Mine

1. University of Gondar
.
Common Behavioral Disorder in Children

2. OUTLINE
• Objective
• Definition of behavioral disorder
• Categorization of behavioral problem
• Assessment of behavioral disorders
• Common behavioral disorder
• Recommendation
• Reference

3. OBJECTIVE
After the session the participants should able to know :
• Common behavioral disorders in childhood
Types
Causes
Diagnostic criteria
Management

4. BEHAVIORAL DISORDER
 A young person is said to have a behavioral disorder
• Different from expected
• Not doing what adultswant to do
• Cannot adjust to a complexenvironment
• Unable to behave in the sociallyacceptableway
 Classification
• Age
• Nature
 Categorized into
• Spontaneous responsive
• Non spontaneous responsive
 In the settings

5. BEHAVIORALDISORDER
Most common behavioral disorder
1. Language problems
2. Behavior or emotional disorders
3. Attention-deficit hyperactivity disorder
4. Learning disabilities
Less common and more disablingdisorder
1. Intellectual disabilities (1–2%)
2. Autism spectrum disorders (1 in 59
children)
3. Cerebral palsy and related motor
impairments (0.3%)
4. Hearing impairment
5

6. BURDEN OF MENTAL AND BEHAVIORAL IN ETHIOPIA
 A cross-sectional survey to determine the magnitude of specific mental and behavioral
disorders in 1477 children and adolescents
• 3.5% had at least one or more mental or behavioral disorders
Ashenafi Y. Prevalence of mental and behavioral disorders
Mentaland behavioral diagnoses Percentage
Anxiety disorders 1.6
ADHD 1.5
Disruptive behavior disorders 1.5
Mood disorders 1
Elimination disorders 0.8

7. CAUSESOF BEHAVIORAL DISORDER
 Heredity
 Environment
• Pooreconomy
• Mass media
• Changing lifestyle and urbanization
 Physical and mentally sick or handicapped condition
• Unhealthyrelationship
• Lackof discipline
• Changein moralstandardsandvalue

8. ELEVEN MENTALHEALTHACTIONSIGNS
1. Feeling very sad or withdrawn
2. Seriously trying to harm or kill
3. Involvement in many fights
4. Severe out-of-control behavior
5. Intense worries or fears
6. Sudden overwhelming fear for no reason
7. Not eating, throwing up, or using laxatives
8. Concentrating or staying in physical danger
9. Use of drugs or alcohol
10. Severe mood swings
11. Changes in behavior or personality

9. RAPIDPSYCHOSOCIAL ASSESSMENT
 Rapid psychosocial assessment
HEADSS
1. Home
2. Education
3. Activities
4. Drugs
5. Sexuality
6. Suicide/Depression

10. SCREENINGTOOL
1. PSC
2. SDQ
3. SCARED
4. Vanderbilt ADHD DRS
5. MCHAT
6. CES-DC
7. MFQ Short Version

11. COMMONBEHAVIORAL PROBLEMSINCHILDREN
 Infant
1. Abdominalcolic
2. Resistance to feeding
3. Stranger anxiety
 Children
1. Emotionalproblems
2. Stereotypic movement disorder
3. Elimination disorder
4. Speechproblems
5. Sleepproblems
 Adolescent
1. Eating disorder
2. Sexualproblems
3. Delinquency

12. INFANT COLIC
 Benign self-limited
 Crying or fussiness is present in all babies
• Medical attention in about 20%
 Diagnostic criteria:
1. An infant who is < 5 mo of age
2. Recurrent and prolonged periods of infant crying, fussing or irritability
• Without obvious cause and not prevented
3. No failure to thrive, fever or illness
 Wesselcriteria, rule of Three
1. Beginning
2. Duration in a day
3. Occurrence in a week
4. Total period of colic
5. Resolution

