practice. Both tics and stereotypies are characterised by a complex co-morbidity profile, however little is known about the co-occurrence of these hyperkinetic disorders in the same patient population.

OBJECTIVE

This review aimed to assess the relationship between tics and stereotypies when these conditions present in co-morbidity.

METHODS

We conducted a systematic literature review of original studies on co-morbid tics and stereotypies, according to the standards outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Our literature search identified six studies of suitable sample size (n ≥ 40) presenting data on the association between tics and stereotypies in otherwise typically developing patients. A considerable proportion (23%) of patients diagnosed with stereotypic movement disorder present with co-morbid tics (range 18-43%). Likewise, the prevalence of primary stereotypies is increased in patients with tic disorders such as Tourette syndrome (8%, range 6-12%).

DISCUSSION

Tics and stereotypies can often develop in co-morbidity. The association of tics and stereotypies in the same patient has practical implications, in consideration of the different treatment approaches. Future research should focus on the assessment and management of both conditions, particularly in special populations (e.g. patients with pervasive developmental disorders).

Possible tics diagnosed as stereotypies in patients with severe autism spectrum disorder: a video-based evaluation

BACKGROUND

The association of stereotypies and tics is not rare in children with severe autism spectrum disorder (ASD). The differential diagnosis between stereotypies and tics in this patient population can be difficult; however, it could be clinically relevant because of treatment implications.

METHODS

A total of 108 video recordings of repetitive behaviors in young patients with stereotypies in the context of ASD were reviewed by a movement disorders expert and a trainee, in order to assess the prevalence of possible co-morbid tics. The Modified Rush Videotape Rating Scale (MRVS) was used to rate tic frequency and severity.

RESULTS

Out of 27 patients with stereotypies (24 males; mean age 14 years), 18 (67%) reported possible tics. The most frequently observed tics were eye blinking, shoulder shrugging, neck bending, staring, and throat clearing. The mean MRVS score was 5, indicating mild tic severity. The only significant difference between patients with tics and patients without tics was the total number of stereotypies, which was higher in the subgroup of patients without tics (p = 0.01).

CONCLUSIONS

Expert review of video-recordings of repetitive behaviors in young patients with ASD and stereotypies suggests the possibility of a relatively high rate of co-morbid tics. These findings need to be integrated with a comprehensive clinical assessment focusing on the diagnostic re-evaluation of heterogeneous motor manifestations.

Sleep Problems and Trajectories of Restricted and Repetitive Behaviors in Children with Neurodevelopmental Disabilities

Sleep problems are prevalent in children with neurodevelopmental disabilities and are associated with the expression of restricted and repetitive behaviors (RRBs). Children (n = 57) with autism spectrum disorder (ASD, n = 38) or developmental delay (DD, n = 19) participated in multiple assessments of intellectual ability, ASD symptoms, and RRBs (3 timepoints for ASD, 2 for DD). Sleep problems assessed at age 4 via parent report were associated with trajectories of higher-order RRBs (sameness/ritualistic/compulsive behaviors) from age 2-6 in the ASD group, and from age 2-4 in the DD group, even after controlling for intellectual ability, social-affective symptoms, and anxiety. Trajectories of stereotyped/restricted behaviors were unrelated to sleep problems. Sleep problems were associated with trajectories of higher-order (but not lower-order) RRBs in a transdiagnostic sample.

A Feasibility Study of a Wearable Real-Time Notification System for Self-Awareness of Body-Rocking Behavior

Wearable sensors have been shown to be effective for promoting self-awareness, wellness and re-education. In this work, we perform a preliminary study analyzing the real-time detection and annotation of body-rocking behavior in individuals, which is a type of Stereotypical Motor Movement (SMM). We develop a platform for real-time annotation and detection using wireless inertial sensors and an embedded device. The annotations are analyzed in order to study the duration and frequency of the behavior, and they are corrected offline in order to better understand any offsets in the real-time annotation procedure. Finally, we show the feasibility of a real-time feedback system based on a proof of concept algorithm and the necessary computation resources to execute it.

[Movement disorders in children and adolescents]

Tourette syndrome, obsessive-compulsive disorder, ticlike compulsions and motoric stereotypies are all movement disorders, which start in childhood and can be difficult to differentiate. In this article, we have outlined the most important focus points on how to differentiate the conditions in order to diagnose correctly and in order to refer to proper treatment.

Psychometric properties of a Dutch version of the behavior problems inventory-01 (BPI-01)

There are only a limited number of Dutch validated measurement instruments for measuring behavioral problems in people with a moderate to profound intellectual disability. In this study, the psychometric properties of a Dutch version of the behavior Problems Inventory-01 (BPI-01; Rojahn et al., 2001) have been investigated among 195 people with a moderate to profound intellectual disability who live in a residential facility. The BPI-01 was completed by 42 informants (staff members) of 23 care units. The inter-rater reliability, intra-rater reliability and internal consistency turned out to be good. Factor analysis confirmed two of the three a priori factors and the third factor was a mix of self-injurious (SIB) behavior and stereotypic behavior. The BPI-01 was compared to the Aberrant Behavior Checklist (Aman et al., 1985a) and showed a good convergent validity. This study shows that a Dutch version of the BPI-01 has good psychometric properties for measuring behavior problems in individuals with moderate to profound intellectual disability.

[Motor disorders in neurodevelopmental disorders. Tics and stereotypies]

Tics are repetitive, sharp, rapid, non-rhythmic movements or utterances that are the result of sudden, abrupt and involuntary muscular contractions. Stereotypies are repetitive, apparently impulsive, rhythmic, purposeless movements that follow an individual repertoire that is specific to each individual and that occur under a variable time pattern, which may be either transient or persistent. Both are included in the Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5), among the neurodevelopmental disorders, and together with coordination development disorder go to make up the group of motor disorders. For tics, the categories of 'Tourette's disorder', 'chronic motor or vocal tic disorder' and 'unspecified tic disorder' have been maintained, whereas the category 'transient tics' has disappeared and 'provisional tic disorder' and 'other specified tic disorders' have been incorporated. Within stereotypic movement disorder, the DSM-5 replaces 'non-functional' by 'apparently purposeless'; the thresholds of the need for medical care are withdrawn and replaced with the manual's standard involvement criterion; mental retardation is no longer mentioned and emphasis is placed on the severity of the stereotypic movement; and a criterion concerning the onset of symptoms and specifiers of the existence or not of self-injurious behaviours have been added, together with the association with genetic or general medical diseases or extrinsic factors. Moreover, a categorisation depending on severity has also been included.

