Developmental Coordination Disorder Criteria:
A. Coordinated motor skills below expected age manifested as slowness and inaccuracy of performance of motor
skills & clumsiness (e.g., dropping or bumping into objects)
B. significantly and persistently interferes with daily living activities and impacts academic/ vocational activities,
leisure, and play.
C. Onset in early developmental period.
D. Not due to other mental medical problems.
Epidemiology: 5-6% of school-age children ♂2:1♀- 50%è comorbid ADHD or dyslexia
Comorbidity: ↑ risk of learning≠ & poor peer relationship- Poor self-esteem & academic performance
Clumsy Child Syndrome: used to denote awkward motor behaviors that couldn’t be correlated with any specific
neurological disorder
Two mechanisms have been hypothesized: In both scenarios the cerebellum is believed to play a role.
1. Automatization deficit hypothesis: Children have difficulty developing automatic motor skills
2. Internal modeling deficit hypothesis: Children are unable to perform the typical internal cognitive models
that predict the sensory consequences of motor commands.
Tools to test motor coordination:
• Bender Visual Motor Gestalt Test
• Frosting Movement Skills Test Battery
• Bruininks-Oseretsky Test of Motor Development
Formulation:
Predisposing Factors Precipitating Factors
• Genetic !!
• prematurity→ 50% of them
• Low birth wt.
• Perinatal malnutrition
• Prenatal exposure to drug
Perpetuating Factors Prognostic Factors
• Lack of support & presence of comorbidity • Level of severity
• presence or absence of comorbidity
• +ve outcome è average & above intelligent capacity
• typically persist into adolescent & adult life
• affected pt. are @↑ risk of: academic problems, poor self-
esteem, obesity, difficulty in running & cardiovascular
diseases.
Management:
Social
• Deficit oriented approach: including sensory integration therapy, sensory-motor oriented treatment, & process oriented treatment.
• Task specific intervention: neuromotor task training & cognitive orientation to daily occupational performance
• Relaxation therapy
• Adaptive physical education program: help children enjoy exercise without the pressure of team sports
Psychological
• Parent counseling
• Behavioral therapy
• Supportive therapy
Stereotypic Movement Disorder criteria:
A. Repetitive purposeless motor behavior (e.g., hand shaking or waving, body rocking, head banging, self-biting,
hitting own body).
B. interferes with social, academic, or other activities and may result in self-injury.
C. Onset is in the early developmental period.
D. not due to substance, medical or mental problem.
Specify if:
With self-injurious behavior
Without self-injurious behavior
Associated with a known medical, genetic, neurodevelopmental, or environmental factor
Specify current severity:
Mild: easily suppressed by sensory stimulus or distraction.
Moderate: require explicit protective measures and behavioral modification.
Severe: Continuous monitoring and protective measures are required to prevent serious injury.
Epidemiology:
7% in typically developed children, 15-20% in <6YO- 10-20 in pt.è ID- ♂2:1♀- 2-3% è self-injury behaviors
¤ These movements are typically rhythmic, involuntary but can be suppressed è concentrated effort
¤ ↑ frequency in children è ASD & ID
¤ Nail-biting, thumb sucking, & nose picking are not included except if they cause impairment of function
¤ To differentiate it from tic→ younger age onset, lack of changing anatomical location, lack of urge, ↓response to Rx.
¤ self-injury behaviors more frequent è genetic syndromes→ Lesch Nyhan, & è sensory≠→ blindness, deafness
¤ hypothesized to originate from basal ganglia, dopamine agonist ↑it, & serotonin likely involved too.
¤ Transient stereotypic behaviors in very young children considered normal.
¤ In head-banging ask if it’s associated with temper tantrum.
Formulation:
Predisposing Factors Precipitating Factors
• Genetic • Neglect & deprivation
• Neglect & deprivation • Anxiety & stressors
Perpetuating Factors Prognostic Factors
• Lack of support & presence of comorbidity • Level of severity → self-injury behaviors
• Neglect • presence or absence of comorbidity
• Anxiety & stressors • presence or absence of support
• symptoms may wax & wane
• may diminish as child gets older.
Management:
• Behavioral therapy→ habit reversal – reinforcement
• Pharmacological→ to ↓ self-injury behaviors with atypical antipsychotics.
