Understanding Behavioral Disorders in Children: Common Problems and Treatments

1. Chapter 4 Behavioral Disorders

3. Common Behavioral Problems  Habit problems: Thumb-sucking, nail-biting, bruxism, tics, enuresis, encopresis, breath-holding spells, trichotillomania, and aerophagia.  Eating problems: Pica, food fads, food refusal/overeating, vomiting, and anorexia.  Personality problems: Shyness, timidity, fears, anger, and jealousy.  Sleep problems: Night terrors, nightmares, somnambulism, insomnia, sleep-talking, and narcolepsy.  Speech problems: Stuttering, mutism, phonation, and articulation disorders.  Scholastic problems: Reading, writing or mathematical disorders, repeated failures, absenteeism, truancy, and school phobia.

4. ETIOLOGY • Usually caused by maladjustment at home or school • Precipitating factors operating during pregnancy, during delivery and in neonatal period. • Faulty emotional environment, constituted by parental attitudes, siblings, neighborhood, school and mass media, play a major role. • Faulty parental attitudes resulting in behavioral difficulties include rejection, overprotection, unrealistic expectations, overdiscipline, and unfavorable comparisons with siblings and peers. discrimination, overcriticism,

5. TREATMENT • Behavioral assessment ˗ Used to determine the precipitating events and consequences that maintain the behavioral problem. ˗ The antecedent-behavior-consequence (ABC) model and the principles of reinforcement and punishment are used for assessment and management of behavioral problem. Behavioral assessment Behavioral intervention ˗ Designed to modify variables that trigger, maintain, or mediate problem behavior. Psychopharmacology ˗ Less role ˗ Main classes of drugs used are typical and atypical antipsychotic drugs, tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), stimulants, and antianxiety drugs. ˗ The choice of drug depends on the predominant behavior and/or the underlying disorder. • •

6. Infantile Evening Colic INTRODUCTION • Characterized by the rule of three. - Crying for no apparent cause in children younger than 3 months - Intermittent episodes of abdominal pain and excessive crying lasting >3 hours per day, - For >3 days per week, in an otherwise well fed and healthy child. • Colic is a diagnosis of exclusion • Around 5–25% of infants in the community have colic. ETIOLOGY • Exact cause of colic is not known. • Possible causes - Increased gas production from colon - Milk allergy - Hyperperistalsis - Psychosocial, and neurodevelopmental disorders - Overactive child and overanxious parents - Hunger, aerophagia, or overfeeding.

7. CLINICAL FEATURES • Usually begins suddenly with a bout of screaming in the evening. • Crying is associated with motor behaviors such as flushed face, furrowed brow, and clenched fists. - The legs are pulled up to the abdomen, and the infant emits a piercing, high- pitched scream. - Crying is concentrated in the late afternoon and evening, occurs in prolonged bouts, and is unpredictable and spontaneous. • These episodes are associated with hypertonia, facial flushing, circumoral pallor, tense or distended abdomen, drawing up of the legs, clenching of the fingers, stiffening and tightening of the arms, or arching of the back. • The child cannot be soothed, even by feeding. • Attacks may terminate after the infant is exhausted or passes feces or flatus.

8. Diagnosis • Essentially clinical, investigations not needed. Natural course • Typically, the paroxysms of colic start within a few weeks after birth, reach a peak by 4–6 weeks, and subside by 3–4 months of age. Differential diagnosis • Differential diagnosis includes CNS abnormality or infection, gastroesophageal reflux (GER), otitis media, urinary tract infection, fractured bone, and child abuse.

9. TREATMENT • Rule out any organic cause for the crying • Offer balanced advice on treatment and provide support to the family. • Parents need reassurance that their baby is healthy, colic is self-limited • During an episode, hold the child erect or prone in the lap • No role of carminatives, suppositories, or enema. • Avoid drugs to reduce intestinal motility. Sedate the child, if attacks do not respond to above measures. • Anticholinergic drugs should be used with caution. • Infant should not be given undue attention. • Try to calm the anxious parents and clear their self-doubts • Encourage exclusive breastfeeding . • Feed in erect position. Practice proper burping and place the child on right lateral position for about half an hour after feeding.

10. IN A NUTSHELL Infantile Colic 1. Infantile colic is characterized by the “rule of 3”, i.e., excessive cry for >3 hours/day for >3 times/week and lasting for >3 weeks; in a child younger than 3 months. 2. Etiology is not known. Infantile colic is a diagnosis of exclusion after ruling out other common causes of incessant cry. 3. There is no effective medication. 4. Child needs to be comforted and parents need counseling. 5. Infantile colic is self-remitting and subsides spontaneously by 4–6 months of age.

11. Feeding Problems INTRODUCTION • Feeding problems in the first year of life occur because of erratic feeding, oversensitive infant and parents’ ignorance regarding feeding. • Other parental problems leading to feeding difficulties include anxiety, depression, unwillingness to nurture, substance abuse, psychosocial stress, or other serious mental illness. • Usual manifestations are underfeeding, overfeeding, spitting, regurgitation, and constipation.

