Developmental and behavioral disorders in children can include global developmental delay, intellectual disability, autism spectrum disorder, attention deficit hyperactivity disorder, specific learning disabilities, enuresis, encopresis, tic disorders, temper tantrums, and eating disorders. Causes may be genetic, environmental, or due to infections or injuries. Treatment involves a multidisciplinary approach including early intervention, educational support, behavioral therapy, and medication if needed. Accurate diagnosis and management can help improve outcomes for affected children.

1. Developmental and
Behavioral disorders
in children
DR ROMILA CHIMORIYA
LECTURER
PEDIATRICS DEPARTMENT

2. Global Developmental delay
intellectual disability
• Delay in acquiring milestones in two or more of the following
domains
• Intellectual disability-above 5 years
• Prevalence-2.5-5%

3. DEVELOPMENTAL
DEVIANCE AND
DISSOCIATION
• Deviance
-acquisition of milestones in a sequence that is different than
others
• Dissociation
-acquisition of developmental milestones in various domains at
differing rates

4. ETIOLOGY
• Antenatal
-Syndromes(fragileX,Rett syndrome)
-Chromosomal disorders(Down syndrome)
-Cortical malformations
-Intrauterine infection
-Inborn errors of metabolism
-Teratogen exposure
-Neuromuscular disorders

5. • Perinatal,neonatal
-HIE
-Kernicterus
-Meningitis/encephalitis
-Hypoglycemic brain injury
-Hypothyroidism
-Head trauma
• Postnatal
-Deficiency of vitamin B12,Iodine,toxins(lead)

6. Management
• Diagnostic test
-Neuroimaging
-Metabolic tests
-Genetic studies
-TFT,Blood and urine lead
-Micronutrients
-Electrophysiological studies
• Multidisciplinary approach
• Early intervention required

7. Autism spectrum disorder
• Triad-with onset before 3 years
-Social behaviour impairement
-Communication(verbal and non-verbal)impairement
-Sterotypic and restrictive behavioural patterns
• 1-2%
• Incidence: 20/10000
• M:F- 4:1
• Cause- genetic
• Environmental factors
• Prematurity

8. Autistic disorders
Pervasive developmental disorders
Autistic disorder, Asperger syndrome , Childhood
disintegrative disorder, Rett syndrome
Inability to attain expected social,
communication, emotional ,cognitive and
adaptive abilities

9. Clinical features
• Impairments in social interaction, communication
and developmentally inappropriate behavior,
interest and activities.
• Stereotyped body movements, marked need for
sameness and very narrow range of interest

10. Early social skill deficit include abnormal eye
contact, failure to respond to name, use gesture,
to point or show
Verbal- nonverbal to having some speech,
repetition of words
Play skills-little symbolic play, spend time in
solitary play
Intellectual- mental retardation, decrease

11. intelligence
Early identification –better outcome
Early signs: unusual use of language or loss of
language skills, non functional rituals, inability to
adapt to new setting, lack of imitation, absence of
imaginative play

12. Treatment
Educational intervention
- Behavior therapy
- Speech, occupational, physical
therapy
Systematically planned educational
activities, low student to teacher
ratio, promoting opportunity for
interaction, visual activity, using

13. Attention deficit hyperactivity
disorder
• Most common
• 1.3/1000
• 4-18 years
• Academic and behavioural problems
• Inattention,hyperactivity and impulsivity
• Management
-Psychotherapy
-Methyphenidate
-Atomoxetine

14. Inattention
Six or more of following criteria persisting for ≥
6 months
- Fails to give close attention and makes careless
mistakes
-Has difficulty sustaining attention
-Doesn’t seem to listen when spoken directly
- Doesn’t follow through instructions and fails to
finish school works

15. - has difficulty organising tasks and activities
- is reluctant to engage in task which require sustained
mental effort
- easily distracted by external stimuli
- forgetful in daily activities
• Has difficulty playing or engaging in leisure activities
quietly
• Is “on the go” or as if “driven by a motor”

16. Impulsivity
• Bursts out answers before questions have been
completed
• Has difficulty awaiting turns
• Interrupts or intrudes on others

17. Attention deficit hyperactivity disorder-
combined
Attention deficit hyperactivity disorder-
predominantly inattentive type
Attention deficit hyperactivity disorder-
predominantly impulsive type

18. • Must begin before 7 years
• Must be present for at least 6 months
• Must be present in 2 or more setting
• Must NOT be secondary to another
disease

19. Cause
• Maternal drug uselead, smoking,
alcohol
• Genetic- dopamine transporter
,dopamine receptor gene
• Brain injury- traumatic
Incidence 5 to 10 %

20. Treatment
• Education to child and parents
• Behavioral session- 8 to 12 sessions
• Reward
• Medications: Psychostimulants-
Methylphenidate, amphetamines

