Some common behavioral problems seen in children.

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BehavioralBehavioral ProblemsProblems

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DefinitionDefinition
• Behavioral Disorders represent
significant departure or deviation
from the accepted ‘normal’
behavior.
• Incidence: up to 20% of children.

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Common Behavioral ProblemsCommon Behavioral Problems
1. Habit Problems,
2. Eating Problems,
3. Personality Problems,
4. Anti-social Problems,
5. Sleep Problems,
6. Speech Problems,
7. Scholastic Problems.

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Habit ProblemsHabit Problems
• Thumb Sucking,
• Nail Biting,
• Enuresis,
• Encopresis,
• Breath Holding Spells,
• Trichotillomania,
• Aerophagia.

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Eating ProblemsEating Problems
• Pica,
• Food Fads,
• Food Refusal/Overeating,
• Anorexia,
• Vomiting

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Personality ProblemsPersonality Problems
• Shyness,
• Timidity,
• Fears,
• Anger,
• Jealously.

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Anti-Social ProblemsAnti-Social Problems
• Juvenile Delinquency,
• Juvenile Crimes.

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Sleep ProblemsSleep Problems
• Night Terrors,
• Nightmares,
• Somnambulism,
• Insomnia
• Sleep Talking,
• Narcolepsy.

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Speech ProblemsSpeech Problems
• Stuttering,
• Mutism,
• Phonation,
• Articulation Disorders.

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Scholastic ProblemsScholastic Problems
• Reading, writing, and mathematical Disorders,
• Repeated Failure,
• Absenteeism,
• Truancy,
• School Phobia.

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EtiologyEtiology
• Maladjustment:
– At home,
– At school

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Neurobehavioral ProblemsNeurobehavioral Problems
• ADHD,
• Autism,
• Learning Disorders.

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Specific Problems

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Thumb SuckingThumb Sucking

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Thumb SuckingThumb Sucking
• Common,
• Harmless,
• Infancy & Early Childhood,
• A way of securing extra self-nurturance.

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Harmful EffectsHarmful Effects
• When persisting beyond 4 yrs of age:
– Dental,
– Dermatological,
– Orthopedic, and
– Psychological.

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Dental ProblemsDental Problems
• Malocclusion of developing teeth,
• Digital deformity,
• Speech difficulty.

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ResumptionResumption
• Resumption: A child who discarded this
habit initially and resumes again at 7 to 8
years. This is known as resumption.
• Such cases need to be evaluated for
psychological problems.
• Resumption of this habit suggests the
child is suffering from stress or insecurity.

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ManagementManagement
• Not required in most cases.
• No treatment if thumb-sucking is
infrequent.
• Management is indicated is thumb-
sucking is persistent after 4 – 5 years of
age.

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StrategiesStrategies
• Planned ignoring,
• Pay attention to more positive aspects of
the child’s behaviour.
• Rewards/Incentives for sucking free days.

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Parental CounselingParental Counseling
• Self remitting nature,
• No punishment,
• Keep the engaged in activity other than
thumb-sucking.

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Breath Holding SpellsBreath Holding Spells

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Breath Holding SpellsBreath Holding Spells
• Paroxysmal self limiting events,
• 6 mo – 6 years.
• 10% of healthy children.

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Sequence of EventsSequence of Events
Provocation
Crying to a point of noiselessness
Change of color
1. Loss of consciousness,
2. Alteration in body color

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EtiologyEtiology
• Neurobehavioral Problem,
• Non-epileptic paroxysmal disorder,
• Genetically mediated deregulation of
autonomous nervous system reflexes.

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Old Belief!Old Belief!
• Spells result from frustration
due to disciplinary conflict
between parents and the child.

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ClassificationClassification
(According to color change)
• Cyanotic,
• Pallid,
• Mixed.

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Cyanotic TypeCyanotic Type
• Face becomes blue,
• Precipitated by anger or frustration.

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Pallid TypePallid Type
• Face appears pale,
• Provoked by sudden fright or pain.

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MixedMixed
• No clear distinction between
cyanosis and pallor, or
• A conflicting history by parents.

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Clinical FeaturesClinical Features
• Typical age:
– From 6 to 18 months.
• Frequency:
– Variable
– Multiple episodes daily, or
– One per year.
• Tantrum   Spells.

