Behavioral disorders.

NTRODUCTION

Every child should have tender loving care and sense of security about protection from parents
and family members. They should have opportunity for development of independence, trust,
confidence and self-respect some children have extremely difficult and challenging behaviors
that are outside the norm for their age. Most of the problem are minor and do not have any
permanent disturbance but produce anxiety to the parents.

DEFINITION:

Behavioral problems are the significant deviations from socially accepted normal behavior.
These problems are mainly due to failure in adjustment to external environment and presence of
internal conflicts.

Causes

Behavioral disorders are caused by multiple factors. No single events areresponsible for this
condition. The important contributing factors are:

Faulty Parental attitude

Over- protection, dominance, unrealistic expectation, over-criticism, unhealthy comparison,

under-discipline or over-discipline, parental rejection, disturbed parent-child interaction, broken
family (death, divorce), etc. are responsible factors for development of behavioral problems.

Some parents are very overprotective.

Some parents expect more than their child achieve

Some parents always compare their child with cousin or with neighboring child

Sometimes they scold you when you failed to achieve something.

Inadequate family environment

Poor economical status, culture pattern, family habits, child rearing practices, superstition,
parent’s mood and job satisfaction, parental illiteracy, inappropriate relationship among family
members, etc. influence on child’s behavior and many cause behavioral disorders.

Mentally and physically sick or handicapped conditions

Children with sickness and disability may have behavioral problems. Chronic illness and prolong
hospitalization can lead to this problem. Long term serious illness may causes frustration to a
child.

Influence of social relationship

Maladjustment at home and school, disturbed relationship with neighbors, school teacher, school
mates and playmates, favoritism, punishment, etc. may predispose behavioral problem.

Your peer group, your neighborhood, your teachers has an impact on your behavior.

Preschool and school going children are learning both good and bad from their peers.

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.

Especially during this pandemic time everyone is busy in their mobile. Even the nursery students
are doing online classes. So parents are bound to provide mobile and Parents can't look every
time what their children are doing in mobile. So social media has strongly influenced the child in
developing behavioral problems.

Influence of social change

Social unrest, violence, unemployment, change in value-orientation, group interaction and

hostility, frustration, economic insecurity, etc, affected older children along with their parents
and family member resulting abnormal behavior.

Here are some behavioral disorders:

A. Anorexia nervosa
B. Bulimia nervosa.

C. Pica

D. Temper tentrum

E. Breath holding spells

F. Difficulty in toilet training

G. Enuresis

Behavioral disorders:

Behavioral disorders typically develop in childhood or adolescence. While some behavioral

issues may be normal in children, those who have behavioral disorders develop chronic patterns
of aggression, defiance, disruption and hostility. Their behaviors cause problems at home, school
or work, and can interfere with relationships.

Anorexia nervosa.

Anorexia nervosa is 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 a marked disturbance of body image. The
adolescent thinks that they are fat even though they are under weight.

As we all know Anorexia means loss of appetite, but in this condition the affected individual
experience true hunger though they have absolute control over their appetite.

It may result from emotional trauma, depression, or anxiety. Some people may view extreme
dieting or weight loss as a way to regain control in their lives.

These eating disorders are characterized by:

i) Body weight<85% of expected weight for age and height;

(ii) Intense fear of becoming fat even though underweight;

(iii) Disturbed body image and denial that the current body weight is low; and,

(iv) In postmenarcheal girls. It is most common among 15-19 yr-old.

Treatment will be based on severity of the condition.

As this condition is a behavioral disorder, so the treatment will include behavioral therapy,
psychotherapy, cognitive therapy and also nutritional therapy to gain her weight.

Psychotherapy, including individual and family therapy, and in some cases, group therapy, are
required to establish appropriate eating patterns and restore normal perceptions of hunger and
satiety.

Severely undernourished patients require nutritional rehabilitation targeting normal weight for
height. While oral supervised feeding is preferred, some patients require nasogastric or parenteral
nutrition. Antidepressant and antipsychotic drugs are prescribed as required.

Bulimia Nervosa

Bulimia Nervosa is same like anorexia nervosa but here the girl will eat more amount of food at
a time and immediately after eating they will induce vomiting to loss her weight.

Bulimia nervosa is characterized by:

(i) Recurrent episodes of binge eating characterized by eating in a discrete period of time an
amount of food that is definitely more than what normal individual eat during a similar time
period, without control over eating during the episode;

(ii) Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced
vomiting, misuse of laxatives, diuretics, enemas, fasting, or excessive exercise.

The disorder is more common among girls between 10-19 yr of age.

That means in Anorexia nervosa there will be loss of appetite and the girl will not eat food as
fear of gaining weight. But In Bulimia Nervosa the girl will eat more than a normal meal at a
time or frequently and then she will do vigorous exercise, induce vomiting to reduce weight.
Signs and symptoms of Bulimia Nervosa

• Constantly worrying about weight or appearance

• eating to the point of discomfort

• going to the bathroom immediately after eating

• exercising too much, especially after they’ve eaten a lot in one sitting

• restricting calories or avoiding certain foods

• Not wanting to eat in front of others

Management of Bulimia Nervosa is same like Anorexia nervosa.

Management includes a combination of psychotherapy (specifically, cognitive behavior therapy)

and anti-depressant medications (such as fluoxetine) active follow-up needs to be maintained to
ensure motivation and adherence to therapy.

Pica

Pica is the persistent ingestion of non-nutritive substances such as plaster, charcoal, and paint.

If children continuously eat non nutritive substances for at least 1 month in a manner that is
inappropriate for the development level, then it called as pica.

