Behavioral disorders in children

1. Introduction
Parents often complain to the paediatrician about
their child as:-
• Very stubborn
• Does not listen to their commands
• Is very demanding
• Aggressive
Sometimes the school authorities may refer the
child for recurrent abdominal pain.
These are some examples pointing towards
behavioral problems in children.

2. • It is important to identify these problems in
the initial stages as they can be managed
optimally to help child grow normally and
have balanced mental health.
• Behavioural problems in children are reported
by parents and school teachers in the
developmental period.
• These children are also termed as maladjusted
or having emotional disturbances.

3. • The child’s behaviour may deviate from normal
behaviour expected from a child of same age.
• These problems are related to:-
1. Inappropriate behaviour and feelings
2. Unsatisfactory inter-personal relationships
3. School learning problems
4. Unhappiness
5. Physical symptoms
6. Fears related to school

4. • They range from mild short-lived periods of
unexpected behaviours to more severe
problem such as hyperactivity, conduct
disorders, and refusal to go to school.

5. Prevalance
• Very common in children.
• Serious disorders:- 10-15%
• Seen in both genders. But certain disorders
are more common in males.(Ex: ADHD)
• Changing socio-cultural scenario is one of the
important factors for increase in the
behavioural problems.

6. Criteria To Label A Child To Be Having A
Problem
1) Age: Certain behaviours are normal for
particular age.
(Ex :- thumb sucking and enuresis may be
normal in 2yrs old child but abnormal in 10 yr
old child)

7. 2) Frequency:-
A particular behaviour occuring once in a
while may be normal but if it occurs very often
then its a matter of concern.
(Eg:- A child has abdominal pain every morning
before going to school)
3) Severity:-
Even a single episode of high intensity or
severity may require attention.
(Eg:- violent behaviour, fainting, muteness etc)

8. 4) Effect on development:-
some behaviour is persistent and has negative
impact on growth of the child.
(Eg:- Poor concentration,school refusal may
cause decline in academic perfomance)
way to identify a problem in the child is:-
a) if that behaviour inhibits his ability to work
in classroom or interact with peers.
b) if he is constantly talking and disrupting
other classmates and is not focussing on the
work

9. Common behavioural problems
1) Habbit disorders:-
Habbit disorder is the term used to describe several
related disorders linked by the presence of repititive
and relatively stable behaviours that seem to occur
beyond the awareness of the person performing the
behaviour.
some common habbit disorders are:-
tics; temper tantrums; thumb sucking; nail biting;
breath holding spells; teeth grinding or bruxism.

10. a)Breath holding spells:
• Reflexive events typically initiated by a
provocative events that causes anger
frustration or pain causing the child to cry
• The crying stops at full expiration and child
becomes apneic and cyanotic or pale, child
may loose consciousness ,become hypotonic
and fall
• Brief tonic clonic seizure may occur if spell
lasts more than few seconds

11. • Breath holding spells always revert on their
own within several seconds with child
resuming normal activity or falling asleep for
some time
• These spells are rare before 6 months , peaks
at 2 yrs and abate by 5 yrs
Diagnosis :
• Based on the setting and typical sequence of
crying, cyanosis or pallor with or without brief
loss of consciousness

12. Differential diagnosis:
• Seizures
• Cardiac arhrythmias
• Brainstem malformations
How to differentiate b/w breath holding spells and
seizures?
• The history of provoking event, stereotyped
pattern of events and colour change preceeding
the loss of consciousness , helps in dsitinguishing
breath holding spells from seizures
• EEG

13. • In case spells are with pallor ECG to rule out
cardiac arrhythmia and long QT synd.
Management:
• After a thorough examination of the child,
parents should be reassured
• They should be explained that apneic spells are
always self limited and do not lead to brain injury
or death
• Family should be consistent in behaviour and
remain calm during event

14. • Child should be turn to side to drain the
secretions
• A video recording may be requested
• Parents should avoid exhibiting undue
concern nor give in his demand if spell
provoked by anger or frustration
• Children with iron deficiency should receive
iron therapy

