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Behavioral problems in children

common behavioral problem faced in children.
though there are hundreds of behavioral problems, but here we are discussing just few important ones.

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Behavioral problems in children

  1. 1. COMMON BEHAVIORAL PROBLEMS IN CHILDREN DR ANKUR PURI PEDIATRIC INTENSIVIST
  2. 2. Objectives • Introduction • Definition • Causes of Behavioural Disorders • Types of Behavioural Disorders • Assessment of common Behavioural Disorders. • Description of Behavioural Disorders • Conclusion
  3. 3. Behavioural disorders include many tension reducing activities that appear during childhood at various levels of development. Some of these habits develop from adults through imitation where as other as purposeful movement.
  4. 4. 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 known as behavioural problem.
  5. 5. CAUSES OF BEHAVIORAL DISORDERS • Faulty Parental Attitude • Inadequate Family • Environment • Mentally and Physically Sick or Handicapped Conditions
  6. 6. •Influence of Social Relationship •Influence of Mass Media. •Influence of Social Change.
  7. 7. TYPES OF BEHAVIORAL PROBLEMS IN CHILDREN Behavioural disorder results due to deprivation in any one of the area mentioned below :- 1. Emotional Deprivation. 2. Physical Deprivation. 3. Social Deprivation 4. Other forms.
  8. 8. Emotional Deprivation It occurs when a child is criticized, neglected, ignored or abused by primary caregiver. Behavioural problems resulting from emotional deprivation are :- • Temper tantrum • Breath holding spells • Jealousy • Insomnia • Nightmares/ night terrors • Somnolence • Bruxism
  9. 9. Physical Deprivation A physically deprived child has profound effects on developing brain. Behavioural disorders coming under this are :- • Enuresis (Bed wetting) • Encopresis • Tics • Nail Biting • Pica • Thumb Sucking
  10. 10. Social Deprivation It is the reduction of culturally normal interaction between individual and society, It includes :- • Juvenile Deliquency • School Phobia • Stealing • Repeated Failures • Lying • Agressiveness/Destructiveness • Sibling Rivalry • Speech Disorder
  11. 11. Common Behavioral problems Pica Bed wetting (Enuresis) Thumb sucking Breath holding spells Temper tantrums Tics Bruxism Encopresis
  12. 12. PICA • PICA - Persistent ingestion of non‐nutritive substances for at least 1 month in a manner that is inappropriate for the developmental level. – Examples: mud, paint, clay, plaster, charcoal, soil. • It’s an eating disorder. • Normal in infants and toddlers. • Passing phase.
  13. 13. Predisposing factors : • Lack of parental nurturing • Mental retardation • Psychological neglect (orphans) • Family disorganization • Lower socioeconomic class • Autism
  14. 14. • Coprophagia: Consumption of feces • Hyalophagia: Consumption of glass • Urophagia: Consumption of urine Types
  15. 15. • Geophagia: Eating of mud, soil, clay, chalk, etc. • Trichophagia: Consumption of hair • Pagophagia: Consumption of ice Types
  16. 16. Screening indicated for • Iron deficiency anemia • Worm infestations • Lead poisoning • Family dysfunction
  17. 17. Management • Parental care • Developing safe eating habits • Multivitamins and calcium intake • Avoid punishment
  18. 18. Enuresis • Evacuation of bladder at a wrong place and time at least twice a month after 5 yrs of age • Prevalence: ‐ 5‐10 yr olds: 2‐3% ‐ adolescence: 0.5‐1%
  19. 19. TYPES OF ENURESIS Primary nocturnal enuresis : child has never been dry at night (90% of cases). Secondary nocturnal enuresis : child has been continent for ≥ 6 months and then begins to wet bed during sleep. Diurnal enuresis : child passes urine in clothes during day and while awake
  20. 20. PRIMARY NOCTURNAL ENURESIS‐CAUSES • Marked familial pattern. • 68% concordance rate in monozygotic twins. • 38% concordance rate in dizygotic twins. • Maturational delay is the most common cause • Hypo secretion of arginine vasopressin (AVP) hormone may be possible etiology.
  21. 21. SECONDARY NOCTURNAL ENURESIS‐CAUSES • Psychosocial Stress : Family quarrels/Academic stress • Urinary Tract Infection. • Juvenile Diabetes Mellitus. • Management of secondary nocturnal enuresis depends on cause.
