This chapter addresses the key points of the clinical approach to evaluation of movement disorders in children. By convention, the term movement disorders designates conditions where one or both of the following occur: (1) impairment in initiation and/or execution of movement occurs that is not due to weakness; and/or (2) adventitious movements occur that are not automatic, purposeful, or goal directed. A common classification scheme divides phenomena into hyperkinetic and hypokinetic conditions, although this distinction can be imperfect when observing certain movement problems. Mastery of diagnosis involves a combination of visual pattern recognition and understanding principles of neuroanatomy and phenomenologic classification. This chapter and the following 2 chapters will emphasize practical approaches to more common conditions.
Parents, guardians, and general physicians have an expectation and understanding of the trajectory of typical development of motor control. Although there is variability, referrals to pediatric neurologists often involve recognition that motor control has fallen off the curve of expected gains, as in children who are ataxic or clumsy, or, more commonly, that an abnormally appearing movement is occurring, as in children with tics, stereotypies, or tremor. Comprehensive medical, developmental, family, and social history and general neurologic and physical examinations are vital for rarer presentations. Some typical straightforward presentations may be recognized quickly in the clinic room or based on a smartphone video brought to the visit.
The time-tested approach to diagnosis of movement disorders involves pattern recognition of phenomenology based on visual observation and findings on neurologic examination.1 Understanding principles of normal function of cortical-striatal-pallidal-thalamo-cortical circuits as well as input and output pathways supporting cerebellar function is stimulating and can play a role in more complex presentations but lies outside the scope of this text. Ultimately, the goals of initial clinical phenomenologic assessments are to make decisions about whether to obtain additional medical diagnostic testing and to determine approaches to treatment or management.
Given the crucial role of observation, the clinician should observe the patient as much as possible, even while taking a history. Successful encounters with younger children may involve play, so age-appropriate toys may be offered during the history with the parent. With a verbal child, direct communication about the subjective experience of the movement and its impact on life at home, school, and with friends is very important. Taking time to establish a trusting relationship with parent and child is therefore important, and “small talk” about school, home life, and fun activities often helps accomplish this.
Some parents believe they are protecting their child by discussing the movement problem without the child present. This can create more, rather than less, emotional distress, while inhibiting the clinician’s opportunity to obtain critical information directly from the child. Verbal, school-age children usually have sufficient awareness of their movement disorder phenomenology and may want to know more about it.