Movement Disorders

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

Jose's Story

Let’s find out more about Jose who has been noted to hit his head on the pillow at sleep onset.

Jose’s father brought him to the clinic to be checked because a coworker told him that head banging meant that Jose was developmentally delayed. Jose is 2 years old and up to this point, Jose has been healthy and had appropriate attainment of developmental milestones. When the family had a holiday party at their house and it was time to say goodnight to the children, one of Dad’s coworkers visited Jose at sleep onset with dad. They observed Jose hitting his head on the pillow. Dad had not been alarmed by this activity, which Jose had been doing since about age 9 months, but then the co-worker reported about a distant family member who did this at bedtime and the co-worker seemed to recall that this child had severe developmental problems.

Now Jose’s father is very concerned about this behavior and what it means.

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 Jose and his family.

Bedtime Problems

Jose has no problems falling asleep by himself at home. He sleeps in a crib in his own room, falling asleep without the presence of one of his parents. He typically bangs his head into the pillow while lying on his back. The family can observe his behavior with a video baby monitor and notes he does this at sleep onset and once or twice during the night after awakenings, though he is able to return to sleep. If they go into the room and speak to him, he will stop the head banging and try to get them to pick him up. They resist going into to his room and he will usually fall asleep within 15 minutes.

Expert Insights
  • Head banging or other rhythmic movements occur at sleep onset and after awakenings during the night. Children can cease the activity if requested. Medical conditions that disrupt sleep such as OSA or gastroesophageal reflux may increase awakenings and subsequent head banging. Body rocking is the most common rhythmic movement behavior, followed by head rolling and head banging. Most of these behaviors will resolve by age 5 years.
  • Sleep related seizures can cause stereotypic movements and may occur only during sleep. Children cannot cease seizure activity upon command.
  • Sleep starts are a singular movement at sleep onset so are not repeated like rhythmic movement behaviors. Periodic leg movements are repeated behaviors but do not involve large muscle groups as rhythmic movement behaviors do.
Excessive Daytime Sleepiness

Jose is well rested in the morning and has appropriate napping behavior for his age.

Expert Insights
  • Rhythmic movement behaviors do not typically result in daytime sleepiness. Nocturnal seizures may also occur during wakefulness leading to what may appear as daytime sleepiness. PLMs/RLS may result in daytime sleepiness if sleep is sufficiently disrupted (see first case).

Jose will awaken once or twice a night and return to sleep within minutes with a repeat of his head banging behavior. Jose’s head banging does not awaken him but follows an awakening.

Expert Insights
  • Rhythmic movement behaviors will often be repeated throughout the night after awakenings.
  • Nocturnal seizures can occur throughout the night with stereotypic behaviors noted.
  • PLMs can also occur throughout the night but involve small muscle movements rather than movements of large muscle groups.
Regularity & Duration

Jose has a consistent bedtime and wake time. He has a regular bedtime routine and enough time in bed to obtain adequate sleep.

Expert Insights
  • This history helps determine what might be causing symptoms of non-restorative sleep and daytime sleepiness if they are felt to be an issue. It is important to determine if a child has adequate for age sleep before attributing daytime sleepiness to an underlying sleep disorder.
Sleep-Disordered Breathing / Snoring

Jose has mild snoring and restlessness noted during sleep.

Expert Insights
  • Screening for OSA is important as movements during sleep can be noted at the termination of respiratory events mimicking PLMs. Additionally, untreated OSA may result in awakenings and increased occurrence of rhythmic behaviors during sleep. Untreated OSA has also been linked to poorer control of seizures.

