Stereotypic Movement Disorder (SMD) is a neurodevelopmental disorder characterized by repetitive, stereotypical movements that interfere with daily life. These movements are often rhythmic, purposeless, persistent, and can be self-soothing or anxiety-reducing. Follow us here at Developmental Coordination Disorder

Criteria

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria for Stereotypic Movement Disorder (SMD) are:

Criteria A

1. Repetitive, stereotypical movements, such as:

• Hand flapping
• Rocking
• Head banging
• Finger twisting
• Arm waving

2. Movements are:

• Recurring
• Persistent

Criteria B

1. Movements interfere with:

• Daily life
• Social or academic/occupational functioning
• Physical health (e.g., injury)

2. Movements cause significant distress or impairment.

Criteria C

1. Onset of symptoms typically before age 18.

2. Symptoms are not better explained by another mental disorder (e.g., autism spectrum disorder, obsessive-compulsive disorder).

Criteria D

1. Symptoms are not attributable to a neurological or medical condition (e.g., tremors, tics).

2. Symptoms are not better explained by substance use or medication.

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Diagnostic Criteria Changes in DSM-5-TR

1. Removal of the requirement for mental retardation/intellectual disability.

2. Addition of severity levels.

3. Clarification of criteria C.

4. Addition of specifiers for self-injurious behavior and frequency/duration.

Severity Levels

1. Mild: Symptoms cause minimal impairment.

2. Moderate: Symptoms cause significant impairment.

3. Severe: Symptoms cause profound impairment.

Specifiers

Additional descriptors such as specifiers are used to clarify or refine a diagnosis, such as severity, frequency, or duration.

1. Frequency: Specify the frequency of stereotypic movements:

• Mild (less than 1 hour/day)
• Moderate (1-3 hours/day)
• Severe (more than 3 hours/day)

2. Duration: Specify the duration of stereotypic movements:

•  Brief (less than 10 minutes)
•  Prolonged (10 minutes to 1 hour)
•  Extended (more than 1 hour)

3. Intensity: Specify the intensity of stereotypic movements:

• Mild ( minimal disruption)
• Moderate (some disruption)
• Severe (significant disruption)

4. Trigger: Specify triggers for stereotypic movements:

• Anxiety
• Stress
• Sensory stimulation
• Routine disruption

5. Function: Specify the function of stereotypic movements:

• Self-soothing
• Sensory seeking
• Anxiety reduction
• Social interaction

Recording Procedures

Recording Procedures are the methods used to document and record symptoms, behaviors, and treatment responses, including:

1. Clinical Observation: Observe an individual's behavior in different settings.

2. Parent/Teacher Reports: Gather information from caregivers and educators.

3. Behavioral Rating Scales: Use standardized scales (e.g., Stereotypy Severity Scale).

4. Video Recording: Record behavior for further analysis.

5. Self-Report: Collect self-report data from individuals with SMD.

Signs and Symptoms 

Signs and Symptoms of Stereotypic Movement Disorder (SMD)

