NAIL BITING,PICA,THUMB SUCKING,ENURESIS,BREATH HOLDING SPELLS

1. CHILD HEALTH NURSING
SEMINAR

2. INTRODUCTION
 Nobody’s perfect and all children will have bouts of
bad behaviour. They may have temper tantrums, or
talk back to their parents or teachers. Children
and teens can seem irritable or even hostile when they
are tired or aren’t feeling well. They may argue with
parents or disobey them because they are trying to
show that they’re growing up.Child hood is the period
of dependency gradually children learn to adjust in
the environment .

3. DEFINITION
 Behavioural disorders are the deviations from socially
acceptable behaviours due to multiple factors.

4. CAUSES OF BEHAVIOURAL
DISORDER
 Faulty Parental Attitude
 Inadequate Family Environment
 Mentally and Physically Sick or Handicapped
Conditions
 Influence of Social Relationship
 Influence of Social Change
 Influence of Mass Media

5. COMMON BEHAVIOURAL
DISORDERS
 a. Feeding problems—Food fad, food refusal,
overeating,vomiting, impaired appetite, pica,anorexia
nervosa.
 b. Habit dis0rders—Thumb sucking (finger sucking),
nailbiting, enuresis, encopresis, tics, breath holding
spellbruxism (teeth-grinding), rolling and head
banging,trichotilomania.
 c. Speech probIems—Unclear speech, delayed
speech,dyslalia, stammering or stuttering.

6.  d.Sleep problems—Sleep walking (somnambulism),sleep
talking (somnoloquy), night terrors, nightmares,insomnia,
hypersomnia, narcolepsy, cataplexy.
 e. Educational difl‘iculties—School phobia, truancy,
repeated failure, school absentism, hyperactive attention
deficit disorders.
 f, Adjustment problems—Disobedience, misconduct
temper tantrum. '
 g.Emotional problems—Negativism. jealousy, shyness,
fearanger, anxiety, timidity.Antisocial ,Delinquency,
destructive attitudes ,kleptomama
 i Sexual problems— precocious sexuality, substance
abuse,homosexuality, sexual assault

7. BEHAVIOURAL PROBLEMS OF
INFANCY
 Resistance To Feeding
During infancy feeding problems often develop at the
time of weaning. Infant may refuse new foods due to
dislike of taste or due to separation anxiety from
mother. It may be due to forced feeding by the mother
or may be due to indigestion of new food and
abdominal colic.

8.  Abdominal colic
 Stranger anxiety
 Resistance to parental interference
 Vomiting.

9. BEHAVIORAL PROBLEMS OF
CHILDHOOD
 Temper tantrum
 Breath-holding spell
 Thumb sucking, nail biting
 Enuresis, encopresis
 Pica
 Tics
 Speech problems
 Sleep
 Disorders
 School phobia
 Attention deficit disorders

10. Temper Tantrums
 Temper tantrums is a sudden outburst or violent
display of anger, frustration and bad temper as
physical aggression or resistance such as rigid body,
biting, kicking, throwing objects, hitting, crying
rollingon floor, screaming loudly, banging limbs,

11. Causes
Temper tantrum occurs in maladjusted children. The
activity is directed towards the environment not to any
person or anything. It is normal in toddler, may
continues to preschool period and become more
severe indicating the low frustration tolerance

12. Management
 Professionalhelp from child guidance clinic.
 Alternate activity-vigorous exercise and physical
activities
 Nobody should make fun
 Parent should explain the child
 Should be protected from self injury
 Physical restraint usually increase frustration
 Calm and loving approach.
 Overindulgence should be avoided,be firm

13. Breath-holding Spell
 Breath holding spell may occur in children between 6
months to 5 years of age.
 Cause:
lt is observed in response to frustration or anger
during disciplinary conflict. The child is found with
violent crying, hyperventilation and sudden cessation
of breath and cyanosis

