DOI: 10.1542/peds.2005-0532 2005


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DOI: 10.1542/peds.2005-0532 2005

  1. 1. DOI: 10.1542/peds.2005-0532 2005;116;1427-1432Pediatrics Michele L. Yang, Erika Fullwood, Joshua Goldstein and Jonathan W. Mink Disorder: 12 Cases and a Review of the Literature Masturbation in Infancy and Early Childhood Presenting as a Movement located on the World Wide Web at: The online version of this article, along with updated information and services, is rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Grove Village, Illinois, 60007. Copyright © 2005 by the American Academy of Pediatrics. All and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk publication, it has been published continuously since 1948. PEDIATRICS is owned, published, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly by on October 25, 2010www.pediatrics.orgDownloaded from
  2. 2. Masturbation in Infancy and Early Childhood Presenting as a Movement Disorder: 12 Cases and a Review of the Literature Michele L. Yang, MD; Erika Fullwood, MD; Joshua Goldstein, MD; and Jonathan W. Mink, MD, PhD ABSTRACT. Purpose. Infantile masturbation (gratifi- cation behavior) is not commonly identified as a cause of recurrent paroxysmal movements. Extensive and fruitless investigations may be pursued before establishing this diagnosis. Sparse literature is available regarding mas- turbatory behavior as a whole, but literature available as case reports describes common features. The purpose of this case series is to describe consistent features in young children with posturing accompanying masturbation. Methods. Twelve patients presenting to a pediatric movement disorders clinic with a suspected movement disorder were determined to have postures and move- ments associated with masturbation. We reviewed the clinical history, examination, and home videotapes of these patients. Results. Our patients had several features in com- mon: (1) onset after the age of 3 months and before 3 years; (2) stereotyped episodes of variable duration; (3) vocalizations with quiet grunting; (4) facial flushing with diaphoresis; (5) pressure on the perineum with character- istic posturing of the lower extremities; (6) no alteration of consciousness; (7) cessation with distraction; (8) nor- mal examination; and (9) normal laboratory studies. Conclusions. The identification of these common fea- tures by primary care providers should assist in making this diagnosis and eliminate the need for extensive, un- necessary testing. Direct observation of the events is crucial, and the video camera is a useful tool that may help in the identification of masturbatory behavior. Pe- diatrics 2005;116:1427–1432; movement disorders, neurol- ogy, masturbation, sexual behavior. ABBREVIATIONS. EEG, electroencephalography; PDC, paroxys- mal dystonic choreoathetosis. T he concept of childhood masturbation was rec- ognized as early as 1909 by Still.1 Masturbation involves stimulation of the genitals and typi- cally begins at ϳ2 months of age, although in utero masturbatory behavior has been reported also.2,3 In- cidence of this behavior typically peaks at 4 years of age and again in adolescence, occurring in 90% to 94% of males and 50% to 60% of females at some point in their lives.2 Although a normal behavior in childhood, it often is unrecognized by families and caregivers, especially because genital manipulation frequently is absent.2,4,5 In addition, in young chil- dren, unusual postures and movements can occur during masturbation and may lead the primary care provider to infer that seizures, abdominal pain, colic, or other neurologic or medical problems are present.6–9 The literature is sparse in delineating common characteristics of masturbatory behavior, with isolated case reports describing the events, ex- amination, and history. In almost all cases, extensive work-up has been performed, including magnetic resonance imaging (MRI), electroencephalography (EEG), intravenous pyelography, small bowel bi- opsy, and gastrointestinal barium swallow.8–14 In some cases, treatment with antiepileptic agents was initiated before establishing a diagnosis of masturba- tory behavior.8,13,14 However, recognition of mastur- batory behavior as an entity can eliminate the need for unnecessary tests. We report the clinical charac- teristics of masturbatory behavior in 12 patients who were referred for paroxysmal dystonic events. The purpose of this case series is to delineate the typical features of masturbatory behavior so that physicians can better recognize this disorder, prevent costly and invasive evaluations, and provide appropriate guid- ance to parents. REPRESENTATIVE CASE REPORTS Twelve