Common Signs

1. Repetitive movements: Hand flapping, arm waving, leg swinging, etc.

2. Rhythmic movements: Rocking, head banging, etc.

3. Self-soothing behaviors: Thumb sucking, nail-biting, etc.

4. Persistent movements: Lasting more than 4 weeks

5. Interference with daily life: Social, academic/occupational, or physical health impacts

Motor Symptoms

1. Simple motor stereotypes: Hand flapping, finger twisting

2. Complex motor stereotypes: Arm waving, leg swinging

3. Self-injurious motor stereotypes: Head banging, self-biting

Behavioral Symptoms

1. Anxiety and stress relief

2. Self-soothing and calming

3. Sensory seeking

4. Perseveration (repetition of actions)

5. Ritualistic behaviors

Emotional Symptoms

1. Anxiety

2. Frustration

3. Irritability

4. Mood swings

5. Emotional regulation difficulties

Cognitive Symptoms

1. Attention deficits

2. Memory difficulties

3. Executive function challenges

4. Learning difficulties

5. Cognitive rigidity

Physical Symptoms

1. Muscle tension

2. Fatigue

3. Sleep disturbances

4. Injury from self-injurious behaviors

5. Nutritional deficiencies (due to restricted eating)

Symbolic Behaviors

1. Using objects in repetitive ways (e.g., spinning wheels)

2. Insisting on strict routines

3. Displaying intense interests

4. Using gestures or postures to self-soothe

5. Creating and using rituals

Red Flags

1. Early onset (before age 3)

2. Increasing frequency or duration

3. Interference with daily life

4. Self-injurious behaviors

5. Co-occurring conditions (e.g., ASD, ADHD)

Assessment Methods and Tools for Stereotypic Movement Disorder (SMD)

Clinical Evaluation

1. Diagnostic interview: Comprehensive medical and psychological history.

2. Physical examination: Neurological and motor function assessment.

3. Behavioral observation: Direct observation of movements.

Standardized Assessment Tools.

1. International Classification of Diseases, 10th Revision (ICD-10) criteria.

2. Stereotypy Severity Scale (SSS): Measures movement frequency and severity.

3. Abnormal Involuntary Movement Scale (AIMS): Assesses movement type and severity.

4. Child Behavior Checklist (CBCL): Evaluates behavioral and emotional problems.

Behavioral Rating Scales

1. Behavior Assessment System for Children (BASC-2).

2. Conners Rating Scales-Revised (CRS-R).

3. Teacher Report Form (TRF).

Motor Function Assessments

1. Bruininks-Oseretsky Test of Motor Proficiency (BOT-2).

2. Movement Assessment Battery for Children (MABC-2).

Neuropsychological Assessments

1. Wechsler Intelligence Scale for Children (WISC-V).

2. Wechsler Adult Intelligence Scale (WAIS-V).

3. Neuropsychological tests (e.g., Trail Making Test, Stroop Task).

Sensory Processing Assessments

1. Sensory Profile (SP).

2. Sensory Integration and Praxis Tests (SIPT).

Family and Caregiver Assessments

1. Family Environment Scale (FES).

2. Caregiver Strain Questionnaire (CSQ).

Observational Assessments

1. Video recordings.

2. Direct observation in naturalistic settings.

Other Assessments

1. Medical history and physical examination.

2. Neuroimaging (e.g., MRI, EEG).

3. Genetic testing.

Assessment Considerations

1. Multidisciplinary evaluation.

2. Comprehensive assessment battery.

3. Cultural and linguistic sensitivity.

4. Developmental considerations.

5. Comorbidities.

Assessment Goals

1. Accurate diagnosis.

2. Identify underlying causes.

3. Determine severity.

4. Inform treatment planning.

5. Monitor progress.

Accurate assessment is crucial for effective treatment and management of SMD.

Types of Stereotypic Movements

Types of Stereotypic Movements in Stereotypic Movement Disorder (SMD)

