Patient Presentation
A 2-year-old male came to clinic for his health supervision visit.
His father was very proud that he could run, climb, eat by himself and was putting a couple of words together when speaking. When asked if he had any concerns, he noted that the boy would bang his head on pillows. This occurred when he was going to sleep in his bed, on a couch, or even in a stroller when he would turn his head to one side lightly striking the stroller frame. “He does it sometimes too when he gets upset,” the father described. These instances were always short-lived, occurred occasionally and the child had never hurt himself. The past medical history was non-contributory.

The pertinent physical exam showed a smiley boy, who was exploring the room and responded to his father easily. His vital signs were normal and his growth parameters were in the 10% for weight and 25% for length and head circumference. His physical examination was normal including his neurological examination.

The diagnosis of of a healthy boy was made. The pediatrician discussed that head banging or body rocking were normal behaviors for a child of this age, and that they usually improved with more time. “I’d just recommend that you just ignore it and it should go away as he gets older,” the pediatrician said.

Discussion
Head banging and body rocking are common habits that young children exhibit that can be worrisome or frustrating for parents but that do not cause harm to the child. In a normally developing child they occur around 6-9 months age, and generally resolve around 2-3 years with most behaviors gone by 6-8 years. Children usually do not cause harm to themselves, but it can cause furniture to move causing noise, or potentially the child could lose balance and fall off a bed, or strike an object unintentionally and hurt themself (hit edge of a bed just right in a way that causes a small bruise). The behaviors appear to be a self-soothing behavior, that helps the child to get to sleep or to calm-down in some way. The behaviors commonly occur while going to sleep and may reoccur at night if the child awakens and then is trying to return to sleep. With body rocking the child often will be in a curled up position and may rock so vigorously that the bed shakes and even hits the room walls. Other child may just sit up and rock front-to-back or side-to-side.

While the above are normal habits, other repetitive movements can signal problems. Movement disorders can be divided into two major categories:

• Dyskinesias or hyperkinetic movement disorders, which are repetitive abnormal involuntary movements which includes chorea, dystonia, myoclonus, tremors, tics and stereotypies.
• Akinetic/rigid disorders or hypokinetic movement disorders which are relatively uncommon in children. The classic example is Parkinson’s disease.

Tics are usually single, repetitive, non-rhythmic, non-purposeful movements or utterances. They are usually most severe around 10-12 years of age. Motor tics usually appear 2-3 years before vocal tics but vary with the individual. Tics can last for a few weeks, months or be chronic (> 1 year of symptoms). Simple tic or provisional tics last less than 1 year. Treatment for tics can be watchful waiting and/or medication or some behavior modifications. More information about tics can be found here.

Stereotypies are “…patterned, repetitive, purposeless, involuntary movements that are also rhythmic and continual and tend to change little over time.” Examples can include finger wriggling, hand flapping or clapping, facial grimacing, walking in circles, body rocking or head nodding. Stereotypies more often occur in children with developmental disabilities, sensory impairments (e.g. blindness) or social deprivation. They can be seen in ~7% of normally developing children too. They occur at all times of the day, and can get worse with stress or heightened emotions including happiness. Their onset is before age 3 and tend to improve over years, but can persist into adulthood. Treatment includes behavior modifications and pharmacological therapy.

Learning Point
Head banging and body rocking habits are usually only a problem if they result in a non-simple injury, interfere with sleep, cause lots of household disruption, are associated with developmental delays, or are associated with other sleep issues such as obstructive sleep apnea.

As with most habits, treatment is ignoring the behavior as it generally regresses with time. Additional attention may cause the child to then seek more attention or increase tension. Punishment for the behavior can actually increase the tension that the child is trying to relieve with the habit. Parents should check that the bed is safe (check that the bolts and screws are tight, mattress is tight against railing) and the bed can be placed away from walls. If in a crib, the rail should always be up when a child is sleeping. If in a bed, a guardrail often can be placed to not have the child roll out of the bed. A child who head bangs usually does not hit with great force, or chooses soft objects to hit their head against. A child can be directed to an appropriate object such as a stuffed animal.

Questions for Further Discussion
1. How are other dyskinesias treated?
2. What are indications for referral to a developmental pediatrician or neurologist?
3. What are other sleep related movement disorders?

Related Cases

Disease: Head Banging | Child Mental Health | Child Behavior Disorders | Sleep Disorders

Symptom/Presentation: Behavior Problems | Health Maintenance and Disease Prevention

Specialty: Developmental Disabilities | General Pediatrics | Neurology / Neurosurgery

Age: Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Child Mental Health, Child Behavior Disorder, and Sleep Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Zinner SH, Mink JW. Movement disorders I: tics and stereotypies. Pediatr Rev. 2010 Jun;31(6):223-33.

Gwyther ARM, Walters AS, Hill CM. Rhythmic movement disorder in childhood: An integrative review. Sleep Med Rev. 2017 Oct;35:62-75.

Mackenzie K. Stereotypic Movement Disorders. Semin Pediatr Neurol. 2018 Apr;25:19-24.

Cleveland Clinic. Head Banging and Body Rocking.
Available from the Internet at https://my.clevelandclinic.org/health/articles/14305-head-banging-and-body-rocking (cited 11/15/18).

American Academy of Pediatrics. Common Childhood Habits. HealthyChildren.org.
Available from the Internet at https://www.healthychildren.org/English/family-life/family-dynamics/communication-discipline/Pages/Common-Childhood-Habits.aspx (rev. 11/21/2015, cited 11/15/18).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa