ORIGINAL RESEARCH

Abnormal Involuntary Movements in

Neuroleptic-Naive Children and Adolescents
Mark Magulac, MDt, John Landsverk, PhD'\ Shahrokh Golshan, PhD3 , Dilip V Jeste, MD4

Objective: To determine the prevalence ofand identify riskfactors for abnormal involuntary movements in a well-
characterized community sample ofneuroleptic-naive children and adolescents.
Method: The Abnormal Involuntary Movement Scale (AIMS) was administered to 390 subjects aged 3-17 years
who were in foster care. Additional instruments were used to assess intellect and behaviour problems.
Results: A total 12.6% ofsubjects hadat least I rating of "mild" movements on AIMS; these included 4.1% with at
least 2 ratings of "mild" or 2 of "moderate " severity. Significant riskfactorsfor movement disorder were younger
age, lower IQ, and more severe behaviour problems. The abnormal movements were usually orofacial, and the af
fected subjects were generally unaware ofthese movements.
Conclusion: The base prevalence ofabnormal involuntary movements must be considered in children and adoles-
cents assessedfor medication in order to determine the true rate ofmotor side effects.

(Can J Psychiatry 1999;44:368-373)

Key Words: foster care, movement disorder, tardive dyskinesia, antipsychotics, mental retardation, psychosis

he term "dyskinesia" includes choreoathetosis, dystonia,

T stereotypies, and tics but not tremor or myoclonus (1).
Kane and Smith estimated a 5% prevalence of spontaneous
dyskinesia from 19 adult studies including psychiatric or de-
mented subjects not treated with neuroleptics (2). The base-
line prevalence of movement disorder (MD) has been
Part ofthis work was presented at the 41st Annual Meeting ofthe American
Academy of Child and Adolescent Psychiatry, New York, NY, October
25-30, 1994.
Manuscript received September 1997, revised, and accepted August 1998.
1Associate Clinical Professor, Department ofPsychiatry, University ofCali-
fornia, San Diego, California.
2Professor, School of Social Work, San Diego State University, San Diego,
California.
3Associate Project Scientist, Psychiatry Service, San Diego Veterans Affairs
Medical Center, San Diego, California.
4Professor of Psychiatry and Neurosciences, Director, Geriatric Psychiatry
Clinical Research Center, University of California, San Diego; Psychiatry
Service, San Diego Veterans Affairs Medical Center, San Diego, California.
Address for correspondence: Dr DV Jeste, San Diego VA Medical Center
(116A-l), 3350 La Jolla Village Drive, San Diego, CA 92161
email: djeste@ucsd.edu
Can] Psychiatry, Vol 44, May 1999
reported to increase with age (3), reduced intellectual capac-
ity (4-6), medical disorders (7,8), and poor dental health (9)
or lack of teeth (10).
Neuroleptic-induced tardive dyskinesia (TD) is themost
widely researched iatrogenic MD in children and adolescents
(11-21). Research diagnosis of TD requires a minimum of3
months' history of neuroleptic exposure, at least 3 months'
duration of dyskinesia, and a specified severity threshold
(22). Populations with high baseline rates ofMDs may cause
inflated estimates of TD prevalence when the neuroleptic
treatment duration is 3 months or longer (23).
TD prevalence in younger populations has primarily been
studied in individuals with autism (12,24-26) and mental re-
tardation (27-29), who are predisposed to stereotypies and
other abnormal involuntary movements. Conclusions from
these studies are somewhat limited by a lack ofcontrolgroeps
sharing the same psychopathology and by the difficulty in
distinguishing stereotypies from neuroleptic-induced dyski-
nesias (30). Nevertheless, Gualtieri and others reported that
young subjects who developed TD had higher daily andtotal
lifetime neuroleptic amounts (27,31). In this analysis, low IQ
was also a significant risk factor but might have been