Simple Motor Stereotypes

1. Hand flapping: Rapidly waving hands.

2. Finger twisting: Twisting fingers together.

3. Finger tapping: Tapping fingers on the surface.

4. Foot tapping: Tapping feet on the floor.

5. Head shaking: Shaking the head from side to side.

Complex Motor Stereotypes

1. Arm waving: Moving arms in circular motions.

2. Leg swinging: Swinging legs back and forth.

3. Body rocking: Rocking the entire body.

4. Pacing: Walking in repetitive patterns.

5. Jumping: Repetitive jumping.

Self-Injurious Motor Stereotypes

1. Head banging: Banging head against objects.

2. Self-biting: Biting self.

3. Self-hitting: Hitting self.

4. Self-scratching: Scratching self.

5. Hair pulling: Pulling your own hair.

Vocal Stereotypes

1. Vocalizations: Repetitive sounds (e.g., grunting).

2. Word repetition: Repeating words or phrases.

3. Sentence repetition: Repeating sentences.

4. Sound imitation: Imitating sounds (e.g., animal noises).

Object-Related Stereotypes

1. Object manipulation: Repeating actions with objects (e.g., spinning wheels).

2. Object examination: Examining objects closely.

3. Object collection: Collecting specific objects.

Sensory-Seeking Stereotypes

1. Touch: Seeking tactile stimulation (e.g., touching textures).

2. Visual: Seeking visual stimulation (e.g., staring at lights).

3. Auditory: Seeking auditory stimulation (e.g., repetitive music).

Ritualistic Stereotypes

1. Hand gestures: Performing specific hand gestures.

2. Body postures: Maintaining specific body positions.

3. Routine following: Insisting on strict routines.

Other Stereotypes

1. Sleep-related stereotypes: Repetitive movements during sleep.

2. Eating-related stereotypes: Repetitive eating behaviors.

It's essential to note that

1. Individuals may exhibit multiple types of stereotypes.

2. Stereotypes can vary in frequency, duration, and intensity.

3. Understanding the type and function of stereotypes informs treatment.

Prevalence and Demographics 

Prevalence and demographics are two important concepts used to understand the distribution and characteristics of a population's mental health conditions, behaviors, or attitudes.

Prevalence

1. Estimated 2-4% in children and adolescents.

2. 1-2% in adults.

3. Higher prevalence in individuals with intellectual disability (10-30%).

4. Higher prevalence in individuals with autism spectrum disorder (15-40%).

Demographics

1. Age: Typically begins in early childhood (2-4 years).

2. Sex: Males are more affected than females (2:1 ratio).

3. Intellectual level: More common in individuals with intellectual disability.

4. Socioeconomic status: No clear association.

Epidemiology

1. Community-based studies: 2-4% prevalence.

2. Clinical samples: 10-30% prevalence.

3. Comorbidity with other disorders: Autism spectrum disorder, intellectual disability, ADHD.

Demographic Variations

1. Cultural differences: Expression and recognition of SMD vary across cultures.

2. Geographic differences: Prevalence varies across regions.

3. Socioeconomic differences: Access to diagnosis and treatment.

Development and Course

The progression and evolution of a disorder or condition, including its onset, duration, and impact on daily life.

Developmental Stages

1. Infancy (0-2 years): Primary motor stereotypes emerge (e.g., hand flapping).

2. Early childhood (2-4 years): Complex motor stereotypes develop (e.g., arm waving).

3. Middle childhood (5-10 years): SMD symptoms peak.

4. Adolescence (11-18 years): Symptoms may persist or decrease.

5. Adulthood: Symptoms may continue or decrease.

The course of SMD

1. Chronic: Symptoms persist over time.

2. Episodic: Symptoms wax and wane.

3. Progressive: Symptoms worsen over time.

Factors Influencing Course

1. Severity of symptoms.

2. Presence of comorbidities.

3. Effectiveness of treatment.

4. Family support and environment.

5. Cognitive and adaptive functioning.

Early Signs and Predictors

1. Infantile stereotypes (e.g., hand flapping).

2. Sensory processing difficulties.

3. Motor delays.

4. Family history of SMD or related disorders.

Developmental Milestones

1. Motor skills development: Delayed or atypical.

2. Language development: Delayed or impaired.

3. Social development: Impaired social interactions.

Impact on Development

1. Social isolation.

2. Emotional regulation difficulties.

3. Cognitive impairment.

4. Adaptive functioning difficulties.

Etiology and Causes 

The study of the causes and origins of a disorder or condition is known as Etiology.

Factors that contribute to the development of a disorder or condition, including genetic, environmental, and neurobiological factors are known as its Causes.

Neurobiological Factors

1. Genetic predisposition: Familial cases and genetic syndromes (e.g., Fragile X).

2. Brain structure and function abnormalities: Altered connectivity and volume in motor, sensory, and emotional regulation networks.

