Nursing

1. Asso.Prof. Pravin, MCN

2. CAUSES OF BEHAVIORAL
PROBLEMS IN CHILDREN
FaultyParental Attitude
InadequateFamily Environment
MentallyandPhysically Sick or
Handicapped Conditions
Influence of Social Relationship
Influence of Mass Media
Influence of Social Change

3. COMMON BEHAVIORAL
PROBLEMS IN CHILDREN
Feeding problems
Habit disorders
Speech problems
Sleep Problems
Educational difficulties
Adjustment problems
Emotional problems
Antisocial problems
Sexual problems

4. BEHAVIORAL PROBLEMS OF
INFANCY
Resistance to Feeding or impaired
Appetite
Abdominal Colic
Stranger anxiety (separation anxiety)

6. Temper tantrum
Temper tantrum is a sudden outburst
or violent display anger, frustration and
bad temper as physical aggression or
resistance such as rigid body, biting,
kicking, throwing objects, hitting,
crying, rolling on floor, screaming
loudly, banging limbs, etc.

7. Management of Temper tantrum
Professional help from child guidance clinic.
Parent should be made aware about the beginning of
temper tantrum and when the child loses control.
Parent should provide alternate activity at that time.
Nobody should make fun and tease the child about the
unacceptable behavior.
Parent should explain the child that the angry feeling is
normal but controlling anger is an important aspect of
growing up.
The child should be protected from self injury or from
doing injury toothers.

8. Contd…
Physical restraint usually increase frustration and
block the outlet of anger. Frustration can be reduced
by calm and loving approach.
Over indulgence should be avoided.
After the temper tantrum is over the child's face and
hands should washed and play materials to be
provided for diversion.
The child's tension can be released by vigorous
exercise and physicalactivities.
Parents must be firm and consistent in behavior.

9. Breath holding spell
It may occur in children between 6 months to 5 years
of age.
It is observed in response to frustration or anger
during disciplinaryconflict.
The child is found with violent crying,
hyperventilation and sudden cessation of breathing on
expiration, cyanosis and rigidity.

10. Contd….
Loss of consciousness, twitching and 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 lasts for 1to 2 minutes, then glottis relaxed
and breathing resumed with no residual effects.

11. 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.

12. Thumb sucking
Complications
malocclusion and malalignment of teeth
difficulty in mastication and swallowing.
deformity of thumb
facial distortion
speech difficulties with consonants (D &T),
GIT infections.

13. Management
Parents and family members need to support and to be
advised not to become irritable, anxious and tense.
Praising and encouraging child for breaking the habit
are veryuseful.
Distraction during the bored time or engaging the
thumb or finger for other activity, keep the hand busy.
The child should not be scolded for the habit.
Consultation with dentist or speech therapist
Hygienic measures to be followed and infections to be
treated promptly.

14. Nail biting
Nail biting is a bad oral habit especially in school age
children beyond 4 years of age. It is a sign of tension
and self punishment to cope with the hostile feeling
towards parents. It may occur as imitating the parent
who is also a nail biter. It is caused by feeling of
insecurity, conflict and hostility. It may be due to
pressurized study at school or home or due to
watching frightening violentscene.

15. Management
Identify the cause of nail biting with the help of a
psychologist and the steps to be taken to remove the
habit.
The child should be praised for well kept hand by
breaking the habit to maintain the self confidence.
The child’s hands to be kept busy with creative
activities or play
Punishment to be avoided
Parents need reassurance to accept he situation and
the child to overcome the problem.

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

17. Commoncauses
small bladder capacity
improper bladder training
deep sleep with inability to receive the signals from
distended bladder to empty it.
The emotional factors
 hostile or dependent parent – child relationship
 dominant parent
 punishment
 sibling rivalry
 emotional deprivation due to insecurity and parental death

18. Contd…
The other factors
 child emotional conflict and tension
desires to gain care and attention of parents
as in infancy.
Environmental factors
 dark passage to toilet or cold or fear of toilets
toilet at distance from bedroom may cause
bed wetting at night.
The associate organic cause may present e. g.
spina bifida, neurologic bladder, juvenile DM,
seizure disorders

19. Types
Primary
secondary

20. Management
Non-organic causes to be managed primarily with
emotional support to the child and parents along with
environmental modification.
The child needs reassurance, restriction of fluid after
dinner, voiding before bed time and arising the child
to void, once or twice, three to four hours later.
Interruption of sleep before the expected time of bed
wetting is essential. The child should be fully waken
up by the parent and made aware of passing of urine at
night.
The child can assume responsibility for changing the
bed cloths. Parents should not be worried about the
problem.

21. Parents should encourage and reward the child for dry
nights. Punishment and criticism may lead to
embarrassment and frustration of the child.
Bladder stretching during daytime to be done to
increase holding time of urine, using positive
reinforcement and delaying voiding for some time.
Drug therapy with tricylic antidepressant
(Imipramine) is useful.