21. Specific learning disability
• Impairement in reading-dyslexia(80%)
• Impairement in writing-dysgraphia
• Impairement in arithmetic-dyscalculia
• Preserved cognition,vision,hearing and adequate opportunities
• Remedial education ,active participation

22. LEARNING DISORDERS
DYSLEXIA
-Most common learning disorder5 to 15 % of school
aged children problem with decoding and using
single words
-Difficulty with accurate and fluent word recognition
and poor spelling and decoding
-Cause:
• Genetic
• Deficits in phonologic awareness

23. CLINICAL FEATURES
• Problem in both spoken and written language
• Mispronunciation, speech that lacks fluency with
pauses, word finding difficulties
• Struggles in decoding and word recognition

24. Management
In younger children-remediation of the
reading problem
Effective intervention programs provide
systematic instruction in 5 key areas:
-Phonemic awareness
- Phonics
- Fluency
-Vocabulary
-Comprehensive strategies

25. ENURESIS
• Normal,nearly complete evacuation of the
bladder at a wrong place and time at least
twice a month after 5 years of age
• TYPES
Diurnal- wetting while awake
Nocturnal- voiding during sleep

26. Primary- occurs in children who have
Etiology
• Biologic- common if parents had this condition, more
common in twins
• Hyposecretion of AVP, small functional bladder
capacity
• Psychosocial- stress
• UTI
• Bladder bowel dysfunction
• D/D-UTI

27. Investigation
• History-Primary/secondary,Stress
• Physical examination-spinal anomalies
• Urine R/M – glycosuria,pus cells, low specific
gravity
• Ultrasonography
• MCUG

28. Treatment
Non pharmacologic therapy
- Limit fluid intake
-Empty bladder before going to sleep
- “Resolution” to stay dry.
-Calender of dry and wet nights.
-Encourage in cleaning up.
-Treatment of constipation
- Discuss use of alarms/medications.

29. • Alarm system: use of alarm system to use
as conditioning response of awakening to
the sensation of full bladder.
• Application of alarm for 8-12 weeks
shows 75- 95 % success.
• PHARMACOTHERAPY
Desmopressin- decreases nighttime
production of urine

30. ENCOPRESIS
• Passage of stools in clothes beyond an age when bowel control
should have been achieved(4 years)
• Retentive(constipation)/non retentive
• Primary-associated with constipation
• Secondary-stress
• Behavioural therapy
• Positive reinforcement
• Treatment of constipation

31. Habit disorders
• Repeated, seemingly driven and
nonfunctional motor behaviour that
markedly interferes with normal
activities or results in self inflicted
injury that requires medical treatment.

32. Bruxism
Common,begins in first 5 years of life
Associated with daytime anxiety
If untreated , problem with dental occlusion
Treatment- Reduce anxiety
Emotional support
Referral to dentist

33. Thumb sucking
• Normal in infancy and toddlerhood
• 18-21 mths
• Disappears after 4 years
• Self soothing
• Dental malalignment
• Treatment:
• Encourage parents to ignore thumb sucking.
• Praise for substitute behavior.
• Reward
• Use of noxious agents

34. Tic disorder
Sudden, rapid, recurrent,non rhythmic, streotyped
motor movement or vocalization that is
expressed as irresistible but can be suppressed for
varying length of time.
Usually markedly diminishes during sleep

35. Types
Motor – involves muscles of face,neck, shoulders,trunk,hands
• Simple- eye blinking, neck jerking, shoulder shrugging, cough
• Complex- Facial gestures, grooming behavior
Vocal Tics
• Simple- throat clearing, grunting, sniffing,coughing
• Complex- coprolalia,palilalia,echolalia

36. Tourette syndrome
• Onset before 18 years
• Motor and vocal tics
• Persistence beyond 1 year
• Waning phase
• D/D
• Dyskinesias
• Dystonic movements

37. Treatment
• Cognitive behavior therapy
• Treatment of co occurring conditions like
obsessive compulsive symptoms, hyperactivity.
• Drugs: α adrenergic agonists-
clonidine,Risperidone
For older children- provision of accommodation
rather than remediation
Extra time for reading and writing exams
Use of laptops, computers with spelling checkers,
use of recorded books, access to lecture notes

38. Temper Tantrums
• Common disorders in infancy
• Development of autonomy and negativism
• Age typical expressions of frustration or anger
• Biting, crying, kicking, pushing, ,throwing
objects
• 18-36 mths
• Subsides at 3-6 years
• Educate parents
• Advise parents to tell child that reasons for
frustrations are understandable but defiance is not
acceptable.

39. Breath holding spells
Reflex event that occurs after crying ,child holds
his breath, becomes apneic and cyanosed, may
lose consciousness.
Seizures may be seen
Peaks at 2 years,abates by 5 years.
Educate parents, protect from injury.
Iron supplement of anemic

40. Anorexia nervosa
• Common problem in adolescent girls
• Intense fear of becoming obese
• Disturbance in body image- “feel fat”
• Body weight < 85% of expected weight for age and height
• Restricted eating or increased physical activity
• Absence of at least 3 consecutive menstrual cycles when
otherwise expected to occur

41. Types
• Restricting group- severely limit their intake of carbohydrates
and fat intake
• Bulimic/ purging group- eat in binges and then induce vomiting
or use of cathartics

42. Bullimia nervosa
• Recurrent episode of binge eating
• Recurrent inappropriate compensatory behavior to prevent
weight gain
• Binge eating and compensatory behavior occur on average at
least twice a week for 3 months
• Self evaluation is influenced by body shape /weight.

43. Clinical features
• Overestimation of body size, shape or parts leading to weight
control practices to reduce weight or prevent weight gain
• Feeling tired and cold, lacking energy
• Hypothermia, slow CRT, loss of muscle mass, bradycardia

44. Investigation
• Hypokalemic hypochloremic metabolic alkalosis
• Increased liver enzymes
• Increased cholesterol, decreased glucose
• ECG- low voltage, bradycardia or arrythmia

45. Complication
• Bradycardia/hypotension
• Hypothermia
• Ventricular arryhtmia, reduce myocardial
contractility
• Refeeding syndrome- due to rapid drop in serum
phosphorus, magnesium, potassium with
excessive reintroduction of calories is associated
with renal failure and neurological symptoms

46. Management
• Nutrition-
• Calories 100 to 200 kcal every few days, 3 meals and 1 snack
• Supplementation of calcium, vitamin D
• SSRI

47. Treatment
• Order a full physical and screen for missing nutrients
as well as other medical issues, eg, lead poisoning
• Control for behavior and environmental factors.
• Mild aversion therapy has been effective in some
cases
• Seek to reduce impulse to eat abnormally with
pharmacological interventions.

48. • Medications may help reduce the abnormal eating
Stuttering
• Defect in speech characterized by hesitation or stumbling and
spasmotic repetition of some syllables with pauses.
• Most children show some degree of repetition and hesitation in their
speech at some period of early life.
• Stuttering usually begins between the ages of 2 and 5 yrs.
• Stress caused by conflict between the parental expectations and the
child’s achievements may precipitationg factors in some children

49. Management
• Parents should be reassured about a young child with primary
stuttering which can be common between the age of 2 and 5yrs
• Not show undue concern rather accept the speech.
• Older children with stuttering needs emotional support and referred
to speech therapist.
• Stuttering children are not mentally retarded and their IQ may be
higher than average.

50. PICA
-Eating disorder
-persistent eating of nonnutritive substances such as plaster,
charcoal paint and earth for at least 1 month in such a
fashion that it is inappropriate for developmental level, is
not part of culturally sanction practice and is sufficiently
severe to warrant independent clinical attention.
• The Handbook of Clinical Child psychology currently
estimates that prevalence rates of pica range from
4%-26% among institutionalized populations.

51. Etiology
• Not known.
• Mental deprivation
• Psychological stress in the form of maternal deprivation
• Parental neglect and abuse
• Poor socioeconomic status
• Malnutrition
• Iron deficiency

52. RISK FACTORS
1.Lead Poisoning
2.Iron deficiency anaemia
3.Parasitic infestations and should be routinely screened
MANAGEMENT
• Allevation of psychological stress if present
• Iron supplementaion
• Deworming
• Parental counselling

53. Substances uses are
Individuals with pica usually crave a particular non-nutritional
substance, most commonly
• Clay
• Dirt
• Sand
• Ice chips
• Hairballs
• Chalk
• Soap
• Paint
• Glue
• Rocks, feces, pins, nails, or buttons

54. Most famous pica

55. Oppositional defiant disorder
• Repititive/persistent pattern of opposing,defiant,disobedient
and disruptive behaviour towards authority figures persistent
for 6 mths
• Family history of mental problems
• Management
• Reduction of stress
• Stimulants

56. Conduct disorder
• Aggressive and destructive activities that cause disruption
• Atleast a period of 1 year
• Management
-behavioural
-psychotherapy

57. Juvenile delinquency
• Children with oppositional defiant behaviour or conduct
disorder comeinto conflict with juvenile justice system
• Less than 18 years
• Criminal act/illegal behaviours
• Management
• Parental care
• Placement in foster

58. • Munchausen by proxy
-Caregiver(mother)deliberately makes up history of illness in her
child and/or harms child to create illness
• Parasomnias
-Abnormal behavioural or motor manifestations seen in sleep
-First half of sleep-NREM,Sleep walking,confusional
arousals,sleep terrors
-REM-Nightmares,bizarre movements
-Management-self limiting,reassurance,stress
managemnet,benzodiazepines