PEDIATRICS I

2D BEHAVIORAL DISORDERS
Dr. M a. Co nsuelo Manuel | October 8, 2018

COMMON BEHAVIOR DISORDERS IN CHILDREN  Positive reinforcements

Definition: CATEGORIES OF BEHAVIOUR DISORDERS
 A young person is said to have a behavior disorder Habit Disorders (Tension releasing disorders)
when he or she demonstrates behavior that is  Finger (thumb) sucking
noticeably different from that expected in the  Nail biting
school or community.  Tics
 A child who is not doing what adults want him to  Teeth grinding (Bruxism)
do at a particular time. Emotional Disorders
 Breath holding spasms
Classification of Individuals with Emotional or  Temper tantrums
Behavioral Disorders Eating Disorders – Pica
Quay and Peterson’s Dimensions of Problem REPETITIVE BEHAVIOURS
Behaviors 1. Head Banging
Conduct Disorder  Rhythmic hitting of the head against a solid
 This dimension is characterized by physical surface often the crib mattress.
aggression, difficulty controlling anger, open  In 5-20% of children during infancy & toddler
disobedience and oppositionality. years
Socialized Aggression  Benign & self-limiting
 This dimension includes behaviors similar to conduct  Can result in callus formation, abrasions,
disorders except that children and youth display these contusions
behaviors in the company of others.  Treatment:
 Behaviors include stealing and substance abuse in the o Assurance - significant injury unlikely
company of others, truancy from school, gang o Teach parents to ignore as concern and
membership, stealing and lying punishment can reinforce it.
Attention Problems/ Immaturity o Padding
 This dimension is often associated with attention 2. Nail Biting & Finger (Thumb) Sucking
deficit disorder. It includes behaviors such as short  Sensory solace for child (“internal stroking”) to
attention span, diminished concentration, cope with stressful situation in infants and
distractibility and impulsivity as well as behaviors toddlers.
such as passivity, undependability and childishness  Reinforced by attention from parents.
Anxiety/Withdrawal  Predisposing factors:
 This dimension is related to internalizing disorders. It  Developmental delay
includes behaviors related to poor self-confidence and  Neglect
self-esteem, hypersensitivity to criticism and rejection,  Adverse effects:
generalized fearfulness and anxiety and reluctance to  Malocclusion – open bite
try new behaviors because of fear of failure  Mastication difficulty
Psychotic Behavior  Speech difficulty (D and T)
 This dimension includes psychotic symptoms such as  Lisping
speech disturbance, bizarre ideation, delusions and  Paronychia and digital abnormalities
impaired reality testing  Most give up by 2 years
Motor Tension Excess  If continued beyond 4 years – number of squelae
 This dimension is characterized by overactivity,  If resumed at 7 – 8 years : sign of stress
including restlessness, tension and “jumpiness”  Management:
What can affect Behavior in a child? o Reassure parents that it’s transient.
 Heredity o Improve parental attention/ nurturing.
 Environment o Teach parent to ignore; and give more
 Learning Conditioning attention to positive aspects of child’s
behavior.

