Introduction-Behaviour is anything that is observable and measurable.

Behavior is learned
over time through the environment. All kids misbehave sometimes. And some may have
temporary behaviour problem due to stress. For example-birth of a sibling,a divorce or a
death in family may cause child to act out.The child may become very stubborn, does not
listen to parents command, very demanding and aggressive. Behavior problems are more
serious .It is important to identify these problems in initial stages as they can be managed
optimally to help the child grow normally and have balanced mental health.

Definition-Behaviour problems are defined as manifestation of behaviour that is noticeably

different from community. Hereditary, environment, learning, conditioning and positive
reinforcement are the that expected in school or common factors those affect behaviour in
child.

Basic behavioural pediatric principles :

 Understand the function (WHY) of behaviour

 Understanding comes from observation of ABCs
 Antecedents precede and increase likelihood of behaviour
 Behaviour tends to be repeated or discontinued because of the consequences/ outcomes
 Consequences should be consistent and immediate
 Modelling can strengthen or weaken behaviour.

Etiology of Behavioural problem in children

 Maladjustment of children with parents

 Discipline: Too rigid discipline or no discipline is not desirable for optimum mental
development of a child.
 Overindulgence: Overprotection by the parents hinder the development of sense of
independence and autonomy.
 Unrealistic parental expectation: Parents' desire to achieve scholastic goals by their child
puts the child in conflict and mental stress.
 Unwanted child: Birth of an unwanted child may lack parental love and affection.
 Unfavourable comparison: Parental comparison of their child with other child or sibling
may cause stress or resentment in the child.
 Influence of social relationship and mass media
 Disturbed relationship with neighbours, school, friends and effect of television, internet,
etc. can cause development of various risky behaviours.
 Mentally and physically handicapped children.
 Children with physical sickness and disability like cerebral palsy, mental retardation may
have associated behavioural problems.
Types of Behavioural disorder in children

Infancy and Toddler Preschool School Adolescent

 Repetitive  Stuttering  Enuresis  Eating disorder

Behaviour
o Body rocking  Pica  Encopresis  Juvenile
o Head banging delinquency
 Tic disorder  Sleep disturbance
 Breath holding  Conduct disorder
spell  Enuresis  School phobia
 Oppositional
 Thumb sucking  Encopresis  Mal-adjustment defiant disorder

 Nail biting  Sleep disturbance  Conduct disorder

 Evening colic  Masturbation  Oppositional

defiant disorder
 Stranger anxiety

 Temper tantrum

BEHAVIORAL DISORDER

 REPETITIVE BEHAVIOR

 HEAD BANGING: This involves rhythmic hitting of the head against a solid surface
often the crib mattress. This is seen in 5-6% of children during infancy and toddler years.
This is common at bedtime before going to sleep or after a child wakes during night or in
the morning. It can cause callus formation, abrasions and contusions but no intracranial
injury.
 BODY ROCKING: It is characterized by rhythmic forward and backward swaying of
the trunk most frequently in sitting position.
 Treatment:

Medical Management: There is no medical treatment of head banging.

Nursing Management:

 Assurance to the patient

 Teach parents to ignore as concern and punishment can reinforce it
 Padding of bed rails to prevent injury
 BRUXISM: It is the forcible grinding, clicking or clenching of teeth mostly occurring
during sleep. It can occur due to malocclusion, emotional stress or disturbing dream.

 Treatment

Medical Management: Correction of malocclusion.

Nursing Management:

 Counselling of the child for stress.

 Instruct the child to clinch the teeth tightly for 5 seconds. relax and repeat several times
for 2 weeks to relieve tension.
 Watching or reading horror stories at bed time should be avoided.

 HABIT PROBLEM
 BREATH HOLDING SPELLS: Breath holding spell is an involuntary pause in
breathing, sometimes accompanied by loss of consciousness. It usually occurs in
response to an upsetting or surprising situation. Breath holding spells commonly seen as a
response to fear, pain or a traumatic event. The sudden reaction can cause the nervous.
system to temporarily. slow the heart rate or breathing, causing breath holding and color
changes.
 Types
 Blue spells (cyanotic breath holding) are the most common. A fright or pain often
precipitates a spell. The child cries out or screams, then turns red in the face before going
blue, usually around the lips. The child becomes floppy and unconscious.
 Pale spells (pallid breath holding) are less common. They can occur very early in life,
often followed by a minor injury when the child is upset. The child opens their mouth as
if to cry but no sound comes out, before the child faints, looking pale.
 Some children can have both cyanotic and pallid spells.
 On rare occasions a child can experience a seizure as part of a breath-holding spell, but
these are brief and not harmful.
 Phases of Breath Holding Spells
 Provocation: Consists of some strong physical or emotional stimulus: A fall, anger,
frustration, or pain. Breath holding spell typically starts with crying, lasting 15 seconds or
less.
 Expiratory apnea and cyanosis: Consists of sustained, forced expiration, followed by
progressive cyanosis in major cases.
 Opisthotonic rigidity (backward arching): The patient becomes restless and then
opisthotonic, with strongly extended back, arms, and legs.
 Stupor: The apneic stage of the attack ends with a gasp or the resumption of quiet
breathing. The normal skin color promptly returns, and the patient lies motionless. The
patient typically remains stuporous or drowsy for minutes to hours after an attack.
 Treatment :

Medication: Atropine sulphate may be tried in children with frequent pallid spells.