368
May 1999 Abnormal Involuntary Movements in Children and Adolescents
confounded by the more intense and prolonged treatment
with neuroleptics.
We attempted to determine the risk factors for MDs and
the prevalence, severity, and distribution ofMD symptoms in
a community sample of children and adolescents in foster
care who were at an increased risk for cognitive and behav-
,iour problems but not treated with psychotropic drugs.
Method
Subjects
The subjects were 423 children, aged 3-17 years old, who
required new court-ordered, out-of-home placement and
were still in foster care 6 months later. These subjects com-
prised the community sample of the Foster Care Mental
.Health Project, a prospective study of placement and treat-
ment decisions made by mental health workers in San Diego
County. The history of family dysfunction and foster home
olacement suggested that the population was at an increased
-risk for psychiatric morbidity.
Subjects were excluded if they were less than 3 years old
.oecauseofanticipated difficulties in comprehension, concen-
:ration, and cooperation with the Abnormal Involuntary
Movements Scale (AIMS) (32). No medical or psychiatric di-
ignoses resulted in exclusion, but past neuroleptic treatment
) f current psychotropic-medication use was an exclusion cri-
:erion. Medical health status and all current medications were
assessed at the time of the evaluation.
Assessment
Detailed neuropsychiatric, pharmacological, and other
medical histories were obtained, and psychiatric and physical
examinations were performed. Specific instruments, de-
scribed below, were used to evaluate intellect, behaviour
.problems, and MDs.
:. Intellect. The Peabody Picture Vocabulary Test-2
::PPVT-2) was used to estimate IQ (33). The standard scores
In this measure are scaled for age to allow comparison among
different age-groups. The PPVT-2 estimates of intelligence
In children and adolescents are comparable to those arrived at
Jy the Weschler Intelligence Scale for Children (34).
Behaviour Problems. The major behaviour instrument
vas Achenbach's (35) Child Behavior Checklist (CBC). It
vas completed with the help of the subject's primary care-
aker based on the subject's behaviour during the previous 3
nonths. The CBC yields a "total problem score," which,
vhen elevated above the 90th percentile (T-score = 63), iden-
ifies 82% ofthe children and adolescents that are referred for
nental health care (35). A cutpoint at the 82nd percentile (T-
'core ~ 60) may be used to identify subjects with borderline
ehaviour problems.
369
Abnormal Involuntary Movements. The AIMS was devel-
oped by the Psychopharmacology Research Branch of the
National Institute of Mental Health (NIMH) (32) to assess
neuroleptic-induced and other MDs in adults. It has been ap-
plied to children and adolescents at risk for TD by several re-
searchers with good interrater reliability (11,27,29,36). This
study used the AIMS without attempting to discriminate
among different types of MDs. The AIMS ratings include
choreoathetotic and stereotypic movements and tics but ex-
clude tremor and myoclonus.
The AIMS examination used in this study was modified,
as described by Munetz (37), to omit the original AIMS con-
vention of subtracting I point of the severity rating when an
abnormal movement was seen during a prescribed activated
motor state (such as rapidly alternating fmger movements).
When he or she was examining children, it was helpful for the
examiner to model the AIMS examination postures.
Raters were 11 graduate-level students who attended
group training, which included calibration of severity ratings
to videotaped ratings of 20 young subjects with movement
disorders by Gualtieri and others (38). Ongoing instruction
included blind ratings and discussion of videotaped AIMS
examinations.
MDs may vary in intensity within the same patient. Anxi-
ety and brief voluntary suppression are factors in such vari-
ability (39). In this study, children interacted with the rater for
30 minutes before the AIMS assessment, allowing the child to
become accustomed to the rater and the rater to observe
movements for a prolonged period without the child's aware-
ness. Raters usually required approximately 10 minutes to
complete the AIMS examination and record the ratings.
Statistical Analysis. The data were analyzed using Statisti-
cal Package for the Social Sciences (SPSS) software. The
group differences were studied using 2-tailed t-tests, analysis
of variance (ANOVA), or chi-square, and relationships
among variables were examined using Pearson correlation
coefficients. A logistic regression analysis was performed to
determine predictors of MDs.
Results
This study included 390 subjects from the original pool of
423 intended subjects. Nineteen potential subjects were ex-
cluded because they were currently being treated with psy-
chotropic drugs-specifically, an antidepressant (n = 1), a
neuroleptic (n = 5), an anticonvulsant (n = 6), and a stimulant
(n = 7). Two intended subjects refused, and 1 was unable to be
tested because of severe hyperactivity. Eleven other subjects
were excluded after I rater who had rated those subjects failed
the AIMS trainer's minimum eligibility, which required con-
currence with the AIMS "gold standard" in more than 50% of
the ratings. The Intraclass Correlation Coefficient (ICC) (40)
for AIMS score was 0.69.
370 The Canadian)ournal of PsycWatry Vol 44,No4