13. PROPOSED ETIOLOGIES OF INFANT COLIC
 Gastrointestinal disturbance
• Faulty feeding techniques
 Underfeeding, overfeeding, infrequent burping and swallowing air
• Cow's milk protein intolerance allergy
 Hydrolysate formulas
 Hypoallergenic diet
• Lactose intolerance
• Gastrointestinal immaturity
• Excessive gas is produced when the unabsorbed carbohydrate is fermentation
• Intestinal hyper motility
• Alterations in fecal microflora

14. PROPOSED ETIOLOGIES OF INFANT COLIC
 Biologic
• Immature motor regulation
 Increased vulnerability to feeding intolerance
• Increased serotonin
• Tobacco smoke and nicotine exposure
 Psychosocial theories
• Colic is a psychosocial phenomenon
• Caretaker's perception of what is excessive and prolonged
• Temperament, overstimulation and parental variables
 Family stress, Maternal anxiety & Transmission of tension from mother to infant

15. CLINICAL FEATURES
 Paroxysms
 Qualitative differences
 Physical characteristics
• Facial flushing
• Tense or distended abdomen
• Drawing up of the legs
• Clenching of the fingers and tightening of the arms
• Arching of the back
 Difficulty consoling
 Relief may be noted

16. MANAGEMENT
 To decrease crying and bolster the infant-family relationship
 Parental support
• Confirms the diagnosis
• Reassurance
• Take breaks from the crying infant
 Parental education
• Common and usually resolves spontaneously
• Not caused by something they are doing or not doing
 Feeding technique

17. SOOTHING TECHNIQUES
 Decreasing sensory stimulation
• Taking the infant for a ride in the car or a walk
• Rocking and swing infant
• Changing the scenery
• Infant Providing a warm bath
• Rubbing abdomen
• Playing an audiotape
• Providing white noise generators
 In any order and/or combination
 Try a technique for several minutes

18. DIETARY CHANGES
 Trial of dietary interventions
 Breastfed infants
• Maternal milk product consumption or a hypoallergenic maternal diet
• Look sign of allergy
 Option for formula fed infants with colic
• Extensive hydrolysate formula like Alimentum, nutramigen, pregestimil
 Continued if there is a decrease in fussiness
 Response usually occurs within 48 hours
 Original formula is resumed if there is no change
 Soy protein formula
 Fiber-enriched formula

19. MANAGEMENT CON’T
 Probiotics
• Lactobacillus reuteri
• Not for routine management ,Cost of probiotics
 Simethicone
 Herbal remedies
 Follow-up
• Individualized and re-examination
 Referral
• For parents who are extremely anxious
 Outcomes
• Parents of colicky infants experience stress, fatigue, guilt and depression

20. DISRUPTIVE, IMPULSE-CONTROLAND CONDUCT DISORDERS
 Interrelated sets of psychiatric symptoms
• Characterized by a core deficit in self-regulation
• Anger, aggression, defiance, and antisocial behaviors
 Include
1. Oppositional defiant
2. Intermittent explosive
3. Conduct
4. Other specified/unspecified disruptive/impulse control/conduct
5. Antisocial personality disorders

21. OPPOSITIONAL DEFIANT DISORDER
 Angry, irritable mood, argumentative/defiant behavior or vindictiveness
• Exhibited during interaction with at least 1 individual
• Lasting at least 6 month
 For preschool children
• Must occur on most days
 In school-age children
• Must occur at least once a week
 Severity is based on setting
• Mild ,Moderate and Severe

22. ETIOLOGY AND RISK FACTORS
 Number of neurobiologic markers
• Pre-, peri-, and postnatal insults
• Reduced basal cortisol reactivity
• Serotonergic abnormalities
Parents of behaviorally disordered children
•Negative parenting responses
Impaired parent child attachment
Child maltreatment
•Family poverty and crime
Peer-level influence and Neighborhood influences