3. Neurotransmitter imbalance: Dopamine, serotonin, and GABA dysregulation.

4. Neurodevelopmental disorders: Autism spectrum disorder, intellectual disability.

Environmental Factors

1. Prenatal and perinatal complications: Maternal infection, fetal distress.

2. Early life experiences: Institutional care, sensory deprivation.

3. Trauma: Physical or emotional abuse.

4. Social and cultural factors: Cultural norms, family dynamics.

Psychological Factors

1. Sensory processing difficulties: Hypersensitivity or hyposensitivity.

2. Anxiety and stress: Self-soothing mechanisms.

3. Emotional regulation difficulties: Mood dysregulation.

4. Learning and cognitive difficulties: Repetitive behaviors as coping mechanisms.

Medical Conditions

1. Neurological disorders: Cerebral palsy, epilepsy.

2. Sensory impairments: Visual or hearing impairments.

3. Infectious diseases: Encephalitis, meningitis.

4. Metabolic disorders: Phenylketonuria.

Medications and Substances

1. Antipsychotic medications: Tardive dyskinesia.

2. Stimulants: Induced stereotypy.

3. Substance use: Cocaine, amphetamines.

Other Factors

1. Sleep disturbances: Sleep deprivation.

2. Nutrition and diet: Nutritional deficiencies.

3. Physical activity: Lack of exercise.

The interplay between Factors

1. Gene-environment interaction: Genetic predisposition and environmental triggers.

2. Neurobiological and psychological interplay: Brain structure and function influencing behavior.

Theoretical Models

1. Neurodevelopmental model: Altered brain development.

2. Sensory-processing model: Abnormal sensory integration.

3. Anxiety-reduction model: Self-soothing mechanisms.

4. Learning theory model: Repetitive behaviors as coping mechanisms.

Understanding the etiology and causes of SMD is crucial for

1. Accurate diagnosis.

2. Effective treatment planning.

3. Prevention strategies.

4. Family support and education.

Prognostic Factors

Variables that predict the likely outcome or course of a disorder or condition, including severity, duration, and treatment response are known as Prognostic factors.

Positive Prognostic Factors

1. Early intervention and treatment.

2. Mild symptoms.

3. Absence of self-injurious behaviors.

4. Presence of supportive family environment.

5. Cognitive and adaptive functioning within normal range.

6. Effective treatment adherence.

7. Comorbidities well-managed.

Negative Prognostic Factors

1. Severity of symptoms.

2. Presence of self-injurious behaviors.

3. Comorbid intellectual disability or autism spectrum disorder.

4. Poor treatment adherence.

5. Family history of SMD or related disorders.

6. Trauma or stressful life events.

7. Co-occurring mental health conditions.

Predictors of Treatment Response

1. Severity of symptoms.

2. Type of stereotypic movement.

3. Presence of comorbidities.

4. Cognitive and adaptive functioning.

5. Family support and involvement.

Factors Influencing Outcome

1. Duration of symptoms.

2. Frequency and intensity of movements.

3. Impact on daily life and social relationships.

4. Response to treatment.

5. Presence of secondary complications (e.g., anxiety, depression).

Long-Term Prognosis

1. Variable outcome.

2. Symptoms may persist or decrease.

3. Functioning level improves with effective treatment.

4. Some individuals may experience significant improvement.

5. Others may experience chronic symptoms.

Prognostic Indicators for Adults

1. Severity of symptoms in childhood.

2. Presence of comorbidities.

3. Cognitive and adaptive functioning.

4. Social and occupational functioning.

5. History of treatment adherence.

Negative Impact of Stereotypic Movement Disorder (SMD) on Different Aspects of Life