  22. 22. MANAGEMENT OF PRIMARY NOCTURNAL ENURESIS • Detailed clinical/developmental history • Family history • Rule out urinary tract infection. • Rule out occult spina bifida/abnormalities of urinary tract • X‐ray lumbosacral spine • USG abdomen • Rule out Diabetes Mellitus
  23. 23. BEHAVIOR THERAPY FOR PRIMARY NOCTURNAL ENURESIS • Adequate fluid intake during the day as 40% in the morning, 40% in the afternoon and 20% in the evening • Caffeinated drinks to be avoided in the evening • Reassurance and emotional support to the child
  24. 24. • Encourage child to keep a dry night diary and void urine before bed • Dry nights to be credited with praise
  25. 25. Never humiliate or punish the child
  26. 26. Alarm therapy
  27. 27. PHARMACOTHERAPY FOR PRIMARY NOCTURNAL ENURESIS • If behaviour therapy fails or if parents want prompt response: • Imipramine (2.5 mg/kg/24 hrs at bed time) for few weeks and taper • Desmopressin acetate (DDAVP) orally or intra nasally at bed time
  28. 28. THUMB SUCKING • A habit disorder. • Sensory solace for child(“internal stroking”). • Normal in infants and toddlers. • Reinforced by attention from parents. • Predisposing factors: • Developmental delay • Neglect
  29. 29. • Most give up by 2 yrs • If continued beyond 4 yrs – number of squelae • If resumed at 7 – 8 yrs : sign of Stress • Adverse Effects – Malocclusion – open bite – Mastication difficulty – Speech difficulty (D and T) – Lisping – Paronychia and digital abnormalities
  30. 30. MANAGEMENT OF THUMB SUCKING • Reassure parents that it’s transient. • Improve parental attention/nurturing. • Teach parent to ignore; and give more attention to positive behaviour. • Provide child praise for substitute behaviours. • Bitter salves may be used reduce thumb sucking. • Chronic thumb sucking in older children may affect alignment of teeth.
  31. 31. T GAURDS
  32. 32. BREATH HOLDING SPELLS • Behavioral problem in infants and toddlers. • Typically initiated by a provocative event • Child cries and then holds breath until limp. • Cyanosis may occur. • Sometimes, loss of consciousness, or even seizure can occur. • Reverts back to normal on their own within several seconds • Rare before 6 months of age ; peak at 2yrs and a bate by 5yrs of age
  33. 33. PALLID SPELLS CYANOSIS SPELLS Triggered by sudden fright or pain Triggered by frustration or anger Child may gasp/ Give brief cry Cries vigorously Becomes pale , limp Following cry  turns blue Brief episode, less than a minute May become unconscious, less than one minute Regains consciousness,, recognize people. Regains consciousness, gasps. Returns to normal.
  34. 34. DIFFERENCE BETWEEN SEIZURE AND BREATH HOLDING SPELLS
  35. 35. Management Identification and correction of precipitating factors (emotional, environmental) are essential approach. Overprotecting nature of parents may increase unreasonable demand of the child. Punishment is not appropriate and may cause another episode. Repeated attacks of spells to be evaluated with careful history, physical examination and necessary investigations to exclude convulsive disorders and any other problems.
  36. 36. Management Elicit clinical sequence of events from parents. Parents reassured , told to ignore behavior. Parents should remain calm during the event Iron supplementation for children with iron deficiency anemia
  37. 37. TEMPER TANTRUM • In 18months to 3 yr olds due to development of sense of autonomy. • Child displays defiance / oppositionalism by having temper tantrums. • Normal part of child development. • Gets reinforced when parents respond to it by punitive anger.
  38. 38. PRECIPITATING FACTORS FOR TEMPER TANTRUMS • Hunger • Fatigue • Lack of sleep • Innate personality of child • Ineffective parental skills • Overpampering • Dysfunctional family/ Family violence • School aversion
  39. 39. TEMPER TANTRUM‐MANAGEMENT • Set a good example to child • Spend quality time • Have open communication with child • Have consistency in behaviour In general,parents advised to: • Parents to ignore child, leave child alone • Once child is calm, tell child calmly that such behaviour is not acceptable • Never beat or threaten child During temper tantrum:
  40. 40. Management Praise/reward child for good behaviour. “Time Out” as disciplinary method if temper tantrum is disruptive and , out of control Refer to Child Guidance Clinic if temper tantrums persist.
  41. 41. TICS • These are the Repetitive movements of muscle groups of face, neck, hands, shoulders, trunk. • Examples: • Lip smacking • Grimacing • Tongue thrusting • Eye blinking • Throat clearing
  42. 42. • TICS are • Tension relieving habit disorder. • Mostly transient. • Persistent tics need psychotherapeutic intervention. • Causes of persistent tics: • Academic under achievement • Low self esteem • Neuropsychologic dysfunction
  43. 43. TICS IN BOLLYWOOD
  44. 44. • Eye-blinking, throat-clearing, facial grimacing and sniffing – tics are brief and sudden unwanted, repetitive, stereotyped movements or sounds. • Though alarming to many parents, about 20 percent of school age children develop tics at some point, though less than 3 percent of them display those tics for more than a year. • If tics persist for beyond 12 months, you may hear the diagnosis “Persistent Tic Disorder.” • If all of the tics are movements, we make the diagnosis “Persistent Motor Tic Disorder.” • If all of the tics are vocalizations, we call it “Persistent Vocal Tic Disorder.” • If both motor and vocal tics persist more than a year, that defines “Tourette syndrome.”