16. b)Temper tantrums:
• Includes behavior that occurs when the child
responds to physical or emotional challenges by
drawing attention to himself
• Like yelling, biting, crying, kicking, pushing,
throwing objects etc
• Typically begins at 18-36 months of age
• Inability to assert autonomy or perform a
complex task on his own causes frustration to
child,which cant be communicated effectively
(limited verbal skills)

17. • The frustration therefore is acted out as
undesired behaviors
• These behavior peaks at 2nd and 3rd year of life
• Subsides by age of 3-6yrs as child learns to
control his negativism
Management:
• Parents to be asked to list situations where
disruptive behavior likely to occur and plan
strategies to avoid them

18. • During tantrum , the parents behavior should
be calm, firm and consistent ,child should not
be permitted to take advantage from such
behavior
• The child should be protected from injuring
self and others
• At an early stage distracting the attention
from immediate cause and changing the
environment can abort the tantrum
• A time out ,asking the child to stay alone in a
safe and quite place for few minutes

20. c) Tic disorders:
these are characterised by
involuntary,rapid,repititive,single or multiple,
motor/vocal/phonic tics that wax and wane
in frequency but have persisted for more
than 1 yr since first tic onset.(<1yr for
provisional tic disorder)
A tic is a sudden,rapid,recurrent,non-
rhythmic motor movement or vocalisation.

21. Types of tics
Motor
tics
Simple complex
Vocal tics
Simple Complex

22. a) Motor tics:-
i) Simple motor tics:- Brief rapid movements that
involve a single muscle or localised group of muscles.
Eg:- Eye blinking; head jerking; nose twitching; shoulder
shrugs; arm jerks and mouth opening.
ii) Complex motor tics:- They involve either a cluster of
simple actions or more co-ordinated sequence of
movements.
Eg:- - movements that can be non-purposeful such as facial
and body contortions or twirling around.
- movements that appear purposeful but serves no
purpose like hopping, touching, hitting, jumping,
bending, picking etc.

23. b) Vocal tics:-
i) Simple vocal tics:- It includes various sounds and
noises without meaning.
Eg:- Grunts; barks; hoots; sniffs; screeches; moans; throat
clearing.
ii) Complex vocal tics:- vocalisation that involves
repetition of words or phrases.
Eg:- obscenities or slures(CAPROLALIA)
repeating one’s own sound or words(PALILALIA)
repeating last heard word or phrase(ECOLALIA)

24. • Individuals with tics can suppress for varying
periods of time, particularly when external
demands exert their influence, when deeply
engaged in a focused task or activity or during
sleep.
• Tics are often worsened by anxiety ,
excitement and exhaustion.

25. Classification of tic disorders

26. Epidemiology:-
20-30% of children
More in males than females.
Ratio is 3:1
Etiology:-
1) Genetic basis: Precise pattern of transmission and
identification of the gene is unclear.
Studies show 10-100 fold increase of TS in 1st degree
relatives

27. 2) Auto-immune disorder:-
In a subset of children tic symptoms are caused by
preceding group a Beta haemolytic streptococcal
infection labelled as PANDAS.(Paediatric Auto-immune
Neuro-psychiatric Disorders associated with
Streptococcal infection).
Co-morbidities:-
ADHD
OCD
Depression and anxiety
Impulse control disorders.

29. Assessment of tic disorders:-
Tic Assessment scales
1) The Yale Global Tic severity scale:-
It is a semi-structured clinical interview
Most widely used
scale consist of 2 components
i) The total tic score consist of 5 separate ratings
(No; Frequency; Intensity ; Complexity and interference) for
both vocal and motor tics.
ii) The tic impairment score representing a ranking
of impairment with a maximum of 50 points.
It is based on the impact of TD on self-esteem; family life;
social acceptance.

30. 2) The Gille’s De La Ts quality of life scale(GTS-QOL):-
it consists of a 27 item patient reported TS specific scale with
4 sub-scales(psychological; physical; obsession and cognitive)
Treatment:-
1) General:-
Individuals with tic disorders should have
a) the careful assessment of tics and co-morbid
conditions.
b) determination of problem severity and impairment.
c) evaluation of general health, family history and prior
therapies.