23. DIAGNOSTIC CRITERIA FOR ODD
A. At least 6 mo as evidenced by at least 4 symptoms
 Angry/irritable mood
1.Angry
2.Temper
3.Often easily annoyed
 Argumentative/defiant behavior
4.Actively defies or refuses to comply
5.Deliberately annoys others
6.Blames others
7.Argues
 Vindictiveness
8.Spiteful or vindictive
B. Associated with distress or impacts negatively
C. Not exclusively during a psychotic, substance use, depressive or bipolar disorder

24. CONDUCT DISORDER
 Is characterized by a repetitive and persistent pattern
•At least 12 mo of serious rule-violating behavior
The symptoms of CD are divided into 4 major categories:
1. Aggression to people and animals
2. Destruction of property
3. Deceitfulness or theft
4. Serious rule violations
Three subtypes based on the age of onset:
1. Childhood onset type
2. Adolescent onset type
3. Unspecified
Based on severity classification: no of Sx and impacts
•Mild, Moderate and Severe

25. CLINICAL COURSE
 Higher in adolescence, males and lower socioeconomic classes
 Becomes a concern
• Intense, persistent, and pervasive
• Affects the child's social, family, and academic life
Earliest manifestations of oppositionality
•Stubbornness
•Defiance and temper tantrums
•Argumentativeness
 Approximately 65 % of children exit from the diagnosis after a 3 yr follow-up
 Age at onset is an indicator of prognosis
 Approximately 30% with comorbid ADHD
 Increases risk for depressive and anxiety disorders

26. PARENT TRAINING PROGRAMS
 Specific parent training programs
• Parent child interaction therapy
• Helping noncompliant child
• Parent management training
 Predictors of nonresponse to interventions
• Initial symptom severity
• Involvement of parent
 Premature termination (<5 treatment sessions) is high as 50– 60%
 Predictors of premature termination of parent training programs
• Single parent
• Family income
• Parental education levels
• Maternal age

27. COGNITIVE BEHAVIORAL THERAPY
Delivered in sessions
Multidimensional treatment
•School-based behavioral interventions
•Youth anger management
•Problem-solving training
•Family therapy
•Psychiatric consultation
Medication management
• Methylphenidate
• Atypical antipsychotics
Predictors of non response
•Higher rule-breaking behavior
•Comorbid mood disorders

28. TANTRUMS
 Asuddenoutburst anger, frustration and badtemper
• Physical aggressionor resistance
 Rigid body,biting, kicking, throwing objects
 Hitting, crying, rolling on floor
 Screaming loudlyandbanging
• Common during the first few years of life
 Averted by a parent's awareness or attunement to certain cues
 Advised that parents plan
• Aware of triggers and minimizing it

29. BREATH-HOLDING SPELLS
Reflexive events occur during a tantrum from 6 months - 6 years of age
May lose consciousness and occasionally will have a brief seizure
Parents are best advised to ignore it
•Generally without reinforcement disappears
Subtypes
•Cyanotic, Pallid and Mixed episodes
Iron deficiency may be present
• May respond to iron therapy
No increased risk of seizure disorders
Medical conditions should be ruled-out

30. MANAGEMENT
 Awareaboutthe beginningof temper andexplainangry feeling
 Nobodyshould makefunand teasethechild
 Parents should model the anger control
 Parents angry worsen the problem
 Providing choice
• Enhancing the parent child relationship
• Building problem-solving skills
Referral for a mental health evaluation
•Not respond to parent coaching
•Head banging or high levels of aggression

31. LYING
 Why lying ? For children 2-4 yr,
• A form of fantasy for children or a method of playing with language
• To avoid an unpleasant confrontation i.e not permit the realization
• Rarely malicious or premeditated
Why lying ? In older children
•Temporary good feeling and to protect against a loss of self-esteem
•To avoid a negative consequence for misbehavior
• Promoted by poor adult modeling
 To avoid adults' disapproval
 Habitual lying