Social Impact

1. Social isolation: Difficulty forming and maintaining relationships.

2. Stigma and embarrassment: Feeling ashamed or embarrassed about movements.

3. Difficulty with social interactions: Struggling to initiate or maintain conversations.

4. Limited social participation: Avoiding social events due to movement concerns.

5. Strained relationships: Family and friends may struggle to understand or cope.

Emotional Impact

1. Anxiety and stress: Increased anxiety due to movement concerns.

2. Depression: Feeling hopeless or helpless about movement control.

3. Low self-esteem: Negative self-image due to movement disorders.

4. Emotional regulation difficulties: Difficulty managing emotions.

5. Mood swings: Irritability, frustration, or anger.

Occupational/Educational Impact

1. Difficulty with focus and concentration: Movements distracting from tasks.

2. Reduced productivity: Movements interfering with work or school performance.

3. Limited career choices: Movements affecting job selection or advancement.

4. Academic struggles: Difficulty completing assignments or participating in class.

5. Increased absenteeism: Missing work or school due to movement-related issues.

Physical Impact

1. Injury risk: Self-injurious movements or accidents.

2. Sleep disturbances: Movements disrupting sleep patterns.

3. Nutrition and diet challenges: Difficulty eating or digesting food.

4. Physical health complications: Movement-related strain on muscles/joints.

5. Reduced physical activity: Avoiding exercise due to movement concerns.

Cognitive Impact

1. Attention deficits: Difficulty focusing due to movements.

2. Memory difficulties: Struggling to recall information.

3. Executive function challenges: Difficulty planning, organizing, or problem-solving.

4. Learning difficulties: Struggling to learn new skills or concepts.

5. Cognitive rigidity: Difficulty adapting to changes.

Family Impact

1. Caregiver burden: Emotional and physical strain on family members.

2. Family dynamics: SMD affecting family relationships and interactions.

3. Financial strain: Medical expenses, therapy, and accommodations.

4. Social isolation: Family avoiding social events due to movement concerns.

5. Emotional impact on siblings: Feeling embarrassed or worried.

Economic Impact

1. Medical expenses: Treatment, therapy, and medication costs.

2. Lost productivity: Reduced work hours or absenteeism.

3. Special accommodations: Modifications to home, work, or school.

4. Support services: Therapy, counseling, or respite care.

5. Reduced quality of life: Impact on overall well-being.

Early intervention, support, and understanding can mitigate the negative impact of SMD.

Differential Diagnosis

Differential Diagnosis is the process of identifying and ruling out other conditions that may present with similar symptoms, to arrive at an accurate diagnosis

Neurodevelopmental Disorders

1. Autism Spectrum Disorder (ASD): Repetitive behaviors, restricted interests.

2. Intellectual Disability: Stereotypic movements, cognitive impairment.

3. Attention Deficit Hyperactivity Disorder (ADHD): Fidgeting, restlessness.

4. Tic Disorders: Motor and vocal tics.

Movement Disorders

1. Tardive Dyskinesia: Involuntary movements due to medication.

2. Chorea: Involuntary, irregular movements.

3. Dystonia: Sustained, involuntary muscle contractions.

4. Parkinson's Disease: Tremors, rigidity.

Psychiatric Conditions

1. Obsessive-Compulsive Disorder (OCD): Repetitive behaviors, compulsions.

2. Anxiety Disorders: Hand flapping, pacing.

3. Trauma-Related Disorders: Self-soothing behaviors.

Neurological Conditions

1. Cerebral Palsy: Motor impairment, stereotypic movements.

2. Epilepsy: Seizure-related movements.

3. Sensory Processing Disorder: Sensory-seeking behaviors.

Other Conditions

1. Self-Injurious Behavior (SIB): Head banging, self-biting.

2. Habit Disorders: Nail biting, hair pulling.

3. Stereotypic Movement Disorder-like behaviors in typical development.

Differential Diagnosis Considerations

1. Age of onset.

2. Type and frequency of movements.

3. Presence of comorbidities.

4. Cognitive and adaptive functioning.

5. Response to treatment.

Key Differentiation Features

1. SMD: Repetitive, non-functional movements.

2. ASD: Restricted interests, social communication impairment.

3. OCD: Repetitive behaviors with compulsive quality.

4. Tic Disorders: Motor and vocal tics.

Accurate differential diagnosis is crucial for

1. Effective treatment planning.

2. Prevention of misdiagnosis.

3. Appropriate management of comorbidities.

Comorbidity 

Comorbidity is the presence of two or more disorders or conditions that co-occur in an individual, which can impact diagnosis, treatment, and prognosis.

