Behavior: Ask the experts




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Q A 3-year-old in our practice seems to have at least one irritating habit at any given time. After several months of grinding his teeth when he was sleepy, this toddler began picking at his fingernails. Mom says the habits are worse on days when his routine is changed or he doesn't have a nap. I have advised Mom to ignore the behavior, pay attention to sleep habits, and keep small toys on hand to occupy idle times—for example, on long car trips. Mom has also tried keeping Band-Aids on hangnails and issues threats about needing "to see the doctor for infections." At the child's last visit, I noticed that Mom picks her own fingernails! Any suggestions?

Sheila D. Boes, MD
Austin, Tex.

A It sounds like you can rule out stereotypic movement disorder. Although the habits are repetitive, seemingly driven, and can be classified as nonfunctional motor behavior, they do not appear to interfere markedly with normal activities or result in self-inflicted bodily injury that requires medical treatment. Neither can they be accounted for by a compulsion (as in obsessive-compulsive disorder), a tic (as in tic disorder), or a stereotype that is part of a pervasive developmental disorder. And although the lay literature frequently mentions that such habits are exacerbated by stress, several studies have actually shown the opposite—that such habits are more likely to manifest when a person is relaxed.

Also bear in mind that teeth grinding (bruxism) is probably the most common habit disorder in the United States. More than 50% of young children grind their teeth at some time. Similarly, more than 40 million people in the United States bite their fingernails, although they usually are older than 3 years when they begin.

Pharmacologic management of a condition that is seen so commonly in young children and is basically benign is inadvisable. One of the mainstays of treatment of habit disorders, habit reversal, is really not applicable to children this young. Nor are cognitive-behavioral procedures that have been effective in older children and adolescents.

What choices do you have, then? The best bet is probably to continue to advise the parents as you have done—in particular, to keep small toys on hand to occupy idle moments. Discourage them from paying attention to the habits; talking about them can backfire and result in their increase. Above all, the parents should be very nurturing when the child is not grinding his teeth or picking his nails. That the mother picks her fingernails is not particularly significant; the habit is just too common and harmless to be considered important.

Edward R. Christophersen, PhD
Kansas City, Mo.

DR. CHRISTOPHERSEN is professor of pediatrics at The Children's Mercy Hospital in Kansas City.


Behavior: Ask the experts. Contemporary Pediatrics 2001;9:36.

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