SEMINAR

ON
BEHAVIOURAL DISORDERS
OF CHILDHOOD
PRESENTED BY: TANVI KUNDRA
M.Sc NURSING,1ST YEAR
 INTRODUCTION
As a child, you might have got into trouble
for not cleaning your room or arguing with a
sibling. Although getting into trouble
occasionally is a normal part of growing up,
some children have behaviors that are
extremely difficult to deal with and are not
common for their age.
 DEFINITION
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 called as
behavioural problems.
 CAUSES
Behavioral disorder are caused by multiple factors. No single event is
responsible for this condition. The important factors are:

1. Faulty parental attitude

2. Inadequate Family environment
3. Mental and physically sick or handicapped situation
4. Influence of social relationship
5. Influence of mass media
 FAULTY PARENTAL ATTITUDE
• Overprotection, dominance, unrealistic expectations
over criticism, unhealthy comparison, under discipline
or over discipline, parental rejection, disturbed parent
child interaction, broken family are responsible for the
development of the behavioral problems.
 INADEQUATE FAMILY ENVIRONMENT
• Poor economical status, cultural pattern, family habits, child
rearing practices, superstition, parents mood and job
satisfaction, parental illiteracy, inappropriate relationship
among family members etc. Influence on child's behavior
and may cause behavior disorder.
 MENTAL AND PHYSICALLY SICK OR
HANDICAPPED SITUATION
• Children with sickness and disability may have
Behavioral problems. Chronic illness and
prolonged Hospitalization can lead to this
problem.
 INFLUENCE OF SOCIAL RELATIONSHIP

Children with sickness and

disability may have behavioral
problems. Chronic illness and
prolonged Hospitalization can lead
to this problem.
 INFLUENCE OF MASS MEDIA

Television, radio, Periodicals and High

tech communication systems affect
the school children and adolescence
leading to conflict and tension which
may cause Behavioral disorders.
 CLASSIFICATION
AGE
• INFANCY
• CHILDHOOD
• ADOLESCENCE
NATURE
• MOVEMENT
• HABIT
• TOILETTING
• SPEECH
• SCHOOL
• SLEEP
• EATING
 DISORDERS IN CHILDHOOD
• TEMPER TANTRUMS
• BREATH HOLDING SPELLS
• THUMB SUCKING
• NAIL BITING
• ENURESIS
• ENCOPARESIS
• PICA OR GEOPHAGIA
 DISORDERS IN CHILDHOOD

SPEECH • STUTTERING OR STAMMERING

PROBLEMS • CLUTTERING

SLEEP • SLEEP WALKING

• SLEEP TALKING
DISORDERS
BEHAVIOR • ATTENTION DEFICIT HYPERACTIVITY DISODER
DISORDERS
 TEMPER TANTRUMS

• It is a sudden outburst or violent display of anger frustration and

bad temper as physical aggression or resistance such as rigid
body biting screaming loudly banging head etc.

• Temper tantrums occurs in maladjusted children, the activity is

directed towards the environment not to any person or anything.

• It is normal in toddler may continue to preschool period and

become more severe indicating the low frustration tolerance.
 TEMPER TANTRUMS
• It is found usually in single child and pampered children.

• Temper tantrums occurs when the child cannot integrate the internal
impulses and the demand of the reality.

• The child becomes frustrated and reacts in the only ways that he/she
knows using the great deals of muscular activity and striking out again
environment when no substitute solution is available Temper tantrum
results.
 BREATH HOLDING SPELL
• Breath holding spell may occur in children between 6 months to 5
years of age. It is observed to response to frustration or anger
during disciplinary conflict.
• The child is found with violent crying hyperventilation and sudden
cessation of breathing on expiration cyanosis and rigidity.
• Loss of consciousness twitching and Tonic - Clonic movements may
also be found.
 BREATH HOLDING SPELL

• There may be spasm of laryngeal muscles. Attack lasts for one or

two minutes then glottis release and breathing resumes with no
residual effects.

• The child may become limp and looks pallor and lifeless. Heart rates
becomes slow.
 MANAGEMENT
• Parents and family members become very anxious with the attack.
Attempt to prevent the spells is usually not successful.

• Parents need assurance about the effects of attack and should be

tolerant, calm, kind and overprotective nature of Parents may leads
to unfavorable demands of the child .
 THUMB SUCKING

• Thumb sucking or finger sucking is a Habit disorder due to

feeling of insecurity and tension reducing activities. It may
develop due to inadequate oral satisfaction during the early
infancy as a result of poor breastfeeding.