14. Signs
 Loss of consciousness, twitching an tonic-clonic
movements may also be found.The child may become
limp and look pallor and lifeless. Heart rates become
slow. There may be spasm of laryngeal muscles. This
attack last for one or two minutes,then glottis relaxed
and breathing resumed with no residual
effects.Parents and family members become very
anxious with the attack

15. Management
 Attempt to prevent the spells is usually not successful.
Parents need assurance about the harmless effects of the
attack and should be tolerant, calm and kind.
Identification and correction of precipitating factors
(emotional, environmental) are essential approach. Over
protective nature of parents may increase unreasonable
demand of the child. The child can use secondary gain as
advantages. Punishment is not appropriate and may cause
another episodes. Repeated attacks of the spells need to be
observed, physical examination and necessary
investigations to exclude convulsive disorders or any other
problems.

16. Thumb Sucking
 Thumb sucking or finger a habit disorder due to
feeling of insecurity and tension reducingaptivities. It
may develop due to inadequate oral satisfaction during
early infancy as a result of poor breastfeeding

17. Management
 Parents and family members need support and to be
adviced not to become irritable, anxious and tense.
Praising and encouraging child for breaking the habit
are very useful.
 Distraction during bored time or engaging the thumb
or finger for other activity to be practiced to keep the
hand busy.The child should not be scolded for the
habit. Consultation with dentist and speech therapist
may be required to correct the complications. Hygienic
measures to be followed and infections to be treated
promptly.

18. Nail Biting
 Nail biting is a bad oral habit especially in school age
children (5-7 years). It is a sign of tension and self
punishment to cope with the hostile feeling towards
parents.

19. CAUSES
 Feeling of insecurity
 Conflict and hostility.
 It may be due to pressurised studies.
 Lt may continue or due to watching frightening violent
scene

20. Management
 The cause for nail biting to be identified by the parent
with the help of clinical psychologist and steps to be
taken to remove the habit.The child's hand to be kept
busy with creative activities or play .Punishment to be
avoided. Parents need reassurance and assistance to
accept the situation and to help the child to overcome
the problem.

21. Enuresis or Bed Wetting
 Enuresis is the repetitive involuntary passage of urine
at inappropriate place especially at bed, during night
time,beyond the age of 4 to 5 years. It is found in 3 to
10 percent school children.

22. Management of enuresis
 Depends up on cause.
 Assessment of exact cause is very essential by thorough history,
clinical examination and necessary investigations.The organic
causes are managed with specific treatment.Nonorganic causes
to be managed primarily with emotional support to the child and
parents along with environmental modification.
 Condition therapy by using electric alarm bell mattress is
effective and safest method when the child wakes up as soon as
the bed is wet.
 Supportive psychotherapy is important for child and parent.
 Changes of home environment to remove the environmental
causes are essential.

23.  Encopresis
 Encopresis is the passage of feaces into inappropriate
places after the age of 5when the bowel control is
normally achieved.
 Assessment of this condition includes history of bowel
training,use of toilets and associated problems. The
child need help in establishment of regular bowel
habits

24. Geophagia or Pica
 Pica is a habit disorder of eating_nonedlble substance;
such as clay,paint,pencil,chalk‘piece ,plaster from walI,
earth, scalp hair etc. It ls normal up to the age of two
years.

25. Pica Causes
 Parental neglect
 Poor attention of caregiver
 Inadequate love and affection etc.
 It is common in poor socioeconomic family and in
malnourished
 mentally subnormal children

26. Management
 Management of this problem is done with
psychotherapy of the child and parents.
 Associated problems should betreated with specific
management.

27. Tics or Habit Spasm
 These are sudden abnormal involuntary movements. It
is the repetitive,purposeless,rapid stereo type
movements of striated muscles, mainly of the face and
neck. Tics most often in school children for discharge
of tension in maladiusted emotionally disturbed child.
It is outlet of suppressed anger and worry for the
control of

28.  Tics can be motor and vocal.
 Motor tics can be found as eye blinking
,grimacing,shrugging shoulder,tongue
protrusion,facial gesture etc.Vocal tics are found as
throat clearing, coughing,barking,sniffing etc.
 A special type of chronic tics - 'Gilles de la Tourette's
Syndrome‘ , characterized by multiple motor tics and
vocal tics . It is a genetic disorder with onset at around
11 years of age.