girls were referred to a pediatric movement disorders clinic between 1997 and 2002 for evaluation of paroxysmal dys- tonic posturing. Referrals were made primarily from pediatric neurologists but also from primary care pediatricians. A detailed history was obtained, and patients underwent detailed general and neurodevelopmental examinations. All children were exam- ined by J.W.M. Videotapes of the events were obtained from the families and reviewed independently by all 4 authors. In all cases, the children were determined to have dystonia-like posturing during masturbation. Several features of the movements were identified and analyzed. These features included age of onset, color changes, features of the head/face, arm posture, leg posture, vocalization, pelvic movements, similarity from event to event, responsiveness during the episode, cessation with distraction, prior evaluation by a neurologist, previous testing, and results of the neurologic examination. Case 2 Case 2 involves a 3-year-old girl who was the product of a pregnancy complicated by transverse presentation resulting in a cesarean section. The neonatal course was unremarkable. Her mother first noted spells at 3 months of age. She began twisting her neck and upper trunk with associated “moaning.” The spells From the Department of Child Neurology, Children’s Hospital of Pitts- burgh, Pittsburgh, Pennsylvania; Children’s Hospital Boston, Boston, Mas- sachusetts; Children’s Memorial Hospital, Epilepsy Center, Chicago, Illi- nois; and Department of Neurology, University of Rochester Medical Center, Rochester, New York. Accepted for publication May 18, 2005. doi:10.1542/peds.2005-0532 No conflict of interest declared. Address correspondence to Jonathan W. Mink, MD, PhD, Department of Neurology, University of Rochester Medical Center, 601 Elmwood Ave, Box 631, Rochester, NY 14642. E-mail: jonathan࿝ PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Acad- emy of Pediatrics. PEDIATRICS Vol. 116 No. 6 December 2005 1427 by on October 25, 2010www.pediatrics.orgDownloaded from
  3. 3. lasted up to 1 hour but were not associated with any change in responsiveness or interaction. At 15 months, the movements evolved to include twisting of her trunk and arms. The episodes occurred up to 10 times a day but were more frequent when she was tired. Family history was significant for a sister with quadri- plegic cerebral palsy and an older sister with aortic stenosis. Work-up and evaluation included an MRI of the brain and EEG, both of which were normal. Before referral, she was treated with trihexyphenidyl, baclofen, clonidine, amitriptyline, carbidopa/ levodopa, and carbamazepine, all without change in the frequency or character of the episodes. She was referred to our movement disorder center, at which she was found to have mild global developmental delay, but she had normal general pediatric and neurologic examinations. A home video showed her lying on her right side, with both hips flexed and adducted, the right knee was extended and the left knee was flexed, the ankles were plantar-flexed. Rhythmic pelvic rocking was present throughout the episode. The left arm was flexed at the elbow and wrist with the hand placed over her abdomen. The right arm was extended at the elbow and wrist. The neck was extended as well. Grunts, cries, snorting sounds, and whimpers were heard at times. The episodes tended to occur while she was getting ready to sleep. Her parents were consis- tently able to distract her during the episode, which caused the movements to pause or cease. Case 7 Case 7 involves a 31⁄2-year-old girl who was the product of a pregnancy complicated by preterm labor treated with magnesium. Subsequent term delivery and postnatal course were unremark- able. At 5 months, she was noted to have episodes in which she would “tense up her body” and turn red. She was reported to be responsive throughout the episodes. The spells increased in fre- quency as she became older, occurring multiple times a day. She reported that she “had to stiffen.” After longer episodes, she would respond affirmatively if asked whether her body “hurts.” The movements were most likely to occur when she watched television, listened to stories being read to her, or was sleepy. Before referral she had an extensive work-up that included brain MRI, head computed tomography, EEG, and upper and lower gastrointestinal series, all of which were normal. She was treated with carbidopa/levodopa, carbamazepine, and several other an- tiepileptic medications, all without improvement. She was re- ferred to our movement disorder center, at which she had normal general pediatric and neurologic examinations. A home video showed her lying