[Non-epileptic motor paroxysmal phenomena in wakefulness in childhood]

Paroxysmal events in childhood are a challenge for pediatric neurologists, given its highly heterogeneous clinical manifestations, often difficult to distinguish between phenomena of epileptic seizure or not. The non-epileptic paroxysmal episodes are neurological phenomena, with motor, sensory symptoms, and/or sensory impairments, with or without involvement of consciousness, epileptic phenomena unrelated, so no electroencephalographic correlative expression between or during episodes. From the clinical point of view can be classified into four groups: motor phenomena, syncope, migraine (and associated conditions) and acute psychiatric symptoms. In this paper we analyze paroxysmal motor phenomena in awake children, dividing them according to their clinical manifestations: extrapyramidal episodes (paroxysmal kinesiogenic, non kinesiogenic and not related to exercise dyskinesias, Dopa responsive dystonia) and similar symptoms of dystonia (Sandifer syndrome); manifestations of startle (hyperekplexia); episodic eye and head movements (benign paroxysmal tonic upward gaze nistagmus deviation); episodic ataxia (familial episodic ataxias, paroxysmal benign vertigo); stereotyped and phenomena of self-gratification; and myoclonic events (benign myoclonus of early infancy). The detection of these syndromes will, in many cases, allow an adequate genetic counseling, initiate a specific treatment and avoid unnecessary additional studies. Molecular studies have demonstrated a real relationship between epileptic and non-epileptic basis of many of these entities and surely the identification of the molecular basis and understanding of the pathophysiological mechanisms in many of them allow us, in the near future will benefit our patients.

The moderating effects of intellectual development on core symptoms of autism and PDD-NOS in toddlers and infants

Little research has been conducted on whether deficits in developmental functioning affect the range of core symptoms for autism spectrum disorders (ASD). This study represents a first attempt to determine whether developmental level has an effect on the expression of ASD symptoms in infants and toddlers. Eight hundred and fifty-three infants were evaluated with respect to the nature and extent of their ASD symptoms and developmental functioning. Young children with autism displayed a higher number of symptoms than those with PDD-NOS on all three domains of impairment (social, communication, repetitive behaviors). As expected, children without an ASD evinced far fewer symptoms than both these groups. Developmental level was not found to be a moderator for expression of ASD symptoms for the entire sample, or individual diagnostic groups. Higher developmental level was associated with lower severity of evinced ASD symptoms in the sample.

Pre-school children with suspected autism spectrum disorders: do girls and boys have the same profiles?

The male to female ratio is raised in autism spectrum disorders (ASD). Previous studies have suggested that girls with ASD have more problems with communication than boys, but boys show more repetitive behaviours than girls. In this study, 20 girls, 1.8-3.9 years of age were matched for chronological and developmental age with 20 boys with suspected ASD. All the children were recruited after population screening and referral by Child Health Care Services to a specialised neuropsychiatry clinic, where they underwent comprehensive neuropsychiatric assessments. Comparisons were made with regard to diagnosis, developmental profiles and global disability. No significant gender differences were found. There were strong correlations between results obtained in different developmental areas. The results suggest that either (1) previous studies finding clear gender differences may have overrated discrepancies between girls and boys in ASD, or that (2) there may be girls, who will not be identified in the early years with our current screening instruments. More research with a much larger population representative study samples is required.

Preference for blocking or response redirection during stereotypy treatment

Response redirection and response blocking reduce stereotypy maintained by automatic reinforcement. The current study evaluated the effects of redirection and response blocking on the stereotypic responding of three elementary-age children diagnosed with autism. During the treatment evaluation, redirection and response blocking were evaluated using an alternating treatment embedded in a reversal design. Both procedures resulted in comparably low levels of motor stereotypy. Following treatment evaluation, a concurrent chain was conducted to evaluate participant preference for redirection or response blocking. All three participants preferred redirection. Practitioners may wish to consider participant preference when developing and implementing treatments for stereotypy.

Differential diagnosis between obsessive compulsive disorder and restrictive and repetitive behavioural patterns, activities and interests in autism spectrum disorders

INTRODUCTION

The obsessive compulsive disorder (OCD) and the restricted and repetitive patterns of behavior, interests and activities inherent to autism spectrum disorders (ASD) share a number of features that can make the differential diagnosis between them extremely difficult and lead to erroneous overdiagnosis of OCD in people with autism.

DEVELOPMENT

In both cases there may appear to have a fixation on routine, ritualized patterns of verbal and nonverbal behavior, resistance to change, and highly restrictive interests, which becomes a real challenge for differentiating rituals, stereotypes and adherence to routines in ASD from obsessions and compulsions in OCD. This article provides key points to clarify this differential diagnosis through the analysis of emotional valence, content, function and psychological theories that explain the obsessions and compulsions in OCD, and the desire for sameness, stereotyped movements and limited interest in autism.

CONCLUSION

The terms "obsession" and "compulsion" should no longer be used when referring to patterns of behavior, interests or restricted and repetitive activities in autism due to syntonic characteristics, low perception of personal responsibility and low neutralizing efforts. Treatment focuses on changing the environment, the use of socio-communicative compensatory strategies and behavioral modification techniques to improve cognitive and behavioral flexibility. When there is comorbidity between, exposure behavioral and response prevention techniques are then used, followed by others of more cognitive orientation if necessary.

Kinematic assessment of stereotypy in spontaneous movements in infants

Movement variation constitutes a crucial feature of infant motor development. Reduced variation of spontaneous infant movements, i.e. stereotyped movements, may indicate severe neurological deficit at an early stage. Hitherto evaluation of movement variation has been mainly restricted to subjective assessment based on observation. This article introduces a method for quantitative assessment yielding an objective definition of stereotyped movements which may be used for the prognosis of neurological deficits such as cerebral palsy (CP). Movements of 3-month-old infants were recorded with an electromagnetic tracking system facilitating the analysis of joint angles of the upper and lower limb. A stereotypy score based on dynamic time warping has been developed describing movements which are self-similar in multiple degrees of freedom. For clinical evaluation, this measure was calculated in a group of infants at risk for neurological disorders (n=54) and a control group of typically developing children (n=21) on the basis of spontaneous movements at the age of 3 months. The stereotypy score was related to outcome at the age of 24 months in terms of CP (n=10) or no-CP (n=53). Using the stereotypy score of upper limb movements CP cases could be identified with a sensitivity of 90% and a specificity of 96%. The corresponding score of the leg movements did not allow for valid discrimination of the groups. The presented stereotypy feature is a promising candidate for a marker that may be used as a simple and noninvasive quantitative measure in the prediction of CP. The method can be adopted for the assessment of infant movement variation in research and clinical applications.