29.  It requires for special management with behavior
therapy
 Counseling
 Drug therapy with haloperidol group of drug.
 Parental reassurance and counseling of the child and
parents usually useful to manage the simple motor or
vocal tics.

30. School Phobia / School Refusal
 School phobia is persistent and abnormal fear of going
to school.It is common in all social group.
 It is an emotional disorder of the childrenwho are
afraid to leave the parents,especially mother, and
prefer to remain at home and refuse to go to school
absolutely

31.  It is a symptom of crisis situation of developmental
stages and cry for help which needs specialattention.
The contributing factorial school phobia are anxiety
about matemal separation. overindulgent,
overprotective anddominant mother. Disinterested
father, intellectual disability of the students and
uncongenial school environment like teasing by other
students, poor teacher-student
relationship,unhygienic environment, fear of
examination, etc

32. Sleep disorders
 Sleep disorders are common in children with anxiety,
tension and overactivity. These problems are present
with or without physical symptoms of behavioral
disorders. Disturbances of sleep usually occur in deep
sleep, i.e. stage 3 or 4 of NREM (nonrapid eye
movement) sleep. The common sleep problems are
difficulty to fall asleep, night mares, night terrors,
sleep walking (somnambulism), sleep talking
(somniloquism). etc.

33.  In night mares, child awakens from a frightening
baddream and is conscious of surroundings. in night
terrors,the child awakens during sleep, sits up with
screaming and terrified to recognize the surrounding
and after sometimes sleep again.

34.  In these problems, the child should have light diet in
dinner and pleasant stories or scene at bed time. No
.exciting games and pictures and frightening stories
(ghost,murder, accidents) should not be allowed at
night .Parents should allow relax comfortable bed and
emotionally healthy environment to the child. In case
of sleep walking ,door and windows to be kept closed
and dangerous objects to be removed. In advanced
case psychotherapy is recommended.

35. Atention-deficit hyperactivity
disorder (ADHD
 Atention-deficit hyperactivity disorder (ADHD) is a
mental disorder of the neurodevelopmental type.
 In children, problems paying attention may result in
poor school performance. Although it causes
impairment, particularly in modern society, many
children with ADHD have a good attention span for
tasks they find interesting

36.  It characterized by problems paying attention,
excessive activity, or difficulty controlling behavior
which is not appropriate for a person's age.
 The symptoms appear before a person is twelve years
old, are present for more than six months, and cause
problems in at least two settings (such as school,
home, or recreational activities).
 Case can be managed with behavioural therapies,zinc
supplementation etc

37. BEHAVIORAL PROBLEMS OF
ADOLESCENCE
 Common behavioral disorders of adolescence are
excessive masturbation, delinquency, antisocial
behavior, substance abuse, anorexia nervosa, etc.
‘These problems need special
 attention and necessary interventions.

38.  Masturbation
 Masturbation or genital_stimulation by handling the
genitals gives pleasure to the children. The infants and
toddlers do this out of pure curiosity.

39. Juvenile Delinquency
 Juvenile delinquency means indulgence in an offence by 3
child in the form of premeditated, purposeful, unlawful
activities done habitually and repeatedly.
 Usually these children belongs to broken family or
emotionally disturbed family with overcrowded unhealthy
environment and having financial or legal problems.
 The factors contributin to the problem are mainly rapid
urbanization and industrialization, social change and
changing lifestyle, influence of mass media,change in
moral standards and value systems , lack of educational
opportunities and recreational facilities,poor economy,
unsatisiactory conditions at schools and colleges,poor
student-teacher relationship and lack of discipline.