Iron therapy in breath holding spells(as these children usually have iron deficiency anemia)

Most children don’t need treatment for breath-holding spells

Nursing management

 Spells will go away as the child gets older.

 To protect the child during a spell, lay the child on says that it h the floor and keep his or
her arms, legs, and head from hitting anything hard or sharp.
 To decrease the chance of more spells, make sure that the child gets plenty of rest.
 Try to help the child feel secure.
 Breath-holding spells can be frustrating for parents. Find in which situation child is
getting angry.
 Advice parents that the child isn't having spells on purpose.
 During the episode, lie them on their side and watch them, đo not put anything in their
mouth or splash with water.

 THUMB SUCKING: Thumb sucking is defined as nonnutritive sucking of fingers or

thumb.

Age of occurrence: Thumb sucking is common in oral stage (0-l year) as the babies have a
natural urge to suck. This usually decreases after the age of 6 months. Many babies continue
to suck their thumb to soothe themselves. Most children stop thumb sucking between 3 and 6
years of age.

Causes of Thumb Sucking

Parental causes

 Over protection by parents

 Neglect by parents Strictness of parents
 Disharmony between parents
 Separation from parents
Due to teachers

 Excessive strictness
 Excessive punitive attitude of teachers

Due to siblings and friends

 Excessive competition
 Separation from close friend or sibling

Other causes : Loneliness and boredom, tiredness, frustration , anxiety

Problems Caused by Thumb Sucking: Thumb sucking in children younger than 4 years is
not a problem, but if it continues up to 5 years or above, it indicates presence of an emotional
problem. Prolonged thumb sucking may lead to dental problems like------(1) malignant teeth
or (2)sometimes malformation of the upper palate of mouth. (3)The child may also develop
speech problems such as mispronouncing "T" and alphabet "D" lisping, and thrusting out the
tongue while talking, A child with this type of problem needs to be evaluated by a doctor.

Management: Usually thumb sucking can be managed at home and includes parents setting
rules and providing distractions. Many experts recommend ignoring thumb sucking in
children as most children stop it on their own.

Nurse’s responsibility: Following measures should be taught to parents:

Do's

 Divert the child's attention.

 Engage him in play activities.
 The hands and fingers of the child should be kept busy in some interesting activity like
drawing.
 Offer praise and rewards to the child for not sucking thumb.
 Distract the child when he feels bored.
 Put gloves on child's hands or wrap the thumb with a cloth or bandage.
 A nontoxic bitter tasting substance can be applied on child's thumb so that he may not
suck it.
 Take help of elder children for explanation to younger siblings.
 Encourage the child to socialize.
 If the child is sucking thumb due to anxiety or distress, address the cause of discomfort.
Talk to the child and reassure him.

Don'ts

 Do not scold the child or punish him or forcefully remove thumb from the mouth.
 Do not tie the child's thumb and fingers.
 Do not nag, scold or beat the child.
 Do not leave the child repeatedly cold, wet or hungry.
 NAIL BITING: Onychophagia or nail biting is a common oral compulsive habit in
children and adults. It is just a way of coping with stress or comforting self.Nail
 Causes :Child may bite nails for number of reasons:
 Out of curiosity or boredom
 To relieve stress or anxiety
 Because of habit
 Because of nervousness
 Lack of confidence Feeling shy
 Fear or jitteriness due to horror scenes or family environment
 Feeling of insecurity
 Tiredness
 Constant nagging
 Management

Medical Management: There is no pharmacological treatment of nail biting.

Nursing Management:The nurse should educate the parents about following-

 The most common treatment, which is cheap and widely available, is application of a
clear and bitter-tasting nail polish to the nails. The bitter flavor discourages nail biting.
 Address the child's anxieties. Make the child speak about his/her worries.
 Do not nag or punish the child.
 Keep the fingernails of child neatly trimmed, to cut down on the temptation to bite.
 Keep the child's hands clean to cut down on ingestion of germs.
 Do not pressurize the children to stop biting nails, as this adds to their stress.
 Reassure the child with love and affection.
 Discuss with the child about unacceptable habits and how to break them.
 Help the child become aware of this bad habit. Suggest a substitute activity like car rides
or holding a smooth stone in free hand while reading or writing and then make the child
practice the alternative habit daily.

In case all these simpler measures fail then behaviour therapy is beneficial. Habit reversal
training, which seeks to unlearn habit of nail biting and possibly replace it with more
constructive habit, has shown its effectiveness. In addition to habit reversal training, stimulus
control therapy is used to both identify and then eliminate the stimulus that triggers biting
urges.