[Video electroencephalographic diagnosis of epileptic and non-epileptic paroxysmal episodes in infants and children at the pre-school age]

The main usefulness of video electroencephalographic (video-EEG) monitoring lies in the fact that it allows proper classification of the type of epileptic seizure and epileptic syndrome, identification of minor seizures, location of the epileptogenic zone and differentiation between epileptic seizures and non-epileptic paroxysmal manifestations (NEPM). In infants and pre-school age children, the clinical signs with which epileptic seizures are expressed differ to those of older children, seizures with bilateral motor signs such as epileptic spasms, tonic and myoclonic seizures predominate, and seizures with interruption of activity or hypomotor seizures, and no prominent automatisms are observed. In children with focal epilepsies, focal and generalised signs are often superposed, both clinically and in the EEG. NEPM may be benign transitory disorders or they can be episodic symptoms of different neurological or psychopathological disorders. NEPM are often observed in children with mental retardation, neurological compromise or autism spectrum disorders, who present epileptic seizures and epileptiform abnormalities in the baseline EEG. It then becomes necessary to determine which episodes correspond to epileptic seizures and which do not. The NEPM that are most frequently registered in the video-EEG in infants and pre-school age children are unexpected sudden motor contractions ('spasms'), introspective tendencies, motor stereotypic movements and paroxysmal sleep disorders.

The Behavior Problems Inventory-Short Form for individuals with intellectual disabilities: part I: development and provisional clinical reference data

BACKGROUND

The Behavior Problems Inventory-01 (BPI-01) is an informant-based behaviour rating instrument that was designed to assess maladaptive behaviours in individuals with intellectual disabilities (ID). Its items fall into one of three sub-scales: Self-injurious Behavior (14 items), Stereotyped Behavior (24 items), and Aggressive/Destructive Behavior (11 items). Each item is rated on a frequency scale (0 = never to 4 = hourly), and a severity scale (0 = no problem to 3 = severe problem). The BPI-01 has been successfully used in several studies and has shown acceptable to very good psychometric properties. One concern raised by some investigators was the large number of items on the BPI-01, which has reduced its user friendliness for certain applications. Furthermore, researchers and clinicians were often uncertain how to interpret their BPI-01 data without norms or a frame of reference.

METHODS

The Behavior Problems Inventory-Short Form (BPI-S) was empirically developed, based on an aggregated archival data set of BPI-01 data from individuals with ID from nine locations in the USA, Wales, England, the Netherlands, and Romania (n = 1122). The BPI-S uses the same rating system and the same three sub-scales as the BPI-01, but has fewer items: Self-injurious Behavior (8 items), Stereotyped Behavior (12 items), and Aggressive/Destructive Behavior (10 items). Rating anchors for the severity scales of the Self-injurious Behavior and the Aggressive/Destructive Behavior sub-scales were added in an effort to enhance the objectivity of the ratings.

RESULTS

The sensitivity of the BPI-S compared with the BPI-01 was high (0.92 to 0.99), and so were the correlations between the analogous BPI-01 and the BPI-S sub-scales (0.96 to 0.99). Means and standard deviations were generated for both BPI versions in a Sex-by-age matrix, and in a Sex-by-ID Level matrix. Combined sex ranges are also provided by age and level of ID.

CONCLUSION

In summary, the BPI-S is a very useful alternative to the BPI-01, especially for research and evaluation purposes involving groups of individuals.

The Behavior Problems Inventory-Short Form for individuals with intellectual disabilities: part II: reliability and validity

BACKGROUND

The Behavior Problems Inventory-01 (BPI-01) is an informant-based behaviour rating instrument for intellectual disabilities (ID) with 49 items and three sub-scales: Self-injurious Behavior, Stereotyped Behavior and Aggressive/Destructive Behavior. The Behavior Problems Inventory-Short Form (BPI-S) is a BPI-01 spin-off with 30 items.

METHODS

The psychometric properties of these two versions of the scale were computed using aggregated archival data from nine different sites in the USA, Wales, England, the Netherlands and Romania with a total of 1122 cases with a BPI-01 total score >0.

RESULTS

The internal consistency of the BPI-01 and the BPI-S ranged from fair to excellent with the BPI-01 showing slightly stronger reliability. Construct validity (confirmatory and discriminant) was computed by comparing BPI sub-scale scores with the scores of four other behaviour rating scales (the Aberrant Behavior Checklist, the Diagnostic Assessment for the Severely Handicapped-II, the Nisonger Child Behavior Rating Form and the Inventory for Client and Agency Planning). Strong evidence for confirmatory and discriminant validity was found for both the BPI-01 and the BPI-S. Confirmatory fit indices for the BPI and the BPI-S were comparable and suggesting that the factor structures fit the data well.

CONCLUSION

In summary, both BPI versions were found to be equally sound psychometrically and can be endorsed for future use. However, independent future studies are needed to replicate the psychometrics of the BPI-S with new data.

Jactatio corporis nocturna and dissociative disorder: a case report

Jactatio corporis nocturna is a type of parasomnia. Rhythmic body movements during sleep are commonly observed in infancy and early childhood, and spontaneous resolution is expected after the age of 4 years. Rarely, the body movements persist until adulthood. Rhythmic body movements characteristically occur during the wake-sleep transition period, rather than during other sleep stages. Some psychiatric diseases can co-occur with sleep-related movement disorders. A relationship between parasomnias and dissociative disorders has been recently reported. Herein we present a 33-year-old male with nocturnal repetitive rolling body movements and daytime fatigue. The patient also had loss of memory of some important events (such as the day his daughter underwent surgery), and reported that he sometimes confused reality with dreams had fantasies during which he experienced his spirit rising above to watch his body and fantasy. Detailed neuropsychological assessment showed that the patient also had a dissociative disorder. Video-polysomnographic recordings showed repetitive, rolling body movements that occurred only during rapid eye movement (REM) sleep.

