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BehavioralBehavioral ProblemsProblems

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DefinitionDefinition

• Behavioral Disorders represent significant departure or deviation from the accepted ‘normal’ behavior.

• Incidence: up to 20% of children.

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Common Behavioral ProblemsCommon Behavioral Problems

1. Habit Problems,

2. Eating Problems,

3. Personality Problems,

4. Anti-social Problems,

5. Sleep Problems,

6. Speech Problems,

7. Scholastic Problems.

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Habit ProblemsHabit Problems• Thumb Sucking,

• Nail Biting,

• Enuresis,

• Encopresis,

• Breath Holding Spells,

• Trichotillomania,

• Aerophagia.

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Eating ProblemsEating Problems

• Pica,• Food Fads,• Food Refusal/Overeating,• Anorexia,• Vomiting

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Personality ProblemsPersonality Problems

• Shyness,• Timidity,• Fears,• Anger,• Jealously.

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Anti-Social ProblemsAnti-Social Problems

• Juvenile Delinquency,

• Juvenile Crimes.

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Sleep ProblemsSleep Problems

• Night Terrors,

• Nightmares,

• Somnambulism,

• Insomnia

• Sleep Talking,

• Narcolepsy.

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Speech ProblemsSpeech Problems

• Stuttering,

• Mutism,

• Phonation,

• Articulation Disorders.

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Scholastic ProblemsScholastic Problems• Reading, writing, and mathematical Disorders,

• Repeated Failure,

• Absenteeism,

• Truancy,

• School Phobia.

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EtiologyEtiology

• Maladjustment:

– At home,

– At school

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Neurobehavioral ProblemsNeurobehavioral Problems

• ADHD,

• Autism,

• Learning Disorders.

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Specific Problems

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Thumb SuckingThumb Sucking

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Thumb SuckingThumb Sucking

• Common,

• Harmless,

• Infancy & Early Childhood,

• A way of securing extra self-nurturance.

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Harmful EffectsHarmful Effects

• When persisting beyond 4 yrs of age:– Dental,

– Dermatological,

– Orthopedic, and

– Psychological.

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Dental ProblemsDental Problems

• Malocclusion of developing teeth,

• Digital deformity,

• Speech difficulty.

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ResumptionResumption

• Resumption: A child who discarded this habit initially and resumes again at 7 to 8 years. This is known as resumption.

• Such cases need to be evaluated for psychological problems.

• Resumption of this habit suggests the child is suffering from stress or insecurity.

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ManagementManagement

• Not required in most cases.

• No treatment if thumb-sucking is infrequent.

• Management is indicated is thumb-sucking is persistent after 4 – 5 years of age.

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StrategiesStrategies

• Planned ignoring,

• Pay attention to more positive aspects of the child’s behaviour.

• Rewards/Incentives for sucking free days.

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Parental CounselingParental Counseling

• Self remitting nature,

• No punishment,

• Keep the engaged in activity other than thumb-sucking.

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Breath Holding SpellsBreath Holding Spells

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Breath Holding SpellsBreath Holding Spells

• Paroxysmal self limiting events,

• 6 mo – 6 years.

• 10% of healthy children.

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Sequence of EventsSequence of Events

Provocation

Crying to a point of noiselessness

Change of color

1. Loss of consciousness,2. Alteration in body color

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EtiologyEtiology

• Neurobehavioral Problem,

• Non-epileptic paroxysmal disorder,

• Genetically mediated deregulation of autonomous nervous system reflexes.

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Old Belief!Old Belief!

• Spells result from frustration due to disciplinary conflict between parents and the child.

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ClassificationClassification(According to color change)

• Cyanotic,

• Pallid,

• Mixed.

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Cyanotic TypeCyanotic Type

• Face becomes blue,

• Precipitated by anger or frustration.

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Pallid TypePallid Type

• Face appears pale,

• Provoked by sudden fright or pain.

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MixedMixed

• No clear distinction between cyanosis and pallor, or

• A conflicting history by parents.

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Clinical FeaturesClinical Features

• Typical age:– From 6 to 18 months.

• Frequency:– Variable– Multiple episodes daily, or– One per year.

• Tantrum Spells.

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C/FC/F

• The child holds his breath in expiration after a bout of crying.

