CHILDHOOD BEHAVIORAL DISORDERS AND ITS MANAGEMENT: AGE AND NATURE: INFANCY , TODDLERS , ADOLESCENCE: SPEECH DISORDERS: SOMNAMBULISM, SOMNILOQUY. EATING DISORDERS: ANOREXIA NERVOSA AND BULIMIA. MOVEMENT DISORDERS: TICS. SPEECH DISORDERS: STUTTERING, CLUTTERING, STAMMERING. DISORDERS OF TOILET TRAINING: ENURESIS, ECOPRESIS. DISORDERS OF HABIT: TEMPER TANTRUM, BREATH HOLDING SPELLS, THUMB SUCKING, NAIL BITING. ADHD, SCHOOL PHOBIA, STRANGER ANXIETY.

1. BEHAVIOURAL DISORDERS IN
CHILDREN
PRESENTED BY:
Ms. Manisha Thakur

2. INTRODUCTION
When children cannot adjust to a complex
environment around them, they become
unable to behave in the socially acceptable
way resulting in exhibition of peculiar
behaviours and this is called as behavioural
problems.

3. CAUSES
• Faulty ParentalAttitude
• Inadequate Family Environment
• Mentally And Physically Sick or Handicapped
Conditions
• Influence of Social Relationships
• Influence of Mass Media

4. CLASSIFICATION OF BEHAVIOURAL DISORDERS
AGE
NATURE

5. CLASSIFICATION OF BEHAVIOURAL DISORDERS
AGE
•INFANCY
•CHILDHOOD
•ADOLESCENCE
NATURE
•MOVEMENT
•HABIT
•TOILETTING
•SPEECH
•SCHOOL
•SLEEP
•EATING

6. INFANCY
– Impaired appetite or Resistance to feeding
– StrangerAnxiety
• Temper tantrums
• Breath holding spell
• Thumb sucking
• Nail biting
• Enuresis or Bed wetting
• Encopresis
• Pica or Geophagia
• Tics or Habit spasm
• School Phobia
• Attention Deficit Hyper Activity Disorder
CHILDHOOD

7. • Speech Problems
– Stuttering or stammering
– Cluttering
– Delayed Speech
• Sleep Disorders
– Sleep walking
– Sleep talking
– Bruxism
• Juvenile Delinquency
• SubstanceAbuse
• Anorexia Nervosa
CHILDHOOD
ADOLESCENCE

8. ACCORDING TO NATURE
• Head Banging
• Breath holding Spells
• Temper tantrums
• Tics
• Thumb sucking
• Nail biting
• Pica
• Trichotillomania
PROBLEMS OF MOVEMENT
PROBLEMS OF HABIT

9. • Enuresis
• Encopresis
• Stuttering
• Elective mutism
• School phobia
PROBLEMS OF TOILET TRAINING
PROBLEMS OF SPEECH
PROBLEMS AT SCHOOL

10. • Somnambulism
• Nightmares
• Anorexia Nervosa
• Bulimia Nervosa
• Pica
SLEEP DISORDERS
EATING DISORDERS

11. PROBLEMS OF
HABITS

12. 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.

13. Cont…
If thumb sucking continues beyond the age of 4 years
then complications may:
1. Malocclusion
2. misalignment of teeth
3. difficulty in mastication and swallowing
4. It may cause deformity of thumb
5. facial distortion
6. speech difficulties

14. MANAGEMENT
• 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

15. CONT..
• T-BAND

16. 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.

17. MANAGEMENT
• Behavioural reinforcement such as positive reinforcement.
• Engage your child in activities.
• Positive emotional support.
• Do-not punish.

18. PICA
• The child may develop habit of eating non-edible
substances such as wall plaster, clay, paint and earth,
etc.
• They are slow in motor and mental development and
show more neurological defects and deviant behaviour.
• Normal up to age of 2 years.

19. CONT…
• 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.

20. Clinical manifestations
• Anaemia
• Perverted appetite
• Intestinal parasitosis
• Lead poisoning
• Vitamins and mineral deficiency,
• trichobezoar etc.