Cheek-biting disorder: another stereotypic movement disorder?

Recurrent cheek biting, a form of self-injurious behavior is a rare entity which presents mostly to dentists and dermatologists. We report a case of recurrent severe cheek biting in an adult male leading to mucosal ulceration. The stereotypic pattern of cheek biting and associated behavior bears striking resemblance to other impulse control disorders.

The effects of gender and age on repetitive and/or restricted behaviors and interests in adults with autism spectrum disorders and intellectual disability

Frequency of repetitive and/or restricted behaviors and interests (RRBIs) was assessed in 140 adults with autism spectrum disorders (ASDs) and severe or profound intellectual disability (ID). The associations of gender and age range were analyzed with RRBI frequency which was obtained using the Stereotypies subscale of the Diagnostic Assessment for the Severely Handicapped-II (DASH-II). A significant main effect of gender was found. Male participants had higher frequency of RRBIs than females regardless of age range. There was not a significant main effect of age range or a significant interaction between gender and age range. Results and implications are discussed.

Autism spectrum disorder in Down syndrome: cluster analysis of Aberrant Behaviour Checklist data supports diagnosis

BACKGROUND

The diagnostic validity of autism spectrum disorder (ASD) based on Diagnostic and Statistical Manual of Mental Disorders (DSM) has been challenged in Down syndrome (DS), because of the high prevalence of cognitive impairments in this population. Therefore, we attempted to validate DSM-based diagnoses via an unbiased categorisation of participants with a DSM-independent behavioural instrument.

METHODS

Based on scores on the Aberrant Behaviour Checklist - Community, we performed sequential factor (four DS-relevant factors: Autism-Like Behaviour, Disruptive Behaviour, Hyperactivity, Self-Injury) and cluster analyses on a 293-participant paediatric DS clinic cohort. The four resulting clusters were compared with DSM-delineated groups: DS + ASD, DS + None (no DSM diagnosis), DS + DBD (disruptive behaviour disorder) and DS + SMD (stereotypic movement disorder), the latter two as comparison groups.

RESULTS

Two clusters were identified with DS + ASD: Cluster 1 (35.1%) with higher disruptive behaviour and Cluster 4 (48.2%) with more severe autistic behaviour and higher percentage of late onset ASD. The majority of participants in DS + None (71.9%) and DS + DBD (87.5%) were classified into Cluster 2 and 3, respectively, while participants in DS + SMD were relatively evenly distributed throughout the four clusters.

CONCLUSIONS

Our unbiased, DSM-independent analyses, using a rating scale specifically designed for individuals with severe intellectual disability, demonstrated that DSM-based criteria of ASD are applicable to DS individuals despite their cognitive impairments. Two DS + ASD clusters were identified and supported the existence of at least two subtypes of ASD in DS, which deserve further characterisation. Despite the prominence of stereotypic behaviour in DS, the SMD diagnosis was not identified by cluster analysis, suggesting that high-level stereotypy is distributed throughout DS. Further supporting DSM diagnoses, typically behaving DS participants were easily distinguished as a group from those with maladaptive behaviours.

[Obsessive-compulsive symptoms, tics, stereotypic movements or need for absolute consistency? The occurrence of repetitive activities in patients with pervasive developmental disorders--case studies]

Repetitive and stereotyped behaviours in the form of stereotyped interests or specific routine activities are one ofthe diagnostic criteria in pervasive developmental disorders. The occurrence of repetitive behaviours in patients with pervasive developmental disorders is a starting point for questions about the type and classification criteria of such behaviours. The aim of the article is to present case studies of patients with pervasive developmental disorders and co-morbid symptoms in the form of routine activities, tics, obsessive-compulsive symptoms or stereotyped behaviours. The first case study describes a patient with Asperger's syndrome and obsessive compulsive symptoms. The diagnostic problems regarding complex motor tics are discussed in the second case study which describes a patient with Asperger's syndrome and Gilles de la Tourette syndrome. The third and fourth case study describes mono-zygotic twins with so called High Functioning Autism whose repetitive activities point to either obsessive compulsive symptoms, stereotypic movements, need for absolute consistency or echopraxia. The possible comorbidity of pervasive developmental disorders and symptoms in the form of repetitive behaviours, possible interactions as well as diagnostic challenges is discussed in the article.

Response interruption and redirection for vocal stereotypy in children with autism: a systematic replication

This study systematically replicated and extended previous research on response interruption and redirection (RIRD) by assessing instructed responses of a different topography than the target behavior, percentage of session spent in treatment, generalization of behavior reduction, and social validity of the intervention. Results showed that RIRD produced substantial decreases in vocal stereotypy. Limitations of this study were that behavior reduction did not generalize to novel settings or with novel instructors and that appropriate vocalizations did not improve.

Sensory features and repetitive behaviors in children with autism and developmental delays

This study combined parent and observational measures to examine the association between aberrant sensory features and restricted, repetitive behaviors in children with autism (N=67) and those with developmental delays (N=42). Confirmatory factor analysis was used to empirically validate three sensory constructs of interest: hyperresponsiveness, hyporesponsiveness, and sensory seeking. Examining the association between the three derived sensory factor scores and scores on the Repetitive Behavior Scales--Revised revealed the co-occurrence of these behaviors in both clinical groups. Specifically, high levels of hyperresponsive behaviors predicted high levels of repetitive behaviors, and the relationship between these variables remained the same controlling for mental age. We primarily found non-significant associations between hyporesponsiveness or sensory seeking and repetitive behaviors, with the exception that sensory seeking was associated with ritualistic/sameness behaviors. These findings suggest that shared neurobiological mechanisms may underlie hyperresponsive sensory symptoms and repetitive behaviors and have implications for diagnostic classification as well as intervention.