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 o Provide child praise/ reward for substitute  Management:
behaviors. In general, parents advised to
o Bitter salves, thumb splints, gloves may be o Set a good example to child
used to reduce thumb sucking. o Pay attention to child
 Treatment options: o Spend quality time
SOLUTION HOW IT o Have open communication with child
EXAMPLES HOW IT FAILS
TYPE WORKS o Have consistency in behavior
Child loses During temper tantrum:
Depends on
Rewards & control when o Parents to ignore child and once child is
child’s
Behavioral punishment sleeping or in
willingness to calm, tell child that such behavior is not
s, stories subconscious
stop acceptable
state
Applying o Verbal reprimand should not be abusive
foul tasting o Never beat or threaten child
Use of pain or Creates more
liquids o Impose “Time Out” - if temper tantrum is
discomfort to stress and pain
Aversive Thumb disruptive, out of control and occurring in
discourage to child / can
guards, public place.
the habit even worsen
finger
4. Evening Colic
guards
Bandages  Intermittent episodes of abdominal pain and
around severe crying in normal infants
Restrict
elbows,  Begins at 1-2 weeks age and persists till 3-4
Mechanical movements,
socks over months
Mechanical impediments can be
process the  Crying usually in late afternoon or evening
to the removed, not
fingers,  Definition: “Infant cries for > 3 hours per day for >
hygienic
fabric
3 days per week for > 3 weeks ”
gloves, etc.
Cannot  Attack:
Remove the remove, o Begins suddenly with a loud cry
Finger
pleasure hygienic, do o Crying continuous – lasts for several
guards /
T Guards associated by not restrict hours – mostly in the late afternoon or
Thumb
eliminating movement, evenings
guards
suction 95% success o Face becomes red and legs drawn up on
rate
the abdomen
3. Temper Tantrums
o Abdomen becomes tense
 In 18 months to 3 year olds due to development of
o Attack terminates after exhaustion or
sense of autonomy.
after passage of flatus or feces
 Child displays defiance, negativism/
 Causes: more likely if the child is over active and
oppositionalism by having temper tantrums.
parents are over anxious, not known
 Normal part of child development.
 Management
 Gets reinforced when parents respond to it by
During Episode
punitive anger.
o Hold the child erect or prone
 Child wrongly learns that temper tantrums are a
o Avoid drugs
reasonable response to frustration.
o No much role to antispasmodics,
 Precipitating factors:
carminatives, simethicone, sup positories
o Hunger
or enemas
o Fatigue
Counseling - Coping with the parents
o Lack of sleep
o Reassure the parents that infant is not
o Innate personality of child
sick
o Ineffective parental skills
o They need to soothe more with repetitive
o Over pampering
sound and stimulate less with decrease in
o Dysfunctional family / Family violence
picking up and feeding with every cry
o School aversion

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 EATING DISORDER During a spell:
Pica  Make sure your child is in a safe place where he or
 Repeated or chronic ingestion of non-nutritive she will not fall or be hurt.
substances. – Examples: mud, paint, clay, plaster,  Place a cold cloth on your child's forehead during
char coal, soil. a spell to help shorten the episode.
 Normal in infants and toddlers.  After the spell, try to be calm.
 Passing phase  Avoid giving too much attention to the child, as
Geophagia Eating of mud, soil, clay, chalk, etc this can reinforce the behaviors that led to the
Pagophagia Consumption of ice event.
Hyalophagia Consumption of glass  Avoid situations that cause a child's temper
Amylophagia Consumption of starch tantrums.
Xylophagia Consumption of wood EMOTIONAL DISORDERS
Trichophagia Consumption of hair School Phobia
Urophagia Consumption of urine  Approximately 1 to 5% of school-aged children
Coprophagia Consumption of feces have school refusal
Pica after 2nd year of life needs investigation  Most common in 5- and 6-year olds and in 10- and
 Predisposing factors : 11year olds
 School refusal differs from truancy (refusal is
 Parental neglect
because of fear or anxiety about school)
 Poor supervision
 The goal is to have the child return to school and
 Mental retardation
attend class daily
 Lack of affection
 However, if the school phobia is extreme, a
 Psychological neglect, (orphans)
therapist or psychiatrist's assistance may be
 Family disorganization
necessary.
 Lower socioeconomic class
What can parents do?
 Autism
1. Have a physician examine the child to determine if
 Screening indicated for:
he or she has a legitimate illness.
 Iron deficiency anemia
2. Listen to the child talk about school to detect any
 Worm infestations
clues as to why he or she does not want to go.
 Lead poisoning
3. Talk to the child's teacher, school psychologist,
 Family dysfunction
and/or school counselor to share concerns.
 Treat cause accordingly.
4. Together determine a possible cause or causes
 Usually remits in childhood but can continue into
5. Develop an appropriate plan of action
adolescence
SPEECH DISORDERS
BREATH HOLDING SPASMS
1. Stuttering/Stammering
1. Simple breath-holding spell
 Defect speech
2. Cyanotic breath-holding spells
 Stumbling and spasmodic repetition of some
3. Pallid breath-holding spells
syllables with pauses
4. Complicated breath-holding spells
 Difficulty in pronouncing consonants
Precipitating Factors:
 Caused by spasm of lingual and palatal muscles
 Frustration
 Usually begins between 2 – 5 yrs
 Injury
 Reminding and ridiculing aggravate
 Anger
 Child loses self-confidence and become more
 Anemia
hesitant
Management – General:
 They can often sing or recite poems without
 No treatment is usually needed
stuttering
 Iron supplements to children with iron deficiency