21. DIAGNOSIS
• Blood investigations
• According to the DSM classification, a
person is said to have pica, only if:
• Persistent eating of non nutritive substances
for a period of at least one month
• Does not meet the criteria for either having
autism, schizophrenia, or Kleine-Levin
syndrome.

22. TREATMENT
• Treatment of the deficiencies.
• Parental counselling
• Education and guidance
• Behaviour modification
• Psychotherapy

23. PROBLEMS OF
TOILET
TRAINING

24. ENURESIS
• Enuresis is a disorder of involuntary micturition in
children who are beyond the age when normal bladder
control should have been acquired.
• Enuresis refers to the wetting of one’s clothes or
one’s bed past the age of 3 years.

25. INCIDENCE
• It is common during 4 years to 12 years age.
• Studies suggest that 2.5 % in the age group of 0-10
years have enuresis and at age 5, it is 7 % for males
and 3 % for females.

26. TYPES
• Enuresis has been classified into :
• Persistent(primary)
• Regressive (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. ETIOLOGY
ETIOLOGY
GENETIC
PHYSIOLOGICAL
PSYCHOLOGICAL
ORGANIC

28. CLINICAL MANIFESTATIONS
• Incontinence
• Dysuria
• Hematuria
• Straining on urination
• Dribbling
• Stress incontinence( with coughing, lifting
or running)
• Poor bowel control
• Continuous dampness

29. INVESTIGATIONS
• Full medical history
• Genital and neurological examination
• Urinalysis for albumin, sugar, microscopy,
and culture
• if the child has UTI, he should be further
evaluated by USG, cysto-urethrogram and
uro-dynamic studies.

30. TREATMENT
• Pharmacologic:
• Desmopressin ( 20 -40 Microgram, nasal spray,4 week
s) -the hormone that reduces urine production during
sleep.
• 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 (0.9- 1.5mg/
kg/day,>7yrs, for 3-6 months)
• Non-Pharmacologic:
– Behaviour Modification
– Parental Counseling
– Bladder Exercises
– Alarm Device

31. NURSING CONSIDERATION
• Help parent to understand the problem and treatment,
tell them to give love.
• It is not a willful misbehavior. 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 behavior.
• Encourage communication with child to relive child
from parental burden of disapproval.
• Decrease fluid intake after 5pm.
• Remind child to empty bladder 2 hourly.

32. 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.

33. Cont…
• The fecal incontinence must not be due
effects of a substance (e.g., laxatives) or
a general medical condition except
through a mechanism involving
constipations.

34. 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.

35. 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 pro
blems
• Voluntary retention because of fear of large-bore
stools (pain-retention-pain cycle)
• Busy schedule
• Disturbed mother child relationship

36. Clinical manifestations
• Stiff posture,
• Itching around the anal area.
• 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

37. MANAGEMENT
• Initial Counseling
• Establish regular bowel habit.
• Liquid paraffin can be used.
• Dietary management

38. PROBLEMS OF
MOVEMENTS

39. TICS
• Tic is an abnormal involuntary movement
which occurs suddenly, repetitively, rapidly and
is purposeless in nature.

40. CAUSES
• Psychogenic
• Neurogenic
• Familial
• Medical conditions

41. TYPES
• Motor Tics- characterized by repetitive motor
movements.
- Simple motor tics: wink
- Complex motor tics: someone might touch a
body part or another person repeatedly.
• Vocal Tics- characterized by repetitive
vocalisations.
- Simple vocal tics: throat clearing
- Complex vocal tics: repeating other people's
words (a condition called echolalia)

42. TREATMENT
Pharmacoloical therapy’
• Haloperidol is the drug of choice. In
severe cases, Pimozide or clonidine can
be used.
• Antipsychotics (blocks dopamine receptors)
• Benzodiazepines to reduce anxiety.
Non- pharmacological therapy
• Behaviour therapy may be used.
• Parents and the family should be educated
and counseled about course of disorder and
spontaneous resolvement of disorder.
• Relaxation exercises have proven efficacy.