Low dimensional temporal organization of spontaneous eye blinks in adults with developmental disabilities and stereotyped movement disorder

This study investigated the mean rate and time-dependent sequential organization of spontaneous eye blinks in adults with intellectual and developmental disability (IDD) and individuals from this group who were additionally categorized with stereotypic movement disorder (IDD+SMD). The mean blink rate was lower in the IDD+SMD group than the IDD group and both of these groups had a lower blink rate than a contrast group of healthy adults. In the IDD group the n to n+1 sequential organization over time of the eye-blink durations showed a stronger compensatory organization than the contrast group suggesting decreased complexity/dimensionality of eye-blink behavior. Very low blink rate (and thus insufficient time series data) precluded analysis of time-dependent sequential properties in the IDD+SMD group. These findings support the hypothesis that both IDD and SMD are associated with a reduction in the dimension and adaptability of movement behavior and that this may serve as a risk factor for the expression of abnormal movements.

Behavior predictors of language development over 2 years in children with autism spectrum disorders

PURPOSE

This exploratory study examined predictive relationships between 5 types of behaviors and the trajectories of vocabulary and language development in young children with autism over 2 years.

METHOD

Participants were 69 children with autism assessed using standardized measures prior to the initiation of early intervention (T1) and 6 months (T2), 12 months (T3), and 24 months (T4) later. Growth curve modeling examined the extent to which behaviors at T1 and changes in behaviors between T1 and T2 predicted changes in development from T1 to T4.

RESULTS

Regardless of T1 nonverbal IQ and autism severity, high scores for inattentive behaviors at T1 predicted lower rates of change in vocabulary production and language comprehension over 2 years. High scores for social unresponsiveness at T1 predicted lower rates of change in vocabulary comprehension and production and in language comprehension over 2 years. Scores for insistence on sameness behaviors, repetitive stereotypic motor behaviors, and acting-out behaviors at T1 did not predict the rate of change of any child measure over 2 years beyond differences accounted for by T1 autism severity and nonverbal IQ status.

CONCLUSIONS

The results are discussed with regard to their implications for early intervention and understanding the complex factors that affect developmental outcomes.

The relationship between stereotyped movements and self-injurious behavior in children with developmental or sensory disabilities

We assessed whether the stereotyped movements (SM) that are a defining characteristic of autism are discriminable from those observed in other disorders, and whether stereotyped self-injurious movements, which are excluded as exemplars of SM in DSM-IV, differ from other SM in severity or in kind. We used the Stereotyped and Self-Injurious Movement Interview to assess self-injurious and other SM in children with autism (n=56), intellectual disability (n=29), vision impairment (n=50), or hearing impairment (n=51) and in typical children (n=30). Cross-tabulation of scores indicated that self-injurious behavior is rarely performed in the absence of other SM. Reliability analyses indicated that patterns of covariation among SM items differ across groups so that different item sets are necessary to reliably measure SM in each group. Analyses of variance indicated the autism group exceeded one or more other groups in the frequency of 15 SM, the vision impaired group exceeded others on 5 SM, and the hearing impaired group exceeded others on 1 SM. Discriminant function analysis of SM items indicated that although only 66% of participants were accurately classified, it was rare for a child with a different disorder to be misclassified as having autism or visual impairment. We concluded that self-injurious behavior is a more severe form of SM, and there is a distinctive pattern of SM, including self-injurious behavior, that characterizes children with autism.

Contemporary encephalitis lethargica presenting with agitated catatonia, stereotypy, and dystonia-parkinsonism

Encephalitis lethargica (EL) syndrome was classically described by Von Economo and has somnolent-ophthalmoplegic, hyperkinetic, and amyostatic-akinetic forms. We describe 2 recent cases of EL characterized by an acute encephalitis with mixed movement disorders (dystonia-Parkinsonism plus stereotypy) and psychiatric disorders (agitated catatonia, coprolalia, and echo phenomena). Both patients suffered concurrent hyperkinetic and Parkinsonian features resulting in therapeutic challenges. Bradykinetic features responded to dopamine replacement therapy and both patients also had adverse affects to dopamine antagonists (oculogyric crises plus neuroleptic malignant syndrome). Investigation was unremarkable other than the presence of CSF lymphocytosis and oligoclonal bands. Despite prolonged in-patient stays and intensive care management, both patients have made complete recoveries. We believe these cases support the hypothesis that this syndrome is an inflammatory encephalitis that specifically effects dopamine neurotransmission.

Open-label escitalopram treatment for pathological skin picking

Pathological skin picking is characterized by dysfunctional, repetitive and excessive manipulation of the skin resulting in noticeable tissue damage. This study sought to assess the effectiveness of escitalopram in treating pathological skin picking. Twenty-nine individuals with pathological skin picking were enrolled in an 18-week, open-label trial of escitalopram. Study measures assessing skin picking severity and impact, anxiety, depression, and quality of life were given at baseline and weeks 2, 4, 6, 10, 14, and 18. The mean maximally tolerated dose was 25.0 mg (standard deviation=8.4). For the 19 study completers, pre-post-treatment analyses revealed significant improvements (P<0.05) on measures of skin picking severity and impact, quality of life, and self-rated anxiety and depression. Completer as well as intent-to-treat analyses indicated that approximately half of the sample satisfied full medication response criteria and one-quarter were partial medication responders. Correlational analyses indicated that changes in depression, anxiety, and quality of life co-occurred with reductions in skin picking severity but not impact. A high percentage of variance in severity, however, remained unexplained. These results suggest that escitalopram can be an effective agent in reducing pathological skin picking. The lack of medication response in a subset of our sample suggests the possibility of pathological skin picking subtypes.

Trichotillomania, stereotypic movement disorder, and related disorders

Trichotillomania is currently classified as an impulse control disorder not otherwise classified, whereas body-focused behaviors other than hair-pulling may be diagnosed as stereotypic movement disorder. A number of disorders characterized by repetitive, body-focused behaviors (eg, skin-picking) are prevalent and disabling and may have phenomenological and psychobiological overlap. Such disorders deserve greater recognition in the official nosology, and there would seem to be clinical utility in classifying them in the same diagnostic category.

Clinical seizure lateralization in frontal lobe epilepsy

PURPOSE

We systematically analyzed the lateralizing value of clinical seizure semiology in patients with frontal lobe epilepsy (FLE).

METHODS

We studied the incidence, positive predictive value (PPV), and the lateralizing significance of various clinical symptoms in 228 seizures (s) of 31 patients (p) with medically refractory FLE (17 with left-sided and 14 with right-sided seizure onset). Seizures recorded during prolonged video-EEG monitoring were assessed by two independent reviewers blinded for the patient's clinical data. Analysis was performed both for patients and seizures.