40.  The juvenile delinquent behavior includes
lying,burglary, truancy from school. run away from
home,disobedience, mixing with antisocial gang,
cruelty to animals, destructive attitude,murder. sexual
assault, etc. in a broad sense, delinquencyis not merely
not File' crime, it includes all deviations from youthful
behavior and antisocial activities.

41. Anorexia nervosa
 Anorexia nervosa, often referred to simply as anorexia,
is an eating disorder characterized by low weight, fear
of gaining weight, and a strong desire to be thin,
resulting in food restriction. Many people with
anorexia see themselves as overweight even though
they are in fact underweight. If asked they usually
deny they have a problem with low weight. Often they
weigh

42.  Treatment of anorexia involves restoring a healthy
weight, treating the underlying psychological
problems, and addressing behaviors that promote the
problem. While medications do not help with weight
gain, they may be used to help with associated anxiety
or depressionwhere parents assume responsibility for
feeding their child known as Maudsley family therapy.
Sometimes people require admission to hospital to
restore weightEvidence for benefit from nasogastric
tube feeding

43. Nursing Diagnosis
 Risk For Self-Mutilation
 Chronic Low Self-Esteem
 Impaired Social Interaction
 Ineffective Coping

44. Learning disorders
 Learning disorders (DSM-IV) include disorders
characterized by one or more significant impairments
in acquisition of reading, spelling, or arithmetical
skills.ICD-10 suggests that the category

45. Definition
 A disorder in one or more of basic psychological
processes involved in understanding or in using
language, spoken or written, that may manifest itself
in imperfect ability to listen, think, speak, read, write,
spell, or to do mathematical calculations, including
conditions such as perceptual disabilities, brain injury,
minimal brain dysfunction, dyslexia, and
developmental aphasia.

46. Types of learning disorders
 •Dyslexia A language and reading disability
 •Dyscalculia Problems with arithmetic and math
concepts
 •Dysgraphia A writing disorder resulting in illegibility
 •Dyspraxia (Sensory Integration Disorder) Problems
with motor coordination
 •Central Auditory Processing Disorder Difficulty
processing and remembering language- related tasks

47.  •Non-Verbal Learning Disorders Trouble with
nonverbal cues, e.g., body language; poor
coordination, clumsy
 •Visual Perceptual/Visual Motor Deficit Reverses
letters; cannot copy accurately;
 •Language Disorders (Aphasia/Dysphasia) Trouble
understanding spoken language; poor reading
comprehension


48. Specific Learning Disorder
 Specific learning disorder in youth is a neurodevelopmental
disorder produced by the interactions of heritable and
environmental factors that influence the brain’s ability to
efficiently perceive or process verbal and nonverbal information.
 It is characterized by persistent difficulty learning academic
skills in reading, written expression, or mathematics, beginning
in early childhood, that is inconsistent with the overall
intellectual ability of a child.
 Academic skills that may be compromised in specific learning
disorder include reading single words and sentences fluently,
written expression and spelling, and calculation and solving
mathematical problems. Specific learning disorder in reading,
spelling, and mathematics appears to aggregate in families.

49. Dyslexia
 It is a specific learning disability in reading. Kids with
dyslexia have trouble reading accurately and fluently.
They may also have trouble with reading
comprehension, spelling and writing.

50. Dyslexia can create difficulty with other skills, however.
These include:
 Reading comprehension
 Spelling
 Writing
 Math

51. Preschool
 Has trouble recognizing whether two words rhyme
 Struggles with taking away the beginning sound from
a word
 Struggles with learning new words
 Has trouble recognizing letters and matching them to
sounds

52. Grade School
 Has trouble taking away the middle sound from a word
or blending several sounds to make a word
 Often can’t recognize common sight words
 Quickly forgets how to spell many of the words she
studies
 Gets tripped up by word problems in math

53.  Middle School
 Makes many spelling errors
 Frequently has to re-read sentences and passages
 Reads at a lower academic level than how she speaks
 High School
 Often skips over small words when reading aloud
 Doesn’t read at the expected grade level
 Strongly prefers multiple-choice questions over fill-in-
the-blank or short answer

54. Possible Causes of Dyslexia
 Genes and heredity
 Brain anatomy and activity

55. Management
 Specific programs and methods of teaching that can
significantly improve the acquisition of skills
 Find a teacher/tutor trained in an approach like
Orton/Gillingham, Lindamood-Bell,Phonographix or
any similar systematic, multi-sensory, explicit method
for teaching the elements of language
 Teach the ʻrulesʼ of language, which include the
sounds paired with symbols (letters, vowel teams,
types and rules of syllables, doubling rule, etc.)

