BEHAVIORAL DISORDERSPRESENTED BY:A.PRIYADHARSHINI M.Sc(N)LECTURER,JAI INSTITUTE OF NURSING AND RESEARCH,GWALIOR.
Definition A child is said to have a behavioral disorder when he or she demonstrates behavior that is noticeably different from that expected in the school or community. In simpler terms - a child who is not doing what adults want him to do at a particular time.
Common behavioral disorders Separation anxiety Thumb sucking Bruxism Head banging Body rocking Stuttering Pica
Separation anxiety is a perfectly normal part of childhood development Around the first birthday, many kids develop separation anxiety, getting upset when a parent tries to leave them with someone else.
Sometime between 6-7 months, babies develop a sense of object permanence They begin to learn that things and people exist even when theyre out of sight. The same thing occurs with a parent. Babies realize that parents are not there and think they have gone away. The child will start do whatever he or she can to prevent this from happening.
Thumb sucking: Thumb sucking is initially a biologically driven reflexive behavior that is often documented in utero and in young infants. In older infants and toddler, the behavior is reinforced as a form of self stimulation or self comfort and most frequently observed when the child is sleepy, hungry, frustrated or fatigued.
Contd.. Children who have stopped thumb sucking may resume the behavior after an acute or chronic distressing event, such as illness, hospitalisation or separation. Sometimes other fingers are also involved.
Thumb Sucking Causes Babies and young children use it to comfort themselves when they feel hungry, afraid, restless, quiet, sleepy, or bored. Thumb-sucking can be an indication of maladjustment or lack of love.
Does thumb-sucking cause any problems? Malocclusion and malalignment of the teeth Difficulty in mastication and swallowing Deformity of the thumb Facial distortion Speech difficulties with consonants( D and T) Gastro intestinal infections.
When to treat them: Develop dental or speech problems Continue to suck thumb after the age of 4 or 5. Also pull their hair especially when they are between 12 and 24 months of age. Feel embarrassed or are teased or shamed by other people because of the behavior. Ask for help to stop the behavior.
Tackling thumb-sucking Give child extra attention and observe if conflicts or anxiety provoke thumb sucking. Reward the child for progress made towards her goal. Paint something that taste bad on his thumb, like vinegar with his permission. Distract the child when you see putting her thumb in mouth. Keep the hand busy Follow hygienic measures to prevent complications.
Bruxism (Teeth grinding): It is one of the commonest habit disorders in children, characterized by non functional repeated grinding of the teeth with a high pitched sound, usually during sleep. Bruxism is usually considered as a tension discharge activity for a child’s unexpressed anger or anxiety.• Begins in first 5 yrs of life.• May lead to problems with dental occlusion
Contd… It is often associated with1. Abnormal sleep activity.2. Familial behavior pattern.3. Pinworm infestation.4. Neurological diseases. E.g. Cerebral palsy
MANAGEMENT: Behavior modification via possible reinforcement. Relaxing stories at bedtime Reviews fears and angers experienced during day Praise child Emotional support Parental counselling. Psychotherapy
Contd.. Pharmacotherapy (eg.) diazepam. Persistent bruxism leads to muscular or temperomandibular joint pain. Dental referral necessary.
HEAD BANGING: This can occur in 3-19% of developmentally normal children younger than three years. It is more frequently observed in children with autism or developmental delay and those living in institutional environments.
Body rocking and rhythmicmovements: These occur in most infants aged 6-12 months. The behavior is most often observed in children with developmental disabilities or sensory impairments: however it persists beyond age 2 years in 3% of children with normal development.
Contd… Body rocking usually involves a forward and backward rhythmic swaying of the trunk at the hips, generally from a sitting position. The intensity may be gentle or it may be forceful enough to move the childs crib or bed. Most episodes last less than 15 min but may persist upto 30 minutes.
Stuttering Stuttering is a form of dysfluency — an interruption in the flow of speech. The first signs of stuttering - 18-24 months old Occurs when starts to put words together to form sentences. They repeat certain syllables, words or phrases or prolong them. Most kids who begin stuttering before the age of 5 stop without any need for interventions.
What Causes Stuttering? Genetics: 60% of those who stutter have a close family member who stutters. Speech and language problems Developmental delays.
When to Seek Help If child is 5 years old and still stuttering Child avoids situations that require talking Excessive repetitions of whole words /phrases Speech starts to be especially difficult Child changes a word for fear of stuttering Child has facial or body movements along with the stuttering
What Parents Can Do Speak slowly and clearly when talking to the child Give time to him - Let your child speak for himself or herself to finish thoughts and sentences. Maintain natural eye contact with your child. When stuttering encourage activities that do not require a lot of talking.
