A Case Study of Idiopathic Infantile Dyskinesia and a Revisit to the Psychological Schools: Saving the Peter Out

We present a 3-year-old girl brought to the Child and Adolescent Mental Health Outpatient of a tertiary care center. This report highlights the significance of managing benign Idiopathic Infantile Dyskinesia (IID) based on analysis through psychological schools (saving the Peter out) and behavioral, social, and biological theories.

Case Report

Around 1 year of her age, parents noticed several episodes of voluntary stiffness of bilateral upper limbs, non-jerky, rhythmic, voluntary squeezing of the perineal region with rocking movements of lower limbs, and sweating by the girl. Immediately following these movements, the child would insert her index finger into the vagina, smell it, and put it on her lips and mouth. These episodes would last for 15–20 minutes. When asked about her movements, she would reply that she was playing. The episodes recurred frequently throughout the day. She would become irritable if anyone tried to stop her from doing that activity. Often, she would rub both her thighs, opposing some clothes in the middle. She would even refuse to wear the clothes below her waist. These episodes were never observed during sleep. History revealed the significant use of smartphones. Parents would remain engaged in their work and managing the households while she primarily watched YouTube videos and infrequently played out with children. None of the family members ever witnessed her watching sexual practices or masturbation on their smartphones. A video recorded by parents at home was reviewed. No significant findings were found during physical and systemic examinations, including genital examination. History or clinical findings did not suggest sexual abuse or perianal irritation.

Electroencephalography was done. Abnormal spike-wave activities were noted. However, the entire history and clinical examination lacked involuntary, jerky, rhythmic, tonic, and/or clonic movements, a fixed blank gaze, or altered consciousness. Hence, a seizure was ruled out. Urine routine and microscopic examination were within normal limits. She was provisionally diagnosed with IID.

She was examined through various psychological, behavioral, and biological frameworks (Table 1 and Figure 1). Tailored interventions were designed for her. First, as a part of psychoeducation, the benign nature of the illness was explained, and parents were reassured. Alternative sensory stimulation techniques were explored. Play therapy was initiated. Activity scheduling was done. Parents were encouraged to interact and play with the child at home. Possible emotional deprivation led to masturbatory behavior. Therefore, reinstitution of affectionate tactile stimulation helped in ceasing excessive masturbation. She was advised to dress in crepe clothes. Parents were guided to let her regularly participate in outdoor games with peers and gradually reduce her screen time, especially YouTube videos. She would also enjoy playing with dolls and balls. Engagement in these desirable, competent behaviors and disengagement from smartphones led to the extinction of masturbatory behavior. After three months of management on an outpatient and inpatient basis, the child has improved.

Table 1.

Various Schools of Psychology and Their Perspective on Childhood Masturbation.