32. STEALING
 Many children steal something at some point in their lives
 An impulsive action to acquire something they want
 Can be an expression of anger
 If noticed it is a teaching opportunity
 Frequent stealing
• May be a response to stressful environmental circumstances
• Further exploration and evaluation
 Can be learned from adults
 Survival mechanism like youth living in poverty
It is important for parents to help the child undo the theft

33. TRUANCY
More common in older children
 Never developmentally appropriate
Causes
•Learning difficulties
•Social anxiety
•Traumatic exposure
•Peer pressure
•Substance use
Best practices
•Addressing underlying causes
•Empowering family
 High risk for Substance abuse, unsafe sexual activity and other risk- taking behaviors

34. HABITS
 Involve repeated action or pattern of behavior
 Common in childhood and range from usually
• Benign and transient behaviors
• More problematic
 In DSM-5, habits are not included as a diagnostic category
• Not viewed as disorders causing clinically significant distress or impairment
 Common habit disorders
• Thumbsucking and nailbiting
• Bruxism
• Trichotillomania

35. THUMBSUCKING
 Common in infancy
 Beyond 5 yr may be associated with squeal
• Abnormality of teeth
• Difficulty in masticationandswallowing
• Deformityof thumb
• Facialdistortion
• Speechdifficultieswithconsonants
• GITinfections

36. MANAGEMENT
 Supportand tobe advised
 Distraction
 Simple reminders and reinforcers
 Mechanical devices
 Consultation
 Hygienicmeasures
 Praising andencouraging
 Parentsneedreassurance

37. BRUXISM
 Common , 5–30% of children
 Can begin in the first 5 yr of life
 Persistent bruxism can manifest
• Muscular or TMJ pain
• Dental occlusion
 Associated with anxiety
• Reduce anxiety might relieve the problem
 Relaxing by reading or talking or allowing for discussion
 Praise and other emotional support
 Persistent bruxism requires referral

38. TICS
 Brief sudden,rapidrepetitive movements of striated muscles
• Mainlyof thefaceand neck
 Itisoutletof suppressedangerand worryfor controlof aggression
 Characterized bymultiplemotortics andvocaltics
• Motor tics
• Vocaltics
 Selfstimulatingbehaviorinresponsetotensionandanxiety
 Ofteninschoolchildren
 May occur in deep sleep

39. ENURESIS
 Repetitiveinvoluntarypassageof urine at inappropriate place especially in bed
• Beyond the age of 4 to 5 years and 3 - 10% schoolchildren
• Occurs twiceweeklyfor at least 3 months
 At age of 5 yr, 7 % for males and 3 % for females
Classified as
1. Persistent; Primary
2. Regressive or Secondary
• Physiological (bladder capacity)
• Psychological
• Organic
 Monosymptomatic enuresis Vs Non-monosymptomatic enuresis

40. MANAGEMENTOF ENURESIS
 Behavioraltherapy
• Environmental modification
• Restrictionof fluid after dinner
• Voiding before bed time
• Interruption of sleep before the expected time of bed wetting
 Fully waken upbytheparentand madeawareof passingof urineat night
 Responsibilityforchanging the bed cloths
• Encourageand reward thechild fordry nights
• Bladder exercise and Electric alarm belldevice
 Punishment and criticism may lead to embarrassment
 Pharmacologic

41. ENCOPRESIS
 Voluntary or involuntary passage of feces into inappropriate places
 At least once per mo for 3 consecutive months once a chronologic age of 4 yr
 Subtypes
• Retentive encopresis
 Representing 65–95%
• Nonretentiveencopresis
 Without constipation and overflow incontinence
 Primaryorsecondary
 Associated problems
• Chronic constipation
• Overaggressivetoilettraining and toilet fear
• ADHD and ID

42. MANAGEMENT OF ENCOPRESIS
 Behavioral techniques
• Regular bowel habit andtraining
• Dietary intake
• Parentalsupport
 Medical management
• Impaction and anal fissures
 Psychologist
• Child and parents
 Reassuranceand counseling