on her left side, partially prone, flexed at the hip and knees and plantar-flexed at the ankles. The left calf rested on top of the right knee or thigh. The left arm was extended and placed on the abdomen. She rhythmically con- tracted and relaxed the thigh muscles and tilted her pelvis. Occa- sional grunting and breath-holding were observed. At times, her face reddened and she displayed various facial expressions, gri- maces, smiles, or staring with an open mouth. She consistently was able to stop the movements to talk or pay attention to a story being read to her. Case 9 Case 9 involves a 41⁄2-year-old girl who began to have epi- sodes of stiffening at 5 months of age (Figs 1 and 2; see also Videos 1 and 2, which is published as supporting information on www. The episodes occurred when lying on her back and consisted of cross- ing and stiffening the legs, straightening the arms, making “grab- bing motions” with the hands, and pursing the lips. During these episodes, her breathing became irregular and she perspired. They occurred multiple times a day, lasting from seconds to hours, but her parents could talk to her and stop the spells. She often told her parents that she couldn’t stop but “had to stretch.” Her work-up included 2 brain MRIs, 2 prolonged EEGs, an upper gastrointes- tinal series, lumbar puncture, electromyography, and extensive laboratory testing, all of which were normal. She was described by her parents as being bright and energetic. Her development was normal, as were her general pediatric and neurology examina- tions. On the video, she reclined in a chair with adducted hips, extended legs, and occasional scissoring of the bilateral lower extremities. Rhythmic pelvis rocking continued while she con- versed with her parent. Occasionally, she paused in the conversa- tion, grimaced, stared, grunted quietly, and then resumed the conversation. When asked what she was doing, she said she was “stretching.” She stated that it did not hurt but that it “feels good all over.” On subsequent follow-up at the age of 11 years, the parents reported that the patient continued to have occasional episodes of “stretching,” precipitated by fatigue. She also has episodes of rocking backing back and forth, with thrusting movements of buttocks, while riding in a car. Case 11 Case 11 involves a 2-year-old girl who was referred by a pedi- atric neurologist for spells of back-arching. She was a term infant born without complications. Approximately 1 year before evalu- ation, she developed spells that always occurred while sitting in a high chair. The episodes were described as starting with rhythmic movements of the right fingers, then rhythmic movements of the right arm, followed by “jerking” of all 4 extremities with back- arching, head tilt, and mouth-grimacing. She appeared responsive during each of the episodes. Her parents report that she re- sponded to her name but appeared to have a “dazed,” distant facial expression. Before referral, she had multiple studies includ- ing a routine EEG, MRI of the head, and laboratory testing for thyroid function, heavy metals, ceruloplasmin, antistreptolysin O titer, basic metabolic panel, lactate, and pyruvate. All studies were normal. Initially, based on the history, she was thought to have seizures. She had a trial of carbamazepine without any change in the episodes. She was referred for additional evaluation of these episodes. Her development was normal, as were her pediatric and neurologic examinations. A home video showed several episodes occurring while she was sitting in a high chair. There were rhythmic, repetitive flexion and extension of the right fingers, sustained plantar flexion, and rhythmic pelvic thrusting against the seat of her high chair. Dur- Fig 1. Still image from time 00:00 of video segment 1. Fig 2. Still image from time 00:00 of video segment 2. 1428 MASTURBATION PRESENTING AS A MOVEMENT DISORDER by on October 25, 2010www.pediatrics.orgDownloaded from
  4. 4. ing the episode, she appeared dazed, with grimacing and repeti- tive eye blinks. Occasionally, she demonstrated tonic extension of the trunk. The episodes had abrupt starts and stops. She was awake and responsive throughout each spell. Case 12 Case 12 involves a 21⁄2-year-old girl who was referred by a pediatric neurologist for spells of posturing. She was a 32-weeks’- gestation infant born to a mother with mild mental retardation and drug and alcohol use during the pregnancy. The patient had no postnatal problems but was in foster care until 2 months of age, when she was adopted by her current adoptive parents. At 1 year of age, she developed posturing, usually while in a high chair or car seat. “Build-up” was noted in which