habit disorder in child health nursing in pediatric

2.  Behavioural disorder is the term used to describe several related
disorders linked by the presence of repetitive and relatively stable
behaviors that seem to occur beyond the awareness of the person
performing the behavior.

4.  It is involuntary passage of urine, in the absence of physical
abnormality, after the age of 5 years in a child of normal ability of
bladder control.
 Most children achieve bladder control by the age of two and half to
three years.
 By the age of 5 years, there are still some children who wet their beds.

5.  1. Primary enuresis: Where bladder control has never been achieved.
There is delay in maturation of sphineter control.
 2. Secondary enuresis: Where enuresis emerges after a period of
bladder control. It may be the result a maladjustment of parent and
child.
 On the basis of timing it is divided into three:
 1. Nocturnal: When the child wets bed during night.
 2. Diurnal → During day.
 3. Mixed→ Combination of both

6. Individual factors:
 Genetic- Half of all children who have this problem had a parent who also struggled
with bedwetting
 Psychiatric disorders-attention-deficit/hyperactivity disorder (ADHD)
 Urinary tract infection
 Small functional bladder capacity
 Anatomical defect of UT and bladder.

7.  Environmental factors:
 Stressful life events
 Large family size
 Social disadvantage
 Psychological factors:
 Disturbed family, broken homes
 Death or illness of parents
 School phobia
 Excessive anxiety
 Others:
 In appropriate toilet training.

8. 1. Assessment:
 Assess for family history of nocturnal enuresis, relationships of child
with parents, sibling, friends and teachers, socio-economic condition,
etc.
 Mild restriction of fluids before bedtime.
 Waking the child for passing urine during the night.
2. Bell and pad technique:
 It is based on Classical Conditioning principle.
 A bell is attached to napkin or panties and when the child passes urine,
the alarm goes off, child then has to wake up, change his napkin, etc.

10. 4. Parental counseling:
 Parents should be instructed not to blame, scold or punish the child for
bed wetting.
 Child should not be embarrassed, it aggravate the problem.
 Habit of passing urine before bedtime is adopted.
5. Star chart: A star chart allows a child and parents to track dry nights,
as a record and as a part of a reward program. This can be done either
alone or with other treatments.
7. Antidepressants: Tricyclic-Imipramine (amitriptyline) 25-50 mg is
given at night for 2-3 months.

12.  It is the inappropriate passage of formed feces,usually in the
underclothes in the absence of any physical pathology after 4 years of
age.
INCIDENCE
 Prevalence rate is 1-3% in 4 years old child.
 More common in males than females.

13.  Genetic factors: Genetic factors play a role with family history of
encopresis.
 Organic cause:spinal cord injuries.
 Physical illness: Diarrhea, electrolyte deficiency, worm infestation,
chronic constipation.
 Emotional factors: Improper toilet training, separation anxiety, starting
of schooling.

14. The psychiatric (DSM-1V) diagnostic criteria for encopresis are:
 Repeated passage of feces into inappropriate places (e.g. clothing or
floor) whether voluntary or unintentional.
 At least one such event a month for at least 3 months.
 Chronological age of at least 4 years (or equivalent developmental
level).

15. Dietary Management
 Recommended changes to the diet in case of constipation-caused
encopresis include:

16. psychological management
1. Behavioral (star chart):
 Offer age-appropriate positive reinforcement for developing regular
toilet habits.
 For young children, a star or sticker chart can be helpful.
 For older children, earning privileges, such extra television or video
game time, may be useful.
2. Establish regular bathroom times:
 The child should sit on the toilet for 5-10 minutes after breakfast and
again after dinner every day.

17. 3. Individual psychotherapy:
 Enlist cooperation
 Show concern
 Develop trust
4. Parent counseling/ family therapy:
 Modify attitudes
 Interactions
 Secondary problems

18. Medical Management
 Bowel washout and/or enemas may be necessary initially.
 An enema pushes fluid into the rectum.
 This softens the stool in the rectum and Creates pressure within the
rectum.
 This pressure gives the child a powerful urge to pass a bowel
movement, and the stool is usually expelled rapidly.
Drugs:
 Motor stimulant (senna laxatives).
 Bulk agents (lactulose).
 Suppositories are often useful as well.

21.  Nail biting is a habitual behavior among children and adults.
 It is common when nervousness is present.
 It has the potential to become compulsive, which consists of repetitive
biting and tearing the nails.