22. Condition therapy by using electric alarm bell
mattress is a 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 feces into inappropriate
places after the age of 5 years, when the bowel control
is normally achieved
It can be primary or secondary encopresis
Associated problems are chronic constipation,
parental overconcern, over aggressive toilet training,
toilet fear, attention deficit disorders, poor school
attendance andlearning difficulties

24. Management
history of bowel training
use of toilets and associated problems.
needs help in establishment of regular bowel habit,
bowel training, dietary intake of roughage and intake
of adequate fluid.
Parental support
reassurance and help from psychologist for counseling
of child and parents may be essential in persistent
problems.

25. Geophagia or pica
Pica is a habit disorder of eating non-edible substances
such as clay, paints, chalk, pencil, plaster from wall,
earth, scalp hair,etc.
it may be due to parental neglect, poor attention of
caregiver, inadequate love and affection, etc.
It is common in poor socioeconomic family and in
malnourished and mentally subnormal children.

26. associatedproblems
intestinal parasitosis
lead poisoning
vitamins and minerals deficiency
trichotillomania
Trichobezoar

27. Management
psychotherapy of the child and parents.
Associated problems should be treated with specific
management

28. Tics or habit spasm
Tics are sudden abnormal involuntary movements. It
is repetitive, purposeless, rapid stereotype movements
of striated muscles, mainly of the face and neck.
Tics occur most often in school children for discharge
of tension in maladjusted emotionally disturbed child
It is outlet of suppressed anger and worry for the
control of aggression.

29. 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

30. Aspecial type of chronic tics - 'Gilles de la Tourette's
Syndrome‘
characterized by multiple motor tics and vocal tics
a genetic disorder with onset at around 11years of age.
It requires for special management with behavior
therapy, counseling and drug therapy with haloperidol
group ofdrug.
Parental reassurance and counseling of the child and
parents usually useful to manage the simple motor or
vocal tics.

31. Speech Problems
Stuttering and stammering
Cluttering
Delayed speech
Dyslalia

32. Stuttering and stammering
Stuttering or stammering is a fluency
disorders begin between the age of 3 to 5
years probably due to inability to adjust with
environment and emotional stress. It is
characterized by interruptions in the flow of
speech, hesitations, spasmodic repetitions
and prolongation of sounds specialty of
initial consonants

33. Cluttering
Cluttering is characterized 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 behavior pattern. They need
psychotherapy.

34. Delayed speech
Delayed speech beyond 3 to 3.5 years can be
considered as organic causes like mental retardation,
infantile autism, hearing defects or severe emotional
problems. The exact cause must be excluded for
necessary interventions.

35. Dyslalia
Dyslalia is the most common disorder of difficulty in
articulation.
It can be caused by abnormalities of teeth, jaw or palate or
due to emotional deprivation.
Treatment of the structural abnormalities and speech
therapy should be done adequately.
In absence of structural problems, the responsible
emotional disorders or factors should be ruled out.
The child needscounseling.
The parents should be informed about the modification of
family environment and correction of deprivation.

36. Sleep disorders
. Disturbances of sleep usually occur in deep sleep, i.e.
stage 3 or 4 of NREM (non-rapid eye movement) sleep.
The common sleep problems are difficulty to fall
asleep, night mares, night terrors, sleep walking
(somnambulism), sleep talking (somnoloquy),
bruxism (teeth grinding),etc.

37. Management
In all 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.
consultation with doctors and psychologists for
specific drug therapy and psychotherapy.

38. School phobia
It is an 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
absolutely. It is a symptom of crisis situation of
developmental stages and ‘cry for help’, which needs
special attention.

39. Contributing factors of
school phobia
Anxiety about maternalseparation
Over indulgent
Over protective and dominant 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.

40. Management
habit formation for regular school attendance
play session and other recreational activities at school
improvement of school environment and assessment
of health status of the child to detect any health
problems for necessaryinterventions.
The most important aspect to manage this problem is
family counseling to resolve the anxiety related to
maternal deprivation.

41. Attention deficit disorders
Attention deficit disorders (ADD) are learning
disabilities can be related to CNS dysfunction or due to
presence of psycho educational determinants. It is
usually associated with hyperactivity and known as
hyperactive attention deficit disorders. These children
are lagging behind in intellectual and learning abilities
with alteration of behavior patterns.

42. causes
The cause of this problem is not understood clearly
predisposing factors
o prematurity or low birth weight
o brain damage due to infections or injury
o interaction between genetic and psychosocial factors.

43. Manifestations
combinations of reading and arithmetic disability
impaired memory
poor language and speech development
inappropriate understanding of spoken words.
The child is usually overactive, aggressive, excitable,
impulsive and inattentive.
They may be easily frustrated, irritated and show
temper tantrums.
Social relationship and adjustment are poorly
developed.

