Movement Disorders

Movement disorders are stereotypic movements noted during sleep that are non-purposeful.

Amir's Story

Let’s find out more about Amir, who is kicking the wall while he sleeps.

Amir’s mom called the health care provider’s office with several concerns about Amir, who is 7 years old. He seems to be tired in the morning even after sleeping for 11 hours. She reports that once he falls asleep, he stays asleep. He has no electronics in his room. She can hear him “kicking the wall” during sleep. He is a "very busy sleeper" and his sheets, blankets and pillows are quite a mess every morning.

He is having a bit of trouble in first grade and his teacher reports that he does not like to stay in his seat for very long.

Expert Insights

BEARS Screening for Movement Disorders

As part of the clinic’s routine protocols all patients are screened with a BEARS assessment tool. Open the categories below to review some of the history that was obtained from Amir's family.

Bedtime Problems

Amir has difficulty settling down to sleep at night without specific complaints. His family notices kicking during sleep.

Expert Insights
  • Children with PLMD will have kicking that is noted at sleep onset which may also delay sleep onset.
  • Children with RLS often have leg discomfort and urge to move that is both worsened with rest and in the evening.
  • More careful questioning about leg discomfort is in order to help Amir articulate what is bothering him at bedtime. Children must describe these feelings in their own words for diagnostic purposes. Often they will use terms like, "soda bubbling in my legs" or "wiggly feelings".
Excessive Daytime Sleepiness

Amir does not seem rested in the morning per his mother despite adequate nocturnal sleep. Additional questions might include behavior observed when sleepy and whether this is appreciated throughout the day.

Expert Insights
  • RLS and PLMD can cause disrupted sleep at night resulting in non-restorative sleep (symptoms of daytime sleepiness despite adequate nocturnal sleep). Remember signs of “sleepiness” in children may mimic those of ADHD.
  • RLS can lead to delayed sleep onset shortening the actual sleep time and resulting in daytime sleepiness.

Amir’s family does not complain of issues with awakenings at night.

Expert Insights
  • Some children with PLMD and RLS may experience prolonged awakenings due to leg discomfort and urge to move during the night.
Regularity & Duration

Amir has consistent bedtimes and wake times. He has a regular bedtime routine with enough time in bed to obtain adequate sleep.

Expert Insights
  • This history is important to help determine what might be causing symptoms of non-restorative sleep and daytime sleepiness. It is important to determine if a child has adequate sleep based on age related needs before attributing daytime sleepiness to an underlying sleep disorder.
Sleep-Disordered Breathing / Snoring

Amir and his family deny snoring, difficulty breathing during sleep, or sleep apnea.

Expert Insights
  • Screening for obstructive sleep apnea is important as leg movements during sleep can be noted at the termination of respiratory events. Knowing the cause of the leg movements (ie PLMs versus OSA) is important for determining the appropriate treatment.

Amir's Evaluation & Diagnosis

What evaluation & diagnostic protocol should Dr. Jones use to diagnose Amir's kicking at night?
Check all that apply:

The evaluation protocol strategies we recommend for Amir's case are:

  • Determine child’s sleep history.
    • It is important to delineate symptoms at sleep onset as well as exacerbating/relieving factors.
  • Perform a physical exam.
    • This is important to evaluate for signs of neuropathy or spinal cord injury that might contribute to leg movements.
  • Order a Sleep Study.
    • This is a consideration if PLMD is suspected without clear RLS.
    • A sleep study is not required if RLS is obvious from symptoms.
  • Order Labs/Other Tests.
    • Serum ferritin, iron and % iron saturation should be obtained to determine iron status and potential for treatment with iron supplementation.

History is essential in the evaluation of Amir’s symptoms. If he has clear symptoms of RLS, a sleep study is not needed. If the concern is PLMS, a sleep study will help document leg movements during sleep and their frequency. Lab work evaluating iron status is helpful to plan intervention if the diagnosis is either PLMD or RLS.

Elements of Amir's Sleep History

Sleep History Case Specific Information Amir's Evaluation Results

What happens at sleep onset?


Does the child seem fidgety and have difficulty settling?

At sleep onset Amir does seem fidgety and has difficulty settling down. Despite 11 hours of sleep, he is difficult to get up in the morning and seems not well rested.

Does the child move his legs?
Does the child complain of leg discomfort?