Jose's Evaluation & Diagnosis

What evaluation & diagnostic protocol should the provider use to diagnose Jose’s nighttime behaviors? Check all that apply and click submit for feedback.
Check all that apply:

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

  • Determine child’s sleep history.
    • Delineate symptoms at sleep onset as well as exacerbating/relieving factors.
  • Perform a physical exam.
    • Evaluate for signs of neuropathy or spinal cord injury that might contribute to leg movements.
    • Some children with head banging may develop hair loss or callous formation at the site of contact.
  • Order a Sleep Study
    • Jose has a history of snoring so evaluation for OSA is important as a cause for his snoring and/or awakenings which may lead to additional episodes of head banging.
  • Have family Videotape the events.
    • Characterize movements noted by family and help determine if they are consistent with head banging. This can be very important in determine if additional testing is necessary.

History is essential in the evaluation of Jose’s symptoms. If the movements noted are consistent with head banging and occur at sleep onset without affecting his daytime performance, his family can be reassured that these movements are a normal phenomenon and do not have long term effects. The sleep study will help determine if Jose also has OSA which needs further treatment. Home video taping can help confirm the diagnosis when Jose is in his usual environment and to document the behaviors noted at home. If Jose did not have signs or symptoms of OSA, the home video taping would be useful to confirm the rhythmic behaviors so a sleep study would not be required.

Elements of Jose's Sleep History

Sleep History Case Specific Information Jose's Evaluation Results

What happens at sleep onset?

  • What type of movement is noted? Can the child stop the movement if asked?
  • Does it happen more than once?
  • Does it only occur at sleep onset?
  • Does the child move their legs?
  • Does the child complain of leg discomfort?
  • Is there a family history of head banging?

What happens at sleep onset?

At sleep onset Jose goes to sleep by himself.  His family is able to watch his behavior in his crib via video baby monitor and notes head banging on his pillow at sleep onset and after awakenings.  No episodes of apnea noted.

Does the movement involve the entire body?

Does the child cry out?

Is the child afraid to fall asleep?

Does the child complain of leg discomfort?

Review timing of events at night (bedtime/wake time)

Does the same movement occur during sleep onset after awakenings during the night?

Jose is noted to bang his head on his pillow at sleep onset and after awakenings for a brief period. Head banging does not appear to change in frequency with stress or sleep deprivation.

Do these events occur more frequently with stress or sleep deprivation?

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

Is there snoring or apnea associated with movements?

The family also reports mild snoring intermittently and occasional restlessness.

Review of medications (antidepressants, seizure medications, and antihistamines all have impacts on sleep)

Is this child taking medications which can interfere with sleep onset such as stimulants?
Is there a history of gasteroesophageal reflux?

Jose is not taking any medications on a regular basis.   He has had no serious illnesses and he has never had seizures.  They have not noticed any symptoms suggesting gastroesophageal reflux.  


Assess for family history of sleep disorders.

Is there a family history of RLS, seizures or OSA?

  • There is no family history of PLMD,  RLS or a seizure disorder.
  • Grandmother reports that Jose’s father exhibited similar behavior when he was young. 

Perform a Physical Exam

Information to obtain includes: Case Evaluation Results

A physical exam should include vital signs, HEENT exam, cardiovascular exam, and a neurologic exam. The neurologic exam is important to evaluate for potential causes of movements including neuropathy, spinal cord injury or seizure disorder.

On physical exam Jose is well developed and well nourished. His HEENT exam shows a Mallampati of 2 with 2+ tonsils. The rest of his exam is normal. He has no signs of neuropathy.

Order a Sleep Study

Information to obtain includes: Case Evaluation Results

The sleep study will evaluate Jose’s snoring, looking for evidence of respiratory events, including apneas and hypopneas. Physiologic response to these events can be observed including drops in oxygen saturation and EEG arousals. Timing of head banging and preceding EEG can also be evaluated for possible seizure activity.

Jose’s family describes mild snoring, restlessness and awakenings during the night. A sleep study is indicated to determine if he has OSA. If so, his OSA should be adequately treated. OSA can cause awakenings during the night which may increase the frequency of head banging. If there is a concern for nocturnal seizures, additional EEG leads can be placed to determine if EEG abnormalities are associated with the rhythmic behaviors.