43. ADHD
 A syndrome with two categories of core symptoms:
• Inattention and Hyperactivity/impulsivity
 Predisposingfactors
• Birth complication
• Dietary influences ( Fe and Zn)
• Drug exposure and Lead poisoning
• Structural and functional differences
• Interaction betweengeneticandpsychosocialfactors
 For children <17 years needs ≥6 symptoms
 For adolescents ≥17 years and adults needs ≥5 symptoms
 Affect cognitive, academic, behavioral, emotional and social functioning

44. SYMPTOMS OF INATTENTION
1. Failure to provide close attention to detail
2. Difficulty maintaining attentionin play, school, or home activities
3. Seems not to listen
4. Fails to follow through
5. Difficulty organizingtasks, activities, and belongings
6. Avoids tasks that require consistent mental effort
7. Losesobjects required for tasks or activities
8. Easily distractedby irrelevant stimuli
9. Forgetfulness in routine activities

45. SYMPTOMS OF HYPERACTIVITY AND IMPULSIVITY
1. Difficulty remaining seated when sitting
2. Excessive fidgetiness
3. Feelings of restlessness or inappropriate running
4. Difficulty playing quietly
5. Difficult to keep up with seeming to always be "on the go"
6. Excessive talking
7. Difficulty waiting turns
8. Blurting out answers too quickly
9. Interruption or intrusion of others

46. MANAGEMENT
 Classified by depending upon the predominant symptoms
 Management done by team approach
 Pharmacological
• Stimulants
• Drug holiday
 Non pharmacological
• Behavioral therapy
 Behavior modification, counseling and guidance of parents
 appropriatetraining andeducationof the child
• CBT

47. COMMUNICATION DISORDER
 Communication requires the interaction of an intact mechanism
 Children learn language in early childhood and later they use it to learn
 Developmental language disorder
• Impairment in the ability to receive,send, process and comprehend conceptsor verbal,
nonverbal, and graphic symbolsystems
• Most common developmental disability of childhood (5 -10 % of children)
• Increased risk for difficulty with reading and written language
 Early intervention minimize more serious consequences

48. SPEECH DISORDER
A. Articulation disorder
• Substitutions, omissions, additions, or distortions of speech sounds
• Speech sounds increases with age
B. Fluencydisorder (stuttering)
• Interruption in the flow of speaking due atypical rate, rhythm, and repetitions
• Begin between the age of 2 to5 years andmore common in males
• Etiology of stuttering is not completely understood
 Can be developmental, acquired and psychological
 Inabilitytoadjustwith environmentand emotional stress
C. Voice disorder
• Vocal quality, pitch, loudness, resonance or duration

49. SPEECH PROBLEMS CON’T
A. Hearingimpairment
• Limited ability to hear others and monitor own speech production
B. Neurologicproblems
• Dysarthria: Caused by NM impairment
• Inability in handling secretions, regurgitation; and recurrent URT & pneumonia
C. Apraxia
• An impairment in ability to program, select, plan, organize & initiate a motor pattern
D. Structural defects
• The tongue movement and tongue size

50. LANGUAGE DISORDERS
 Impaired comprehension or use of spoken, written or symbol systems
 Characterized by:
• Persistent difficulties in the acquisition and use of language
 Expressive or receptive
• Deficits in comprehension or production
 Spoken, written, sign language
• Reduced vocabulary, limited sentence structure and impairments in discourse
 Resultingin functionallimitationsin
1. Effective communication
2. Social participation
3. Academic achievement
4. Occupational performance

51. SCHOOL PHOBIA
 Fear of going to school and Afraid to leave the parents
 Recurrent compliant and subsides if allowed to remain at home
Contributingfactors
• Anxiety
• Intellectualdisability
• school environment
Management
• Improve school environment
• Playsessionand recreational activities
• Family counseling
• Assesses health status