43. TEMPER TANTRUMS
From the age of 18 months to 3 years, the child begin
to develop autonomy and starts separating from
primary caregivers. When they can’t express their
autonomy they become frustrated and angry. Some
of them show their frustration and defiance with
physical aggression or resistance such as biting ,
crying, kicking, throwing objects, hitting and head
banging.
This kind of physical aggressive behaviour
is known as Temper tantrum.

44. ETIOLOGY
• Parental Factors
• Child personality
• Other Factors
• Precipitants
• Not meeting demands
• Interruption of play
• Threat of abandonment
• Stranger anxiety, criticism
• Imitation

45. MANIFESTATIONS
• Screaming,
• biting,
• stamping feet, thrashing arms
• kicking, throwing objects
• rolling on the floor

46. MANAGEMENT
• Temper tantrums often cease with age. Remove
underlying insecurity, over protection and
faulty parental attitude.
• During an attack, the child should be protected
from injuring himself and the others.
• Deviating his attention from the immediate
cause and changing the environment can
reduce the tantrum.

47. Cont…
• Parents should be calm, loving, firm and
consistent and such behaviour should not
allow the child to take advantage of
gaining things.
• Some temper tantrums result from the
child’s frustration at failing to master a
task. These can be managed by
distracting the child and permitting
success in more manageable activity.

48. Cont…
• Ignoring is an effective way to avoid
reinforcing tantrums although young
children should be held till they regain
control.
• “Time out procedure”- In using time out
procedure, parents should not attempt to
inflict a fixed number of minutes of
isolation. The goal should be to help the
child develop self regulation.

49. BREATH HOLDING SPELLS
• Breath holding spells are reflexive events in
which typically there is a provoking event
that causes anger, frustration and child starts
to cry. The crying stops at full expiration
when the child becomes apnoeic and cyanotic
or pale.
• Usually for one minute

50. TYPES
• Cyanotic
• Pallid

51. ETIOLOGY
• Parental Factors
• Precipitants

52. MANAGEMENT
• Pharmacologic management:
• Iron therapy
• Tab theophylline
• Non Pharmacologic management
– Immediate measures
– Long term measures
– Parental education

53. EATING
DISORDERS

54. 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.

55. 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

56. CLINICAL MANIFESTATIONS
• 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 regimen

57. TREATMENT
• Pharmacotherapy
• Neuroleptics
• Appetite stimulants
• Antidepressants
• Psychological Therapies
• Individual psychotherapy
• Behavioural therapy
• Cognitive behaviour therapy
• Family therapy
• Individual therapy
• Group therapy

58. BULIMIA NERVOSA
• It is a psychological eating disorder.
• Bulimia is characterized by episodes of binge-
eating followed by inappropriate methods of
weight control (purging).

59. 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.

60. Manifestations
• Eating uncontrollably
• Purging
• Strict dieting
• Fasting
• Vigorous exercise
• Vomiting or abusing laxatives or diuretics in an a
ttempt to lose weight.
• Vomiting blood
• Using the bathroom frequently after meals.
• Depression or mood swings.
• Heart burn
• Indigestion
• Exhaustion

61. 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.

62. SPEECH
DISORDERS

63. Stuttering or stammering
• Stuttering or stammering is a defect in speech
characterized by interruptions in the flow
of speech, hesitations, spasmodic repetitions
and prolongation of sounds specially of initial
consonants.

64. Cont…
• 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.

65. CAUSES
• Genetics
• Neuro- pathology( brain)
• Neural schizophernia
• Less blood flow to broca’, and wernicke,s
area
• Anxiety and stress situation

66. MANAGEMENT
• Behaviour modification
• Parents need counseling
• Fluency Shaping Therapy
• Breath control exercises and speech
therapy.
• Stuttering Modification Therapy
• Anti stuttering medications.