Have family videotape events

Information to obtain includes: Case Evaluation Results

Capturing video of the movement event in the home setting via a camera or cellphone

Most patients with isolated head banging do not need a sleep study to confirm the diagnosis. However, if there are signs/symptoms of other sleep disorders, a sleep study should be considered. If these events do not occur nightly, it might be very challenging to capture them on a sleep study. Home video taping affords the opportunity to evaluate the nature of the events and confirm they are consistent with head banging. If the movement recorded does not seem consistent with head banging, additional evaluation by sleep study may be indicated.

Options that are Not Recommended

Complete a Sleep Diary

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

Obtain an Epworth Sleepiness Scale Score

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

Refer to a Specialist

Referring to a specialist would not be helpful in this situation.

Red Flags

  • Have caregivers observe the rhythmic movements to determine the timing and extent. If more generalized movement occurs repeatedly during the night, nocturnal seizures may deserve additional consideration.
  • Caregivers should be noting whether the child is exhibits this behavior during wakefulness. This, combined with developmental issues, may suggest additional evaluation for neurological or developmental problems is in order.

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

Expert Insights:
Triggers for Head Banging

Evaluation & Diagnosis

What evaluation & diagnostic is consistent with Jose's night time behaviors?
Check all that apply:

Jose's signs and symptoms are consistent with:

  • Head banging.

In this case, Restless Leg Syndrome, seizure disorder, or Periodic Leg Movmenet Disorder (PLMD) are not consistent with the information provided.

Jose's Treatment & Referrals

Now, let’s recommend treatment options for Jose.
Check all that apply:

The following treatment strategies are recommended for head banging:

  • Reassurane.
    • Reassure family that head banging is commonly seen in normal, healthy children.
  • Avoid reinforcing the behavior.
    • Remind the family not to pay additional attention to Jose when he is banging his head to avoid reinforcing this behavior.
  • Screen for other sleep disorders.
    • Have family continue good sleep hygiene practices including enough time in bed for child to obtain adequate sleep.
  • Practice good sleep hygiene.
    • Screen for OSA or other sleep disorders
  • Review developmental status.
    • Schedule a visit with Jose’s PCP to review his developmental progress.

Treatment Strategies for Head Banging

  • Reassurance for family that head banging is noted in normal and healthy children and does not result in long term issues.
  • Remind family to continue their sleep routine at bedtime and not pay extra attention to Jose when he is banging his head at sleep onset or during the course of the night.
  • Stress the importance of good sleep hygiene practices including enough time in bed for the child to obtain adequate sleep.
  • Screen for OSA as a cause of nocturnal kicking.
  • Suggest a visit with Jose’s PCP to review his developmental status since a concern was raised by dad’s coworker that head banging is related to developmental delay.

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

  • If rhythmic behavior are occurring throughout the day, additional evaluation for neurologic or developmental issues may be indicated.
  • Family representatives may be helpful if the family is having a difficult time with reassurance about the benign nature of head banging.
  • Consider referral to sleep specialist if 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 neurology if there is a concern for seizures.

Interdisciplinary Treatment Components

Jose's Results:

Good news! Jose’s head banging is occurring less frequently. Dad has been reassured that he is doing well developmentally and that head banging is usually self-limited.

Treatment strategies for and results for Jose’s head banging:

  • Family reassurance that head banging is common in normal children and self limited. The family was able to understand that head banging is a self soothing behavior that is common in young children.
  • Continuation of good sleep habits with adequate time for sleep. Jose’s family was congratulated on their excellent sleep practices and encouraged to continue those. They were reminded not to call attention to Jose’s head banging to avoid reinforcing the behavior.
  • Screen for OSA. Jose did have mild snoring and restlessness. His sleep study was normal and raised no concerns.
  • Review of Jose’s developmental status. Jose’s provider was able to discuss his developmental status with his family and reassure the family that he is developmentally appropriate.