• If thumb sucking continues beyond 4 years of age then

complications may arise as malocclusion and malalignment of
teeth, difficulty in mastication and swallowing.
 THUMB SUCKING

• It may cause deformity of thumb, facial distortion and speech

difficulties with consonants (D and T) and Gastro-Intestinal tract
infections.

• In older children this habit may develop when they are tired, bored ,
frustrated or at bed and want to sleep but feel lonely.

• If the child develops thumb sucking at the age of 7 or years. It

indicates a sign of stress
 MANAGEMENT
• Parents and family members need support and to be advised not to
become irritable, anxious and tense.

• Praising and encouraging child for breaking the habit are very useful.
Distraction during bored time or engaging the thumb or finger for
other activity to be practiced to keep the hand busy.

• The child should not be scolded for the habit.

• Hygienic measures to be followed and infections to be treated

promptly.
`
 NAIL BITING

• Nail biting is bad oral habit especially in school age children

beyond 4 years of age (5-7 years).

• 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 nail biter.
 NAIL BITING
• It is caused by feeling of insecurity, conflict and hostility.

• It may occur be due to Pressurized study at school or home

or due to watching frightening violent scenes. It may
continue up to adolescence.
 MANAGEMENT

• The cause for nail biting to be identified by the parents with the help
of clinical psychologist.

• Steps to be taken to omit the habit the child should be praised for well
kept hand by breaking the habit to maintain self confidence.

• The child's hand to be kept busy with creative activities or play.

 MANAGEMENT
• Punishment to be avoided Parents need reassurance and
assistance to accept the situation and to help the child to
overcome the problem.

• The child may bite all 10 finger nails or any specific one. The
bite may include the cuticle or skin margin of nail head or
surrounding tissue
 BED WETTING OR ENURESIS
• Enuresis is the repetitive involuntary passage of urine at
inappropriate place especially at bed, during night time beyond the
age of 4 to 5 years.
• It is found in 3 to 10 percent school going children.
• The most frequent causes are:
1. Small bladder capacity
2. Improper toilet training and deep sleep with inability to receive
the signals from distended bladder to empty it.
 FACTORS RESPONSIBLE FOR ENURESIS
The emotional factors responsible for enuresis are:
1. Hostile or dependent parent-child relationship
2. Dominant Parents
3. Punishment
4. Rivalry
5. Emotional deprivation due to insecurity and Parental
death.
 FACTORS RESPONSIBLE FOR ENURESIS
• The other factors include the child with emotional conflict and
tension, desires to gain care and attention of parents as in infancy.

• Environmental factors like dark passage to toilet or cold or fear of

toilets can also be are reason.
 MANAGEMENT

•Using enuresis alarm, a device attached to a

child's underwear or a mattress pad that's
designed to wake him up as soon as he begins
to wet the bed. It has sensors that trigger a
sound or set off a vibration.
•A once-nightly-dose (Desmopressin)
This medication works like the hormone
vasopressin to decrease the amount of urine
produced at night.
•Taking Tofranil (Imipramine)
 MANAGEMENT OF ENURESIS
• Depends upon the specific cause.

• Assessments of exact cause is very essential by thorough History

collection, Clinical examination and Necessary investigations.

• The organic cause are managed with specific treatment.

• No organic causes to be managed primarily with emotional support

to the child and parents along with the environmental modifications
 ENCOPRESIS

• Encopresis is the passage of feces into inappropriate after the age of

5 years, when the bowel control is achieved.

• It is a more serious form of emotional disturbance due to

unconscious anger, stress and anxiety.
 MANAGEMENT
• Use of toilets and associated problems to be ruled out.

• Associated Problems could be Dark passage towards Toilet, Over-

Aggressive Toilet training.

• The child helps in establishment of regular bowel habits.

• Bowel training dietary intake of roughage and intake of adequate

fluids.
 GEOPHAGIA/PICA
• Pica is a Habit disorder of eating Non- edible substances such as
paints, chalk, pencil, plaster from wall earth, scalp etc. It is normal up
to the age of two years.
• If it persists two years of age, it may be due to Parental Neglect, poor
attention of caregiver, inadequate love and affection, etc.
• Management of this problem is done with Psychotherapy of the child
and Parents Associated problems should be treated with specific
management.
 GEOPHAGIA/PICA
• It is common in poor socioeconomic family and in malnourished and
mentally subnormal Children with pica may have associated problems
of Intestinal Parasitosis, Lead poisoning , Vitamins and Minerals
deficiency.

• These children may have problems like Trichotillomania (pulling out of

scalp hair and swallow) and Trichobezoar (a big palpable lump in the
upper abdomen due collection of swallowed hair)
TRICHOBEZOAR TRICHOTILLOMANIA
 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.
 MANAGEMENT
• It requires for special management with behavior
therapy, counselling and drug therapy with
Haloperidol group of drug.