Pica is an eating disorder typically defined as the persistent ingestion of nonnutritive substances for a period of at least 1 month at an age at which this behavior is developmentally inappropriate (eg, >18-24 mo). The definition is occasionally broadened to include the mouthing of nonnutritive substances.
Causes… Normal till 2 years of age Other neurological disturbances Lower socio economic strata Parental neglect Poor supervision Lack of affection Malnourished
ingest a wide variety of nonfood substances, clay, dirt, sand stones fingernails, paint chips hair Pencils,erasers, paper coal, chalk, wood and burnt match stick.
Complications…Accidental ingestion of poisonsParticularly in lead poisoning.Soil-borne parasitic infections.Gastrointestinal (GI) tract complications.
Nail biting Nail biting (onychophagia) is a common oral compulsive habit in children and young adults. Nail biting usually starts at the age of around five in children. It affects around 30% of children between 7 to 10 years and 45% of teenagers
Causes The main cause is insecurity in the infant, early weaning or long hours of absence of the mother from the child’s sight. Nail biting signifies nervousness older kids. There may be a genetic component as nail-biting is more common when parents were nail-biters as children. Sign of tension and self punishment.
Contd… It may be due to pressurised study at school or home or due to watching frightening violent scenes. The child may bite all the 10 finger nails or any specific one. The bite may include the cutis or skin margins of nail bed or surrounding tissues.
MANAGEMENT: The child should be praised for well kept hand by breaking the habit to maintain self confidence. The child’s hand should be always kept busy. Avoid punishments. Reassure the parents.
Breath-Holding Spells A breath-holding spell is an episode in which the child stops breathing and loses consciousness for a short period immediately after a frightening or emotionally upsetting event or a painful experience. Breath-holding spells usually are triggered by physically painful or emotionally upsetting events. Typical symptoms include paleness, stoppage of breathing, loss of consciousness, and seizures.
Breath-holding spells occur in 5% of otherwise healthy children. They usually begin in the first year of life and peak at age 2. They disappear by age 4 in 50% of children and by age 8 in about 83% of children. Breath-holding spells can take one of two forms – cyanotic (common) and pallid.
Cyanotic form Initiated subconsciously by young children in response to a scolding or other upsetting event. Typically, the child cries out and breathes out, and then stops breathing. Skin begins to turn blue, and the child becomes unconscious. A brief seizure may occur. After a few seconds, breathing resumes and normal skin color and consciousness return.
WHAT TO DO.. Parents must try to avoid reinforcing the initiating behavior. Distracting children and avoiding situations that lead to tantrums are the best ways of preventing and treating these spells. Cyanotic breath-holding spells respond to treatment with iron supplements, even when the child does not have iron-deficiency anemia.
Pallid form Typically follows a painful experience, such as falling and banging the head. The child stops breathing, rapidly loses consciousness, and becomes pale and limp. A seizure and incontinence may occur. The heart beat typically beats very slowly during a spell. After the spell, the heart beat speeds up again, breathing restarts, and consciousness returns without any treatment. Further diagnostic evaluation and treatment may be needed if the spells occur often.
Temper tantrums Temper tantrums range from whining and crying to screaming, kicking, hitting, and breath holding when they do not have control over the situation or needs of the child are not met . Theyre equally common in boys and girls and usually occur between the ages of 1 to 3. Normal part of development
• Tantrums are common during second year of life, a time when children are acquiring language.• Not being able to communicate needs— a frustrating experience that precipitates a tantrum.• Toddlers want a sense of independence and control over the environment — Autonomy• When kids discover that they cant have everything they want, the stage is set for tantrum.• As language skills improve, tantrums tend to decrease.
When to treat? An underlying mental, physical, or social problem tantrum lasts for more than 15 minutes or if tantrums occur multiple times each day.
Time-Out Technique This disciplinary technique is best used (1) when children are aware that their actions are incorrect or unacceptable (2) when they see withholding of attention as a punishment. Typically, children do not understand that withholding attention is a punishment until they are 2 years old. Care should be taken when this technique is used in group settings such as day care centers, because it can result in humiliation.
The inappropriate behavior is explained to the child, who is told to sit in the time-out chair. The child should sit in the chair for 1 minute for each year of age (a maximum of 5 minutes). A child who gets up from the chair before the allotted time is returned to the chair, and the time-out is restarted. Talking and eye contact are avoided.