RESULTS

Version [16 p (52%); PPV, 94%; p=0.001; 47 s (21%); PPV, 75%; p=0.001], unilateral clonic movements [16 p (52%); PPV, 81%; p=0.021; 32 s (14%); PPV, 81%; p=0.001], unilateral dystonic posturing [eight p (26%); PPV, 75%; p=0.289; 46 s (20%); PPV, 80%; p=0.001], unilateral tonic posturing [10 p (32%); PPV, 80%; p=0.109; 19 s (7.4%); PPV, 79%; p=0.019], and unilateral grimacing [10 p (32%); PPV, 100%; p=0.002; 19 s (8%); PPV, 100%; p=0.001] were of lateralizing significance, indicating a contralateral seizure onset. Asymmetric ending [five p (16%); PPV, 80%; p=0.375; nine s (4%); PPV, 89%; p=0.039] after secondarily generalized tonic-clonic seizures was significantly associated with an ipsilateral seizure onset. Pure ictal vocalizations occurred significantly more frequently in seizures of right hemispheric onset [13 p (42%); PPV, 62%; p=0.581; 63 s (28%); PPV, 73%; p=0. 001], whereas in individual patients, this symptom showed no lateralizing significance. The remaining clinical symptoms (figure 4 sign, unilateral hand automatisms, early head turning, postictal nose wiping, and unilateral eye blinking) were not of lateralizing significance in our patients. The results of clinical seizure lateralization corresponded with the final lateralization of the seizure-onset zone in 81% of our patients.

CONCLUSIONS

Clinical seizure semiology can provide correct information on the lateralization of the seizure-onset zone in >80% of patients with medically refractory frontal lobe epilepsy.

Dynamical origins of stereotypy: relation of postural movements during sitting to stereotyped movements during body-rocking

The relation between the movement dynamic properties of sitting still and of seated body-rocking in adults with stereotyped movement disorder and mental retardation and a contrast group of typically developing age-matched adults was examined. Continuous measurement of sequential displacements in center-of-pressure was made using a force platform while subjects were engaged in seated body-rocking and quiet sitting. Properties of movement were compared across conditions (rocking, sitting) and groups (stereotyped movement disorder, contrast). The contrast group had the same modal frequency for both movement properties. The intrinsic dynamics of the stereotyped movement disorder group were similar to those of the contrast group for body-rocking but very different for quiet sitting. Findings support the suggestion that body-rocking in stereotyped movement disorder originates partly as an adaptation to an inability to control posture in a seated position.

Interobserver Reliability of Video Recording in the Diagnosis of Nocturnal Frontal Lobe Seizures

BACKGROUND

Nocturnal frontal lobe seizures (NFLS) show one or all of the following semeiological patterns: (1) paroxysmal arousals (PA: brief and sudden recurrent motor paroxysmal behavior); (2) hyperkinetic seizures (HS: motor attacks with complex dyskinetic features); (3) asymmetric bilateral tonic seizures (ATS: motor attacks with dystonic features); (4) epileptic nocturnal wanderings (ENW: stereotyped, prolonged ambulatory behavior).

OBJECTIVE

To estimate the interobserver reliability (IR) of video-recording diagnosis in patients with suspected NFLS among sleep medicine experts, epileptologists, and trainees in sleep medicine.

METHODS

Sixty-six patients with suspected NFLS were included. All underwent nocturnal video-polysomnographic recording. Six doctors (three experts and three trainees) independently classified each case as "NFLS ascertained" (according to the above specified subtypes: PA, HS, ATS, ENW) or "NFLS excluded". IR was calculated by means of Kappa statistics, and interpreted according to the standard classification (0.0-0.20 = slight agreement; 0.21-0.40 = fair; 0.41-0.60 = moderate; 0.61-0.80 = substantial; 0.81-1.00 = almost perfect).

RESULTS

The observed raw agreement ranged from 63% to 79% between each pair of raters; the IR ranged from "moderate" (kappa = 0.50) to "substantial" (kappa = 0.72). A major source of variance was the disagreement in distinguishing between PA and nonepileptic arousals, without differences in the level of agreement between experts and trainees.

CONCLUSIONS

Among sleep experts and trainees, IR of diagnosis of NFLS, based on videotaped observation of sleep phenomena, is not satisfactory. Explicit video-polysomnographic criteria for the classification of paroxysmal sleep motor phenomena are needed.

Repetitive behaviour in children with high functioning autism and obsessive compulsive disorder

Children with Autism Spectrum Disorders (ASD) and children with Obsessive Compulsive Disorder (OCD) were compared on a range of repetitive behaviours. Parents reported similar levels of sameness behaviour and repetitive movements in the clinical groups, although children with OCD engaged in more repetitive behaviour focussed around routines and rituals. Children with OCD reported more compulsions and obsessions than children with ASD; both groups reported more compulsions and obsessions than a typically developing comparison group. Types of compulsions and obsessions tended to be less sophisticated in children with ASD than those with OCD. Sameness behaviour was more prevalent in younger children with OCD, but for children with ASD, age was not significantly related to sameness behaviour, repetitive movements, compulsions, or obsessions.

A comparison of repetitive behaviors in Aspergers Disorder and high functioning autism

In this study we compared 33 IQ and age matched pairs of individuals with Aspergers Disorder (ASP) and high functioning autism (HFA) on measures of repetitive behavior. On the Repetitive Behavior Scale-Revised (RBS-R), the ASP and HFA groups showed no differences in RBS-R Intensity score (severity) score or Frequency score (number of problems present). This suggests that the two groups are similar with respect to the intensity or severity of repetitive behaviors and the presence of repetitive behaviors. At the item level there were no differences on scales typically associated with autism (Stereotyped Behavior) and ASP (Restricted Interests). Similarly, there were no differences between the groups on the Aberrant Behavior Checklist Stereotypy scale. These findings add to the body of literature showing that HFA and ASP fail to differ with respect to repetitive behaviors. The implications of the findings for neurobiologic and genetic studies are discussed.

