Movement Disorders in Children

Movement disorders are neurological conditions that affect the speed, smoothness and control over movements. They include involuntary jerks and spasms, tremors, normal movements that occur at inappropriate times, excessive movements, rigidity or spasticity, abnormal postures, and difficulty in controlling movement.

Many children make repetitive or apparently involuntary movements at times, such as rocking back and forth or twirling their hair. Some abnormal movements are triggered by stress, while others have physiological causes. Some disappear with time, while others grow progressively more severe. When a movement disorder interferes with a child’s ability to function at home or at school, it is important to seek medical help.

Movement disorders are classified based on how they appear to an observer, rather than by their underlying cause, although understanding the cause of a particular child’s movement disorder is critical to effective treatment.

Movement disorders are divided into two broad groups:

Hypokinetic movement disorders

These disorders are characterized by lack of movement, or by less movement than normal. The primary hypokinetic movement disorder is parkinsonism. Features of parkinsonism include slow movements (bradykinesia), stiff muscles (rigidity or spasticity), decreased movement (akinesia), unstable posture and tremor when muscles are relaxed.

Hyperkinetic movement disorders

These movement disorders are characterized by excessive movement and can present in a wide range of forms, including:

• Ataxia — problems with coordination when a child is engaged in voluntary movement. Children with ataxia may have difficulty bringing a cup to their mouth to drink, or walking smoothly.
• Dystonia — sustained or intermittent muscle contractions that the child cannot control. Children with dystonia may experience contractions in opposing muscles, resulting in twisted or abnormal postures. Dystonia can interfere with a child’s ability to speak, eat or walk, and may cause pain.
• Chorea-athetosis — irregular writhing movements of the face and limbs that the child cannot control. These movements are nearly continuous and may flow from one part of the body to another with dance-like quality. In chorea, the movements are rapid and jerky. Athetosis is a term for slow writhing movements. These terms are part of a spectrum of movement disorders.
• Stereotypies — consistent, rhythmic repetitive movements of the head and upper body without apparent purpose. Stereotypies typically begin before the age of 3 and, for many children, disappear in early childhood. They can occur in children with autism spectrum disorder, but are not a sign, by themselves, that a child has autism spectrum disorder.
• Tics — repeated, sudden non-rhythmic movements or actions that a child can’t always control. These may include sounds and statements. Tics are quite common, occurring in roughly 1 in 5 children. They most often develop during the school-age years, and can worsen during adolescence. When a child has a combination of motor and vocal tics that last for more than a year, it is considered Tourette’s disorder.
• Myoclonus — quick muscle jerks that a child cannot control. Most people have experienced a form of myoclonus while drifting off to sleep. When a child experiences these jerks while awake, it can be a sign of epilepsy or another neurological problem.
• Tremor — rhythmic shaking that a child cannot control. Tremor at rest is a feature of parkinsonism, and is rare in children. Tremor that is more pronounced during voluntary movement (kinetic tremor), including essential tremor, is more common in children and adolescents. Tremors can interfere with a child’s functioning at home and school.

Movement disorders appear in a wide range of forms, and different forms may have different causes. Some milder movement disorders, such as tics, have no known causes. Others may be caused by:

• Injuries to the brain
• Genetic or metabolic conditions
• Infections
• Inflammatory or autoimmune disorders
• Medications
• Toxins

The first step in diagnosis is to identify the nature of the abnormal movement. While the list of types of movement disorders may make the distinctions seem clear-cut, in actual cases a neurologist will need to examine the patient carefully, interview the family to get a history and description of the behavior, and sometimes to study video recordings. It can be difficult to differentiate between a tic and a jerk, for example, or between rapid series of small movements and a continuous movement. When movements occur only occasionally, the child may need to be observed for an extended period in a clinic.

Other diagnostic tools used to identify the type and cause of movement disorders include:

• Blood tests
• Genetic testing
• Cerebrospinal fluid analysis
• Brain imaging, such as magnetic resonance imaging (MRI)

When the movement problem is minor, has little risk of worsening and does not interfere with a child’s activities or cause a child distress, no treatment is recommended. Some of the milder types of movement disorders can be temporary, and a child may outgrow them with time.

When movement disorders are severe enough to interfere with a child’s school and social life, or to invite teasing and bullying, treatment may be recommended. Treatment is always recommended when the disorder has a cause that could lead to neurological or other health damage if left untreated.

Treatment options include:

• Physical and occupational therapy: Stretching, strengthening and range of motion exercises can be helpful in some cases, as can therapy to alter posture. Occupational therapy may include training in limb positioning and the application of splints or braces.
• Behavior therapy: Comprehensive behavior therapy (CIBT) can be useful with some types of tics, especially with older children to help them recognize the urges that precede certain movements and substitute less noticeable behaviors.
• Medication: The intensity of some movement problems may be reduced with medications. In cases where the movement disorder has been caused by medication for another condition, dosages may be adjusted and alternatives considered.
• Intrathecal baclofen (ITB) therapy: Medication may need to be administered directly to the intrathecal space (the fluid surrounding the brain and spinal cord). In ITB therapy, a medication pump is surgically implanted in the patient’s abdomen and a flexible catheter routes the medication to the point of administration.
• Deep brain stimulation: In severe cases, when medication provides no relief, the child’s doctor may recommend deep brain stimulation as a way to inactivate the parts of the brain thought to cause excessive movements or tremors.
• Surgery: Some movement disorders, including stiff muscles (spasticity) can result in muscular or skeletal deformities. Orthopaedic surgery may be an option to address these problems. Other surgical procedures may be considered to interrupt the nerve signals causing spasticity, stiffness or tremors.

Some milder types of movement disorders, including some tics and stereotypies, may be temporary conditions, and may disappear as the child grows older. Others can be more serious, and may present lifelong challenges or the prospect of progressive decline. Because there are many types of movement disorders, such a wide range of severity, and so many causes behind them, patients’ families should consult a medical specialist for useful information about their child’s outlook.

In mild cases, no treatment or follow-up care may be needed. In more severe cases, ongoing treatment with medication or therapy may be required, with periodic examination by the child’s doctor to adjust the treatment plan.

Children’s Hospital of Philadelphia (CHOP) has a skilled team of child and adolescent psychiatrists, psychologists, neuropsychologists, nurse practitioners, social workers and more, who work in collaboration to recognize and help a child or adolescent deal with movement disorders. CHOP has helpful information for parents of children with different conditions to help them navigate the emotional and practical issues they may face, from initial diagnosis through treatment and follow-up.

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Reviewed by: Raghuram Prasad