22.  Impatience, frustration, boredom: When the child is impatient, bored
or frustrated, he/she bites the nails to keep himself/herself occupied.
 Concentration: Sometimes the child is absent minded and is not
aware that he /she is biting the nails.
 Stress and anxiety: When the child is nervous, has anxiety or stress
he /she may bite the nails to find temporary relief from stress and
anxiety.
 Emotional or psychological problems: Nail biting can be associated
with mental health conditions, such as attention deficit hyperactivity
disorder (ADHD), Major Depressive Disorder, Obsessive- Compulsive
Disorder (OCD), separation anxiety disorder etc.

23. 1. Soreness of the nails and surrounding skin.
2. Abnormal-looking nails.
3. Fungal infections of the nail plate and surrounding skin.
4. Illness due to passing bacteria and viruses from your fingers to your
face and mouth.
5. Misalignment of teeth, and denta problems.
6. Temporomandibular joint pain and dysfunction.
7. Increased risk of stomach and intestinal infections

24.  Behavioral Therapy
The first part of nail biting therapy consists of Habit Reversal Training
(HRT), that seeks to "unlearn" the habit of nail biting and possibly replace
it with a more constructive habit.
 Avoid pressurizing the child to stop biting nails.

25.  Awful-Tasting Nail Polish
 Available at most drug stores, this special clear
nail polish can be applied to the nails.
 When the nail biter tries to chew their nails,
it releases a bitter flavor, thus repelling the child to do so again.
 This treatment is one of the most common as it is available without a
prescription, and available everywhere.
 Stress-Management Techniques
 Try substituting another activity, such as drawing or writing or
squeezing a stress ball, when you find your child biting his nails.

26. Medications
 Nail biting has been shown to respond well to certain types of
medication.
 The medications used to treat the problem include the newest, most
potent anti-depressants as clomipramine.

28.  Thumb sucking is a normal soothing activity in infants and younger
children and most tend to stop by the age of 4
 While some babies naturally give up the habit on their own, others may
continue for years.
 It negatively impacts on the development of their teeth and palate.
 Thumb sucking beyond 4 to 6 years of age is considered as a
behavioral disorder.

29.  Physical and emotional stimuli such as boredom, stress, hunger,
hyperactivity, sadness, pleasure, and various kinds of disabilities.
 If the child is not satisfied with the sucking during the feeding period, it
will remain as a symptom of emotional conflict/disturbance in the form
of digit sucking to obtain gratification.

30. 1. Skeletal and dental changes
2. Narrowing of upper jaw
3. Proclination of the Maxillary Incisors or
Crowding
4. Lower Teeth also Develop Crowding
5. Digit changes
6. Social impact

31.  The thumb of a child should be covered with adhesive tape or
unpalatable bitter solution should be applied over the thumb.
 Sock, mitten, gloves, thumb guard, long-sleeve gown should be weared
so that the child cannot suck.

32. Digital reminders: Digital reminder is a simple device. It is comprised of
attachment and alarm part. Attachment is worn on the thumb which is
involved in sucking. The alarm part is wrapped in a wristwatch. Every
time whenever child takes his thumb into the mouth, alarm beeps until
child takes thumb out of the mouth.

33. 1. Use positive reinforcement:
 Praise your child or provide small rewards when he or she isn't thumb
sucking.
 Place stickers on a calendar to record the days when your child
successfully avoids thumb sucking.
2. Identify triggers: If the child sucks his or her thumb and in response
to stress, identify the stressor provide comfort measures such as
hugging or reassuring words or give stuffed animal to squeeze.
3. Chewelry: Chewelry is a jewelry that is chewable. It is a good
substitute to help a toddler

35. 4. Talking:
 Always start by talking to the child about thumb sucking.
 Positive motivation is necessary . Some things to talk about with your
child include:
 Germs: Thumb and finger sucking spreads germs and makes people
sick.
 Teeth: Sucking pushes teeth forward and can make you look funny, and
you might need braces.
 Teasing: Other children will think you are still a baby or might tease.
 Speech: As long as you suck your thumb, it is hard to learn how to
speak the right way. You might sound funny.

37.  A tic is an involuntary, rapid, recurrent, non-rhythmic motor movement
(usually involving circumscribed muscle groups) or vocal production. It
is of sudden onset that serves no apparent purpose.

38. 1. Simple motor tics: Eye-blinking, neck-jerking, shoulder-shrugging,
facial grimacing.
2. Simple vocal tics: Throat clearing, barking, sniffing,hissing.
3. Complex motor tics: Jumping and hopping.
4. Complex vocal tics: Repetition of particular words or sentences, and
sometimes the use of socially unacceptable (often obscene) words
(coprolalia) and the repetition of ones own sounds or words (palilalia).