52. EATINGDISORDERS
 Overvaluation of a thin body and dysfunctional weight control behaviors
 Usually affecting white and adolescent females
 Persistent disturbance of eating
 Include
1. Anorexia nervosa
2. Avoidant/restrictive food intake disorder
3. Binge eating disorder/Bulimia nervosa
4. Pica
5. Rumination disorder
 Screening for ED using SCOFF
 A “yes" to 2 or more questions was associated with a high sensitivity& specificity

53. ANOREXIANERVOSA
 Reducing food intake
 Vigorousexercisesforweightreduction
 Induce vomiting
 Involves significant overestimation of body size and shape
1. Restrictive subtype
 Combines excessive dieting and compulsive exercising
2. Binge purge subtype
 Overeat and vomiting or taking laxatives
 Nospecificcauseforanorexianervosa
• Anorectic parents and Conflict inrelationship
 Mayhaveassociated conditionslikediseaseof liver,kidney, heartor diabetes

54. DIAGNOSTIC CRITERIA FOR ANOREXIA NERVOSA
A.Significantly low body weight
B. Intense fear of gaining weight or of becoming fat
C.Disturbance in which one's body weight or shape on self-evaluation
 Specify:
• In partial remission or In full remission
 Specify severity: BMI
• Mild, moderate ,severe and extreme
 Systemic manifestation

55. AVOIDANT/RESTRICTIVE FOODINTAKE DISORDER
 Lack of interest in food intake
 Persistent failure to meet nutritional or energy needs
 Manifested by at least one of the following:
1. Weight loss or poor growth or FFT
2. Nutritional deficiency
3. Supplementary enteral feeding or oral nutritional supplements required
4. Impaired psychosocial functioning
 Not due to
• Lack of food or Culturally practice
• Bulimia nervosa or anorexia nervosa

56. BINGE EATING
 Binge eating episodes are marked by at least threeof the following:
1. Rapidly
2. Until feeling uncomfortably full
3. Large amounts of food when not feeling physically hungry
4. Eating alone
5. Feeling disgusted or guilty
 Episodes occur on average at least once a week for three months
 No regular use of inappropriate compensatory behaviors
 Severity is based upon the number of binge eatingepisodes per week
• Mild ,moderate, severe and extreme

57. PICA
 Repeated eating of nonfood substances for at least one month
 Geophagia, Pagophagia, Xylophagia, Trichophagia,Urophagia and Coprophagia
 Itmaybedueto
• Parental neglect
• Poorattentionof caregiver
• Nutritional deficiency
 Itiscommon
• Poorsocioeconomicfamily,malnourishedchildren andmentallysubnormal
• Both sex equally
 Resolves spontaneously unless mentally disabled

58. RUMINATION DISORDER
 Repeated regurgitation and rechewing and reswalloiwng for at least one month
 Not due to a general medical condition or during the course of EDs
 Occur between 3-12 month and common in males
 Behavioral intervention like lemon in juice and drugs
 Management of ED
1. Advice on irrelevant to weight loss
2. Not to blame parents for EDs
3. Reinforcement of parents
Dialectical behavioral therapy
•Group therapy
•Combining patients at various levels of recovery

59. Recommendation
• Diagnose common behavioral problems in children
• Early Management
• Referral
• Conduct research on magnitude of the problem

60. REFERENCE
1. Robert m. Kliegman: Nelson textbook of Pediatrics 21 edition chapter 32-54
2. 2021 Up-to-date; www.uptodate.com
3. Sartorius N, The ICD-10 Classification of mental and behavioral disorders
clinical descriptions and diagnostic guidelines, World Health Organization, Geneva 1992:
ISBN 92 4 154422 8
4. Benjamin J.Kaplan and Sadock’s pocket handbook of clinical psychiatry sixth
edition,Nework,2019
5. Y. Ashenafi MD: Prevalence of mental and behavioral disorders in Ethiopian children ,
Ethiopia, East African Medical Journal Vol. 78 No. 6 June 2001