 EVENING COLIC: Colic is characterized by intermittent episodes of abdominal pain

or severe crying in young infants who are otherwise well. Colic usually starts with in few
weeks after birth, reach a peak by 4-6 weeks and subside by 3-4months of age.
 Clinical features:
 Sudden loud cry in the late afternoon or evening,
 Face is red and legs are drawn to the abdomen.
 Stops when completely exhausted.

The diagnosis is confirmed when the infant cries for >3 hours per day for >3 days per week
for >3 weeks.

Medical Management: No medical treatment is required.

Nursing Management: Counselling is the most effective method for helping parents.

 TIC DISORDER: Tic disorders are characterized by persistent presence of tics, which
are abrupt, repetitive, involuntary movements, and sounds that are purposeless. Ties are
sudden non rhythmic behaviors that are either motor (related to movements) or vocal, for
example, knee bends, lip smacking, tongue thrusting grimacing, eye blinking, throat b and
so on, Tics are seen in transient tic disorder vocal or motor tic disorder and Tourette's
disorder.

Types of Tics : Tics can be of following types:

1.Simple: Using only a few muscles or simple words, (a)Simple motor tics: These are simple
brief meaningless movements such as eye blinking, facial grimacing, head jerks or shoulder
shrugs. They usually last less than one l second. (b)Simple phonic tics: These are
meaningless sounds or noises such as throat clearing, coughing, sniffing,barking or hissing.

2. Complex: Using many muscle groups or full words and sentences.

(a)Complex motor tics: These tics involve slower, longer, and more purposeful movements
such as sustained looks, facial gestures, biting, banging, whirling or twisting around or
obscene gestures. (b)Complex phonic tics: These tics include syllables, words, phrases, and
statements such as "shut up" or "yes, you have done it" The child's speech may be abnormal
with unusual rhythms, tones, and accent.

Onset:The age of onset of tic disorder is 2-15 years. In 75% cases i of Tourette's disorder, the
symptoms appear by the age of 1 l years. Transient tic disorder occurs in approximately
4-24% t of school children. Tourette's disorder is three to four times more common in males
than females.

Causes of Tic Disorder :In earlier times, emotional factors were considered as cause of tics,
but now the search for causes focus on biological, chemical, and environmental factors. There
appear to be both functional and structural abnormalities in brains of people with tic
disorders. It is believed that abnormal neurotransmitters contribute to this disorder.
Researchers have also found changes within brain, especially basal ganglia and anterior
cingulate cortex.

 Management: A holistic approach is recommended for the treatment of tic disorder. A

multidisciplinary team should work together with the affected child's parents and
 teachers, to make a comprehensive treatment plan, Treatment should include the
following:
 Completion of necessary diagnostic tests including self reports by child and parents.
 Comprehensive assessment including the child's cognitive abilities, perception, motor
kills, behaviour and adaptive functioning.
 Cognitive behavior therapy: The patient is asked to deliberately perform tíc movement for
specified period of time interspersed with brief periods of rest Contingency management
is another behavioral treatment. It is based on positive reinforcement, usually
administered by parents. Children are praised and rewarded for not performing tics and
for replacing thern with alternative behaviors.
 Habit reversal is most commonly used technique, whích when combined with relaxation
exercises, awareness training, and contingency management shows 64-100% Success
rate.
 Medications: Medicines are the main treatment for motor and vocal tics. Medicatíons
prescribed include Typical neuroleptics (antipsychotícs) such as haloperidol, pimozíde,
and tetrabenazine. Alpha-adrenergic receptor agonist including clonidine and guanfacine.
Atypical antipsychotics such as resperidone and clozapine.
 Nurse’s responsibility : Educating the patient and family about the course of disorder in
a reassuring manner.

 ENURESIS: According to the DSM-IV-TR, enuresis is defined as the repeated voiding

of urine in the bed or clothes at least twice be per week for at least three consecutive
months by a child who is at least 5 years of age. It is considered normal until at least age
6.

Enuresis occurs in 40% in the age of 3-year olds, 109% of 6 years olds, and 3% of 12 year
olds. Primary enuresis is twice as common as secondary enuresis. Nocturnal enuresis is more
prevalent in boys whereas daytime wetting is more common in girls.