she would tense and then sustain a twisting posture of both legs and occasionally of the hands. During these spells she would grunt and had periods of heavy breathing without loss of consciousness. She was able to respond to her parents throughout. They were able to distract her out of the episode, but it would require a strong motivating stimulus to get her to stop. Occasionally, she would continue to have “build-up” with tensing of the legs, then finally sigh and fall asleep. She was able to get up immediately and run around normally. Before referral, she had extensive testing because of these episodes, including several EEGs and brain MRIs, all of which were normal. A pH probe was normal. Genetic testing for the DYT1 mutation and the dentatorubropallidoluysian (DRPLA) triplet repeat was negative. She had medication trials with car- bamazepine, phenytoin, lorazepam, and gabapentin, which did not change the frequency or the character of these events. She developed a rash while on carbamazepine. Her development was normal, although the parents thought that she was clumsier than other children her age. Pediatric and neurologic examinations were normal. Video review showed several episodes occurring when she was sitting in a high chair or car seat. Occasionally the events occurred when awaking from a nap. In the event, 1 leg was crossed over the other, with plantar flexion bilaterally. Her thighs adducted and abducted in a rhythmic manner and was associated with pelvic thrusting. She also had rhythmic extension and flexion of her fingers with variable internal-external rotation at the shoulders. Facial flushing, facial grimacing, and diaphoresis accompanied these events. She appeared dazed and glassy eyed during the episodes. After 1 episode, she appeared to suddenly relax and fall asleep. During these spells, the parents were able to get her attention, with brief cessation of this rhythmic activity. RESULTS Review of the clinical and movement characteris- tics of these patients revealed several common fea- tures (Table 1). All 12 patients were female. No boys have been referred to our clinic for evaluation of similar movements associated with masturbation. The age-of-onset range was 3 months to 3 years, with a median age of 9 months and mean age of 11 months. Eight of 11 patients had facial flushing. Twelve of 12 had quiet grunting or irregular breath- ing. All 12 patients had stereotyped dystonia-like posturing of the neck, arms, legs, or a combination. All 12 patients had rhythmic pelvic movements. Four of 12 had diaphoresis. Episode duration ranged from less than 1 minute to several hours. All patients were responsive to their parents during the epi- sodes. None had alteration of consciousness during the episode. In all 12 patients, the posturing ceased when the child was distracted by the parent or be- came engaged in another activity. All 12 patients had normal neurologic examinations. These movements had been cause for significant concern on the part of the parents and primary care physicians. This concern was reflected in the fact that 11 of the 12 patients were referred to our movement disorders clinic by other neurologists. Ten of the 12 had under- gone previous diagnostic testing including MRI, EEG, or metabolic testing. Four of the 12 had inva- sive diagnostic testing including lumbar puncture or muscle biopsy. Eight of the 12 had been treated previously with antiepileptic medication, benzodiaz- epines, anticholinergic medication, or levodopa. DISCUSSION Masturbation is a common normal behavior.2 However, in infants and toddlers, this behavior can be difficult to recognize because of the absence of genital manipulation and the many manifestations of this behavior. In adults, the physiologic changes that occur during such activity have been well docu- mented: in the excitement phase, a sharp increase in heart rate, respiratory rate, and blood pressure is accompanied by muscular contraction.15 Initially, lower pelvic muscles contract, which then is accom- panied by co-contraction of the extremities, back, and buttocks, resulting in involuntary posturing. At the plateau stage, contractions become rhythmic, and the body can then momentarily stiffen. This is fol- lowed by the resolution phase in which muscular tension decreases and blood is released from en- gorged muscles. In infants and toddlers, these changes are less well recognized and include mani- festations such as rubbing the thighs together and rocking the body against another object.13,16 Co-con- traction of muscles can also occur, and, as in adults, can result in unusual posturing. Several authors who have described cases of masturbatory behavior have recognized posturing