Tourette’s Disorder criteria:
A. multiple motor and 1 or more vocal tics have been present during the illness, not necessarily concurrently.
B. tics may wax and wane & may persisted >1 year since first tic onset.
C. Onset is before age 18 years.
D. Not due to substance or AMC
Persistent (Chronic) Motor or Vocal Tic Disorder criteria:
A. 1 or more motor or vocal tics present during the illness, but not both motor and vocal.
B. tics may wax and wane & may persisted >1 year since first tic onset.
C. Onset is before age 18 years.
D. Not due to substance or AMC
E. Criteria Tourette’s disorder has never been met for.
Specify if:
With motor tics only
With vocal tics only
Epidemiology:
Tourette→ 1-2%- ♂3:1♀- son of mother è Tourette ↑ risk- monozygotic 53% & dizygotic 8%
Persistent Motor or Vocal Tic Disorder1-2%!! In Kaplan it is 100-1000x > than Tourette
❖ tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization.
❖ Research suggest dysfunction in basal ganglia region, overactive caudate, dopamine overactivity, and disinhibition
of cortico-striatal thalamic-cortical pathway.
❖ Agent that antagonized dopamine suppress the tic
❖ Maybe transient or chronic, may wax and wane- & old symptoms may replaced by new ones
❖ Peak age of severity 7-10 Y
❖ Most common initial tic→ eye blinking>> head tics>> then facial grimacing
❖ Common comorbid è OCD 20-40%- ADHD >50%- & ODD
❖ OCD symptoms in pt. è Tourette related to ordering, counting, repetitive touching, OCD without tic related to → fear
of contamination or doing harm.
❖ Tics often disappear during sleep- attenuated by relaxation
❖ Chromosome 13q31
❖ Clinical assessment tool→ Yale Global Tic Severity Scale, & Tic Symptom Self Report
❖ Coprolalia is uncommon, mental coprolalia> coprolalia.
❖ It’s important to rule out other medical≠→ Wilson’s disease, or substance→ gasoline inhalation
❖ In Persistent Motor or Vocal Tic Disorder motor tics> vocal tics
Motor Vocal
Simple Eye blinking- shoulder shrugging Cough, throat cleaning, barking
Grooming, smelling, jumping, Coprolalia (use obscene words)
Complex echopraxia (imitate observed behaviors) Palilalia (repeating his or her words)
Copropraxia (display obscene gestures) echolalia
Formulation:
Predisposing Factors Precipitating Factors
• Genetic • Stress
• 2ry to group A beta-hemolytic streptococcal
Perpetuating Factors Prognostic Factors
• presence of comorbidity (ADHD- OCD) • 1\2 to 2\3 will improve or remit by adolescence or adulthood
• lack of support • Severely affected pt. may develop emotional problem
• Frequency of the symptoms
• Presence of comorbidity
• If ivolve limb-trunk less prompt remission than only facial
Management:
Socially→ Supportive therapy, & ↓ exposure to situation that worsen the tics, & ameliorate the social
Psychologically:
❖ Habit reversal training by suppression or (competing response training) → pt. initiate voluntary behaviors, for
motor tic chose the less noticeable behavior, & for vocal use slow rhythmic breathing.
❖ Exposure and response prevention.
❖ Relaxation training
pharmacological:
❖ If mild→ α2 agonist: clonidine, guanfacine
❖ If sever→ risperidone
❖ If resistant→ pimozide FDA approved for non-responders
❖ If comorbid ADHD→ balance benefits with risk of worsen tics- may add clonidine+ stimulant
Provisional Tic Disorder criteria:
A. 1 or more motor and/or vocal tics.
B. The tics have been present for less than 1 year since first tic onset.
C. Onset is before age 18 years.
D. Not due to substance or AMC
E. Criteria not met for Tourette’s disorder, persistent (chronic) motor or vocal tic disorder
Other Specified Tic Disorder
symptoms cause clinically significant impairment in functioning but not meet criteria for a tic disorder. used when
clinician chooses to communicate the reason → “with onset after age 18 YO”
Unspecified Tic Disorder
symptoms cause clinically significant impairment in functioning but not meet criteria for a tic disorder. used when
clinician chooses NOT to communicate the reason