 Types
 Primary enuresis: It refers to the condition in which children have never been
successfully trained to control urination. There may be delay in maturation of sphincter
control.
 Secondary enuresis: It refers to the condition in which children have been successfully
trained, but revert to bed wetting in response to some stress. It may be due to parent-child
maladjustment.
 Nocturnal enuresis : Enuresis that occurs during sleep.
 Daytime wetting : Urinary incontinence that occurs while the child is awake.
 Mixed enuresis: It includes both nocturnal and diurnal enuresis.
 Etiology of Enuresis
 Biological/Organíc urinary incontinence (1-3%): Diabetes, urinary tract infections,
deficiencies in night time, anti-diruetic hormone, decreased functional bladder capacity,
inability to hold urine at night, sleep disorders such as narcolepsy and obstructive sleep
apnea or anatomical delay of urinary tract.
 Genetic: Increased incidence of enuresis in children if one or both parents have a history
of enuresis.
 Developmental status: Mentally disabled children, delay in central nervous system
maturation and in the development of language and motor skills.
 Psychological factors: Not common with primary nocturnal enuresis but more common
with secondary enuresis. It is considered as a regressive symptom in response to stress or
trauma (e.g, parental divorce, sexual abuse, trauma at school, hospitalization, neglect, a
new sibling).
 Medications: Lithium, theophylline, valproic acid, and clozapine have also been reported
to cause secondary enuresis.

 Diagnosis: Complete history and physical examination, urinalysis, urine culture,

ultrasonography.
 Management

Medical Management: Pharmacotherapy: This decreases the frequency of enuresis or

temporarily resolves symptoms over time until spontaneous resolution occurs.

 DDAVP . DDAVP is synthetic ADH and is used to decrease night time urination.
 Imipramine : Imipramine is a tricyclic antidepressant which is proved to be effective in
the treatment of enuresis although its mechanism is unknown.

Nurse’s responsibility : The nurse should teach the parents about---

 No punishment should be given to the child. Parents should be reassured that bedwetting
is due to maturational delay and is not intentional. If there is any other co-morbid
conditions that can lead to enuresis, they must be treated first.
 Motivational therapy: Reassurance, emotional support, eliminating guilt, and encouraging
the child to take responsibility for the enuresis.
 Behavioral modifications:
 Awaken the child to void at times usually associated with bed-wetting.
 Positive reinforcement for desired behavior (e.g., star or sticker charts for rewarding
periods of continence).
 Make the toilet easy access for the child.
 Let the child help in clean-up after a bed-wetting event. This encourages sense of
responsibility.
 Bladder training:
 Reduce fluids before bedtime.
 Encourage the child to drink a lot during the day. This leads to a larger bladder and
thus, increasing the bladder capacity.
 Dry-bed training : Awakening children at specified intervals until they learn to awaken on
their own when necessary.
 Enuresis alarms : When abed-wetting alarm senses urine, it goes off ,so the child can
wake up and finish voiding .The child eventually becomes conditioned to the signal of a
full bladder and spontaneously wakes up before he wait the bed.

 ENCOPRESIS : Encopresis is defined as repeated passage of feces at inappropriate

places (e.g., clothing or floor) at least once a month for a period of at least 3 months after
chronological or developmental age of at least 4 years. The estimated prevalence of
encopresis in 5-year-olds is ~1-3% and 1-2% in children younger than 10 years. The
disorder is probably more common in males than females, by a factor of 6-1. Encopresis
is frequently related with constipation and fecal impaction. Other causes may be related to
a lack of toilet training or training at too early an age or an emotional disturbance.
 Factors causing Encopresis:
 Eating diets high in fat and sugar (junk food) and low in fiber.
 Not drinking enough water.
 History of constipation or painful experience during toilet training.
 Avoidance of school bathrooms.
 Cognitive delays such as autism or mental retardation.
 Learning disabilities.
 Attention deficit disorders or difficulty focusing.
 Poor ability to identify physical sensations or symptoms.
 Neurological impairment such as spina bifida or paralysis.
 Conduct or oppositional disorders.
 Abuse and/or neglect.

 Diagnosis
 Complete history and physical examination.
 Developmental screening.
 Abdominal X-rays.
 Neurological examination.
 Rectal examination for fecal impaction.

 Management

Medical Management:

 Bowel cleansing: Acute treatment of bowel impaction if necessary. Using an effective

laxative such as polyethylene glycol (Miralax) on a daily basis may be sufficient to clean
out the bowel. Osmotic laxatives such as lactulose or magnesium hydroxide (milk of
magnesia) may also be added.
 Nutritional changes: Include fiber to the diet at a predictable time each day. The
recommended formula for calculating the amount of fiber is ‘age in years + 5 = number
 of grams of fiber/day’. Reduce the intake of constipating foods like dairy, peanuts,
cooked carrots, and bananas,

.Nursing Management: The nurse should teach the parents about--

 Bowel training: Make the child sit for 10 minutes in the toilet 20 minutes after breakfast
and again 20 minutes after dinner. Encourage drinking enough water to elicit urination
every two hours. When urinating, the child should interrupt the stream two to three times
before the bladder is empty. This exercise strengthens pelvic muscles and sphincter
control.
 Behavior management : Use developmentally appropriate strategies, such as pictures,
puppets and stories. Help them to maintain regular bathroom routines. Children can also
keep track of their successes on a calendar or behavior tracking record, and the family can
provide rewards for successes.
 Family support : Family members should keep patience while treating the child and
continue their love and support toward them. School age children may require
cooperation by their teachers to allow the child to use the bathroom frequently whenever
required. Provision ofa clean set of clothes may also prevent embarrassment.