He does move his legs but does not complain of leg discomfort. He goes to bed at 7 pm and it can take him 45 minutes to fall asleep.

Are their prolonged awakenings during the night with similar issues noted at bedtime?

Once he is asleep he does not recall kicking his legs or waking up with leg discomfort. His family reports he is a very restless sleeper and “tears up the bed". In fact, they can sometimes hear him kicking the wall.

Does the caregiver note kicking during sleep?

How often does this happen at night?

When on vacation no one wants to share a bed with Amir because his kicking makes sleep very difficult.

How long has this been going on? What was the age when this started? Are the events becoming more or less frequent?

His family has noticed this problem for the past year and they feel it is getting worse.

Screen for other sleep issues (OSA, restless leg syndrome)


No other sleep issues reported.

Review of Medications

Is this child taking medications which can worsen leg movements including antihistamines, antidepressants or metoclopramide?

Mom reports that she has given him an diphenhydramine at bedtime for the past 6 months because she found information on a parents’ chat room on the internet that this could help his sleep. He takes no other medications.

Are there are medical issues that are associated with RLS or PLMs such as sickle cell anemia, spinal cord injury, iron deficiency or uremia?

Mom reports that she was told that Amir had “low blood” from their previous pediatrician. He has no other serious medical problems.

PSG was ordered showing a sleep onset latency of 45 minutes and otherwise normal sleep architecture.  He had rare respiratory events with an AHI of 0.1 and no snoring.  He was noted to kick his legs prior to sleep onset and during sleep.  His PLM index was 15 and the arousal index associated with his leg movements was 10.

Assess for family history of sleep disorders


Mom is uncertain if any family members have a history of PLMD or RLS.

Dietary intake should also be reviewed specifically for iron containing foods or the lack of these foods. Is the child observing a special diet?


Amir is a picky eater and does not like to eat meat. He prefers vegetables and his older sister is a vegetarian so the mom cooks to allow both Amir and his older sister to eat the same foods.

Caffeine intake is associated with PLMs/RLS and should be specifically reviewed.


Amir has adopted the southern tradition of drinking sweet tea at dinner and has 2 glasses each night.

Any family history of PLMD or RLS?

Mom is uncertain if any family members have a history of PLMD or RLS.

No known family history of PLMD or RLS.

Are there any additional psychosocial stressors affecting the child or family?


The social worker has learned that there has been parental conflict and Amir may be kicking the wall when he hears arguing. School issues may be partially related to this conflict which is upsetting to Amir.

Perform a Physical Exam

Information to obtain includes: Case Evaluation Results

Evaluate for signs of neuropathy or spinal cord injury that might contribute to leg movements

Physical examination was normal.

Order Labs/Other Tests

Information to obtain includes: Case Evaluation Results

Serum iron, ferritin and % iron saturation levels should be obtained. Serum ferritin levels <50 ng/ml have been associated with PLMs and RLS in children and adolescents even when the lab value falls within the “normal limits” for the laboratory used.

He had blood work done showing a serum ferritin of 7, serum iron of 21, and very low % iron saturation.

Sleep Study

Information to obtain includes: Case Evaluation Results

Looking for leg movements prior to sleep onset and during sleep. Specifically do the leg movements fit the criteria for PLMs and what is the PLM index (number of PLMs/hours of sleep). PLM index of >5 is considered abnormal in children. Careful attention must be paid to whether the leg movements are associated with respiratory events which might indicate that OSA rather than PLMs is causing sleep disruption.

PSG was ordered showing a sleep onset latency of 45 minutes and otherwise normal sleep architecture. He had rare respiratory events with an AHI of 0.1 and no snoring. He was noted to kick his legs prior to sleep onset and during sleep. His PLM index was 15 and the arousal index associated with his leg movements was 10.

Options that are Not Recommended

Complete a Sleep Diary

Completeing a Sleep Diary would not be informative in this situation.

Obtain an Epworth Sleepiness Scale Score

Obtaining an Epworth Sleepiness Scale Score would not be informative in this situation.

Refer to a Specialist

Could be considered if picture is confusing or there is concern that leg movements during sleep represent subtle OSA or upper airway resistance syndrome.

Red Flags

  • Repeated generalized movement - consider nocturnal seizures. Have caregivers observe the leg movements to determine the timing and extent.
  • Extreme daytime sleepiness not explained by extent of sleep disruption from leg movements, another sleep disorder, or lack of sleep may be concerning for an intrinsic disorder of sleepiness and warrant a referral to a sleep specialist.