It is not part of a culturally sanctioned practice and is sufficiently severe to warrant independent
clinical attention.

During Infancy eating non nutritive substances are normal. But if it continues after that then it
leads to behavioral problem.

It is a common problem in children less than 5 yr of age. Children with pica are at an increased
risk for lead poisoning, iron deficiency anemia and parasitic infestations.

Diagnose of Pica
No single test confirms pica, but because pica can occur in children who have lower than normal
nutrient levels and poor nutrition (malnutrition), the health care provider should test blood levels
of iron and zinc.

Hemoglobin can also be checked to test for anemia.

Lead levels should always be checked in children who may have eaten paint or objects covered
in lead-paint dust.

The healthcare provider should test for infection if the patient has been eating contaminated soil
or animal waste.

Treatments

Management comprises behavioral modification, alleviating the psychosocial stress if any.

Any kind of behavioral problem will be always, treated by behavioral therapy, psychotherapy,
cognitive therapy and group therapy according to the symptoms and causes.

Iron supplementation is required if iron deficiency is present.

If the child is having severe lead poisoning from eating paint chips, Chelation therapy may be
prescribed to treat the child. This will excrete the lead in the urine.

If pica is caused by nutrient imbalances, they may prescribe vitamin or mineral supplements to
the child.

Temper Tantrum

Temper tantrums include behaviors that occur when the child responds to physical or emotional
challenges by drawing attention to himself and can include yelling, biting, crying, kicking,
pushing, throwing objects, hitting and head banging. Most of the children shows temper tantrum
when their wishes are not fulfilled. Tantrums typically begin at 18-36 months of age.

Inability to assert autonomy or perform a complex task on his/her own causes frustration to child
which cannot be effectively communicated due to limited verbal skills. The frustration therefore
acted out as undesired behaviors.
Techniques of Temper tantrum management

As a nursing personal we should asked the Parent to list situations where disruptive behavior
are likely to occur and plan strategies to avoid these.

During a tantrum, the parent’s behavior should be calm, firm and consistent and they should not
permit the child to take advantage from such behavior.

The child should be protected from injuring himself or others.

At an early stage, distracting his attention from the immediate cause and changing the
environment can abort the tantrum.

A ‘time out’, i.e. asking the child to stay alone in a safe and quite place for a few minutes, is
useful. So, there is no medical treatment for TT. These are the some techniques of Temper
tantrum management.

Breath holding spells

Breath holding spells are reflexive events typically initiated by a provocative event that causes
anger, frustration or pain causing the child to cry. The crying stops at full expiration and the child
become apneic and cyanotic or pale means the child will cry and eventually stops crying at full
expiration and hold his breath until he become apneic and cyanotic. In some cases the child may
lose consciousness become hypotonic and fall.

Breath holding spells are rare before 6 months of age, peak at 2 yr and abate by 5 yr of age.

Diagnosis

Diagnosis is based on the setting and the typical sequence of crying, cyanosis or pallor with or
without brief loss of consciousness. Identifying BHS is very difficult. Because child usually cries
when they need something, or if they are hungry. But you may not say that, that is BHS. You
need to assess the child for sign and symptoms.

After a thorough examination of the child, the parents should be reassured.

They are explained that the apneic spells are always self-limited and do not lead to brain injury
or death.

The family should be advised to be consistent in their behavior with the child, remaining calm
during the event, avoid picking the child up (since this decreases blood flow to the brain) and to
turn him to the side so that secretions can drain.

As the child recovers, they should avoid exhibiting undue concern or give in to his demands if
the spell was provoked by anger or frustration.

Difficulty with toilet training

Toilet training should be started after 2 years of age when the child has spontaneously started
indicating bladder and bowel fullness and is able to follow simple instructions.

If the toilet training is begun by the parents before the child is developmentally ready to be
trained, unnecessary power struggle between parents and child during that time.

Refusal to defecate in the toilet with development of constipation is a common problem in

children. This leads to parental frustration and increased pressure on the child.

Parents should be advised for temporary cessation of toilet training and making a fresh beginning
after some time.

Punishment for voiding outside of the bathroom should be avoided. Be patient, understanding
and attentive.

Do not talk about bed wetting or soiling in front of others. Try to respond calmly and use it as an
opportunity to support and communicate with the child.
Early treatment of a wetting, soiling, or bowel control problem can help prevent and reduce
social and emotional pain for both child and family.

A child psychologist can help the child cope with and overcome feelings of embarrassment,
shame, guilt, and loss of self-esteem.

A therapist can also help a parent overcome feelings of anger and frustration over the lack of
proper toileting behavior from their child.
Enuresis

Enuresis is defined as urinary incontinence beyond the age of 4 years for daytime and 6 years for
nighttime, or as the loss of continence after at least 3 months of dryness.

The diagnosis of enuresis is made when wetting occurs twice a week for 3 consecutive months or
child suffers significant distress because of it.

Untreated enuresis may lead to a lack of self-esteem or avoidance of social activities.

Management of enuresis varies and includes identification and correction of the underlying
cause, behavioral therapy, and the use of medications.

a) Behavioral therapy

Simple behavioral interventions may prove to be superior in comparison to no ongoing form of

treatment and are recommended as initial treatment.

It includes-

 Nighttime fluid limitation

 Motivational therapy
 Bladder training - training the bladder to hold more urine
 Reward systems - give star charts for dry nights
 Lifting - carrying the child, who is still asleep, away from the bed to an appropriate place
to urinate.
 Waking a child up at night is not a medically supported long-term cure or solution for
nocturnal enuresis, and may just be a one-time solution even if it appears to resolve
enuresis.