 PERSONALITY DISORDER
 STRANGER ANXIETY : By about 6-7 months, the infant can differentiate between the
primary care giver and others. Thus at this age develop fear of unfamiliar people or
strangers. When approached by some stranger, the chìld turns away, even cry or runs
toward the primary caregiver. It may lead to separation anxiety disorder in older children.
 Treatment

Medical Management: No medical treatment is required.

Nursing Management:

 Teach relaxation technique such as gradually exposing them to stranger initially from a
distance and asking them to greet and slowly advance.
 Reassure the parents.

 TEMPER TANTRUM : It is a sudden outburst or violent display of frustration and

anger as physical aggression or resistance. Biting, throwing objects, crying, rolling on
floor or banging lìmbs are common activities during temper tantrum, In 18 months to 3
years of age, due to development of sense of autonomy child displays defiance,
negativism, oppositionalism by having temper tantrums, It is a normal part of child
development but gets reinforced when parents respond to it by punitive anger Child
wrongly learns that temper tantrums are a reasonable response to frustration. It gradually
subsides within 3-6 years of age.
 Precipitating Factors
 Hunger.
 Fatigue.
 Lack of sleep.
 Innate personality of child.
 lneffective parental skills.
 Over pampering
 Dysfunctional family or family violence.
 Management:

Medical Management: No medical treatment is required.

Nursing Management: ln general, parents are advised to:

 Set a good example to child.

 Pay attention to child.
 Spend quality time with the child.
 Have open communication with child.
 Have consistency in behavior.

During temper tantrum:

 Parents should ignore the child during the episode and once child is calm, tell child that
such behavior is not acceptable,
 Verbal reprimand should not be abusive.
 Never beat or threaten child.
 Impose ‘time Out’(fixed number of minutes o isolation), if temper tantrum is disruptive,
out of control and occurring in public place.

 SCHOOL PHOBIA : School phobia is a complex syndrome that can be influenced by

the child's temperament, the school environment and the family problem. Current
thinking defines school phobia or school refusal as an anxiety disorder related to
separation anxiety. Children refuse to attend school because of uncomfortable feelings,
stress, anxiety, or panic.

School phobia is often accompanied by other anxiety disorders such as agoraphobia or other
mental health disorders such as depression. Another possible cause of school refusal may be
traumatic and prolonged separation from the primary giver in early childhood.

 Manifestations
 Physical symptoms: Dizziness, headaches, stomach-ache, diarrhoea, nausea, vomiting,
body shaking or trembling, increased heart rate, chest pains, and back or joint pains.
These symptoms usually improve once the child is allowed to stay home.
 Behavioral symptoms: Temper tantrums, crying, angry outbursts, and threats to hurt
themselves.
 Risk Factors
 Individual factor: Fear of failure, Low self-efficacy, Physical illness , learning
difficulties. Separation anxiety
 Family factors: Separation and divorce. Parent mental health problem , Overprotective
parenting , loss or bereavement , high levels of family stress.
 School factors: Bullying , Fear of getting punished , Examination, Peer or staff mal
adjustment.
 Management

Medical Management: No medical treatment is required.

Nursing Management: ln general, parents are advised to:

 Identify the factor responsible.

 Increase parent child interaction.
 Help the child to express his/her problem.
 Individual behavioral counselling.
 Increase the parental separation time gradually.
 Positive reinforcement for attending school regularly.
 Address peer problem.
 Relaxation therapy, cognitive therapy to improve social competence.
 Parents are taught to set routines for their children and punish and reward them
appropriately.
 Structure school activities student friendly as much as possible.
 Increase teacher student interaction.

 JUVENILE DELINQUENCY: Juvenile delinquency is an antisocial behavior, in

which a child or adolescent purposefully and repeatedly does illegal activities. The
Children Act, 1960 in India defines a delinquent as "a child who has committed an
offence such as theft, sexual assault, murder, burglary or inflicting injuries, running away
from home, etc"

Presentation of Antisocial Problems in Children : The common forms of presentation of

juvenile delinquency are---

 Constant disobedience
 Lying
 Stealing
 Fire setting
 Destructiveness
 Cruelty
 Truancy from school
 Running away from home
 Sexual problems
 Drug and alcohol intake with dependence
 Gambling

Other forms of delinquency that are not so commonly seen are assault robbery, rape,
homicide, burglary, theft, , forgery, fraud, trading stolen goods and property, vandalism,
prostitution, boot-legging, and smuggling.

 Management :It is difficult to decide, whether the delinquent should be put away in an
institution or treated in the community. The therapy for delinquency should be of three
types:

1. Preventive therapy

2. Corrective therapy

3. Drug therapy

Prevention of Juvenile Delinquency: Prevention of delinquency is often a very difficult

problem and can best be described as under:

 Primary prevention, which extends to the removal of all factors which directly or
indirectly cause delinquency.
 Secondary prevention, which aims at prompt diagnosis and treatment of delinquency.
 Tertiary prevention, which aims at rehabilitatíon of delinquents.