as a feature but not as a com- mon one.10,11,13 For instance, Nechay et al,14 who reviewed 31 cases of masturbatory behavior, found that the majority were referred for possible seizures, and only 1 was referred for dystonia. Apparent dys- tonia was a key descriptive feature of the event in 19 of 31 cases. In Fleisher’s case series, posturing was stereotyped with tightening of the thigh muscles or mechanical pressure to the suprapubic or pubic area, with intermittent quiet grunting, irregular breathing, facial flushing, and diaphoresis.9 In our case series, masturbation was previously misdiagnosed as a movement disorder, usually dys- tonia, resulting in extensive diagnostic testing in the majority of our patients and initiation of multiple medications. In his article on masturbatory behavior, Fleisher and Morrison9 described 12 features of the history, description of the events, and examination common to the clinical presentation of his 5 patients. We found similar common features in our patients that we feel distinguish masturbatory behavior. On- set occurred after the age of 3 months and before 3 years, with stereotyped episodes of variable dura- tion. From all the children vocalizations with quiet grunting and irregular breathing could be heard. Facial flushing with diaphoresis often was present. Patients assumed characteristic posturing of the lower extremities with pressure on the perineum. Consciousness was preserved throughout the epi- sodes, with cessation of the activity with distraction. In all cases, laboratory studies and examination were ARTICLES 1429 by on October 25, 2010www.pediatrics.orgDownloaded from
  5. 5. TABLE1.CharacteristicFeaturesofEventsonVideoReview PatientAgeof Onset Color Change Head/FaceArmPostureLegPostureVocalizationPelvic Movements Episodes Stereotyped ResponsiveEpisodes CeaseWith Distraction Previously Seenby Neurologist Previous Testing (MRI,EEG, Lumbar Puncture, etc) Neurologic Exam 16moFlushingStaringNormalHipflexion;thigh adduction QuietgruntingRhythmicYesYesYesNoNoNormal 23moFlushingStaringTwistingHipflexion;thigh adduction QuietgruntingRhythmicYesYesYesYesYesNormal 33yFacenot seen FacenotseenExtensionHipextension;thigh adduction QuietgruntingRhythmicYesYesYesYesYesNormal 43moFlushingStaringTwistingHipflexion;thigh adduction QuietgruntingRhythmicYesYesYesYesYesNormal 54moFlushingNecktwistingTwistingHipextensionQuietgruntingNoYesYesYesYesYesNormal 612moNochangeStaring;open mouth FistsclenchedThighadductionHeavybreathingRhythmicYesYesYesYesYesNormal 75moFlushingNecktwistingTwistingThighadductionQuietgruntingRhythmicYesYesYesYesYesNormal 81yFlushingStaring;neck twisting TwistingSitsonfootQuietgruntingRhythmicYesYesYesYesYesNormal 913mo?(dark skin) StaringExtensionwith fistsclenched Hipflexion;thigh adduction QuietgruntingRhythmicYesYesYesYesYesNormal 103moFlushingStaringTwistingHipflexion;thigh adduction QuietgruntingRhythmicYesYesYesYesYesNormal 112yFlushingStaring; grimace FistingHipflexion;thigh adduction QuietgruntingRhythmicYesYesYesNoNoNormal 121yNochangeStaringTwistingwith fistsclenched ThighadductionQuietgruntingRhythmicYesYesYesYesYesNormal 1430 MASTURBATION PRESENTING AS A MOVEMENT DISORDER by on October 25, 2010www.pediatrics.orgDownloaded from
  6. 6. normal. The episodes usually occurred in the context of boredom or states of excitement or anxiety. In our series, direct observation of these events was invaluable; this cannot be overemphasized. As a rule, in evaluating possible movement disorders, di- rect observation is essential for the clinician to make a diagnosis. The use of home videos for the assess- ment of tics has been described by Goetz et al.17 Because events can be fleeting, as well as environ- ment and state dependent, they may not be wit- nessed in a limited office setting. Goetz et al found that when 3 environments were compared (home with family, home alone, and office), tics were more pronounced when the patient was home alone and not in the office. The severity and character of the tics were increased dramatically in some cases as com- pared with the office setting. Similarly, with mastur- batory behavior, these events may not be witnessed in the office. What can be portrayed in the history as dystonia or seizures can appear differently on direct observation. Others have emphasized the impor- tance of direct observation in masturbatory behavior as well.10,13 In case 12, a neurologist concluded that the patient had seizures by history, but when multi- ple medications failed, the conclusion was made that the symptoms represented dystonia. Direct observa- tion was the key to diagnosis in this case. Mistaken diagnosis by event description only is understandable. The spectrum