School of Psychology	Theory/Model Regarding Sexual Behavior	Explanation for Childhood Masturbation
Before eighteenth century	Histography of the eighteenth-century anti-masturbation campaigns (Sauerteig et al., 2012) 1	• A child performing masturbation would come under “moral” turpitude. Such children were considered evil, wicked, and corrupt. • Such children would be considered diseased both physically and mentally, and dangerous for their development and will be doomed. • Various anti-masturbation campaigns were conducted, warning of the deterrent effects of masturbation. • To safeguard the “innocence” of childhood, a high level of “self-control” was advocated.
Eighteenth century: Age of Enlightenment	The innocence of experience (Sauerteig et al., 2012) 1	• Rousseau and Gottfried condemned the idea of children’s “original sin” as children are not aware of shame and consider it to be their innate innocence.
Psychoanalytic	Theory of infantile sexuality (Freud, 2017 [1905 edition]) 2	• Developmentally normal and universal. • Highlighted autoerotic activity and masturbatory play during infancy among three periods of masturbatory activity. • The infant begins with a condition of absolute self-absorption. Their primary focus is basic needs like food, warmth, and pleasurable sensory experiences.
	McCray (1978) 3	• Children with reasonable tactile stimulation and satisfactory object relationships may start to masturbate following an alteration in the parent–child relationship resulting from the birth of another sibling or separation from the parents. The reinstitution of affectionate tactile contact ceases excessive masturbation. • Excessive masturbation may indicate emotional deprivation or neglect and could arise following a decreased perceived parental care or affection.
Behaviorism	Based on learning model–operant conditioning (Skinner, 2019) 4	• The pleasure and comfortable sensation discovered during masturbation becomes a reward and gets conditioned to perform the behavior again.
	Social learning theory (Bandura & Walters, 1977) 5	• People learn behaviors by observing, imitating, and modeling others’ behavior. Mediational processes involved in behavioral learning are attention, retention, and motor reproduction and motivation. This process is more pronounced if their observational experiences are positive or include rewards. • Children may develop masturbatory behavior if they observe parents or significant others indulging in sexual acts, especially if they find it pleasurable. 6
Biological perspective	Sex hormones associated with childhood masturbation (Ajlouni et al., 2010) 7	• There is an association between childhood masturbation and reduced levels of estradiol. However, such an association was not significant for other sex hormones. • The cases showed significantly lower levels of estradiol than those of the controls. • Additional research is needed to validate such results.
	Brain stimulation reward circuit (Olds & Milner, 1954) 8	• Brain stimulation reward is a theory that links the brain with the mind and behavior. Reward is a de novo brain operation where various stimuli (events or activities) get associated with a positive or desirable outcome. The reward pathway primarily consists of the mesolimbic system, made by dopaminergic neurons in the ventral tegmental area to the striatum, amygdala, hippocampus, prefrontal cortex, and other parts of the limbic system. A positive stimulus stimulates the reward pathway and makes a person prone to pursue pleasure by repeatedly engaging in the same behavior.

Figure 1.

Learning Model to Explain Childhood Masturbation.

According to behaviorism psychological school, pleasure and comfortable sensation discovered during masturbation (exposure through internet or witnessing sexual acts by parents) may act as the reward to maintain the behaviour. ⁷

Benign Idiopathic Infantile Dyskinesia (IID)

Gratification disorder (GD), or childhood masturbation, being circumscribed by social stigma, is also known as IID. The IID is a normal self-stimulatory sexual behavior commonly observed between 3 months and 5 years in children. It is characterized by stereotypic episodes of variable duration, vocalizations with grunting, diaphoresis, perineal squeeze with characteristic posturing of the lower limbs, eidetic imagery without altered consciousness, cessation with distraction, routine examination, and laboratory findings. ⁶ IID may be associated with sexual abuse or perianal irriation. ⁹ It is often misdiagnosed as a seizure disorder. Video recordings of events assist in diagnosis and avoid unnecessary investigations and treatment. Past reports show extensive workup, including magnetic imaging resonance and electroencephalography, without remarkable findings. ⁶

Reassurance and psychoeducation of the parents are the best strategies. ⁶ As reward plays a significant role in maintaining the behavior, the response extinction becomes relevant. Moreover, reinforcement provided by desirable competing behavior may redirect attention from masturbatory activities to a predetermined reinforcement schedule. The behavior usually subsides once the child finds alternate pleasurable activities.

Widespread smartphone accessibility and cheap internet expose children to sexual content early. ¹⁰ Limiting internet and smartphone access while encouraging alternative recreational activities is advisable. Play therapy allows the child to express their thoughts and feelings, helps ventilate stressors, and thus is helpful. IID follows a relapsing-remitting course. Therefore, regular follow-up, psychoeducation, and continuous behavioral management are of paramount significance. ⁶

Conclusion

Managing IID necessitates a nuanced grasp of its psychological, behavioral, social, and biological foundations. Integrating perspectives from various disciplines enables clinicians to tailor therapeutic approaches to the specific needs of children with IID.