39. The exact cause of tic disorders is unknown. Recent studies have identified some
specific gene mutations that may have a role. Brain chemistry also seems to be
important, especially the brain chemicals glutamate, serotonin, and dopamine.
Risk factors for tic disorders include:
 Genetics: Tics tend to run in families, so there may be a genetic basis to these
disorders.
 Sex: Men are more likely to be affected by tic disorders than women.
 Head injuries
 Stroke
 Infections
 Poisons
 Surgery
 Other injuries

40. 1. Educating the child and family about the course of the disorder in a
reassuring manner.
2. Completion of necessary diagnostic tests, including self-reports (by
child and parents); clinician-administered ratings; and direct
observational methods.
3. Comprehensive assessment, including the child's skills, cognitive
abilities, perception, motor behavior and adaptive functioning.
4. Collaboration with school personnel to create a learning environment
conducive to academic Success.

41. Behavior Therapy
 Children are praised and rewarded for not performing tics and for
replacing them with alternative behaviors.
Relaxation Techniques
 Relaxation techniques may be useful in relieving the stress.
Pharmacotherapy
 Pharmacotherapy is the preferred mode of treatment. The drug of
choice is haloperidol.

43.  When a child takes something that belongs to somebody else without
permission, after the age of 5-6 years, it is considered as stealing.
 The stolen object can be as small as a piece of candy or as big as a
car. It can be taken from someone a person knows or from a stranger.
 It can also be taken from a store, a kind of stealing called shoplifting, or
from someone's home.

44.  Lack of knowledge and understanding It's common for preschoolers
to take other people's belongings. At this age, they lack a clear
understanding of how stealing affects others and how it can be harmful.
 Poor impulse control: Elementary and middle school-age children
often struggle with impulse control. They may quickly put an object they
want into their pockets without considering the consequences.

45.  Peer pressure:
High school and higher secondary students may steal because it is cool
for them. They can be peer pressured into taking goods from the store or
stealing money from someone's bag or locker.
 Mental health:
A child who is struggling with depression may use stealing as a way to
cope.

46. When parents find out their child has stolen something, they should do
the following:
1. Tell the child that stealing is wrong.
2. Help the youngster to pay for or return the stolen object.
3. Make sure that the child does not benefit from the theft in any way.
4.Avoid lecturing, bad behavior, or consider the child to be a thief or a
bad person.
5. When the child has paid for or returned the stolen objects, the matter
should not be brought up again by the parents.
6. Teach the children value of money. Explain that money can be earned,
and encourage children to do chores in return for pocket money.

47. There are some Discipline Strategies to Address Stealing which include:
1. Emphasize honesty:
 Have frequent conversations about honesty with children.
 Provide the child with a less serious consequences when they tell the truth
and give them plenty of praise when they are honest about wrong doing.
2. Teach respect for property:
 Make the children responsible for their belongings.
 Discuss the importance of taking good care of borrowed items and returning
them to their Owner.
3. Return stolen goods: If you catch the child with stolen items, order them to
return the stolen goods and apologize to the owner.
4. Problem-solving solutions: Work together to problem-solving strategies
that will reduce the likelihood of further stealing incidents, e.g. don't allow a 12 -
15 year-old child to be unsupervised with anyone at stores.

48.  A lie is an assertion that is believed to be false, typically used with the
purpose of deceiving Someone.
 The practice of communicating lies is called lying.
 When confronted with a child who is lying, it is important to first
remember; child's age and developmental stage.

49.  1. Children may lie, if their parents' expectations of them are too high.
 2. Children may lie about their grades, if parents assume that they are doing better in
school than they really are.
 3. The child may lie because he or she is unable to explain the actions.
 4. Children who are not disciplined on a consistent basis may lie.
 5. Children who don't receive praise and rewards may lie to get this attention.
 6. Children lie cover something up so they don't get into trouble.
 7. Children lie to make a story more exciting.
 8. By adolescence, children regularly tell white lies to avoid hurting other people's
feelings.

50.  Encouraging children to tell the truth.
 Emphasize the importance of honesty in the family and help children to
understand about the consequences of lying.
 Make a time to talk calmly with the child
 Lying should be discouraged from an early age so they grow up and
understand the concept of what is the right thing to do.
 Make it easier for the child not to lie, e.g. if the child is lying to get the
attention, consider more positive ways you could give the child attention
and boost their self-esteem.

52. STUTTERING (STAMMERING)
 Stuttering is a speech disorder.
 In this the flow of speech is disrupted by involuntary repetitions and
prolongations of sounds, syllables, words or phrases, and involuntary
silent pauses or blocks.
 These problems cause a break in the flow of speech (called disfluency).
 Incidence is more in boys than girls.