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C/FC/F
• The child holds his breath in expiration
after a bout of crying.
• The child becomes rigid and attains
ophisthotonic posture   limpness  
normal breathing and alertness within a
minute.

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Differential DiagnosisDifferential Diagnosis
• Epilepsy,
• Hypercyanotic Spells.

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BHS Epilepsy
Predisposed
by
Anger,
Frustration,
Fright
No predisposing
factor.
After attack
Completely
normal
Post-ictal stage:
headache,
vomiting and
drowsiness
Cyanosis May be present. Mostly absent.
EEG Normal Abnormal.

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BHS
Hypercyanotic
Spells
C/F of CCHD Absent Present
Cyanosis
Only during attack;
no cyanosis before
and after attack.
Always present.
More obvious during
spells.

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InvestigationsInvestigations
• ECG TRO long QT syndrome,
• EEG: Not required.
• Work up for iron deficiency.

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ManagementManagement

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Immediate ManagementImmediate Management
• Prevent injury,
• Prevent aspiration,
• Maintain airway (ABC).

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Don’tDon’t
• Don’t start CPR,
• Don’t shake the baby,
• Don’t splash water,
• Don’t put anything in mouth.

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Long Term MeasuresLong Term Measures
• No prophylactic medicine.
• Treat iron deficiency:
– Oral iron (4 – 6 mg/kg/day) for 6 – 8 weeks.

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Parental EducationParental Education
• Assure    Normal Life.
• Avoid precipitating factors.
• What to do and what no to do during
attacks.

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ReferRefer
• Child < 3 months age.
• Unconsciousness lasts for > 1 minute.
• Too frequent attacks.
• Suspected seizure disorder.
• Suspected cyanotic spells.

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PicaPica

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PicaPica
• Eating disorder,
• Repeated and chronic ingestion of
non-nutritious substances such as
mud, plaster, charcoal, chalk, paint,
earth, clay, etc for a period of at least
one month.

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EtiologyEtiology
• Cause: Unknown.
• 18 – 24 months of age.
• Persistence beyond 24 months
needs attention.

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Work Up!Work Up!
• Lead toxicity,
• IDA,
• Parasitic infestation.

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ManagementManagement
• < 2 yrs of age: no treatment.
• Deworming.
• Education, guidance and counseling
of family.

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Infantile ColicInfantile Colic
oror
Evening ColicEvening Colic

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Rule of 3Rule of 3
• < 3 months of age,
• Crying > 3 hrs/day,
• > 3 days/week,
• Longer than 3 weeks.

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EtiologyEtiology
• Not known.
• Possible:
– Increased gas production in colon.
– Milk allergy,
– Hyperperistalsis,
– Psycho-social,
– Neurodevelopmental disease.

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EtiologyEtiology
• Baby otherwise well, feeds and healthy,
• Gains weight,
• Incidence:
– 5 to 25% infants.

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EtiologyEtiology
• More likely to occur if child is over-reactive
and parents over-anxious.
• These episodes could also be a
manifestation of hunger, aerophagia or
overfeeding.
• Starts within 4 wks after birth, reaches a
peak by 4-6 wks and subsides by 3-4 mo.

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C/FC/F
• Evening,
• Flushed face,
• Clenched fists,

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C/FC/F
• Legs pulled up to abdomen,
• Cannot be soothed by feeding,
• Attack terminates after the infant is
exhausted or passes feces or flatus.

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Differential DiagnosisDifferential Diagnosis
• CNS abn / infection,
• FB in eye,
• GERD,
• OM
• UTI,
• # bone,
• Child abuse.

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ManagementManagement
• Reassurance,
• Support the family,
• Limited treatment,
• Ensure ‘no organic cause,

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ManagementManagement (continued)
• Provide support to family,
• Assure that this is a self limiting
phenomenon,
• No long term adverse effect.

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During an episodeDuring an episode
Hold the child erect or prone on the lap
Hot Water Bottle?
Fails
Sedate the child and parents

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ExplainExplain
• Explain feeding technique,
• Practice burping,
• Place the child in right-lateral position for
about ½ hr after feeding.
• Avoid allergenic food.

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Further Learning!!Further Learning!!
• Rumination, bulimia, anorexia nervosa,
• Enuresis, Encopresis,
• Anxiety Disorders,
• Mood Disorders,
• Temper Tantrums,
• ADHD,
• Autism (Pervasive Developmental Disorders).