31. 2) non-pharmacological treatment:-
a) Relaxation therapy:
It includes
• Progressive muscle relaxation
• Deep breathing
• Visual imagery
• Autogenic training i.e. Repetition of
statements suggesting a relaxed state.
b) Habbit reversal therapy

32. c) Comprehensive behavioural intervention for tics (CBIT):-
Components of CBIT
i) HRT
ii) Psycho education
iii) Enviornmental alteration
iv) Reward system
v) Relaxation training
3) Pharmacological therapy:
Two gruops:
Tier 1: non neuroleptic medication
Tier 2: neuroleptic and atypical neueoleptics

33. • Tier 1 medication:
these are used first,esp in patients with milder
tics
it includes :
– Alpha adrenergic like clonidine
– Anticonvulsants(topiramate and leviracetam)
– Baclofen
– Clonazepam

34. • Tier 2 medication:
• Dopamine receptors antagonists
• Typical neruleptics:
• Pimozide
• Fluphenazine
• Ecopipam
• Haloperidol

35. d) Head banging or head rolling or
body rocking:
• May occur separately or together in otherwise
healthy children around sleep time
• Reassure parents – rarely results in injury and
will usually remit by 4 yrs of age without
intervention
• Parents should remain calm and not give
attention to the behavior
• If behavior persist beyond 4 yrs may need
further evaluation

37. e) Nail biting
• Nail biting is a bad oral habit especially in
school age children beyond 4 years of age. It is
a sign of tension and self punishment to cope
with the hostile feeling towards parents. It
may occur as imitating the parent who is also
a nail biter. It is caused by feeling of insecurity,
conflict and hostility. It may be due to
pressurized study at school or home or due to
watching frightening violent scene

38. Management:
• Ignore
• Keeps nail short
• Rule out underlying emotional disorder
• Habit reversal therapy- includes 3 components
1. Increase awareness of habit,eg have them
look in the mirror while biting the nails
2. Teach a competing response, eg chewing
gum , blow air through pursed lips
3. Relaxation techniques

39. f)Thumb sucking:
Normal in infancy and toddlers whereas
abnormal in preschool and above years
• Complications
• malocclusion and malalignment of teeth
• difficulty in mastication and swallowing.
• deformity of thumb
• facial distortion
• speech difficulties with consonants (D & T),
• GIT infections

40. Management:
• Parents and family members need to support and to be
advised not to become irritable, anxious and tense.
• Praising and encouraging child for breaking the habit
are very useful.
• Distraction during the bored time or engaging the
thumb or finger for other activity, keep the hand busy.
• The child should not be scolded for the habit.
• Consultation with dentist or speech therapist
• Hygienic measures to be followed and infections to be
treated promptly.

41. 2.Oppositional defiant disorder and
conduct disorders
• Characterized by a core deficit in self
regulation of anger, aggression, defiance, and
antisocial behaviors.
• Oppositional defiant disorder (ODD) is
characterized by a pattern lasting at least 6
mo of angry, irritable mood,
argumentative/defiant behavior, or
vindictiveness exhibited during interaction
with at least 1 individual who is not a sibling

42. • For preschool children,the behavior must occur
on most days whereas in school-age children,the
behavior must occur at least once a week.
• The severity of the disorder is considered to be:
1. Mild if symptoms are confined to only 1 setting
(e.g., at home, at school, at work, with peers)
2. Moderate if symptoms are present in at least 2
settings
3. Severe if symptoms are present in 3 or more
settings.

44. • Conduct disorder (CD) is characterized by a
repetitive and persistent pattern over at least 12
mo of serious rule-violating behavior in which the
basic rights of others or major societal norms or
rules are violated
• The symptoms of CD are divided into 4 major
categories: aggression to people and animals,
destruction of property,deceitfulness or theft, and
serious rule violations (e.g., truancy, running
away)

46. • Three subtypes of CD (which have different prognostic
significance) are based on the age of onset: childhood-
onset type, adolescent onset type, and unspecified
EPIDEMIOLOGY:
• The prevalence of ODD approximates 3% and in
preadolescents is more common in males than females
(1.4 : 1).
• One-year prevalence CD approximate 4%,
• For CD,prevalence rates rise from childhood to
adolescence and are higher among males than among
females.