--Prevention of juvenile delinquency may extend to marriage guidance that may help to
create a happier family.

--Effective family planning so that all children are wanted, is useful.

--Methods to bring-up children should be taught at prenatal stage and a balance of discipline
and permissiveness should be encouraged in parents. An atmosphere of emotional and
financial security should be there at home. Proper physical care prevents delinquency.

--Close contact of parents also prevents delinquency.

--The energy of adolescents should be channelized to prevent delinquency.

Corrective therapies : Corrective therapies used for juvenile delinquents are:

 Protective therapy, which not only extends to custodial care, but also to probation or
parole.
 Punitive therapy, with an idea to serve as a deterrent.
 Reformative therapy, to bring about certain changes in the personality and behavior of the
delinquent.
 Rehabilitative therapy, which is very essential to assist the delinquent in his progress and
give him a new way of living.
Drug Therapy : The use of drug therapy for delinquents is beneficial only in case of
aggressive behavior. Tranquilizers in adequate dose need to be given. Chlorpromazine, given
orally in dose of 25-50 mg, three times a day is the best. Also, Haloperidol can be given
orally in dose of 1.5-10 mg, three times a day. In case of severe uncontrolled aggression,
injectable route can be used.

 DISRUPTIVE BEHAVIOUR DISORDER

 OPPOSITIONAL DEFIANT DISORDER: Around one in ten children under the age
of 12 years are thought to have oppositional defiant disorder (ODD), with boys
outnumbering girls by two to one. Some of the typical behaviours of a child with ODD
include:
 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.

 CONDUCT DISORDER : Children with conduct disorder (CD) are often judged as ‘bad
kids' because of their delinquent behaviour and refusal to accept rules. Around five per
cent of 10 year olds are thought to have CD, with boys outnumbering girls by four to one.
Around one-third of children with CD also have attention deficit hyperactivity disorder
(ADHD).

Some of the typical behaviours of a child with CD may include:

 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
 Being aggressive to animals and other people of showing sadistic behaviours including
bullying and physical or sexual abuse
 Keenness to start physical fights
 Using weapons in physical fights
 Frequent lying
 Criminal behaviour such as stealing, deliberately lighting fires, breaking into houses and
vandalism
 A tendency to run away from home
 Suicidal tendencies - although these are more rare.

 ATTENTION DEFICIT HYPERACTIVITY DISORDER

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. The characteristics of
ADHD can include:

 Inattention – Difficulty concentrating, forgetting instructions, moving from one task

to another without completing anything.
 Impulsivity - Talking over the top of others, having a 'short fuse', being accident-
prone.
 Overactivity -Constant restlessness and fidgeting.

Risk factors: The causes of ODD, CD and ADHD are unknown but some of the risk factors
include:

 Gender - Boys are much more likely than girls to suffer from behavioural disorders. It is
unclear if the cause is genetic or linked to socialisation experiences.
 Gestation and birth -Difficult pregnancies, premature birth and low birth weight may
contribute in some Cases to the child's problem behaviour later in life.
 Temperament - Children who are difficult to manage, temperamental or aggressive from
an early 4ge are more likely to develop behavioural disorders later in life.
 Family life - Behavioural disorders are more likely 1In dysfunctional families. For
example, a child is at increased risk in families where domestic violence, Poverty, poor
parenting skills or substance abuse are a problem.
 Learning difficulties - Problems with reading and Writing are often associated with
behaviour problems.
 Intellectual disabilities -Children with intellectual disabilities are twice as likely to have
behavioural disorders.
 Brain development - Studies have shown that areas of the brain that control attention
appear to be less active in children with ADHD.

Treatment of behavioural disorders in children : Untreated children with behavioural

disorders may grow up to be dysfunctional adults. Generally, the earlier the intervention, the
better the outcome is likely to be. A large study in the United States, conducted for the
National Institute of Mental Health and the Office of School Education Programs, showed
that carefully designed medication management and behavioural treatment for ADHD
improved all measures of behaviour in school and at home.

Treatment is usually multifaceted and depends on the particular disorder and factors
contributing to it, but may include:
 Parental education -For example, teaching parents how to communicate with and manage
their children. .
 Family therapy- The entire family is helped to improve communication and problem-
solving skills.
 Cognitive behavioural therapy - To help the child to control their thoughts and behaviour.
 Social training-The child is taught important social skills, such as how to have a
conversation or play cooperatively with others.
 Anger management -The child is taught how to recognise the signs of their growing
frustration and given a range of coping skills designed to defuse their anger and
aggressive behaviour. Relaxation techniques and stress management skills are also taught.
 Support for associated problems For example, a child with a learning difficulty will
benefit from professional support.
 Encouragement -Many children with behavioural disorders experience repeated failures at
school and in their interactions with others. Encouraging the child to excel in their
particular talents (such as sport) can help to build self-esteem.
 Medication -To help control impulsive behaviours.