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  Management:
o Parents should be reassured
o They should not show undue concern and
accept his speech without pressurizing him to
repeat
o Children should be given emotional support
o Older children with secondary stuttering
should be referred to speech therapist.
2. Tics
 Sudden, repetitive, nonrhythmic motor movement
or vocalization involving discrete muscle groups
 Common types of tics:
a. Simple Tics – Grimacing, Yawning, Grunting.
Sighing, Blinking, Wrinkling, Scratching nose,
Head jerking , Throat clearing
b. Complex Tics – Jumping, Spinning, Touching
objects or people, Echopraxia: Repeating
other‟s actions, Copropraxia: Obscene
gestures, Palilalia: Repeating one‟s own
words, Echolalia: Repeating what someone
else said, Coprolalia: Obscene, inappropriate
words
 Tic Disorders
Transient Chronic  Tourette’s
(Gilles de la Tourette syndrome)
o both multiple motor and one or more vocal
tics should have been present at some time
during the illness, although not necessarily
concurrently;
o the tics should occur many times a day nearly
every day or intermittently throughout a
period of more than 1 year; and during this
period there should never be a tic-free period
of more than 3 consecutive months;
o the onset should be before age 18 years;
o the disturbance should not due to the direct
physiological effects of a substance (e.g.,
stimulants) or a general medical condition
 Management:
o Medication to help control the symptoms and
o Habit reversal training (HRT): a behavioral
therapy
o The child and adolescent psychiatrist can also
advise the family about how to provide
emotional support and the appropriate
educational environment for the youngster.
o Formulations in the Management:
 Haloperidol
 Pimozide
 Clonidine
 Nifedipine are use in low doses
 Risperidone
 Olazapine mecamylamine
 Tetrabenazine
 Benzodiazepines baclofen
 Botulinum toxin
BEAVIORAL DISORDERS
1. Oppositional defiant disorder (ODD)
 Easily angered, annoyed or irritated
 Frequent temper tantrums
 Argues frequently with adults, particularly the
most familiar adults in their lives, such as parents
 Refuses to obey rules
 Seems to deliberately try to annoy or aggravate
others
 Low self-esteem
 Low frustration threshold
 Seeks to blame others for any misfortunes or
misdeeds.
2. Conduct Disorders
 Frequent refusal to obey parents or other
authority figures
 Repeated truancy
 Tendency to use drugs, including cigarettes and
alcohol, at a very early age
 Lack of empathy for others
 Aggressive to animals and other people or
showing sadistic behaviours including bullying
and physical or sexual abuse
 Keenness to start physical fights & Using weapons
 Frequent lying Criminal behaviour such as
stealing, deliberately lighting fires, breaking into
houses and vandalism A tendency to run away
from home Suicidal tendencies – rarely.
3. Attention Deficit hyperactivity disorder (ADHD)
 Around two to five per cent of children are
thought to have attention deficit hyperactivity
disorder (ADHD), with boys outnumbering girls
by three to one.
a. Inattention – difficulty concentrating,
forgetting instructions, moving from one task
to another without completing anything.
b. Impulsivity – talking over the top of others,
having a “short fuse”, being accident-prone.
c. Overactivity – constant restlessness and
fidgeting.