Common Comorbidities

1. Autism Spectrum Disorder (ASD): 15-40% co-occurrence.

2. Intellectual Disability: 10-30% co-occurrence.

3. Attention Deficit Hyperactivity Disorder (ADHD): 10-20% co-occurrence.

4. Anxiety Disorders: 5-15% co-occurrence.

5. Obsessive-Compulsive Disorder (OCD): 5-10% co-occurrence.

6. Tic Disorders: 5-10% co-occurrence.

7. Sensory Processing Disorder: 5-10% co-occurrence.

Neurodevelopmental Comorbidities

1. Cerebral Palsy.

2. Epilepsy.

3. Neurodegenerative disorders (e.g., Huntington's disease).

Psychiatric Comorbidities

1. Mood Disorders (e.g., depression).

2. Trauma-Related Disorders.

3. Personality Disorders.

Medical Comorbidities

1. Sleep Disorders.

2. Gastrointestinal issues.

3. Nutrition and feeding difficulties.

Factors Contributing to Comorbidity

1. Genetic predisposition.

2. Neurobiological factors.

3. Environmental factors (e.g., trauma).

4. Shared underlying mechanisms.

Impact of Comorbidity

1. Increased symptom severity.

2. Reduced treatment effectiveness.

3. Increased caregiver burden.

4. Decreased quality of life.

Treatment and Management Strategies

Treatment and Management Strategies for Stereotypic Movement Disorder (SMD)

Management Strategies are the methods and techniques used to treat and manage disorders, including behavioral, pharmacological, and psychosocial interventions.

Behavioral Interventions

1. Applied Behavior Analysis (ABA): Reduces problem behaviors.

2. Positive Behavioral Supports (PBS): Enhances adaptive behaviors.

3. Habit Reversal Training (HRT): Replaces stereotypic movements.

4. Cognitive-Behavioral Therapy (CBT): Addresses underlying issues.

Pharmacological Interventions

1. Selective Serotonin Reuptake Inhibitors (SSRIs): Reduces anxiety, and depression.

2. Antipsychotics: Manages severe symptoms.

3. Dopamine-blocking agents: Reduces movement severity.

Psychosocial Interventions

1. Family Therapy: Enhances coping skills, and communication.

2. Group Therapy: Social skills training, and support.

3. Parent Training: Management strategies, education.

Environmental Modifications

1. Sensory Integration Therapy: Regulates sensory input.

2. Environmental Enrichment: Stimulates cognitive, and motor development.

3. Adaptive Equipment: Facilitates daily functioning.

Alternative Therapies

1. Occupational Therapy (OT): Enhances daily functioning.

2. Physical Therapy (PT): Improves motor skills.

3. Music Therapy: Reduces anxiety, and stress.

Support and Education

1. Family Support Groups: Emotional support, education.

2. Individualized Education Plans (IEPs): Tailored educational goals.

3. Respite Care: Temporary relief for caregivers.

Treatment Goals

1. Reduce symptom severity.

2. Enhance adaptive behaviors.

3. Improve daily functioning.

4. Increase social participation.

5. Reduce caregiver burden.

Treatment Settings

1. Outpatient clinics.

2. Inpatient facilities.

3. Residential treatment centers.

4. School-based programs.

Multidisciplinary Team

1. Psychiatrists.

2. Psychologists.

3. Occupational Therapists.

4. Physical Therapists.

5. Special Education Professionals.

Treatment Challenges

1. Limited research.

2. Variable treatment response.

3. Comorbidities.

4. Family dynamics.

Future Research Directions

1. Investigating novel treatments.

2. Examining treatment effectiveness.

3. Developing personalized treatment approaches.

Effective treatment and management of SMD require

1. Comprehensive assessment.

2. Individualized treatment planning.

3. Multidisciplinary collaboration.

4. Ongoing monitoring and adjustment.