personality disorder, sleep disorders, speech problems, habit problems, enuresis, encopresis

1. AMRITA A.S
ASSISTANT PROFESSOR

2. INTRODUCTION
• Child behaviour problems can crop up from anything and
everything, and they can be anything.
• It is necessary to differentiate between mischievous
children and child behaviour problems.
• Child behaviour problems can occur in toddlers as well as
teenagers.
• Child behaviour problems or behaviour disorders are
when children have show a permanent pattern of hostile,
destructive or disruptive behaviour towards oneself or
towards the society.

3. DEFINITION
• DEFINITION: Behaviour refers to the actions or
reactions of an object or organism, usually in relation to
the environment, Behaviour can be conscious or
unconscious, overt or covert, and voluntary or
involuntary.
• BEHAVIOURAL PROBLEMS: Behavioural problems
include disorders that represent significant deviation from
the normal behaviour. The root of the problem usually is
traceable to the home/ or school environment.

4. CATEGORIZATION OF COMMON BEHAVIOUR
PROBLEMS:
• Habit problems
• Problems of eating
• Sleep problem speech problems
• Scholastic problems
• Sexual problems
• Personality problems
• Antisocial problems

5. HABIT PROBLEMS
• Thumb sucking
• Nail biting
• Tics
• Enuresis
• Encopresis trichotilomania
• Breath holding

6. • Pica
• Food fads
• Food refusal/overeating
• Vomiting
• Anorexia

7. SLEEP PROBLEMS
• Night terrors
• Nightmares
• Somnambulism
• Insomnia
• Sleep-talking
• Hypersomnia
• Narcolepsy
• Cataplexy

8. SPEECH PROBLEMS
• Stammering
• Stuttering
• Mutism
• Phonation
• Articulation disorder

9. LEARNING DISABILITIES:
• Reading
• Writing or mathematical disability
• Repeated failures
• School phobia
• Aggressiveness

10. SEXUAL PROBLEMS
• Masturbation
• Homosexuality
PERSONALITY PROBLEMS
• Shyness
• Timidity
• Fears
• Anger
• Jealousy

11. ANTISOCIAL BEHAVIOUR
• Juvenile delinquency in the form of stealing
• Destructiveness
• Cruelty
• Gang activities

12. ACCORDING TO AGE GROUP
• Feeding problem
• Colic
• Stranger anxiety
• Breath holding spells
• Temper tentrum

13. INFANTS AND TODDLER
• Repetitive behaviour [ Body rocking and Head banging]
• Breath holding spells
• Thumb sucking
• Nail biting
• Evening colic
• Stranger anxiety
• Temper tantrum

14. PRESCHOOLER AGE
• Thumb sucking
• Nail biting
• Masturbation
• Lack of clarity of speech
• Stuttering
• Tic disorder
• Encopresis
• Sleep disturbances

15. SCHOOLER AGE
• Stuttering
• Sleep problems
• Enuresis
• Encopresis
• School phobia
• Mal-adjustments
• Conduct disorders

16. ADOLOSCENT AGE
• Juvenile delinquency
• Eating disorders
• Conduct disorder
• Oppositional defiant disorder

17. FACTORS ASSOCIATED WITH
BEHAVIUORAL PROBLEMS
• CHILD :
• Health
• Development
• Coping mechanism
• PARENTS :
• Misinterpreted behaviour
• Mismatched expectations
• Parenting styles
• Coping mechanisms

18. BEHAVOIUR PROBLEMS:
HABIT PROBLEMS -- THUMB SUCKING
Many children have the habit of thumb sucking most of
them would give it up by 2 years of age, but it should be
treated as normal till 5 years of age.
If the child discards this habit initially and resumes again at
7 to 8 years, he needs to be evaluated for associated
psychological problems.
Resumption of this habit suggests that the child is suffering
from stress or insecurity.

19. • If thumb sucking continues beyond the age of 4 years
then complications may arise as malocclusion and
misalignment of teeth, difficulty in mastication and
swallowing.
• It may cause deformity of thumb, facial distortion and
speech difficulties.

20. MANAGEMENT
• Parents should be counselled regarding the self remitting
nature.
• Children with thumb sucking should not be punished for this
act.
• A positive feedback is helpful when the child is not sucking.
• Child who looks depressed should be referred for detail
psychological evaluation and management.
• This child should be praised and encouraged, if he tries to
indulge activities other than thumb sucking.
• Use of bitter agents on thumbs or tying a cloth on thumb
should not be considered as first line approach.

21. NAIL BITING
• It is a common disorder of children and adults.
• It is most common in 10-14 years but can occur as early
as 4 years.
• Biting all ten-finger nails, cuticles and soft tissue may
lead to infection, bleeding and inflammation.
• This is the manifestation of emotional insecurity.