Sleep-related Minor Motor Events in Nocturnal Frontal Lobe Epilepsy

PURPOSE

Nocturnal frontal lobe epilepsy (NFLE) is characterized by a wide spectrum of sleep-related motor manifestations of increasing complexity, ranging from major episodes to brief motor events (minor motor events, MMEs). NFLE patients may exhibit a large quantity of MMEs in the form of short-lasting stereotyped movements. Whereas major episodes are considered epileptiform manifestations, it remains unclear whether the MMEs are related to epileptiform discharges (EDs).

METHODS

To study the relation between EDs and the occurrence of MMEs, we report a detailed neurophysiolgical evaluation in NFLE subjects explored by using implanted electrodes.

RESULTS

The median value of ED-related movements was 71.8%. Motor expression in relation to epileptiform discharge was surprisingly variable; no peculiar expression of MMEs could be attributed to the presence of EDs.

CONCLUSIONS

Our data suggest that ED-associated MMEs are extremely polymorphous, and no univocal relation to EDs can be identified. We hypothesize that MMEs are not a direct effect of epileptiform discharge (i.e., not epileptic in origin), but the result of aspecific disinhibition of innate motor patterns. We warn clinicians that the epileptic nature of minimal motor phenomena in NFLE cannot be established on the clinical phenomenology of the event.

Variation in vocal-motor development in infant siblings of children with autism

In this study we examined early motor, vocal, and communicative development in a group of younger siblings of children diagnosed with autism (Infant Siblings). Infant Siblings and no-risk comparison later-born infants were videotaped at home with a primary caregiver each month from 5 to 14 months, with follow-up at 18 months. As a group, Infant Siblings were delayed in the onset of early developmental milestones and spent significantly less time in a greater number of postures, suggestive of relative postural instability. In addition, they demonstrated attenuated patterns of change in rhythmic arm activity around the time of reduplicated babble onset; and they were highly likely to exhibit delayed language development at 18 months.

Ictal Grasping: Prevalence and Characteristics in Seizures with Different Semiology

PURPOSE

The aim of this study was to investigate ictal grasping (IG), defined as the act of gripping something firmly during focal epileptic seizures, and to evaluate whether it characterizes specific seizure types.

METHODS

We analyzed the video-recordings of 694 seizures in 109 consecutive candidates to epilepsy surgery. Seizures with motor manifestations (n = 511) were selected and divided into four semiological groups: (a) frontal "hyperkinetic" seizures (FHS): 30 seizures, 12 patients, (b) frontal lobe seizures (FLS) other than FHS: 228 seizures, 26 patients, (c) temporal lobe seizures (TLS): 194 seizures, 55 patients, (d) extra-frontal/extra-temporal seizures (EF/ETS): 59 seizures, 16 patients. We evaluated IG features by means of video-analysis.

RESULTS

IG was observed in 96.7% of FHS (100% of patients), with a mean latency of 3 s, and a mean prevalence of 7.9 IG per seizure, directed to a limited number of surrounding objects or body parts. In 22.4% of FLS (11.5% of patients) 1-3 prolonged IGs were present, with a mean latency of 2 s and mainly directed to a fixed external point. IG was occasionally present in TLS (10.3%, in 20% of patients) and EF/ETS (5.1%, in 12.5% of patients), with longer latencies and without any stereotypy. We did not find a reliable lateralizing value of IG.

CONCLUSIONS

Prevalence of IG in FHS was significantly higher than in other seizure groups. In FHS and FLS, IG had shorter latency and stereotyped features, characterizing an automatic ("release"?) behavior. In extra-frontal seizures, IG seemed to be an occasional purposeful movement.

The relationship between restrictive and repetitive behaviors in individuals with autism and obsessive compulsive symptoms in parents

This study investigated the relationship between repetitive behaviors in individuals with autism and obsessive-compulsive behaviors in parents. We hypothesized that repetitive behaviors in probands with autism would be associated with increased obsessive-compulsive behaviors in parents in sporadic families (1 known case of autism per family and no known history of autism). Parents with clinically significant Y-BOCS scores were more likely to have a family history of obsessive-compulsive disorder. The empirically derived Autism Diagnostic Interview-R (ADI-R) factor, Insistence on Sameness, was positively correlated with obsessive-compulsive behaviors in parents. Further, when probands were grouped on the basis of parental Y-BOCS scores (clinically significant versus non-clinically significant), probands whose parents had clinically significant Y-BOCS scores had higher ADI-R Insistence on Sameness factor scores. The findings of the current study of sporadic families extend previous work that has shown an association between restrictive/repetitive behaviors in probands with autism and obsessive-compulsive features in parents.

Buspirone for stereotypic movements in elderly with cognitive impairment

Repetitive and stereotypic behavioral disturbances in patients with dementia are common; however, little is known regarding successful treatments. The authors describe six cases of elderly cognitively impaired patients exhibiting repetitive and stereotypic behaviors who were treated successfully with buspirone. The cases demonstrate that buspirone may be an effective and safe treatment for patients with dementia who demonstrate repetitive and stereotypic behavior disorders.

Stereotypy in schizophrenia

OBJECTIVES

In schizophrenia, stereotypy is observed, a symptom characterized by repetitive, functionless motor behaviour. Whereas cognitive dysfunctioning is known to remain stable throughout the illness, less is known about the course of the motor symptoms. The Zeigeversuch [Mittenecker, E., 1953. Perseveration und Persönlichkeit: 1. Teil: experimentelle Untersuchungen. Z. Exp. Angew. Psychol. 1, 5-31], which entails the generation of a random sequence of button presses, was claimed to capture stereotypy. We used a newly designed computerized version of the Zeigeversuch, the Stereotypy Test Apparatus (STA) to evaluate the evolution of STA performance through the course of the illness.

METHODS

To assess stereotyped and perseverative behaviour, 58 schizophrenic inpatients and 48 healthy controls performed the STA and the Wisconsin Card Sorting Test (WCST), respectively, as well as several other traditional neuropsychological tests and the Symbol Digit Substitution Test (SDST) on a writing digitizer.

RESULTS

The STA correlated only weakly with the WCST and SDST measures but not with the cognitive or motor slowing on the SDST, nor with the other cognitive measures. Stereotyped and perseverative idiosyncrasies both seem to increase in the course of the illness, in contrast with other cognitive dysfunctions. However, whereas perseveration is already present in the early stages of the illness, stereotyped behaviour only manifests itself in the later stages of schizophrenia. Failure of cognitive inhibition may result in an activation of prepotent stereotyped responses captured by the STA.

