Rocking the Boat (and Everything Else): Stereotypic Movement Disorders, Autism, Triggers, and Treatments

Thursday, April 02, 2015 by Meg   •   Filed under General

Stereotypic movement disorders or bodily focused repetitive movements (BFRM) are repetitive actions that may involve physical harm to the person doing them. In smaller children, these movements may be normal as they try to control very big feelings. But they can become problematic, especially in older children. While no specific cause has been found for some stereotypic movement disorders, they do tend to increase with stress, boredom and frustration. And there is a great deal of overlap between stereotypic movement disorders and impulse control disorders like excoriation (skin picking) and many specific behaviors can fall under both the impulse control umbrella and the movement disorder umbrella.

Stereotypic movement disorders are common in those with OCD, younger children, abused or neglected children, those with mental retardation and the autistic population. SMDs also tend to be present with stimulant drug use, such as amphetamines and cocaine, though whether you should walk up to a crack addict and yell, “Hey! That’s a stereotypic movement issue!” is a grey area. I’m going to go with, “Leave him alone,” but that’s me.

Okay, so first things first: 

What Are The Symptoms of Stereotypic Movement Disorders? 

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), repetitive behaviors that cause trouble with other functioning qualify as stereotypic movement disorder. The behaviors have to be repetitive and without purpose (though I would argue that many who engage in them are driven for a real reason which we’ll discuss in a minute). The DSM-5 also says that they have to start in the early developmental period (childhood) and that the actions must interfere with social, academic or other activities.

Stereotypic Movement Disorders Include Movements Such As:

  • Sucking on hands or fingers
  • Trichotillomania (hair pulling or twisting)
  • Rocking the body
  • Head banging
  • Grinding teeth 
  • Nail Biting
  • Skin Picking (more here)
  • Flapping
  • Waving
  • Opening and closing of fists
  • Wrist flexing
  • Moving fingers
  • Pacing, Running Skipping

SMDs may also involve movements that are focused on other senses:

  • Visual: gazing at objects, such as lights or blocking light from eyes with a pillow
  • Smell: sniffing things 
  • Taste: placing objects in the mouth or licking things
  • Auditory driven: clicking the tongue to make sounds 

There are a few theories on why stereotypic movement disorders happen:

  1. Hyposensitivity and Sensory Stimulation: This theory holds that the one doing the behavior is trying to excite the nervous system because they are less sensitive. As an illustration, some children who have sensory processing disorders, and are on the “low touch” side, may hurt others or the family pet accidentally because they can’t process those touches like everyone else. They think they’re being gentle. They just aren’t. Kids who move for sensory stimulation may not be able to feel as much and are doing something repetitive to regulate their system up and allow them to feel more. And indeed, in some people these movements have been shown to increase action on the HPA axis1,  a marker of arousal which is important for overall health. Other studies show that because some have less physical sensitivity, the rocking also serves to increase the production of beta endorphins, chemicals that give the one moving a sense of pleasure2
  2. Hypersensitivity and Reducing Stimulation: If instead of being less sensitive they feel and register too much, individuals may feel overloaded and use the behaviors to calm down. The behaviors may serve to reduce focus on the surrounding environment and allow them to block everything out. And there is evidence that for some the movements help to calm them and organize their behaviors afterwards3

These behaviors in children on the spectrum might have a slightly different initial trigger than in other kids, but the end result is strikingly similar. Abused or neglected children might use the behaviors as a way to cope with scary emotions when other mechanisms for calming are not developed enough. Fear in a child who has been abused may cause them to sit and rock while thumb sucking as a way to reduce nervous system arousal. An abused child may also use the movements to increase their arousal if their body is stuck in the "numb" stage due to PTSD and a prolonged fight/flight/freeze response.  Children with Obsessive Compulsive Disorder may also show similar movements. However, children who are completing the behaviors based on OCD-type thoughts of, “I need to rock twelve times or else my mom will die,” are usually diagnosed as having Obsessive Compulsive Disorder as opposed to stereotypic movement disorder. (More on OCD coming soon, so stay tuned.)

In the autistic population, feeling overwhelmed by information sometimes leads to repetitive movements due to information processing issues and stress. In some kids, the buzzing of a bee while trying to focus on what you are telling them is overwhelming enough to trigger the behaviors. In others, it puts some necessary space between someone asking you a question and having to answer it, as described by Naoki Higashida, an autistic teenager and author of The Reason I Jump. He notes that when someone talks to him, he rocks or jumps to give him time to process the information and figure out how to respond because it is like being in a foreign country where no one speaks your language4. And if you haven’t read The Reason I Jump, WHAT ARE YOU WAITING FOR? Click on it and get it now. It’s amazing insight into the plight of children on the spectrum.

So how can we help? 

Treatments For Stereotypic Movement Disorder

Wait Safely: It can be terrifying to watch a child or another person bang their head on the floor, and in some cases intervention will be necessary. If you choose not to interrupt the behavior, you can put a pillow or a few foam mats under their head or arm or leg (or against whatever they are banging it on). The behaviors generally stop on their own and don’t lead to seizures or other issues, so waiting it out can be a good first line of defense if you can do it safely. 

Exercise tends to reduce these behaviors because it both increases stimulation and hormone production in those who are hyposensitive AND purges stress hormones for those who are hypersensitive. Good stuff. 

Behavioral tactics are generally used to change the behavior over time but it is always important to keep in mind that the one completing the behavior probably has a reason for doing it. You must address this need as well as changing the behavior, whether it’s finding other ways to rev up, or to cool off. Some of the more popular are: 

  • Replacement: These may include snapping a rubber bank on the wrist instead of slapping oneself, biting a rubber chew toy instead of one’s arm, etc. Just make sure the replacement choice goes with the senses they are using for the behavior. If someone is using taste and you want him to stop licking strangers, offer a lollipop or something that it is acceptable to lick. It probably won’t work if he wants to lick and you tell him to snap the rubber band instead. However, some have luck with replacing hand flapping with verbal responses such as "Goodbye" or "Excuse me" if the behavior is triggered only in certain instances. 
  • Some push a positive reinforcement (the stick and carrot) approach to the behaviors, though it works better with certain movements and not as well for those with other issues. For instance, because the movements have been shown to interfere with learning, some parents use,“You can’t do that behavior until after you’ve done your homework.” The behavior itself  tends to act as a positive reinforcer and gets the kid to finish up fast so they can move as their “reward”. Though the behaviors are biologically adaptive, in cases where the issue is not severe and the child is not incredibly distressed, spacing the behaviors out, or using them as a bribe, works well. Your own thoughts on the matter from a theoretical standpoint will probably drive your decision about whether to use behavioral tactics. There’s no right or wrong answer here. (You can read more about my ideas here in Why B.F. Skinner is a Dick.)
  • Medications, including some antidepressants, may help. However, this might be because they slow down all movement and not just the ones related to SMDs, so be cautious in accepting pharmaceutical intervention. 

While stereotypic movement disorders can be frightening to witness, it is important to understand that they are being used for a reason. A normal, healthy reason. If you see a mother at the grocery store trying to shop while her child screams and bangs his head on the floor, smile at her and go about your business. Maybe offer her a cookie. And if you're a parent shopping with your kid, praying that today isn’t the day some stranger decides to tell him to stop being a brat, practice this mantra with me to pull out for just such occasions: “It’s not a behavioral issue. It’s a regulation issue. It’s a sensitivity issue. And it’s not your issue. Also, fuck you.” 

Last sentence optional. 

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Topic-Relevant Resources

The Reason I Jump
Insight into the mind of the autistic from a thirteen year old boy. Wonderful read for any parent.