• Parental reassurance and counseling of the child and

parents usually useful to manage the simple motor or
vocal tics.
 TICS OR HABIT SPASM
• Vocal tics in are found as throat clearing, coughing, barking, sniffing,
etc.

• A special type of chronic ties is found as 'Gilles de la Tourette's

Syndrome characterized by multiple motor tics and vocal tics. It
seems to be a genetic disorder with onset at around 11 years of age.

• Tics can be motor or vocal tics. Motor tics can be found is Eye Blinking
grimacing shrugging shoulder tongue protrusion, facial gesture, etc.
 SPEECH PROBLEMS

• Speech disorders are common in childhood. These can be found as

disturbances of voice (pitch disorder), Articulation and fluency.
• Speech problems can be associated with organic causes like Hearing
defect, cleft lip and cleft palate, Cerebral palsy, Dental
malocclusions, facial and bulbar paralysis, etc.
• The emotional deprivation are also very significant cause of speech
disturbances. The common speech problems related to emotional
disorders are Stuttering or Stammering, Cluttering, Delayed speech,
Dyslalia.
 STUTTERING OR STAMMERING
• Stuttering or stammering is a speech disorders begins
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 specially of initial consonants.

• These children are usually rigid and have positive family

history of language and speech difficulty.
 MANAGEMENT
• Behavioral modifications and relaxation therapy to resolve the
conflict and emotional stress, thus to improve self-confidence in the
child.
• Parents need Counseling to rationalize their expectations of child's
achievement according to the potentiality. The child should be
reassured and helped in breath control exercise and speech therapy
• These children are not mentally retarded, they may have normal or
high IQ level. So they need encouragement and guidance Stammer
suppressors, psychotherapy and drug therapy may be needed for
some children.
 CLUTTERING AND DELAYED SPEECH
• 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

• Delayed speech beyond 3 to 3.5 years can be considered as organic

causes like mental retardation, Infantile autism, hearing defects of
severe emotional problems.
SLEEP DISORDERS
 SLEEP DISORDERS

• Sleep disorders are common in children with Anxiety, Tension and

Overactivity. These problems are present with or without physical
symptoms of Behavioral 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,
sleep walking (somnambulism), sleep talking (somniloquism), bruxism
(teeth grinding), etc.
• In night mares, the child awakens from a frightening bad dream and is
conscious of surroundings.
 MANAGEMENT FOR SLEEP DISORDERS
• 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 be allowed at night.

• Parents should Provide 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
 SCHOOL PHOBIA OR SCHOOL REFUSAL

• School phobia is Persistent and abnormal fear of going to school.

• It is common in all social groups.
• 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.
 SCHOOL PHOBIA OR SCHOOL REFUSAL
• The contributing factors of school phobia are Anxiety, Dominant
Mother, Disinterested Father, Intellectual disability about Maternal
separation, Overindulgent, Over protective parents.
SCHOOL PHOBIA OR SCHOOL REFUSAL
• Uncongenial school environment like:
1. Teasing by other students
2. Poor Teacher- Student relationship
3. Unhygienic environment
4. Fear of examination, etc.
5. The child may complain of recurrent Physical Complains just to
remain at home, like Abdominal pain, Headache, which subside, if
the child is not sent to School.
 ATTENTION DEFICIT DISORDERS (ADD &
ADHD)

• Attention deficit disorders (ADD) can be related to CNS dysfunction

or due to Psycho Educational determinants.
• It is usually with hyperactivity and known as Attention Deficit
Hyperactive disorder(ADHD).
• These children are lagging behind in and learning abilities with
alteration of behavior.
 PREDISPOSING FACTORS
• The cause of this problem is not understood clearly, but
Predisposing factors can be:
1. Prematurity or Low birth Weight Brain
2. Damage due to infections or injury
3. Relation between Genetic and Psychosocial factors.
4. Impulsive child with Poor Attention Span, Hyperactivity are more
likely to show poor learning abilities
 ADHD

The manifestations may be combinations of :