47. CLINICAL COURSE:
• ODD- Oppositional behavior can occur in all
children and adolescents from time to time,
particularly during the toddler and early
teenage periods when autonomy and
independence are normative developmental
tasks.
• Oppositional behavior becomes a concern
when it is intense, persistent, and pervasive
and when it affects the child’s social,
family,and academic life

48. • Some of the earliest manifestations of
oppositionality are stubbornness (3 yr),
defiance and temper tantrums (4-5 yr), and
argumentativeness(6 yr)
• Approximately 65% of children with ODD exit
from the diagnosis after a 3 yr follow-up;
earlier age at onset of oppositional symptoms
conveys a poorer prognosis
• ODD often precedes the development of CD

49. • Onset of CD may occur as early as the preschool
years, but the first significant symptoms usually
emerge during the period from middle childhood
through middle adolescence; onset is rare after
age 16 yr.
• Symptoms of CD vary with age
• In the majority of individuals, the disorder remits
by adulthood; in a substantial fraction, antisocial
personality disorder develops.
• Individuals with CD also are at risk for the later
development of mood, anxiety, posttraumatic
stress, impulse control, psychotic,somatic
symptom, and substance-related disorders

50. DIFFERENTIAL DIAGNOSIS:
• The disorders in this diagnostic class share a
number of characteristics with each other as
well as with disorders from other classes, and
as such must be carefully differentiated
• ODD can be distinguished from CD by the
absence of physical aggression and
destructiveness, and by the presence of
angry/irritable mood;

51. COMORBIDITY:
• Rates of ODD are much higher in children with
ADHD, which suggests shared temperamental
risk factors
• ADHD and ODD are both common in
individuals with CD, and this comorbid
presentation predicts worse outcomes.
• CD also may co-occur with anxiety,
depressive, bipolar, learning, language, and
substance-related disorders.

52. Management:
• Treatment of both ODD and CD has to be dealt
with together as for all practical purposes
both the disorders seem to be part of a
continuum
• Another factor to be taken into consideration
is the presence of ADHD,Learning disorder,
depression, anxiety, substance abuse further
making management complicated

53. • Interventions includes
1. Prevention
2. Pharmacological treatment
3. Non pharmacological treatment
4. Counseling
5. School based interventions

54. 1. Prevention:
• Prevention seems the most important early
intervention in children at risk for developing
ODD and CD
• Risk stratification done based on multitude of
risk factors :
1. Genetic influence
2. Presence of parental psychopathology
3. Adverse environment
4. Temperamental issues seen in early childhood
5. Presence of comorbidities
• These at risk children need to be monitored
closely, parents made aware of early signs

55. 2. Psychopharmacological treatment:
• Can be tried in few cases , shows good results
when associated with ADHD
• Methylphenidate is drug of choice and help in
most cases
• Risperidone is used to improve aggressive
behaviors
• Stimulants stays as the first line of drug for use
in ODD and CD, anticonvulsants second group
of medication for nonspecific aggression
• Lithium is the third choice

56. • In cases of CD without ADHD ,depression, bipolar
disorders medications have no role
3) non-pharmacological interventions:-
• it includes
a) Individual counselling for adolescents
and young adults to enhance coping
skills
b) Anger management
c) stress management
d) Assertiveness training
e) Social skills

57. • Acceptance of self, understanding of people
and getting rid of unrealistic expectation helps
adolescent to develop healthy coping and
problem solving skills.