56. DYSGRAPHIA
 Neurologically based learning disorder that affects
writing, spelling, and math, which require a complex
set of motor and information processing skills
 • Lack of automaticity in writing, thought to be caused
by deficiency in normal muscle memory, visual &
sensory deficits, and message delivery brain-hand-
brain.

57.  Early Signs
 • The earliest detectable signs are fine motor issues
 • Lack of interest in coloring, drawing, writing,
puzzles, difficulty with scissors
 • Late acquisition of skills with zippers, buttons, snaps,
shoelaces, eating utensils
 • Poor sensory feedback

58. Academic Signs
 • Slow and/or messy writing, inconsistent letter
formation
 • Excessive or poor pressure in writing
 • Frequent failure to erase errors, simply write over
other symbols
 • Unusual/awkward pencil grasp
 • Complains of a sore hand when writing
 • Complains about the feel of the paper as hand slides
over

59. Strategies:
 • Early intervention with an Occupational Therapist to
develop fine motor skills
 • Use of tri-grasp pencils, pencil grips, widelined paper,
graph paper, slant boards
 • Reduce need for writing
 • Enlarge worksheets and leave plenty of space for
answers

60.  • Specific instruction in keyboarding - daily use of
computer, voice recognition software
 • Give copy of notes
 • Teach skills for tracking details
 • Do not deduct for spelling, punctuation errors,
consider grading separately for content/mechanics

61. DYSCALCULIA
 Difficulty in mathematics as a result of impairment to
particular parts of the brain, but without a general
difficulty in cognitive function (Kosc 1974)
 • Mathematics involve visual spatial, language, and
digital processing in the brain
 • Dyscalculia refers to a wide range of lifelong learning
disabilities involving math

62. Symptoms
 • Difficulty visualizing patterns, understanding spatial
direction, memorizing facts, making comparisons
 • Language processing problems can make it difficult
for a person to get a grasp of the vocabulary of math
 • Difficulty following multi-step procedures and
inability to identify critical information needed to
solve equations and more complex problems

63.  Trouble recognizing printed numbers
 • Poor memory for numbers
 • Difficulty learning to count
 • Difficulty connecting numbers to real world
application (3 bowls, 3 spoons, 3 girls)
 • Difficulty organizing objects by shape
 • Trouble learning math facts (+, -, x, ÷)

64. Nursing Management For Learning
Disability
 Resource Room
 Inclusion Mainstreaming or Full/Partial
 "Bypass" Interventions.
 Home-Based Support.
 Hiring a tutor

65. Nursing Responsibility
 Assessing and planning care requirements
 Advising about and organising appropriate care,
resources or benefits
 Writing care plans that outline timescales
 Assisting with basic, practical living skills, such as
getting dressed, preparing food and travelling
 Liaising with relatives, colleagues and other social
welfare or healthcare professionals

66.  Monitoring and administering medication and
injections
 Providing support to relatives
 Writing records and reports
 Meeting clients at home or at clinics to discuss
progress
 Organising social activities and holidays for clients in
residential care
 Helping to enable clients to have full and independent
lives

67. Summary
 Every child has a unique profile of strengths and
weaknesses depending on the learning disorder and/or
combination of learning disorders.There are many
strategies to assist each student in finding success in
school and life.Contact your school to request an
evaluation if you suspect your child has a learning
disorder . Communication between parents, school
personnel and outside practitioners is essential.