  45. 45. Management • Behavioral Therapy: The best-known behavioral treatment for tic disorders is a form of cognitive-behavioral therapy (CBT) called habit reversal training. • A child is taught to recognize the premonitory urge that precedes an oncoming tic, and to identify the situations that may trigger the tics. • The child and therapist develop a “competing” response—an action the child performs when he feels the urge—that is incompatible with the tic, and less noticeable to others. • For example, a child whose tic involves sniffling his nose may do a breathing exercise instead. Children may also be taught relaxation techniques to decrease the frequency of the tics.
  46. 46. Management • Pharmacological: There are a variety of medications commonly prescribed to help control the symptoms of tic disorder, and an experienced professional should closely monitor any course. Your child’s doctor may prescribe neuroleptic medications, which appear to help control tics by blocking the brain’s dopamine neurotransmitters.
  47. 47. BRUXISM • A habit disorder. • Begins in first 5yrs of life. • Associated with day time anxiety. • May lead to problems with dental occlusion.
  48. 48. MANAGEMENT OF BRUXISM • Help child find ways to reduce anxiety : Parent reads relaxing stories at bedtime Emotional support • Persistent bruxism leads to muscular or temperomandibular joint pain. • Dental referral necessary.
  49. 49. ENCOPRESIS • Passage of faeces at inappropriate places after 4 yrs of age. • Usually associated with constipation and overflow. • Subtypes: –Primary: persisting from infancy onward – Secondary: appears after successful toilet training • Can be A)Retentive(with constipation and overflow incontinence) B)Nonretentive (without constipation and overflow incontinence)
  50. 50. PREDISPOSING FACTORS FOR ENCOPRESIS Primary subtype: – Developmental delay Secondary subtype: – Psychosocial stressors – Conduct disorder
  51. 51. CLINICAL FEATURES • – Ridicule by schoolmates / teachers • – Punitive measures / scolding from parents / teachers Offensive odour leads to: Poor school attendance and performance Abdominal pain Impaired appetite UTI
  52. 52. MANAGEMENT Clearance of impacted faeces using enemas. Short term use of mineral oil/ laxatives to prevent Behavior therapy : Regular post prandial toilet habits High fiber diet / improve water intake. Individual or group psychotherapy sessions. Family support : encourage child, rewards for compliance, avoid power struggles.
  53. 53. TipsforparentsWhoHavechildrenwith EmotionalDisturbance • Get to know your child • Develop rules • Watch out for triggers • Be positive • Be firm with your child in instructions. • Pay proper attention.
  54. 54. Keep Your Eyes Open • Open your eyes and observe if a child seems sad, withdrawn, distant, more moody than usual, or angry. • Recognize if there seems to be greater confrontation between this child and siblings, if friends stop calling or coming over, or if the child can’t seem to find his place in school.
  55. 55. Develop a Working Relationship With Teachers • Reach out to your child’s teachers before your child reaches ‘zero hour.’ • If you think that there may be an issue, it is a good idea to set up a meeting with the teacher and ask how you can work in harmony.
  56. 56. Work on social skills • Help your child be successful academically and socially. • A child who is happy in school is a child who can focus on studying and doing well. • One who believes that school is all about academics and no social life unfortunately makes a big mistake.
  57. 57. Cont… • Set rules. • Set routines for meals and bedtimes. • Develop your child’s ability to empathize others. • Help your child learn how to express frustration, disappointment and anger without hurting others. • Establish basic rules of conduct: no hitting, kicking, biting, spitting, (no hands allowed), and no hurting others through our words.
  58. 58. Help children become independent When children feel as if they are gaining skills and becoming self- sufficient, they grow more confident in their abilities. You will watch their self-esteem take off. Each year, every child should be able to point with pride to a newfound skill or added responsibility that comes with age.
  59. 59. Cont… • Teaching our children to; • Pick out their clothing • dress themselves as they grow older • Tie their own shoes • Pack school snacks and make lunches • set their own alarm clocks instead of waking them up
  60. 60. Cont… • Allow a young child to complete puzzles and feed himself on his own and as he grows, to do his homework and projects by himself.
  61. 61. Cont.. • Have your child help around the house and gain responsibilities instead of waiting to be served like; • putting away laundry helping to serve guests Cooking keeping their room in order.
  62. 62. Communicate with Each Child • Our children should never be afraid to speak with us. No matter how tough the topic. • They should hesitate to communicate with parents. • After all, we are their parents and if they cannot believe in our love for them, whose love can they believe in?
  63. 63. Cont… • Work on communicating with your child • Put the time and energy in so that he knows that he matters in your life. • Talk to your child every day-even if it’s just for a few minutes. • Put down your iPhone • Turn off your laptop when your child (or you) return home, at mealtimes and story times, and when you pick your child up from school. • Look at him and make eye contact while having a conversation. • Speak to your child in the tone and with the words that you wish he would use with others.
  64. 64. Most Important • Express your love every day, no matter how tough the day. • Always encourage your child. • Give positive reinforcement.

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