58. Pica
• Pica involves the persistent eating of
nonnutritive, nonfood substances(e.g., paper,
soap, plaster, charcoal, clay, wool, ashes, paint,
earth) over a period of at least 1 mo
• The eating behavior is inappropriate to the
developmental level (e.g., the normal mouthing
and tasting of objectsin infants and toddlers)
• A minimum age of 2 yr is suggested.
• The eating behavior is not part of a culturally
supported or socially normative practice

59. EPIDEMIOLOGY:
• Pica can occur throughout the lifetime, but
occurs most commonly in childhood.
• It appears to be more common in those with
intellectual disability and autism spectrum
disorders, and to a lesser degree in obsessive-
compulsive and schizophrenic disorders.
• It appears to increase with the severity of an
intellectual disability. It usually remits in
childhood but can continue into adolescence
and adulthood

60. • Children with pica are at increased risk for lead
poisoning, iron-deficiency anemia , mechanical bowel
problems,intestinal obstruction, intestinal perforations,
dental injury, and parasitic infections.
• It can be fatal based on substances ingested.
ETIOLOGY:
• nutritional deficiencies(e.g., iron, zinc, and calcium)
• low socioeconomic factors (e.g., leapaint exposure),
• child abuse and neglect
• family disorganization (e.g.,poor supervision),
• mental disorder
• learned behavior
• cultural and familial factors

61. • Assessment for neglect and family supervision
combined with a psychiatric assessment for co
occurring mental disorders and
developmental delay are important in
developing an effective intervention strategy.
• The sequelae related to an ingested item can
require specific treatment (e.g., lead toxicity,
iron-deficiency anemia, parasiticinfestation).
• Ingestion of hair can require medical or
surgical intervention for a gastric bezoar

62. Enuresis or bedwetting
• Enuresis is the repetitive involuntary passage
of urine at inappropriate place especially in
bed, during night time beyond the age of 4 to
5 years. It is found in 3 to 10 percent school
children
• Common causes :
• small bladder capacity
• improper bladder training
• deep sleep with inability to receive the signals
from distended bladder to empty it

63. • The emotional factors
 hostile or dependent parent – child
relationship
 dominant parent
 punishment
sibling rivalry
emotional deprivation due to insecurity and
parental death

64. • Environmental factors
 dark passage to toilet or cold or fear of toilets
 toilet at distance from bedroom may cause
bed wetting at night.
• The associate organic cause may present e. g.
spina bifida, neurologic bladder, juvenile DM,
seizure disorders

65. Management
• Non-organic causes to be managed primarily with
emotional support to the child and parents along with
environmental modification.
• The child needs reassurance, restriction of fluid after
dinner, voiding before bed time and arising the child to
void, once or twice, three to four hours later.
• Interruption of sleep before the expected time of bed
wetting is essential. The child should be fully waken up
by the parent and made aware of passing of urine at
night.
• The child can assume responsibility for changing the
bed cloths. Parents should not be worried about the
problem.

66. • Parents should encourage and reward the child
for dry nights. Punishment and criticism may lead
to embarrassment and frustration of the child.
• Bladder stretching during daytime to be done to
increase holding time of urine, using positive
reinforcement and delaying voiding for some
time.
• Drug therapy with tricylic antidepressant
(Imipramine) is useful

67. • Condition therapy by using electric alarm bell
mattress is a effective and safest method,
when the child wakes up as soon as the bed is
wet.
• Supportive psychotherapy is important for
child and parent. Changes of home
environment to remove the environmental
causes are essential.

69. Substance abuse
• Substance abuse and alcohol are increasing
like an epidemic in children and adolescent.
• Commonly abused substances are inhalants-
thinner , cough syrups, smokeless tobacco-
ghutka and pan masala , bidi-cigarettes,
opioids and cannabis.
• 20% of children and adolescent start
experimenting with alcohol and drugs by
11yrs of age .

70. Psycho-social factors leading to addiction:-
• Change in lifestyle
• Low frustration tolerance
• Easy availability of drugs
• Peer pressure
Clinical manifestations of substance abuse:-
• Decline in academic performance
• Change in behaviour
• Irritability
• Decreased interaction with family members
• Lying and stealing
• Changes in eating and sleeping behaviour

71. • Cognitive behavioural therapy and family
therapy can help to control craving and
developing coping strategies.

72. ADHD
What is adhd?
The DSM-V defines ADHD as a “persistent
pattern of inattention and/or hyperactivity-
impulsivity that is more frequently displayed
and more severe than is typically observed in
individuals at a comparable level of
development”

73. • a disorder that appears in early childhood
• signs and symptoms of ADHD typically appear
before the age of 7
• it can be difficult to distinguish between
ADHD and normal “kid behavior.”