 SPEECH DISORDERS
 STUTTERING / STAMMERING : Stammering, also known as stuttering, is a speech
disorder in which the flow of speech is disrupted by involuntary repetitions and
prolongation of sounds, words or syllables. Also there a involuntary silent pauses or
blocks.
 Clinical Features
 Problems in starting a word or phrase
 Hesitation before certain sound has to be uttered
 Repetition of a sound, word or syllable
 Speech may come out in spurts
 Trembling lips and jaws (when trying to talk)
 Interjections like "uhm" used more frequently before attempting to utter certain sounds

 Causes of Stammering/Stuttering: The following factors may cause or trigger

stuttering--
 Developmental factors: If the child has cleft lip, cleft palate or tongue tie, the speech is
affected. There may be central nervous system impairment which may affect the speech
 Neurogenic stuttering: A stroke or brain injury may affect the signals between brain,
speech nerves, and muscles, thereby leading to stuttering.
 Psychological factor: Factors such as stress and embarrassment may make stuttering
worse in people who stutter

 Management

Medical Management: If there is any developmental factors or neurogenic stuttering,

those should be treated accordingly.
Nursing Management: The parents should be advised to-

 Teach the child skills, strategies, and behaviors that help in oral communication. This
may include fluency shaping therapy and stuttering-modification therapy.
 Parents should not put undue pressure on the child, regarding fluency of speech during
preschool age.
 Give the child sufficient time to express himself.
 Never criticize the child for his/her speech.
 Encourage the child to speak clearly by teaching him/ her songs and nursery rhymes.
Make the child feel that parents are interested in his talks.

 EATING DISORDERS
 PICA : It is a habit disorder characterized by repeated or chronic ingestion of non-
nutritive substances. Examples: mud, paint, clay, plaster, charcoal, soil, etc. and the habit
must persist for more than l month, at an age when eating such objects is considered
developmentally inappropriate.
 Types: The subtypes of pica are characterized by the substance eaten, for example:
 Amylophagia: Consumption of starch
 Coprophagy: Consumption of animal feces
 Geophagy: Consumption of soil, clay or chalk
 Hyalophagia: Consumption of glass
 Pagophagia: Pathological consumption of ice
 Trichophagia: Consumption of hair or wool
 Urophagia: Consumption of urine
 Predisposing Factors
 Parental neglect
 Inadequate supervision
 Mental retardation
 Lack of affection
 Psychological neglect , orphans
 Family disorganization
 Lower socioeconomic class

Management:

Medical Management:

 Screening should be done for iron deficiency anemia , worm infestations, lead poisoning ,
other nutritional deficiencies.
 Treat cause accordingly.
 Usually remits in childhood but can continue into adolescence.

Nurses responsibility: The nurse should teach the parents and family member regarding
following points—
 Discrimination training between edible and non-edible items.
 Make meal time pleasant.
 Meet the emotional needs of the child.
 Do not leave the child alone.
 Keep the child busy , as boredom may give time for eating non-edible substance.

 ANOREXIA NERVOSA : Anorexia nervosa, which primarily affects adolescent girls

and young women, is manifested by distorted body image and excessive dieting that
results in severe weight loss with a pathological fear of becoming fat. According to DSM
5 criteria, anorexia nervosa is characterized by restriction of energy intake relative to
requirements, intense fear of gaining weight or becoming fat and disturbance in the way
in which one's body weight or shape is experienced.

In anorexia nervosa, weight is maintained at least 15% below that expected, or in adult's
body mass index (BMI) - calculated as weight in kilograms divided by height in meters
squared- is below 17.5 kg/m.

 Symptoms
 Refusal to eat enough food, despite extreme hunger
 An intense fear of becoming 'fat' and of losing control.
 A disturbance of perception of body image in that people may regard themselves as fat,
overestimating body size.
 A tendency to exercise obsessively.
 A preoccupation with determining “good” and "bad' foods and with the preparation of
food. Absence of menstrual periods

 Adverse Effects
 Thinning of the bones (osteopenia or osteoporosis).
 Brittle hair and nail
 Dry and yellowish skin
 Growth of fine hair all over the body (lanugo)
 Mild anemia and muscle wasting and weakness
 Severe constipation
 Low blood pressure, slowed breathing and pulse
 Damage to the structure and function of the heart
 Brain damage
 Multiorgan failure
 Drop In internal body temperature, causing a pesron to feel cold all the time
 Lethargy, sluggishness or feeling tired all the time
 Infertility
 Inability to concentrate and think rationally

 Causes
 Genetic
 Biochemical or hormonal imbalances
 Personal: Changes in life circumstances, such as the onset of adolescence, breakdown of
relationships, childbirth or death of a loved one; perfectionism and a belief that love from
family and friends depends on high achievement and fear of the responsibilities of
adulthood,
 Social Media, internet etc.

 Management

Medical Management:

 Restore weight with psychological support.