When evaluating a child for possible parasomnias, consider how other health care providers may also need to be involved.

Expert Insights:
Triggers for Movement Disorders

Evaluation & Diagnosis

What diagnosis is consistent with Amir's night time kicking?
Check all that apply:

Amir's signs and symptoms are consistent with:

  • Periodic Leg Movement Disorder (PLMD).

He cannot articulate leg discomfort to help with the diagnosis of RLS and has no immediate family members with RLS.

In this case, Restless Leg Syndrome, signs of sleep starts or a seizure disorder are not consistent with the information provided.

Amir's Treatment & Referrals

Now it’s time to recommend treatment options for Amir.
Check all that apply:

The following treatment strategies are recommended for Amir's PLMD:

  • Avoid medications that exacerbate leg movements.
  • Eliminate caffeine intake.
  • Evaluate iron status.
  • Screen for OSA or other sleep disorders.

Treatment Strategies for PLMD

  • Medications that worsen PLMD should be avoided. Antihistamines should not be taken for a sleep aid. Other medications that worsen leg movements may be required to control other important conditions such as antidepressants. The impact of these medications compared to the leg movements on the overall impact of the child’s health should be considered.
  • Eliminate caffeine intake. Help family identify sources of caffeine intake and suggest alternative foods and beverages.
  • Evaluate iron status and institute supplementation for ferritin levels < 50 ng/ml. However, if patient at risk for iron overload (sickle cell anemia), iron therapy should not be started. Therapeutic doses of iron should be given for a 3 month trial and iron status re-evaluated. Iron preparations are better absorbed when given with Vitamin C, so iron supplementation can be given with orange juice. Iron supplements are less well absorbed when combined with calcium.
  • Screen for OSA as a cause of nocturnal kicking.

When to consult a sleep specialist or refer to another discipline:

  • Nutritionists should be consulted to help the family with strategies to improve iron in the diet as well as maximizing absorption of oral supplements.
  • Pharmacists are essential in helping identify medications that may be contributing to leg movements. They are also key in helping families find the correct supplement, most of which are over the counter preparations. Pharmacists may also discuss strategies to promote adherence to the supplement.
  • Nurses can be helpful in communication with the school nurse in delineating school issues and how poor sleep may be impacting school performance.
  • Social workers and/or clinical psychologists are very helpful in determinig daytime behavior as well as strategies to help the patient and family cope with these issues. Additionally they can help family deal with parental conflict and its impact on the child.
  • Family representatives may be helpful if the family is having a difficult time adhering to recommendations and to determine family and cultural issues which may serve as barriers.
  • Consider referral to sleep specialist if PLMD seems refractory to treatment or other sleep disorders are suspected. If excessive daytime sleepiness is an issue despite adequate treatment and adequate sleep an intrinsic disorder of sleepiness may be co-existing with the movement disorder.
  • Consider referral to pediatric neurologist if there is a concern for seizures.

Interdisciplinary Treatment Components

Amir's Results:

Good news! Amir’s nocturnal kicking and daytime issues have improved since putting treatment strategies to use. His family reports his sleep seems much less restless, is more restorative and he is doing well in school with improved focus and ability to stay in his seat. Brief family therapy was recommended and this has helped the parental conflict.

Treatment strategies and results for Amir’s PLMD:

  • Avoidance of medications that worsen leg movements.
    Mom stopped giving diphenhydramine at bedtime to help Amir sleep. The medication was not working and his sleep actually improved.
  • Eliminate caffeine intake.
    Amir replaced his intake of sweet tea at dinner with water.
  • Evaluate iron status and treat as needed.
    Amir’s low ferritin level was treated with an over the counter iron preparation taken with orange juice and several hours apart from calcium intake. His mother consulted their local pharmacist to obtain the correct preparation and review appropriate administration. His mother also consulted with the nutrition team who had several excellent suggestions on how to increase iron in the diet (e.g., use a cast iron skillet for cooking) and respect the family’s dietary considerations.
  • Screen for OSA.
    Amir did not have symptoms of snoring, apnea or choking during sleep.
  • Psychosocial interventions.
    Family Therapy to addressed family issues and though a 504 Plan was not needed, information about a 504 plan was given to the parents.