Table l. Frequency and severity of abnormal movements on AIMS on the AIMS ratings. One required at least 1 rating of2 (mild)
exam (% of total) on any ofthe first 7 items ofthe AIMS (mild MD). The other
Minimal or Moderate or more conservative definition required at least 2 ratings of2
None borderline Mild severe (mild) or 1 rating on (moderate) on any ofthe first 7 items of
(score = 0) (score = I) (score = 2) (score = 3 or 4)
the AIMS. This second definition is similar to the Research
Muscles of face 82 15 3 OJ Diagnosis ofTD (RD- TD) criteria proposed by Schoolerand
Lips and 87 10 3 OJ Kane (22) and will be referred to henceforth as "RO-MD,"
perioral
Sixteen subjects (4.1 % prevalence) met the criterion for
Jaw 91 6 2 OJ RD-MD, and 49 subjects (12.6% prevalence) met or ex-
Tongue 87 10 2 OJ ceeded the criterion for mild MD. The mean sum ofthe AIMS
Upper 93 6 body-region ratings (items 1-7) was used for dimensional
extremities analyses.
Lower 90 9
extremities
Topographic Distribution
Neck, 96 3 MDs appeared most frequently in 1 ofthe 4 facial andoral
shoulders, and regions and then in the extremities. Truncal movements ofthe
hips
neck, shoulders, and hips were least common (Table 1).
AIMS = Abnormal Involuntary Movement Scale. Table 2 compares the topographical distribution in this
sample with that from other published studies ofdyskinesiain
children and adolescents. These studies may not be directly
Table 2. Symptom distribution in RD-MD cases in published
reports (% of cases) on neuroleptic-induced tardive dyskinesia comparable because no effort to exclude tics was made inthe
present study. Nonetheless, the distributions of MD and
Orofacial Extremity Truncal
n (%) (%) (%) dyskinesias are similar, despite the difference in drug-
Gualtieri and others (31) 15 87 33 27
treatment history.
Campbell and others (36) 10 64 27 9 Awareness
Perry and others (26) 13 76 40 20 When questioned about their abnormal movements, 88%
Gualtieri and others (27) 13 78 26 21 ofthe subjects with mild MDs reported no awareness ofMDs,
6% were aware of but not distressed by their symptoms, and
Campbell and others (24) 22 83 45 29
only 6% were distressed by the MDs.
Present study (RD-MD 16 87 44 37
in neuroleptic-naive Age
subjects)
The relationship between the subjects' age and their AIMS
RD-MD = Research Diagnosis-Movement Disorder, that is, movement disorder score was studied using Pearson correlation coefficient.
(MD) with at least 2 ratings of 2 (mild) or I rating of 3 (moderate) on any of the first
7 items of the Abnormal Involuntary Movement Scale (AIMS). There was a low but significant negative correlation between
these 2 variables (r = -0.13, n = 390, P < 0.01).