44. Management
done by team approach including pediatrician,
psychologist, psychiatrist, pediatric nurse specialist,
school health nurse, teachers, social workers and
parents.
behavior modification, counseling and guidance of
parents and appropriate training and education of the
child.
Drug therapy can help to improve the CNS
dysfunction or other associated problems.

45. BEHAVIORALPROBLEMSOF
ADOLESCENCE

46. Masturbation
Masturbation or genital stimulation by handling the
genitals gives pleasure to the children. The infants and
toddlers do this out of pure curiosity. The older
children masturbate due to anxiety or sexual feelings.
Boys during teen years mostly engage with this
practice.

47. Juvenile Delinquency
Juvenile delinquency means indulgence in an offence
by child in the form of premeditated, purposeful,
unlawful activities done habitually and repeatedly.
Usually children belong to broken family or
emotionally disturb family with overcrowded
unhealthy environment &having financial or legal
problems.

48. factors contributing:
(a) Rapid urbanization andindustrialization
(b) Social change and changing lifestyle
(c) Influence of massmedia
(d) Change in moral standards and value systems
(e) Lack of educational opportunities and recreational
facilities
(f) Poor economy
(g) Unsatisfactory conditions at schools and colleges
(h) Unhealthy student teacher relationship and
(i) Lack of discipline

49. Delinquent behaviors
The juvenile delinquent behavior includes lying, theft,
burglary, truancy from school, run away from home,
habitual disobedience, fights, ungovernable behavior,
mixing with anti social gang, cruelty to animals,
destructive attitude, murder, sexual assault, etc. in
broad sense, delinquency is not merely a juvenile
crime, it includes all deviations from normally
youthful behavior and anti social activities.

50. Prevention
Prevention of juvenile delinquency is possible by
elimination of contributing factors.
Healthy parent child relationship, tender loving care in
the family, fulfillment of basic needs, educational
opportunities, facility for sports exercise and
recreations, healthy teacher taught relationships, etc.
are important aspects of prevention.

51. Contd…
Delinquent child needs sympathetic attitude with
necessary guidance and counseling for modification of
behavior.
The child should be referred to child guidance clinic
for necessary help. Ateam approach is necessary in
management of this condition including social
workers, psychologists, pediatricians, community
health nurse, school teachers, family members and
parents.
Modification of social environment and rehabilitation
of delinquent child should be promoted.

52. Substance abuse
It is periodic or chronic intoxication by
repeated intake of habit forming agents. It is
persistent or sporadic use of drugs or any
substance inconsistent with or unrelated to
acceptable medical and social patterns
within thegiven culture.

53. Preventive Measures
Provision of adequate facilities for recreation and
entertainment
Proper channelization of adolescents into constructive
activities
Inculcation of dangers of drug abuse among students,
teachers and family members.
Provision of mental health programs and periodical
psychiatric guidance facilities in schools.

54. Strict implementation of drug control measures.
Individual and group health education about the ill
effects of drug abuse.
Provision of emotional support to the older children to
prevent frustration, conflict, confusion and mental
tension.
Provide psycho therapy, de addiction services and
rehabilitation for addictedchildren.

55. Anorexia Nervosa
Refusal of food to maintain normal body weight by
reducing food intake, especially fats and
carbohydrates. The affected adolescent girls practice
vigorous exercises for weight reduction or induce
vomiting by stimulating gag reflex to maintain slim.

56. Etiology
There is no specific cause for anorexia nervosa.
The affected adolescent may have associated
conditions like disease of liver, kidney, heart or
diabetes.
Parents of the affected adolescent may be anorectic
and having conflict in relationship with the child or
overprotective which lead to development of
immaturity, isolation and excessive dependence.

57. Manifestations
Under nutrition
Marked weight loss
Bizarre food intake patterns
Dryness of skin
Hypothermia
Hypotension
Bradycardia
Amenorrhea
Constipation

58. Management
Psychotherapy
antidepressant drugs
behavior modification
nutritional rehabilitation
Parental counseling for modification of parent child
relationship
Hospitalization may be needed in complicated cases.

59. NURSING RESPONSIBILITIES
BEHAVIORAL DISORDERSOFCHILDREN
Assessment of specific problem of the child by
appropriate history and detection of the responsible
factors.
Informing the parents and making them aware about
the causes of behavioral problems of the particular
child.
Assisting the parents, teachers and family members for
necessary modification of environment at home
school and community.
Encouraging the child for behavior modification, as
needed.

60. Contd….
Promoting healthy emotional development of the
child by adequate physical, psychological and social
support.
Creating awareness about psychosocial disturbances
which may lead to behavioral problems during
developmental stages.
Providing counseling services for children and their
parents to solve the problems, whenever necessary and
for tender loving care of the children.

61. Contd….
Participating in the management of the problem child,
as a member of health team along with pediatrician,
psychologist and social worker. Organizing Child
guidance clinic.
Referring the children with behavioral problems for
necessary management and support to better health
care facilities, child guidance clinic, social welfare
services and support agencies.