74. Specific culture, age, gender features
• Symptoms of ADHD are typically at their most
prominent during the elementary grades.
• Prevalence- 3% - 7% in school age children

77. Familial pattern
• ADHD has been found to be more common in
the first-degree biological relatives of children
with ADHD than in the general population.

78. Subtypes
• Attention-Deficit/Hyperactivity Disorder, Combined
Type
– This subtype should be used if six (or more) symptoms
of inattention and six (or more) symptoms of
hyperactivity-impulsivity have persisted for at least 6
months. Most children and adolescents with the
disorder have the Combined Type.
• Attention-Deficit/Hyperactivity Disorder,
Predominantly Inattentive Type
– This subtype should be used if six (or more)
symptoms of inattention (but fewer than six
symptoms of hyperactivity-impulsivity) have
persisted for at least 6 months.

79. • Attention-Deficit/Hyperactivity,
Predominantly Hyperactive-Impulsive Type
– This subtype should be used if six (or more)
symptoms of hyperactivity-impulsivity (but fewer
than six symptoms of inattention) have persisted
for at least 6 months.

80. Conclusion
– In early childhood, it may be difficult to distinguish
symptoms of ADHD from age-appropriate
behaviors in active children (e.g., running around
or being noisy)
– Inattention in the classroom may also occur when
children with high intelligence are placed in
academically understimulating environments.

81. Biological Psychosocial
Genetic disposition
Fragile X Syndrome
Down’s syndrome
Brain damage
Intelligence
Temperament
Illness
Physical handicapness
Malnutrition
Family School Culture
Attitudes of parents Stress Media
Over protection Self-esteem Terrorism
Rejection Achievement Violence
Child abuse Peer group Neighborhood
Discipline Discipline Ethnicity
Anxiety Social skills
Role model Antisocial
Expectation
Time spent with child
Conflict
Parents
Alcoholism
Causes of childhood behavioural disorders

82. Assessment of behavioural disorders
• Examination of the child consist of interviewing
the child as well as his/her family.
• A child’s understanding of what troubles him/her
may be at variance with the reports of parents
and teachers.
• Many behavioural problems are situation specific.
• Information should be gathered from multiple
sources
Eg: Parents; peers; teachers etc

83. • Child behaviour and co-operation may vary
from time to time.
• Child may have his/her good days and bad
days. Therefore child should be observed
serially over several sessions.

84. Steps for the assessment of behavioural
problems
1) Case history and mental status
examination:
• Detailed case history is taken from the time of
conception to the present.
• It includes beginning of behavioural problem,
development of the child, family history, family
environment, child’s temperament, school performance
and inter-personal relationships

85. • The mental status examination refers to child’s
current abilities to understand his/her actions
and interaction with the environment.
• Both case history and mental status
examination are important in making the
diagnosis of the child.
2) Cognitive Assessment:-
• Includes attention,concentration,verbal
performance,intelligence, social maturity
adaptive behavior and memory
• Attention and span assessed by digit span test
, colour/letter cancellation test

86. • Intelligence assessed by verbal and
performance test of intelligence, wechsler
intelligence scale for children(WISC), malins
intelligence scale for indian children(MISIC)
3) projective technique:
• These are unstructured stimulus matarial on
which childs unconscious conflicts and
thoughts are elicited
• Very helpful in understanding the
psychodyanamic aspect of childs behavior and
their interaction with family members

87. Examples:
• Draw a person test
• House-tree-person test – child is asked to
draw on plain sheet of paper with his/her
imagination
• Children apperception test-child has to make
stories on pictures given to them

88. 4)Rating scales and questionnare
5)Behavioral assessment of a child
Child behavior is systematically observed and
recorded according to
antecedents(situations), feeling, thought,
behavior and consequences. Parents are
involved

89. references
• Nelsons textbook of pediatrics
• IAP textbook of paediatrics
• Parthswarthy clinical pearls in pediatrics
• Swarsons abnormal pscyhology