1. Reading and arithmetic disability
2. Impaired memory
3. Poor language and speech development
4. Inappropriate understanding of spoken words etc.
5. The child is usually overactive, aggressive excitable, Impulsive and
Inattentive.
6. They may be Easily Frustrated, Irritated and show Temper tantrums.
7. Social relationship and adjustment are poorly developed.
 ADHD MANAGEMENT
• Management is done by Team approach including Parents.
• The Team members may include Pediatrician, Psychologist, Psychiatrist,
Pediatric Nurse Specialist, School health nurse, Teachers, Social workers.
• Counseling and guidance of parents for appropriate Training and education
of the child.
• Drug therapy can help to improve the CNS dysfunction or other associated
problems.
 NURSING RESPONSIBILITIES IN BEHAVIORAL
DISORDERS OF CHILDHOOD
1.Assessment of specific problem of the child by appropriate history
and detection of the responsible factors.
2.Informing the parents and making them aware about the causes of
behavioral problems of the particular child.
3.Assisting the parents, teachers and family members for necessary
modifications of environment at home, school and community.
4.Encouraging the child for behavior modification needed.
5. healthy emotional development of the child adequate physical,
psychological and social support.
NURSING RESPONSIBILITIES IN BEHAVIORAL
DISORDERS OF CHILDHOOD
6.Creating awareness about Psychosocial disturbance which may lead
to behavioral problems during developmental stages.
7.Providing counseling services for children and their parents to solve
the problems whenever necessary and for tender loving care of the
children.
8.Organizing child guidance clinic session
9.Referring the children with behavioral problems for necessary
management and support to better facilities, child guidance clinic,
social welfares and to support agencies.
 SUMMARY
• We discussed about Behavioral disorders related to Nature and age
• Related to Age it was broadly classified as Infancy, Childhood and
Adolescence.
• In nature we included Eating disorders, Speech Disorder, Habit
disorder, Sleep disorders etc.
• Including factors related to disorders and its management.
 CONCLUSION
• Concluding the Topic on a note that we all must have acquired some
Information regarding Behavioral disorders in Childhood.
• Classification of disorders, Management of disorders.
 BIBLIOGRAPHY
• Wong’s Essentials of Pediatric Nursing, 8th Edition,
Marilyn.J.Hockenberry, Elsevier Publishing
• Pediatric Nursing, Parul Dutta, 4th Edition, Jaypee publishers,Chapter-
10
• https://www.childrens-specialized.org/programs-and-
services/physician-specialties/developmental-behavioral-pediatrics
• http://www.sdbp.org/
• https://indianpediatrics.net/Epub29032017/REC-00055
 BEHAVIORAL DISORDERS IN ADOLSCENCE
• MASTURBATION
• JUVENILE DELIQUENCY
• SUBSTANCE ABUSE
• ANOREXIA NERVOSA
 MASTURBATION

• Masturbation or Genital stimulation 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, engage with this practice.
• Girls may do it to a less though the number of these practice is increasing year by year.
• Boys may masturbate in front of friends but girls are more private.
• Adolescents experience sexual excitement Stimulated by Penis or Clitoris followed by
relief during masturbation.
• It contributes in developing sense of mastery over sexual impulses and Help the
adolescents to capacitate and prepare for Heterosexual Relations.
• Parents should be informed that masturbation is a natural response during Prepubescent
phase
 RESISTANCE TO FEEDING

• Resistance to Feeding or Impaired Appetite During infancy feeding

problems often develop at the time invest of weaning. Infant may refuse
new foods due to dislike of taste due to separation anxiety from mother.
• It may be due to for on feeding by the mother or may be due to
indigestion of new food and abdominal colic. The infant may have painful
ulcer in the mouth or sore throat causing difficulty in swallowing.
• There may be nasal congestion or any other pathological cause which
need to be excluded.
• Mothers usually become frustrated and anxious with this situation, so
they need reassurance and guidance in rescheduling the feeding time and
change of food items Problems like mouth ulcer, sore throat, nasal
congestion any other conditions to be treated accordingly. Mothers be
encouraged to provide tender loving care to her infant to avoid
separation.
JUVENILE DELIQUENCY
Indulgence in an offence by child in the form of premeditated, purposeful, unlawful activities done
habitually and repeatedly. Usually these children belongs to broken family or emotionally disturbed
family with overcrowded unhealthy environment and having financial or legal problems.

• The factors contributing to the problem are mainly:

(a)Rapid urbanization and industrialization
(b) Social change and changing lifestyle
(c) Influence of mass media, change in moral standards and value systems
(d) Lack of educational opportunities and recreational facilities
(e) Poor economy
(f) unsatisfactory conditions at schools and colleges
(g) Unhealthy student-teacher relationship and lack of educational opportunities in schools and
colleges
h) lack of discipline
PREVENTION OF JUVENILE DELIQUENCY