There were 224 (57.4%) female subjects with a mean
(± SD) age of8.6 ± 4.0 years and 166 (42.6%) male subjects
with a mean age of7.4 ± 4.0 years in the sample. The mean
age for the entire sample was 8.1 ± 3.9 years. The ethnic dis-
tribution was 45% white, 35% African American, 15% His-
panic, and 5% others. The mean PPVT-2 standard score was
88, identifying the overall population as being intellectually
adequate. Achenbach's CBC confirmed that the majority of
the population was at psychiatric risk. Using Achenbach's
(35) clinical cutpoint of T-score :?: 60 (82nd percentile),
51.3% of the subjects had at least borderline behaviour prob-
lems, while 38% had clinically significant behaviour prob-
lems (CBC score 2 standard deviations above the norm in
Achenbach's sample).
The severity ratings on the AIMS are as follows: 0 = none,
1 = minimal, 2 = mild, 3 = moderate, and 4 = severe. We de-
fined the presence of an MD using 2 different criteria based
Physical and Dental Health
Physical health was rated as "poor" in less than 1% ofthe
population, precluding further analysis.
Gender
A subject's gender did not confer a statistically significant
risk for MDs. Three percent of the males versus 4.9% ofthe
females (X2 = 0.35, ns) met the RD-MD criterion, while
13.3% of the males versus 12.1% of the females (X2 = O.73,
ns) met the mild-MD criterion.
Intellect
The mean standard score for the PPVT-2 was 87, with a
mean of 87.9 for subjects without mild MDs and 84.5 forsub-
jects with mild MOs. There was no significant difference be-
tween these 2 groups on standard PPVT-2 score. Usingthe
RD-MD criterion, however, subjects without RD-MDs
(mean = 87.9) had significantly (t = 5.7, P < 0.02) higher
May 1999 Abnormal Involuntary Movements in ChUdren and Adolescents 371

PPVT-2 scores than did subjects with RD-MDs (mean = Table 3. Results of 3-way ANDVA
76.25). Mean N df F P
Subjects were assigned to 1 of2 groups based on intellec- PPVT -2 standard score
tual competency: those with an estimated IQ of70 and above
Ethnicity
(87.6%) versus those with an estimated IQ of 69 and below
White 93.2 172
(12.4%). The 2 groups were significantly different from each
other in the prevalence of RD-MDs (X2 = 9.8, df = 1, P < Hispanic 80.6 56

0.002); 2.1% of the more intellectually competent group had African American 83.7 134 2350 22.3 <0.01
RD-MDs, compared with 10.6% of the other group. Such a Age
difference did not exist with respect to mild MOs.
3-11 years 87.0 282
Behaviour Problems 12-17 years 90.5 80 1350 4.1 < 0.05
Subjects were compared on their behavioural and motor AIMS total score
dyscontrol employing an Achenbach CBC total behaviour-
Age
problems score. The subjects were divided into 2 groups de-
3-11 years 1.1 291
termined by Achenbach's borderline clinical cutpoint (per-
centile ::::: 82, T-score ::::: 60) for the CBC total behavioural- 12-17 years 0.5 82 1361 92 <0.01

problems score (35). Subjects with a total behavioural- Achenbach CBC total
:problems score < 60 (group 1) had a lower total mean AIMS score