22. MANAGEMENT
• Behavioural reinforcement such as positive
reinforcement.
• Relaxation exercises.
• Positive emotional support

23. HABIT PROBLEMS
TICS
• Tic is a habit disorder, which is characterized by
repetitive movement of muscle groups.
• Most of the frequently there is lip smacking, tongue
thrusting, eye blinking, shoulder jerking and twitching of
fingers.
• It can be controlled consciously for shorten periods and
does not occur in sleep.
• Usual age is 6 years with a peak of prevalence in
preadolescent years.

24. MANAGEMENT:
• Parents should be counselled about spontaneous
evolvement of disorders
• Behaviour therapy.
• Relaxation exercises have proven efficacy.

25. ENURESIS:
• More than 85% children will not have a coexisting mental
disorder have complete diurnal and nocturnal control by
five years of age .
• 15% gain confidence at rate of 15% per year.
• Remaining 0.5-1% will have enuresis
• Enuresis is defined as normal nearly complete evacuation
of the bladder at wrong place and time at least twice a
month after the fifth year of life.

26. TYPES : PRIMARY AND
SECONDARY
Primary
• Bed-wetting in children who have never been dry for
extended periods.(3 times more common in boys)
Secondary
• The onset of wetting after a period of established urinary
continence.

27. CAUSES OF BEDWETTING:
Neurological-developmental
• Delayed development.
• Other neurological-developmental issues, these can range
from mild to severe.
Infection/disease
• Less than 5% caused by infection (UTI)
• connected to secondary nocturnal enuresis and with daytime
wetting

28. CAUSES CONTD…
Physical abnormalities
• Smaller than normal bladder.
• Increased bladder tone in some enuretics, functionally
decreases bladder capacity
Insufficient anti-diuretic hormone (ADH) production
(NOCTURNAL THEORY) :
• Normally ADH increases at night.
• This increase doesn't occur in child enuretics, but does
occur in adolescent enuretics.

29. CAUSES CONTD…
Stress
• Stress is controversial as a possible cause of bedwetting.
Some sources report that bed wetting during times of
conflict at home or school, is more.
Psychological
• When Enuresis is caused by a psychological disorder, the
bedwetting is considered a symptom of the disorder
Caffeine: increases urine production

30. CAUSES CONTD...
Improper toilet training
• Some say bedwetting can be caused by toilet training that is
started too early or is too forceful.
• Recent research has shown more mixed results and a
connection to toilet training has not been proved or
disproved
Alcohol Abuse
• Diuretic and sedative.
• Enuresis can become a more frequent problem when
dealing with chronic alcoholism

31. INVESTIGATIONS OF ENURESIS
• Full medical history along (toilet training, Parental attempts at
coping with problem)
• Time, duration, total incidence etc.
• Genital and Neurological examination
• Tests for DM, DI, CRF
• Examination of urine is done for albumin, sugar, microscopy,
specific gravity and culture.
• If the child has evidence of UTI, he should be further
evaluated with ultrasonography, voiding cystourethrogram and
urodynamic studies (for bladder capacity =300 to 350ml
normal)

32. TREATMENT OPTIONS WITH
HIGH SUCCESS RATES
Waiting
• Almost all children will outgrow bedwetting.
• Recommend delaying treatment until the child is at least six
or seven years old.
• Bedwetting Alarm: which sound a loud tone when they
sense moisture. This can help condition the child to wake at
the sensation of a full bladder.
• These alarms are considered effective, with study
participants being 13 times more likely to become dry at
night. There is a 29% to 69% relapse rate, however, so the
treatment may need to be repeated.

33. MEDICAL TREATMENT
• Desmopressin ( 20 -40 Microgram, nasal spray,4 weeks)
• Is a synthetic replacement for ADH , the hormone that reduces
urine production during sleep.
• The drug replaces the hormone for that night with no cumulative
effect.
• Tricyclic antidepressants
• Anti muscarinic properties have been proven successful in
treating bedwetting, but also have an increased risk of side effects.
• These drugs include Amitriptyline, Imipramine (.9-
1.5mg/kg/day,>7yrs, for 3-6 months)

34. CONDITION MANAGEMENT
OPTIONS :
• Diapers
• Can reduce the embarrassment and mess of wetting incidents.
• Dry Bed Training (ineffective)
• Dry Bed Training consists of a strict schedule of waking the child
at night, attempting to condition the child into waking by
himself/herself.
• Studies show this training is ineffective by itself and does not
increase the success rate but if used in conjunction with a
bedwetting alarm can be effective.