• The child becomes rigid and attains ophisthotonic posture limpness normal breathing and alertness within a minute.

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Differential DiagnosisDifferential Diagnosis

• Epilepsy,

• Hypercyanotic Spells.

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BHS Epilepsy

Predisposed by

Anger, Frustration, Fright

No predisposing factor.

After attack Completely normal

Post-ictal stage: headache, vomiting and drowsiness

Cyanosis May be present. Mostly absent.

EEG Normal Abnormal.

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BHS Hypercyanotic Spells

C/F of CCHD Absent Present

CyanosisOnly during attack; no cyanosis before and after attack.

Always present.More obvious during spells.

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InvestigationsInvestigations

• ECG TRO long QT syndrome,

• EEG: Not required.

• Work up for iron deficiency.

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ManagementManagement

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Immediate ManagementImmediate Management

• Prevent injury,

• Prevent aspiration,

• Maintain airway (ABC).

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Don’tDon’t• Don’t start CPR,

• Don’t shake the baby,

• Don’t splash water,

• Don’t put anything in mouth.

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Long Term MeasuresLong Term Measures

• No prophylactic medicine.

• Treat iron deficiency:– Oral iron (4 – 6 mg/kg/day) for 6 – 8 weeks.

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Parental EducationParental Education

• Assure Normal Life.

• Avoid precipitating factors.

• What to do and what no to do during attacks.

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ReferRefer

• Child < 3 months age.

• Unconsciousness lasts for > 1 minute.

• Too frequent attacks.

• Suspected seizure disorder.

• Suspected cyanotic spells.

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PicaPica

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PicaPica

• Eating disorder,

• Repeated and chronic ingestion of non-nutritious substances such as mud, plaster, charcoal, chalk, paint, earth, clay, etc for a period of at least one month.

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EtiologyEtiology

• Cause: Unknown.

• 18 – 24 months of age.

• Persistence beyond 24 months needs attention.

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Work Up!Work Up!

• Lead toxicity,

• IDA,

• Parasitic infestation.

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ManagementManagement

• < 2 yrs of age: no treatment.

• Deworming.

• Education, guidance and counseling of family.

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Infantile ColicInfantile Colicoror

Evening ColicEvening Colic

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Rule of 3Rule of 3• < 3 months of age,

• Crying > 3 hrs/day,

• > 3 days/week,

• Longer than 3 weeks.

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EtiologyEtiology

• Not known.

• Possible:– Increased gas production in colon.– Milk allergy,– Hyperperistalsis,– Psycho-social,– Neurodevelopmental disease.

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EtiologyEtiology

• Baby otherwise well, feeds and healthy,

• Gains weight,

• Incidence:– 5 to 25% infants.

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EtiologyEtiology

• More likely to occur if child is over-reactive and parents over-anxious.

• These episodes could also be a manifestation of hunger, aerophagia or overfeeding.

• Starts within 4 wks after birth, reaches a peak by 4-6 wks and subsides by 3-4 mo.

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C/FC/F

• Evening,

• Flushed face,

• Clenched fists,

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C/FC/F

• Legs pulled up to abdomen,

• Cannot be soothed by feeding,

• Attack terminates after the infant is exhausted or passes feces or flatus.

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Differential DiagnosisDifferential Diagnosis

• CNS abn / infection,

• FB in eye,

• GERD,

• OM

• UTI,

• # bone,

• Child abuse.

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ManagementManagement

• Reassurance,

• Support the family,

• Limited treatment,

• Ensure ‘no organic cause,

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Management Management (continued)

• Provide support to family,

• Assure that this is a self limiting phenomenon,

• No long term adverse effect.

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During an episodeDuring an episode

Hold the child erect or prone on the lap

Hot Water Bottle?

Fails

Sedate the child and parents

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ExplainExplain

• Explain feeding technique,

• Practice burping,

• Place the child in right-lateral position for about ½ hr after feeding.

• Avoid allergenic food.

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Further Learning!!Further Learning!!

• Rumination, bulimia, anorexia nervosa,

• Enuresis, Encopresis,

• Anxiety Disorders,

• Mood Disorders,

• Temper Tantrums,

• ADHD,• Autism (Pervasive Developmental Disorders).