of paroxysmal events in children, especially in the infant and toddler pe- riod, is broad.6,7 The distinction between masturba- tory behavior and seizures can be difficult. Children with masturbatory behavior can appear to have al- tered consciousness with a glassy-eyed, fixed gaze. However, a key feature to masturbatory behavior is that it is volitional and can cease with distraction. Children will often appear annoyed if they are inter- rupted. In addition, torsional postures and rocking are uncommon in seizures.8,13 Another diagnostic consideration is paroxysmal dystonic choreoatheto- sis (PDC). Episodes of PDC can occur bilaterally or unilaterally without triggering factors and last for variable periods of time.18,19 Children under the age of 1 year can be affected. In contrast to PDC, how- ever, children with masturbatory behavior can abruptly and easily move out of their assumed pos- tures. However, even for experienced movement dis- orders specialists, the distinction between paroxys- mal movement disorders and masturbatory behavior can be difficult.20 Once the diagnosis of masturbatory behavior is made, a history of sexual abuse and perineal irrita- tion should be ruled out.2,9 Masturbatory behavior has been reported in sexually abused children.21 Per- ineal discomfort such as that caused by vulvovagi- nitis, urinary tract infections, or dermatitis may ex- acerbate the behavior but may also be the result of the behavior.13,16 The exact relationship between per- ineal irritation and masturbatory behavior is unclear: perineal irritation may intensify the behavior and increase the frequency with which it is performed. On the other hand, daily application of friction to the perineum may precipitate irritation of the region. In either case, an external genital examination should be performed, and perineal irritation should be treated. If the physical and neurologic examinations are normal, no additional diagnostic testing needs to be performed. Reassurance for the family is the key to management, with redirection should the behav- ior prove embarrassing for the family or occur in public.2,9 The parents should be educated that this is a normal behavior resulting from random explora- tion of the body by the infant.2 Masturbation likely is initiated when the infant discovers that certain ma- neuvers can bring about a pleasant and comforting sensation. It may be viewed in the same category as thumb-sucking, body-rocking, or other behaviors that infants use to enhance comfort. This behavior may subside as the infant becomes engaged in other objects or activities in the environment. Again, the parents should be reassured that this is a normal behavior and it may be seen in infancy.7,10,14,16 Little is available in the literature regarding long- term follow-up of children with masturbatory behav- ior. In a study on normal sexual behavior in children, sexual behavior that appeared most frequently in- cluded self-stimulating behaviors and peaked at 5 years of age for both boys and girls, dropping off over the next 7 years.4 For the most part, these chil- dren have normal development and the behaviors do subside. Providers should note that masturbation is a behavior seen at all ages, as it was for the girl in case 9, who, at the age of 11 years, continues to exhibit this behavior, particularly in times of mild anxiety. We suggest a few practical points for management of masturbatory behavior: 1. Videotape the event in question. Not only will this facilitate diagnosis, but viewing it with the par- ents can help them realize that it is not a life- threatening event. 2. Help parents change their view of the child’s be- havior as a disease. This is a normal behavior, and parents should view it as a harmless, nonpainful habit. 3. Scolding or threatening the child is not appropri- ate. Efforts to stop the behavior forcefully will only reinforce it and possibly instill a sense of shame or wrong-doing as the child gets older. 4. Redirection can be helpful. Engaging the child’s interest in other activities or toys can draw her attention away from the behavior. 5. As the child gets older, a milestone can be defined to end the behavior, at least in public. For in- stance, 1 parent used the child’s fourth birthday as an opportunity to tell the child, “Now you’re 4 and a big girl. Big girls don’t have to use diapers anymore. Big girls also don’t do ‘stretchies’ out- side of the house. Let’s try to do our ‘stretchies’ at home.” 6. Some parents can be offended by a discussion of masturbation with regard to their child. We some- times use the term “gratification behavior” in- stead of masturbation when discussing this be- havior with parents. REFERENCES 1. Still GF. Common Disorders and Diseases of Childhood. London, United Kingdom: Oxford University Press; 1909:336–380 ARTICLES 1431 by on October 25, 2010www.pediatrics.orgDownloaded from
