This document discusses various behavioral disorders commonly seen in children, including definitions, causes, and management strategies. Some of the behavioral disorders covered include separation anxiety, thumb sucking, bruxism, head banging, stuttering, pica, nail biting, breath holding spells, temper tantrums, enuresis, and tics. The document provides details on each disorder such as typical symptoms, what causes them, and how caregivers can help address them.

1. BEHAVIORAL
DISORDERS
PRESENTED BY:
A.PRIYADHARSHINI M.Sc(N)
LECTURER,
JAI INSTITUTE OF NURSING AND RESEARCH,
GWALIOR.

2. 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.

3. Common behavioral disorders
 Separation anxiety
 Thumb sucking
 Bruxism
 Head banging
 Body rocking
 Stuttering
 Pica

4. Contd…
 Nail biting
 Breath holding spells
 Temper tantrums
 Enuresis
 Tics
 Encopresis
 Sibling rivalry

5. Separation Anxiety

6.  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.

7.  Sometime between 6-7 months, babies develop a
sense of object permanence
 They begin to learn that things and people exist
even when they're 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.

8. Thumb Sucking

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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

16. Contd…
 It is often associated with
1. Abnormal sleep activity.
2. Familial behavior pattern.
3. Pinworm infestation.
4. Neurological diseases. E.g. Cerebral palsy

17. MANAGEMENT:
 Behavior modification via possible
reinforcement.
 Relaxing stories at bedtime
 Reviews fears and angers experienced during day
 Praise child
 Emotional support
 Parental counselling.
 Psychotherapy

18. Contd..
 Pharmacotherapy (eg.) diazepam.
 Persistent bruxism leads to muscular or
temperomandibular joint pain.
 Dental referral necessary.

19. 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.

20. Body rocking and rhythmic
movements:
 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.

21. 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.

22. 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.

23. What Causes Stuttering?
 Genetics: 60% of those who stutter have a close
family member who stutters.
 Speech and language problems
 Developmental delays.

24. 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

25. 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.

26. A !
P IC

27.  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.

28. Causes…
 Normal till 2 years of age
 Other neurological disturbances
 Lower socio economic strata
 Parental neglect
 Poor supervision
 Lack of affection
 Malnourished

29.  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.

30. Complications…
Accidental ingestion of poisons
Particularly in lead poisoning.
Soil-borne parasitic infections.
Gastrointestinal (GI) tract complications.

31. TI NG
IL BI
NA

32. 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

33. 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.

34. 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.

35. 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.

36. 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.

37.  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.

38. 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.

39. 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.

40. 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.

41. Temper tantrums

42. 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 .
 They're equally common in boys and girls and
usually occur between the ages of 1 to 3.
 Normal part of development

43. Causes …
 Frustration
 Seeking attention
 Tired
 Hungry
 Uncomfortable

44. • 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 can't have
everything they want, the stage is set for tantrum.
• As language skills improve, tantrums tend to
decrease.

45. 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.

46. 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.

47.  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.

48.  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.

49. Enuresis

50. 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%

51. 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.

52. Causes of Primary Enuresis:
 Marked familial pattern.
 Exact pattern of transmission not clear.
 ? Abnormal bladder function.
 ? Diminished capacity to be aroused from sleep.

53. Causes of Secondary Nocturnal
Enuresis:
 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.

54. 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

55. 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).

56. 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

57. Bell and pad alarm system
(conditioning device) used:

58. 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

59. TICS:
 Definition: Repetitive movements of muscle
groups of face, neck, hands, shoulders, trunk.
 Examples:
 Lip smacking
 Grimacing
 Tongue thrusting
 Eye blinking
 Throat clearing

60. 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.

61. 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

62. Predisposing Factors for
Encopresis:
 Primary subtype:
 Developmental delay
 Secondary subtype:
 Psychosocial stressors
 Conduct disorder

63. 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

64. 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.

65. Sibling rivalry:
 Sibling rivalry is antagonism between brothers
and/or sisters that results in physical fighting,
verbal hostility, teasing, or bullying

66. 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

67. 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.

68. THANK YOU