53. There are several types of stuttering:
1. On the basis of origin of problem
2. On the basis of Clinical Manifestations

54. 1. Developmental stuttering: This is the most common type of
stuttering in children. It may happen when a child's speech and language
development lags behind what they need or want to say something. It
usually happens when a child is between 2 to5 years of age.
2. Neurogenic stuttering: It happens when there are signal problems
between the brain and nerves and muscles involved in speech.
Neurogenic stuttering may happen after a stroke or brain injury.
3. Psychogenic stuttering: Psychogenic stuttering is not common. It
may happen after emotional trauma, Problems with thinking or
reasoning.

55. 1. Repetitions: This is when a sound, part of a word, whole word, or
phrase is repeated over and over, e.g. ‘my my my my name is Arun'.
2. Prolongations: This is when a sound is stretched out - for example,
"mmmmmmmmm my name is Arun".
3. Blocks: This is when a child tries to speak and no sound comes out.

56. 1. A family history of stuttering.
2. Other language disorders. Eg. Expressive Language Disorder..The
child may be unable to join words correctly into sentences.
3. Abnormalities in speech and motor control.

57. 1. Feeling frustrated
2. Pausing or hesitating when starting or during pronounce sentences,
phrases, or words, often with the lips together.
3. Putting in (interjecting) extra sounds or words ("We went to
the...uh...store").
4. Repeating sounds, words, parts of words or phrases ("T want..I want
my doll,""I...I see you," or "Ca-ca- ca-can").
5. Tension in the voice.
6. Very long sounds within words ("I am Booooobbbby Jones" or
"LIIlIllike).

58. 1. Speech therapy can help make the speech more fluent or smooth and
can help the child feels better about the stuttering.
2. Parents are encouraged to:
 Avoid expressing too much concern about the stuttering.
 It can actually make matters worse by making the child more self-
conscious.
 Avoid stressful social situations whenever possible.
 Listen patiently to the child, make eye contact, do not interrupt; show love
and acceptance.
 Avoid finishing sentences for them.
 Give them time for talking.

60.  Cluttering is a communication disorder that affects one's ability to
convey messages to others in a clear and/or concise manner.
 Individuals with cluttered speech often report that their listeners have
difficulty understanding.

61. The exact cause of cluttering is unknown but there are many theories
that attempt to explain its cause which include:
1. Abnormal functioning in the area of the brain that controls speech rate,
language based speech planning, and fluency behaviors.
2. According to abnormal brain function theory there is emerging
evidence that suggests cluttering has a genetic component too.

62.  Racing thoughts.
 Rapid and/or irregular rate of speech.
 Leaving off the ends of words.
 Omitting sounds or syllables
 Lots of starts and stops in speaking.
 Difficulty organizing thoughts and/or getting to the point.
 Limited awareness of how one's speech sounds to others.
 Difficulties in slowing down even when asked to do so.
 Distractibility, hyperactivity or a limited attention .

63.  Identify disfluencies of the child.
 Introduce relaxation skills.
 Emphasize, organized and sequenced thoughts.
 Teach memory skills, decrease overall rate of speech, and increase
self-awareness of the issues.
 Increase awareness and develop self-monitoring skills by recording and
playing back spontaneous conversations with the child.

64. NURSING RESPONSIBILITIES
 Informing the parents and making them aware about the causes of
behavioural problems of the particular child.
 Assessment of specific problem of the child by appropriate history and
detection of the responsible factors.
 Nurse play a vital role for prevention, early identification and
management of behavioural disorders in children.
 Promoting healthy emotional development of the child by adequate
physical, psychological and social support.
 Encouraging the child for behaviour modification, as needed.
Parents, teachers and family members for necessary modification of
environment at home, school and community.

65.  Risk For Self-Mutilation
 Chronic Low Self-Esteem
 Impaired Social Interaction
 Ineffective Coping

68. BOOK REFERENCE:
 Wongs essential of paediatric nursing 8th edition by marilyn J. hocken berry, david
WilsonChild health nursing 2 nd edition by Padmaja, jaypee publisher pvt lid.
 Pediatric nutrition by suraj guptee 2 nd edition, PEEPE publisher , pg nol to 9
 Nilson paediatric nursing book; 4th edition; pg no 448-452
 OP Ghai edition 8th page number 229 to 237
NET REFERENCE:
 https://emedicine.medscape.com/article/965367-overview
 https://www.scribd.com/presentation/501276847/Changing-Trends-in-Paediatric-
Nursing