score (0.8 ± 1.4) than did those with a total CBC total score
60 (group 2) (AIMS score 1.3 ± 2.3) (t = 2.98; P = 0.003).
Similarly, 8% of group 1 subjects (n = 14) and 16% of the
.group 2 subjects met criteria for mild MDs (X2 = 4.67, df = 1,
P < 0.04), while 3% of group 1 (n = 5) and 5% of group 2
(n = 9) subjects met criteria for RD-MOs (X2 = 1.19, df= 1,
P < 0.3).
Interactions Among Predictors
To study the interaction effects, a 3-way ANOVA was
used, with gender, age, and ethnicity as grouping factors (Ta-
ble 3). For this purpose, MD was defined as mild MO. Be-
cause of the small sample sizes, only 3 levels for ethnicity
(white, Hispanic, African American) were used. There was
no significant 3-way or 2-way interaction. Significant main
effects were those of ethnicity and age for the PPVT-2 stan-
dard score, age for the AIMS total score, and gender for the
Achenbach CBC total score (using 60 as a cutpoint).
To study the contributions of gender, ethnicity, PPVT-2
standard score, dental problems, and overall health on the
prevalence of mild MDs, a logistic regression model was de-
veloped. This model did not significantly explain the vari-
ance in MO prevalence (X2 = 10.51, n = 371, df= 7, P=0.16).
Themodel became significant, however, when age was added
to the equation (X 2= 15.85, n = 371, df= 8, P<0.05). This sig-
nificance was mainly because of 1 level ofethnicity (white, P
< 0.01) and the age factor (P < 0.03).
Discussion
The current study complements a handful of older investi-
gations that determined the prevalence of MOs in very large
samples using less stringent methodology. In the earliest such
study (41), 24% of 1700 French children aged 2-13 years old
had tics. A randomly selected group of 482 children in the
Gender
Male 0.44 141
Female 0.55 1318
189 4.0 <0.05
AIMS = Abnormal Involuntary Movement Scale; CBC = Child Behavior Checklist;
PPVT-2 = Peabody Picture Vocabulary Test-2.
United States (US) aged 6-12 years old had a 12% prevalence
oftics (42). An epidemiologic study of7970 British 6- and 7-
year-old children found a 4% prevalence of tics (43). Al-
though these studies did not use a rating scale such as the
AIMS, calibrate severity to videotaped ratings, or assess in-
terraterreliability, the 4% RD-MD and 12% mild-MO preva-
lence rates found in the current study are compatible with the
British and US reports. The exact defmitions of tics and
dyskinesias likely varied across these investigations. As de-
fmed by the American Psychiatric Association Task Force on
TO, the term "dyskinesia" includes choreoathetosis, stereo-
typies, and tics (1). To avoid confusion, MO was used as the
outcome in this study and included different types of abnor-
mal involuntary movements but not tremor and myoclonus.
The accuracy of research on drug-related dyskinesias is
predicated on measuring the baseline rate of nonpharma-
cologie dyskinesias. This is particularly true in populations
with psychosis, autism, and mental retardation, who tend to
have higher prevalence of MOs prior to psychotropic-drug
exposure. Further studies of dyskinesia using diagnosis-
matched, drug-naive control groups are needed in these spe-
cial populations.
Our study has several limitations related to the assessment
of MD. The instrument used, the AIMS, does not distinguish
tics from other types of dyskinesias, including choreoathe-
totic and stereotypic movements. These different types of
372 The Canadian Journal of Psychiatry
MDs may have different underlying neuro- or psychopathol-
ogy.
Also, the rating scale may have been restrictive. Although
the AIMS is the most widely used instrument for dyskinetic
disorders, it is a single-syndrome scale. A scale that measured
both parkinsonisn and dyskinesia, such as the Extrapyramidal
Symptom Rating Scale (44), might have given a more com-
prehensive assessment. Further, for every rater, we required
> 50% (rather than > 90%) concordance with "gold-standard"
ratings. Also, the interrater reliability (ICC = 0.69) was estab-
lished after, not before, the initiation ofthe study. However,
we evaluated a large sample ofcommunity-dwelling subjects
not receiving psychotropic drugs and used standardized in-
struments for assessing MD, intellect, and behaviour prob-
lems. Though the children in this study group were living in
the community, they may not be representative ofthe popula-
tion at large but may be somewhat more representative of
children who are referred for mental health intervention. We
do not know if the behavioural difficulties of the population
being studied reflected neurodevelopmental problems, social
disadvantage, or both.
There are variable fmdings regarding gender differences
in the risk for MDs. Tourette syndrome is 3 times more com-
mon in boys than in girls (45). In contrast, the prevalence of
neuroleptic-induced TD is higher in women than in men (46).
The present study found no significant gender difference.