When it is time for the child to get up, the caregiver asks the reason for the time-out without anger and nagging. A child who does not recall the correct reason is briefly reminded. As soon as possible after the time-out, the caregiver should make an effort to identify good behavior and praise the child for it.
Bed wetting (Enuresis) Repeated discharge of urine into clothes or bed after a developmental age when bladder control should be established. Repeated means: twice a week for 3 consecutive months. Prevalence: < 5 yrs: 3-7% 5-10 yrs: 2-3%
Types of Enuresis: Primary enuresis: child has never been dry at night (90% of cases). Secondary enuresis: child has been continent for ≥ 6 months and then begins to wet bed during sleep. Nocturnal enuresis: voiding urine at night. Diurnal enuresis: child passes urine in clothes during day and while awake.
Causes of Primary Enuresis: Marked familial pattern. Exact pattern of transmission not clear. ? Abnormal bladder function. ? Diminished capacity to be aroused from sleep.
Causes of Secondary NocturnalEnuresis: Psychosocial Stress: e.g. Child insecure after birth of younger siblings. Family quarrels Academic stress (school failure, does not like class room, teacher) Urinary Tract Infection. Juvenile Diabetes Mellitus. Management of secondary nocturnal enuresis depends on cause.
Cause of Diurnal Enuresis : Micturition deferral: child waits until last minute to void urine (as busy playing). Urinary Tract Infection. Associated Constipation. Management of diurnal enuresis depends on cause
Management of Enuresis: Detailed clinical / developmental history. Family history. Rule out urinary tract infection. Rule out occult spina bifida / abnormalities of urinary tract X-ray lumbosacral spine USG abdomen Rule out Diabetes Mellitus (do random blood sugar, urine osmolality).
Behavior Therapy: Parents counseled to: Encourage child to win cooperation Reward child for being dry at night Ensure child doesn’t drink fluids after 7 pm Sleeps by 10 pm after voiding urine wake up child at 12 midnight (2 hrs after falling asleep) to void urine Never humiliate or punish child Enuresis subsides in a few months. Psychotherapy for secondary enuresis
Bell and pad alarm system(conditioning device) used:
Pharmacotherapy : If behavior therapy fails: Imipramine (2.5 mg/kg/24 hrs at bed time) for few weeks and taper Desmopressin acetate (DDAVP) orally or intra nasally at bed time 50% success rate Higher relapse rate
TICS: Definition: Repetitive movements of muscle groups of face, neck, hands, shoulders, trunk. Examples: Lip smacking Grimacing Tongue thrusting Eye blinking Throat clearing
Characteristics of Tics: Tics can be suppressed by child for short periods if made conscious. Never associated with transient inability to interact (unlike petit mal epilepsy). Disappear when child asleep (unlike dystonias / dyskinetic movements). Rarely, tics precipitated in child on stimulant medication (methylphenidate) for ADHD.
Encopresis: Definition: Passage of faeces into inappropriate places after 4 yrs of age. Usually associated with constipation and overflow. Subtypes: A) Primary: persisting from infancy onward B) Secondary: appears after successful toilet training
Clinical Features of Encopresis: Offensive odour leads to: 1. Teased by schoolmates 2. Scolding from parents / teachers 3. Child becomes ashamed, angry 4. Poor school attendance and performance
Management of Encopresis: Clearance of impacted faeces using enemas. Short term use of mineral oil / laxatives to prevent constipation. Behavior therapy: Regular postprandial toilet sitting. High fiber diet / improve water intake. Individual or group psychotherapy sessions. Family support: encourage child, rewards for compliance, avoid power struggles. Soiling stops in few months.
Sibling rivalry: Sibling rivalry is antagonism between brothers and/or sisters that results in physical fighting, verbal hostility, teasing, or bullying
What causes sibling rivalry? A feeling of threat when the new sibling is welcomed home A feeling of boredom also makes siblings to fight each other A feeling of impartiality also makes children to fight Feeling of hungry or tiredness in children leads to irritation and rivalry Feeling of dominance over the other also increases conflicts and fights Lack of proper intimacy among siblings
How to avoid? Never try to compare the sibling’s capabilities or skills to one another. Frequently show the children that you love them equally. Praise children for their getting along behaviors. Pay close attention to each child by allotting special time individually. Don’t be partial in solving the siblings fight Educate children about compromising and cooperation and how to do it on their own.