• Prevention of juvenile delinquency if possible by elimination of

contributing factors. The problems of these factors are increasing in India
and in other countries too. Preventive measures to emphasized by the
healthy family and school environment. Healthy parent child relationship
tender loving care in the family, fulfilment of basic needs educational
facility sports facility exercise and recreational facility are important aspect
of prevention.
• A team approach is necessary in management of this condition including
Social workers, Psychologist ,Psychiatrist, Pediatrician, Community Health
Nurse, School teachers, Family members and Parents.
• Modification of social environment and rehabilitation of the deliquent child
should be promoted.
SUBSTANCE ABUSE

• Substance Abuse or Drug Abuse is a Threatening social problem of school going and
adolescence age group.
• 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 a given culture
• The Agents are mainly Tobacco, Alcohol, Sleeping pill, Tranquillizers, Mood Elevators,
Stimulants, Opiates, LSD, Cocaine, Heroin and Cannabis (bhang, ganja, charas).
• The children with this Behavioral disorders are having frustration, Emotional conflicts and
Disturbed Family and School relationship. They are victims of gang activities , wrong
adventure
• Poor parental guidance and lack of recreation and education. They may involve in
various antisocial activities like stealing, shoplifting and even begging. The substance
abuse is commonly found in boarding public school.
 SUBSTANCE ABUSE PREVENTION

• Preventive Measures of substance abuse include the followings:

1.Provision of adequate facilities for recreation and entertainment, especially in the hostels.
2.Proper channelization of energies of the adolescents into constructive activities.
3.Inculcation of the dangers of drug abuse among students, their teachers and family members.
4.Provision of mental health program and Periodical Psychiatric Guidance Facilities in schools.
5.Strict implementation of drug control measures:
• The ill effects of substance abuse to be informed to the public through individual or group health
education or by mass media communication to create public awareness.
• Parents, Teachers and Family members are also responsible to provide emotional support to the
older children to prevent frustration, the addicts and arrange for de addiction, wherever
necessary. conflict, confusion and mental tension.
• They should identify The addicted children need Psychotherapy, De addiction services and
Rehabilitation.
 ANOREXIA NERVOSA

• Anorexia Nervosa is an eating disorder occurs most often in adolescent

girls.
• The problem is found as refusal of food to maintain normal body weight by
reducing food intake, especially fats and carbohydrates.
• The affected adolescent girls practices vigorous exercise for weight
reduction or induce vomiting by stimulating gag reflex to remain slim.
• It is marked disturbance of body image.
• The adolescent thinks that they are fat even though they are under weight.
• Anorexia means loss of appetite, but in this condition the affected
individual experience true Hunger though they have absolute control over
their appetite.
 ANOREXIA NERVOSA
• There is no specific organic cause of 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 leads to Development
of Immaturity, Isolation and Excessive dependence.
• The Affected individual is characterized by Under Nutrition, Marked weight
loss, Bizarre food intake patterns, Amenorrhea, constipation, etc. dryness
of skin, hypothermia, hypotension, bradycardia. Management of the
condition include psychotherapy antidepressant drugs, behavior
modification and nutritional rehabilitation. Parental counseling for
modification of child relationship is essential. Hospitalization may be
needed in complicated cases.
 DISORDERS IN INFANCY
•RESISTANCE TO FEEDING
•ABDOMINAL COLIC
•STRANGER ANXIETY
 ABDOMINAL COLIC
• Abdominal colic is an important cause of discomfort in children. Some infants may
cry in continuous periods.
• This problem usually starts within the first week after birth, reaches a peak by the
age of 4 to 6 weeks and after 3 to 4 months.
• The infants may cry loudly with fists and flexed legs.
• The cause of this colic is not clear yet, but commonly occurs in overactive infants.
It may be due to hunger, or improper feeding techniques or physiological
immaturity of the intestines or cow's milk allergy.
• Excessive carbohydrates in food may lead to Intestinal fermentation and
accumulation of gas which may cause abdominal distension and pain. Abdominal
colic of the baby increases anxiety of the mother. She requires explanation and
help for solving the problem.
• Baby should be placed in a upright position and burping can be done to removed
swallowed air.
 STRANGER ANXIETY
• Mother is the significant person during infancy for satisfaction of needs, feeling
of comfort, pleasure and security. The infants does not believe any other person
except mother, because they have trust relationship with mother only.
• In absence of mother if any new person approaches the child will cry due to the
fear of insecurity, fear and anxiety.
• The child crying may upset the parents but it is an indication that the parent have
done a great job in the emotional development of the infant by Deep Mother
Child Bonding.
• Separation anxiety is the vital step for the emotional development and may
continue upto 13-15 months of age. This anxiety usually reduced when the
stranger gradually approach them and distance in a familiar place specially in
presence of the mother and father. In absence of parents loving concern of the
stranger is very important.