35. NURSING CONSIDERATION:
• Help parent to understand and the problem and treatment and
tell them to give love..
• It is not a willful misbehaviour. They need to understand that
enuresis is a medical disorder and that scolding, shaming,
threatening, and punishing a child are contraindicated because
of their negative emotional impact and limited success in
reducing the behaviour.
• Encourage communication with child to relive child from
parental burden of disapproval
• Decrease fluid intake after 5pm
• Teach bladder stretching exercises
• Remind child to empty bladder 2 hrly

36. ENCOPRESIS:
• According to the American Psychiatric Association (1994),
encopresis is repeated involuntary or intentional passage of
feces into inappropriate places (e.g., clothing or floor)
• The event must occur at least once a month for at least 3
months, and the chronologic or developmental age of the child
must be at least 4 years.
• The fecal incontinence must not be due effects of a substance
(e.g., laxatives) or a general medical condition except through a
mechanism involving constipation.

37. TYPES OF ENCOPRESIS:
• Primary encopresis :A child who has never achieved
fecal continence by 4 years of age is said to have. This
type is more frequently observed as a result of neglect,
lax training methods, mental subnormalities, and familial
causes.
• Secondary encopresis: is fecal incontinence occurring in
a child over 4 years of age after a period of established
fecal continence (American Psychiatric Association,
1994). The disorder is more common in males than in
females.

38. CAUSES:
• Birth of new sibling
• Moving to new house
• Changing to school
• Unfamiliar toilet facility (like in school)
• Anal fissures
• Involuntary retention because of emotional problems
• Voluntary retention because of fear of large-bore stools
(pain-retention-pain cycle)
• Busy schedule
• Disturbed mother child relationship

39. CLINICAL MANIFESTATIONS:
• Hard pellet like stool, blood streaked stool
• Stiff posture, standing at corner, little dancing
• Red face, hiding behind furniture
• Hide soiled underwear
• Refusing to go school
• Low self esteem
• Offensive odor
• Child not liked by peer group and rejected by parents

40. NURSING MANAGEMENT:
• Through history (when it began, how often under what
circumstances)
• Physical assessment
• Help the child to sit toilet at routine intervals
• Diet management with high fibers
• Decrease milk products and dairy products
• Administer enema, suppository/ mineral oil if prescribed
• Behavior therapy
• Family counseling

41. EATING PROBLEMS
PICA:
• The child may develop habit of eating non-edible substances
such as wall plaster, clay, paint and earth, etc. Children
• They are slow in motor and mental development and show
more neurological defects and deviant behaviour.
• Normal up to age of 2 years.
• Persistence of this habit beyond the age of 2 years may be a
manifestation of parental neglect, or supervision or lack of
affection
• Iron is often prescribed, without any definite incidence of
benefit.

42. MANAGEMENT:
• Rumination disorder is an uncommon disorder of infants and
young children in which the child repeatedly spits up food
without effort.
• He may spit out the food, but in some cases, he will re-chew
and re-swallow it.
• For many infants, the disorder simply resolves by itself. For
children and adults, a brief course of behavioural training can
teach breathing techniques that can counteract the regurgitation
of food.
• In many cases, one session is sufficient to address rumination.
• Other treatment options that can be added to this training are
biofeedback, relaxation training, and cognitive-behavioural
therapy.

43. EATING PROBLEMS
ANOREXIA NERVOSA:
• Is the most common chronic illness for teenage girls
• A psychosomatic disorder, it is characterized by self-
starvation stemming from an intense fear of gaining
weight and a distorted body image .

44. CAUSES
• Genetic role 50%
• Neurobiological factors
• Neurotransmitter serotonin and various psychological symptoms
such as mood, sleep, emesis (vomiting), sexuality and appetite.
• Nutritional factors
• Zinc deficiency causes a decrease in appetite
• Psychological factors
• Feelings of fatness and unattractiveness
• Depression
• Social and environmental factors
• Promotion of thinness as the ideal

45. SIGNS AND SYMPTOMS:
• Loss of menstrual periods
• Extreme concern with body weight and shape
• Feeling "fat" despite dramatic weight loss
• Fear of weight gain
• Preoccupation with weight, food, calories and dieting in an
attempt to compensate for overwhelming feelings and
emotions
• Denial of hunger
• Avoidance of meal times or social gatherings where there is
food involved.
• Excessive exercise regime

46. SIGNS AND SYMPTOMS:
CONTD...
• Withdrawal from friends and family
• Reduction of bone density resulting in osteoporosis.
• Risk of heart failure.
• Risk of kidney failure as a cause of severe dehydration.
• Fainting and fatigue
• Hair loss.
• Excessive hair growth all over the body, in an effort to
keep the body warm

47. DIAGNOSIS
• History taking
• Family history
• Check for fluid and electrolytes
• Psychiatric consultation to check disturbed body image,
low self esteem
• Hormonal assessment (estrogen deficiency)

48. NURSING MANAGEMENT:
• Diet management : but rapid wt gain should be avoided
• Set a goal convince patient and meat the goal slowly
• Practice good eating habits
• Behavior therapy :
• Support good weight gain and positive eating behavior
• Clearly define modification plan and follow.
• Treat any physical complications or associated mental health
problems.
• Address thoughts, feelings and beliefs concerning food and
body image.
• Encourage family support

49. BULIMIA NERVOSA:
• Bulimia, also called bulimia nervosa (BN), is a
psychological eating disorder.
• Bulimia is characterized by episodes of binge-eating
followed by inappropriate methods of weight control
(purging).