  7. 7. 2. Leung AK, Robson WLM. Childhood masturbation. Clin Pediatr (Phila). 1993;32:238–241 3. Meizner I. Sonographic observation of in utero fetal “masturbation.” J Ultrasound Med. 1987;6:111 4. Friedrich WN, Fisher J, Broughton D, Houston M, Shafran CR. Norma- tive sexual behavior in children: a contemporary sample. Pediatrics. 1998;101(4). Available at: 4/e9 5. Bradley SJ. Childhood female masturbation. Can Med Assoc J. 1985;132: 1165–1166 6. Bower B. Fits and other frightening or funny turns in young children. Practitioner. 1981;225:297–304 7. Shuper A, Mimouni M. Problems of differentiation between epilepsy and non-epileptic paroxysmal events in the first year of life. Arch Dis Child. 1995;73:342–344 8. Livingston S, Berman W, Pauli LL. Masturbation simulating epilepsy. Clin Pediatr (Phila). 1975;14:232–234 9. Fleisher DR, Morrison A. Masturbation mimicking abdominal pain or seizures in young girls. J Pediatr. 1990;116:810–814 10. Casteels K, Wouters C, Van Geet C, Devlieger H. Video reveals self- stimulation in infancy. Acta Paediatr. 2004;93:844–846 11. Couper RT, Huynh H. Female masturbation masquerading as abdom- inal pain. J Paediatr Child Health. 2002;38:199–200 12. Finkelstein E, Amichai B, Jaworowski S, Mukamel M. Masturbation in prepubescent children: a case report and review of the literature. Child Care Health Dev. 1996;22:323–326 13. Mink JW, Neil JJ. Masturbation mimicking paroxysmal dystonia or dyskinesia in a young girl. Mov Disord. 1995;10:518–520 14. Nechay A, Ross LM, Stephenson JBP, O’Regan M. Gratification disorder (“infantile masturbation”): a review. Arch Dis Child. 2004;89:225–226 15. Masters WH, Johnson VE. Human Sexual Response. Boston, MA: Little, Brown and Company; 1966 16. Bakwin H. Erotic feelings in infants and young children. Am J Dis Child. 1973;126:52–54 17. Goetz CG, Leurgans S, Chmura TA. Home alone: methods to maximize tic expression for objective videotape assessments in Gilles de la Tourette syndrome. Mov Disord. 2001;16:693–697 18. Richards RN, Barnett HJ. Paroxysmal dystonic choreoathetosis: a family study and review of the literature. Neurology. 1968;18:461– 469 19. Lance JW. Familial paroxysmal dystonic choreoathetosis and its differ- entiation from related syndromes. Ann Neurol. 1977;2:285–293 20. Frucht S, Fahn S. Paroxysmal kinesigenic dyskinesia in infancy. Mov Disord. 1999;14:694–695 21. Sauzier M. Sexual abuse of children and adolescents. Audio Dig Psychi- atry. 1984;13(17) College Textbook Prices Surge at Twice the Inflation Rate “Once just a weighty tome, the college textbook has evolved into a package including text, colorful supplements and software. But those bells and whistles, which critics and many students call unnecessary, are the main reason textbook prices are rising at more than twice the rate of inflation, according to a new government report. The Government Accountability Office, in a study officially being released today, finds the average student spends nearly $900 on textbooks and supplies, or 26% of tuition and fees per year at typical public four-year colleges. . . . Critics say publishers are gouging students, ‘bundling’ their products with unnecessary add-ons and undermining the market for used textbooks by coming out with new editions—even in subjects that evolve little if at all, such as Latin.” Associated Press. Wall Street Journal. August 16, 2005 Noted by JFL, MD 1432 MASTURBATION PRESENTING AS A MOVEMENT DISORDER by on October 25, 2010www.pediatrics.orgDownloaded from
  8. 8. DOI: 10.1542/peds.2005-0532 2005;116;1427-1432Pediatrics Michele L. Yang, Erika Fullwood, Joshua Goldstein and Jonathan W. Mink Disorder: 12 Cases and a Review of the Literature Masturbation in Infancy and Early Childhood Presenting as a Movement & Services Updated Information including high-resolution figures, can be found at: Supplementary Material Supplementary material can be found at: References at: This article cites 15 articles, 4 of which you can access for free Citations les This article has been cited by 1 HighWire-hosted articles: Rs)3Peer Reviews (P Post-Publication R has been posted to this article:3One P Subspecialty Collections Office Practice following collection(s): This article, along with others on similar topics, appears in the Permissions & Licensing tables) or in its entirety can be found online at: Information about reproducing this article in parts (figures, Reprints Information about ordering reprints can be found online: by on October 25, 2010www.pediatrics.orgDownloaded from