 Nutritional/physical rehabilitation,
 Identify/understand dysfunctional attitudes,
 Family therapy: Parents should be involved in meal planning, reduce criticism
 Psychotherapy: Behavior therapy, group therapy.
 Drug: Antidepressants, Tricyclic antidepressants (amitriptyline, clomípramine), SSRIs
(fluoxetine, citalopram), Antihistamines (cyproheptadine), Antipsychotics (pimozide,
sulipride).

Nursing Management:

 BULIMIA NERVOSA : Bulimia nervosa is characterized by frequent episodes of binge

eating followed by recurrent inappropríate compensatory behavior (vomiting, purging,
fasting or exercising or a combination of these) in order to prevent weight gain. In
bulimia nervosa BMI is maintained above 17.5 kg/m in adults and the equivalent in
children and adolescents.

 Symptoms
 Eating binges that include consumption of large amounts of calorie-rich foods, during
which the person feels a loss of personal control and self-disgust.
 Purging attempts to compensate for binges and to avoid weight gain by self-induced
vomiting, and/or over the counter use of laxatives and fluid tablets.
 A combination of restricted eating and compulsive exercise so that control of weight
dominates the person's life.

 Adverse Effects
 Chronically inflamed and sore throat.
 Swollen salivary glands in the neck and jaw area.
 Worn tooth enamel, increasingly sensitive and decaying teeth as a result of exposure to
stomach acid.
 Acid reflux disorder and other gastrointestinal problems.
 Intestinal distress and irritation from laxative abuse.
 Severe dehydration from purging of fluids.
 Electrolyte imbalance (loo low or too high levels of sodium, calcium, potassium and
other minerals) which can lead to heart attac
.
 Management:

Medical Management: Cognitive behavioral therapy (CBT) and use of antidepressants.

Nursing Management:

 Encourage eating 3 or more balanced meals a day.

 Adopt flexible food rules and body image concerns.
 Develop cognitive and behavioral strategies. Binge Eating Disorder

 BINGE EATING DISORDER : Binge eating disorder is defined as recurring episodes

of eating significantly more food in a short period of time than most people would eat
under similar circumstances, with episodes marked by feelings of lack of control. Unlike
bulimia nervosa, periods of binge-eating are not followed by purging, excessive exercise
or fasting. Therefore, people with binge-eating disorder often are overweight or obese.
People with binge-eating disorder who are obese are prone to develop cardiovascular
disease and high blood pressure.

 Management

Medical Management: Treatment includes psychotherapy and fluoxetine and other

antidepressants

 SLEEP DISORDERS
 DYSSOMNIAS (disorders of initiating sleep and maintaining sleep)
 PARASOMNIAS (abnormal activities during sleep) : t is defined as episodic nocturnal
behavior involving cognitive disorientation and autonomic and skeletal muscle
disturbance. Partial arousal insomnia includes sleep walking and sleep terror. It is more
prevalent among preschool and school age children. Rhythmic movement disorders like
body rocking and head banging occurs mainly during sleep wake transitions.
 HYPERSOMNIAS (excessive sleepiness)
 Management :

Medical Management: No pharmacological treatment is required.

Nursing Management:

 Establish a bedtime routine

 Establish a wake-up time.
 Avoid giving stimulants such as sugar or caffeine to the
 child near bedtime.
 Make the bedroom cozy and inviting
 Avoid disturbances in sleep like television.
 Maintain silence in and near bedroom.
 Be with the child while he falls asleep.
 Provide pleasant activity like story tellíng prior to sleep.

 SEXUAL DISORDERS
 MASTURBATION: Parents should explain children that masturbation is not a social
activity and it should not be practiced in public.
 GENDER LDENTITY DISORDERS: It may develop more prior to 4 years of age but
more common in adolescence, Transsexualism is conviction by a person biologlcally of
one gender that he/she is a member of the other gender.Transvestism is cross dressing
when boys dress up in women’s clothing. Homosexuality refers to emotional and physical
attraction to some one of the same gender.
 Management
 Treatment includes psychotherapy

Nurse’s Responsibility:

 Parenting techniques to teach the gender appropriate behavior.

 No punishment or shaming should be done.

CONCLUSION: Behavioural disorder in children are very common. They often under-
recognised and under-treated. Untreated children may leads to a disruptive adult. However
treatment for behavioural disorder depends on the nature of child’s condition and the
sensitivity of their symptoms. A positive and conductive approach is the best way to deal
with behavioural problem in children.
BIBLIOGRAPHY:

1.kurian s, Textbook of Pediatric Nursing,2nd edition 2020, Bangalore, EMMESS Medical

Publishers, pg no- 727-792

2.Sharma R, Essentials of Pediatric Nursing ,#rd edition 2021, New Delhi, Jaypee Brothers
Medical Publishers(p0 Ltd. Pg no-432-440

3. Pal P., Textbook of Pediatric Nursing for Nursing Students,2 nd edition 2021, Delhi , CBS
Publishers & Distributers Pvt Ltd, pg no-481-495