67. Cont….
• 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.

68. CLUTTERING
• Cluttering is a speech and communication
disorder characterised by unclear and
hurried speech in which words tumble over
each other. There are awkward movements
of hands, feet, and body. These children
have erratic and poorly organized
personality and behaviour pattern.
– It is also called as: Tachyphemia i.e fast
speech

69. MANAGEMENT
• Management:
• Behaviour modification
• Psychotherapy
• Story telling
• Show pictures book
• Language therapy: pausing practice

70. SLEEP
DISORDER

71. SOMNILOQUY
It is a sleep disorder that refers to talking
aloud while asleep. It can be quite loud
ranging from simple mumbling sounds to
loud shouts.

72. MANIFESTATION
• Talking irregularly and giving gaps like
normal conversation.
• Child gives good facial expression in sleep
also.

73. MANAGEMENT
• Sleep along-with the child and assure that parents
are with him/her.
• Satisfy the child’s needs.
• Resolve conflicts with other children.
• Try to make good relationship with child.
• Do not show movie or tell story before sleeping.

74. SOMNABULISM
It is a phenomenon of combined sleep and wake
fulness. In this sleep walking occurs at a state of
low consciousness and child performs activities
that are usually performed in full consciousness.

75. SYMPTOMS
Activities like:
– Sitting up in the bed.
– Walking to the bathroom and cleaning it.
– Initiating hazardous activities like cooking,
and grabbing hallucinated objects.
– Homicide

76. MANAGEMENT
• Lock the doors and windows of the room in
which child is sleeping.
• Remove all dangerous and hazardous objects
• Give small dose of Diazepam in advance case
• Consult physician in uncontrollable cases.

77. OTHERS:
• SCHOOL PHOBIA
• STRANGER ANXIETY DISORDER
• ABDOMINAL COLIC
• JUVENILE DELIQUENCY
• ATTENTION DEFICIT
HYPERACTIVITY DISORDERS

78. SCHOOL PHOBIA
– School phobia is persistent and abnormal
fear of going to school.
– It is emotional disorder of the children who
are afraid to leave the parents, especially
mother and prefer to remain at home and
refuse to go to school profusely.

79. MANIFESTATIONS
• Recurrent physical complaints:
– abdominal pain
– headaches which subside if allowed to
remain at home.

80. MANAGEMENT
• Habit formation
• Improvement of school environment
• assessment of health status of the child to
detect any health problems for necessary
interventions.
• Family counselling
• Behaviour techniques

81. STRANGER ANXIETY DISORDER
By about 6-7 months, the infant can differentiate
between the primary caregivers and others. Thus
at this age, they develop fear of unfamiliar
people or strangers. The infant , when
approached by unfamiliar person, turns away,
even cry or runs towards the primary caregiver.
This is known as stranger reaction.

82. MANAGEMENT
• Nurses should advise the parents to be calm.
• Relaxation techniques.
• Reassurance of parents.
• Child should be referred to psychiatrist
to evaluate for associated anxiety
disorders.
• Cognitive behavioural therapy and
family therapy are being tried.

83. JUVENILE DELIQUENCY
According to Dr. Sethna, “Juvenile delinquency
involves wrong doing by a child or a young
person who is under an age specified by the law
of the place concerned.”
A juvenile delinquent is a person who is
below 16 years of age (18 years in case of a
girl) who indulges in antisocial activity.

84. ETIOLOGY
• Social Causes
• Psychological causes
• Economic Causes
• Physical

85. Cont…

86. Cont…

87. MANAGEMENT
• Reform of Juvenile Delinquents
• Probation
• Psychological Techniques
– Play Therapy
– Finger Painting
– Psychodrama

88. ATTENTION DEFICIT HYPERACTIVITY
DISORDER
It is a condition that affects the behavior of
children which is marked by persistent
inattention, hyperactivity and impulsivity.

89. SYMPTOMS
• .

90. MANAGEMENT
• Parents can create small manageable goals for
their child like sitting in chair for 10 min and
giving rewards for its completion.
• Sleeping for extra half hour helps in dealing
with restlessness.
• Start practicing good health habits.
• Make sure that child gets plenty of
opportunities to play.