Repetitive and stereotyped behaviours in pervasive developmental disorders

BACKGROUND

Repetitive and stereotyped behaviours are a heterogeneous group of behaviours present in many neuropsychiatric disorders. Despite their core significance in PDD, it is not clear whether there are distinct groups of these behaviours with different specificity to autism.

METHODS

A two-factor model of the repetitive behaviours, namely sensory/motor (lower-order) and cognitive rigidity (higher-order), was conceptualised. The model's goodness of fit to the data was examined in a clinic population of children with PDD, with and without mental retardation, and of those with only mental retardation (MR).

RESULTS

Subjects with PDD had higher rates of all repetitive behaviours compared to those with MR only. The existence of two independent 'lower-order' and 'higher-order' sub-groups of the repetitive behaviours was confirmed only in the MR group. The lower-order behaviours appear to be associated more with global developmental problems, whereas the higher-order behaviours were significantly associated with ruminations in the PDD group.

CONCLUSIONS

This study suggests that there may be two distinct sub-groups of repetitive behaviours whereby the sensory and motor repetitive behaviours are generally associated with lower developmental age and less specific to the autistic syndrome whereas the 'higher-order' behaviours may be a more 'autism specific' feature. The co-occurrence of the lower- and higher-order behaviours in PDD might reflect the end result of diffuse altered neural networks in these disorders thus being a specific feature of PDD. There is a need for more systematic studies of these behaviours not only in autistic disorders but also in other neuropsychiatric disorders.

Longitudinal assessment of stereotypic, proto-injurious, and self-injurious behavior exhibited by young children with developmental delays

Twelve children (CA, 12 to 32 months) with developmental delay were observed in their homes during monthly analogue functional analysis probes to document patterns of emerging self-injurious behavior. Two patterns of emerging self-injury were observed for 5 participants: (a) The topography and functional analysis pattern remained the same, but the behavior eventually caused tissue damage; or (b) a new topography emerged that was similar to an established stereotypic motor behavior. Functional analysis results were inconclusive for the majority of target behaviors across participants due to undifferentiated responding across conditions. One participant exhibited two topographies that appeared to become sensitive to positive reinforcement over time. Results are discussed in terms of implications for future research on early intervention and prevention of self-injury.

Video analysis of sensory-motor features in infants with fragile X syndrome at 9-12 months of age

This study utilized retrospective video analysis to distinguish sensory-motor patterns in infants with fragile X syndrome (FXS) (n = 11) from other infants [i.e., autism (n = 11), other developmental delay (n = 10), typical (n = 11)] at 9-12 months of age. Measures of development, autistic features, and FMRP were assessed at the time of entry into the study. Home videos collected from families were edited and coded with previously validated procedures. Findings revealed a pattern of sensory-motor features (e.g., repetitive leg movements, posturing, less sophistication/repetitive use of objects) associated with FXS, and suggest these infants were most similar to the group of infants with other developmental delays, irrespective of co-existing autistic symptoms later in life. Infant sensory-motor features in the FXS group were more predictive of an early developmental milestone (i.e., age walking) than later, more broad, developmental outcomes, or FMRP. Implications for early identification and differential diagnosis are discussed.

Early features of autism: Repetitive behaviours in young children

This study examined whether repetitive behaviours were a differentiating feature of autism in children aged less than 51 months. The study also examined the relationship between age (chronological and developmental) and repetitive behaviours in young children with autism. Standardised developmental and diagnostic assessments were conducted on 55 children aged between 22 and 51 months, consisting of 40 developmentally delayed children with DSM-IV-TR Autistic Disorder and 15 developmentally delayed children without Autistic Disorder. Results indicated that several measures of repetitive behaviour, particularly more complex high-level ones, were significantly positively associated with the probability of receiving a diagnosis of autism. No significant relationships were found between developmental age and the presence of repetitive behaviours in children with autism, but younger chronological age was associated more with simple or low-level repetitive behaviours.

Repetitive Behavior Profiles in Asperger Syndrome and High-Functioning Autism

Although repetitive behaviors are a core diagnostic domain for autism spectrum disorders, research in this area has been neglected. This study had two major aims: (1) to provide a detailed characterization of repetitive behaviors in individuals with Asperger Syndrome (AS), high-functioning autism (HFA), and typically developing controls (TD); and (2) to examine whether differences in repetitive behavior profiles could provide evidence for the external validity of AS separate from HFA. Specifically, it was hypothesized that circumscribed interests would be more prevalent and cause more impairment in the AS group than the HFA group, while the reverse would be true for other categories of repetitive behavior. The parent(s) of 61 children and adolescents (19 with AS, 21 with HFA, and 21 TD) completed two interviews focused specifically on lifetime and current repetitive behavior symptoms. No reliable differences in repetitive behavior between AS and HFA children were found. Results suggested that circumscribed interests differ in developmental course from the three other DSM-IV-TR categories of repetitive behavior. Internal consistency among the four DSM-IV-TR categories of repetitive behavior was high, alpha = .84, providing evidence for a unitary repetitive behaviors factor. The importance of expanding research in the repetitive behavior domain is highlighted as part of the necessary integration of behavioral and neurobiological approaches to understanding the etiology of autism.

Adult-onset tic disorder, motor stereotypies, and behavioural disturbance associated with antibasal ganglia antibodies

The onset of tics in adulthood is rare and, unlike the childhood variety, there is commonly a secondary environmental cause. We present four cases (1 man, 3 women) with an adult onset tic disorder (mean age of onset, 36 years; range, 27-42 years) associated with the presence of serum antibasal ganglia antibodies (ABGA). One patient had motor tics and unusual motor stereotypies, 2 had multiple motor and vocal tics, and the remaining patient had motor tics only. Concomitant psychiatric disturbance was noted in 3 cases. In 2 cases, there was a close temporal relationship between upper respiratory tract infection and the subsequent onset of tics. Imaging was possible in three cases and was normal in two but revealed a lesion involving the right caudate and lentiform nuclei in the other. We suggest that there might be a causal relationship between ABGA and the clinical syndrome in these cases and that ABGA should be considered as a possible etiology for adult-onset tics.