A new finding of this study was the association between
MD and behavioural problems in children. Mental retarda-
tion also was associated with RD-MD in this study, in a man-
ner independent of behavioural problems. Both intellectual
deficits and behavioural problems are common in special-
education settings. California children assessed for special
education classes had a 28% prevalence of tics, and 12% had
a diagnosis of Tourette syndrome (47). Another special-
education sample (48) identified a 23% prevalence of tics.
The AIMS previously has been established for use in
populations at risk for TD. In this study, raters applied the
AIMS to a neuroleptic-naive community sample, with inter-
raterreliability (ICC = 0.69) determined during the study. Us-
ing the AIMS in this manner allows physicians to document
MDs before they prescribe psychotropic drugs. The process
is potentially relevant, since Jeste and others (49) and other
investigators (1) have found subtle movement disorder at
baseline to be a risk factor for neuroleptic-induced TD in
older patients. Stimulant drugs may also exacerbate tics in
children, as reported by Denckla and others (50), who found
that children with preexisting tics were 13 times more likely
than those without tics to have worsening of dyskinesia after
treatment with methylphenidate. This study of nonpharma-
cologie MDs found a topographical distribution ofMDs simi-
lar to that reported in studies of drug-induced dyskinesia.
Vol44,No4
Clinical Implications
• Of community-dwelling children not receiving psychotropic
drugs, 13%had abnormal movements.
• Youngerchildren and those with lower IQ and more severe
behaviour problems weremorelikelyto haveabnormal move-
ments.
• Movement disorders should be assessed in children before
psychotropic drugs with motor side effects (such as antipsy-
choticsand stimulants) are prescribed.
Limitations
• The Abnormal Involuntary Movement Scale (AIMS) is a
single-syndrome scale and does not measureparkinsonism.
• For every rater, we required> 50% (rather than> 90%) con-
cordance with "gold-standard" ratings.
• Children inthisstudyweremorerepresentative of children re-
ferred for mental health intervention than of all community-
dwelling children.
Prospective studies are needed to rule out nonpharmacologic
MDs during psychotropic-drug treatment.
Our fmding that more severe behaviour problems are arisk
factor for MD further supports the recommendation that psy-
chiatrists specifically examine for baseline MD in children
and adolescents being considered for psychotropic-drug
treatment. Our study had only 38% of subjects with Achen-
bach CBC total behaviour-problems scores elevated 2 stan-
dard deviations above normal mean, yet 82% of clinical
psychiatric populations are expected to be characterized in
this way. Therefore, higher dyskinesia prevalence than was
found in this community sample might be expected in clinical
populations.
Two cortical functions-that is, intelligence and behav-
ioural dyscontrol-were correlated with MD prevalence in
this study. Shared infectious, metabolic, or traumatic insults
to the cortical and subcortical regions could conceivablyun-
derlie such associations. Younger children were at a higher
risk for motor dyscontrol, perhaps based on a developmen-
tally mediated immaturity similar to that found in intellectual
and behavioural development (51). Maturation, intelligence,
behavioural regulation, and motor regulation covaried inthis
study, prompting the search for a common substrate.
Acknowledgements
This work was supported, in part, by National Institute ofMental
Health grants MH49671, MH43693, and MH45131 and by the De-
partment of Veterans Affairs.
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Resume

Objectif: Determiner la prevalence et la nature des facteurs de risque des mouvements involontaires anormaux
dans un echantillon communautaire bien caracterise d'enfants et d'adolescents novices aux neuroleptiques.
Methode: On a administre I 'echelle des mouvements involontaires anormaux (AIMS) a390 sujets de 3 a17 ans
qui etaient enfoyer nourricier. On a utilise d'autres instruments pour evaluer les problemes d'intellect et de com-
portement.
Resultats : Un total de 12,6 % des sujets avaient au moins un resultat de mouvements « legers » a I 'AIMS, dont
4,1 % avaient au moins deux resultats de gravite « legere» ou « moderee ». Lesfacteurs de risque significatifs du
trouble du mouvement etaient Ie bas age, un QI irferieur et des problemes de comportement prononces. Les mou-
vements anormaux etaient habituellement bucco-faciaux, et les sujets affectes en etaient generalement inconsci-
ents.
Conclusion: Laprevalence de base des mouvements involontaires anormaux doit eire prise en consideration chez
les enfants et les adolescents qu 'on evalueen vue d'un traitement pharmacologique, afin de determiner Ie taux ve-
ritable des effets secondaires sur Ie systeme moteur.