50. CAUSES:
• There is currently no definite known cause of bulimia.
• Researchers believe it begins with dissatisfaction of the
person's body and extreme concern with body size and
shape.
• Usually individuals suffering from bulimia have low self-
esteem, feelings of helplessness and a fear of becoming
fat

51. SYMPTOMS:
• Eating uncontrollably
• Purging
• Strict dieting
• Fasting
• Vigorous exercise
• Vomiting or abusing laxatives or diuretics in an attempt to
lose weight.
• Vomiting blood
• Using the bathroom frequently after meals.

52. SYMPTOMS CONTD…
• Preoccupation with body weight
• Depression or mood swings.
• Feeling out of control.
• Swollen glands in neck and face
• Heart burn
• Bloating,
• Indigestion
• Constipation
• Irregular periods
• Dental problems
• Sore throat Weakness
• Exhaustion
• Bloodshot eyes

53. MEDICAL COMPLICATIONS
• Dental cavities , sensitivity to hot or cold food.
• Swelling and soreness in the salivary glands (from
repeated vomiting).
• Stomach ulcer .
• Ruptures of the stomach and oesophagus.
• Abnormal build up of fluid in the intestines
• Disruption in the normal bowel release function.
• Electrolyte imbalance.
• Dehydration

54. DIAGNOSIS:
• Same as AN
• Specify type
• Purging type : during episode of BN person was regularly
engaged in self induced vomiting or misuse of laxatives,
diuretics.
• Non-purging type : during episode person was engaged in
activities other than above mentioned like excessive
exercise.

55. MANAGEMENT
• Treatment focuses on breaking the binge-purge cycles.
• Outpatient treatment may include behaviour modification
techniques as well as individual, group, or family
counselling.
• Antidepressant drugs may also be used in cases that
involve depression.
• Support Groups Self-help groups like Overeaters
Anonymous may help some people with bulimia.

56. NURSING MANAGEMENT
• Similar to AN
• Keep a eye in patient, using toilet again and again and is
vomiting, is likely to have fluid and electrolyte
imbalance.

57. SPEECH PROBLEMS
• STUTTERING (AGE 2-5 YEAR):
• Stuttering is a defect in speech characterized by hesitation
or stumbling and spasmodic repetition of some syllables
with pauses.
• There is difficulty in pronouncing the initial consonants
and it is caused by the spasm of lingual and palatal
muscles.
• Some degree of stuttering is normal and the major cause
of stuttering is that environmental and emotional stress.

58. MANAGEMENT
• Do not remind child the mistake and ridicule him, that
increase the stress and further aggravate the condition.
• The conflict occur between childs achievement and the parents
expectation and the child loses his confidence.
• Reassure parents that between this age group is normal and
will pass off and the IQ level of these children is normal.
• They should not show undue concern and accept his speech
without pressurizing him to repeat or making him conscious of
his handicap.
• Older children should be referred to speech therapist.

59. SLEEP DISORDERS
Sleep disorders
Sleep issues are another controversial potential cause of
bedwetting.
• Sleep apnoea stemming from upper airway obstruction has
been associated with enuresis.
• This can be signalled by snoring and enlarged tonsils or
adenoids Many parents report that their bedwetting children
are heavy sleepers.
• Research in this has some contradictory results. Studies
show that children wet the bed during all phases of sleep,
not just the deepest (stage four).

60. SLEEP DISTURBANCE
Manifestation could be
• Dark
• Difficulty falling asleep
• Night walking (somnambulism)
• Sleep talking
• Night terror

61. MANAGEMENT :
• Stay with child
• If night walking is there don’t leave child alone
• Consult physician

62. SEXUAL PROBLEMS
MASTURBATION :
• Child obtain pleasure by self stimulation of genitals,
rubbing the thighs against each other or rhythmic
swaying movement.
• Normal if not excessive.
• Common up to 4 years of age and also in adolescent
period
• For preschooler it is part of sexual curiosity and
exploration.

63. MANAGEMENT:
• Needed for those who openly and publicly masturbate
and are inviting punishment, criticism and discipline.
• Or for child continuously touches his/her genital and
ensuring it is intact, it is a sign of unresolved conflicts.
• Channel them to more constructive outlet.

64. THANK YOU