12. UNDERFEEDING Underfeeding occurs when either (1) infant is not offered enough feed; or (2) the infant is not able to take a sufficient quantity of food even when offered. Causes • improper feeding techniques such as decreased frequency or duration of feeding, • inadequate quantity and quality of feeding, • early introduction of top feeding, • nipple confusion, • breast problems, • improper burping, • abnormal mother–infant bonding and • chronic systemic illness in the infant.

13. Clinical Features • These depend upon the extent and duration of underfeeding. • Initially, there might be constipation, failure to sleep, irritability, and excessive crying. • If underfeeding continues for prolonged period, the child fails to gain weight and may progress to have failure to thrive. Diagnosis • Detailed clinical evaluation with anthropometry and physical examination helps in making a diagnosis

14. TREATMENT It depends upon the condition of the child. If severe malnutrition is present, it is of utmost importance to manage fluid hypoglycemia, hypothermia, and anemia. Following this, the child should be provided adequate calories and supplemented with appropriate minerals and vitamins. Treat the underlying systemic infection and diseases, if any. Identify and treat associated psychological problems such as child abuse or neglect. Counsel the parents about feeding techniques. and electrolyte, associated infection,

15. OVERFEEDING • Overfeeding can be qualitative or quantitative. • Usually caused by parents’ ignorance about nutritional requirement of their infants. • Psychosocial problems in parents may also result in overfeeding. • Unwillingness of mother to breastfeed and reliance on bottle feeding is another major factor. Clinical Features • Most common clinical manifestations are regurgitation and vomiting. • Infant may present with abdominal distention, discomfort and excessive flatulence if the diet contains too much fat or carbohydrates. • Overfeeding leads to rapid and excessive weight gain, resulting in obesity.

16. Diagnosis • Suspect in following - change in weight combined with intense exercise; - maintained with laxatives and vomiting; - binge eating • Rapid weight gain or weight fluctuations. • Obtain a good history TREATMENT • Determine the infant’s status by calculating intake and comparing with required dietary allowances. • Parents should be counseled regarding daily dietary allowance, feeding technique, and types of food to be used. • Adequate and exclusive breastfeeding can overcome the problem of overfeeding.

17. EXCESSIVE SPITTING • It is normal in 15% of infants. It can also be associated with GER and overfeeding. • Clinical manifestations depend upon severity of the problem. • Failure to thrive occurs in extreme cases. TREATMENT • Reassure the parents, if their infant is gaining weight adequately and there are no underlying factors such as overfeeding, psychosocial stress and GER. • Determine whether stress is present during feeding. If yes, identify its cause and manage appropriately. • Provide proper counseling.

18. RUMINATION • This is habitual regurgitation and reswallowing of stomach contents by increasing intra- abdominal pressure by putting finger or fist in the mouth. • Occurs secondary to unconscious but voluntary contraction of abdominal wall muscles leading to increasing intragastric pressure with reflux of gastric contents into mouth and esophagus. • May be associated with GER, esophagitis, or intellectual disability. • Associated Symptoms: abdominal pain, constipation, and nausea Treatment • Diaphragmatic breathing is the mainstay of management in children with rumination. • Infants with psychogenic rumination respond well if they are held 15 minutes before and after feeding. • Child with intellectual disability or global developmental delay can be managed with behavior technique such as “time out.”

19. Stranger Anxiety • Occurs By about 6–7 months. • Develop fear of unfamiliar people or strangers. • Turns away, cries when approached by unfamiliar person. • It is a normal phenomenon to peak at about 13–15 months. • It might be an indication for later development of separation anxiety disorder.

20. Treatment • Relaxation technique: slowly exposing them to the stranger, initially from a distance, asking them to greet and slowly advancing toward them. • Reassurance of parents is required as this behavior gradually declines. • Refer to psychiatrist, if the behavior persists. • Cognitive behavioral therapy (CBT) is an effective form of psychotherapy if stranger anxiety persists in adolescents as separation anxiety. • Parents can learn to provide emotional support to the child. • In severe cases in older children and adolescents, selective serotonin reuptake inhibitors in combination with CBT can help.

21. IN A NUTSHELL Stranger Anxiety 1. Stranger anxiety is a normal phenomenon and may last a few months or persist to peak at about 13–15 months. 2. Persistence might be an indication for later development of behavioral problem, especially separation anxiety disorder. 3. Cognitive behavioral therapy may be an effective treatment modality.

22. Thumb Sucking • Common, harmless behavior • Appears to be a way of securing extra self-nurturance. • Most children stop thumb sucking by 2 years of age. • Considered as a marker of insecurity and loneliness if it persists till late childhood or adolescents. CLINICAL FEATURES When persisting after age 4, may occasionally lead to dental, dermatological, orthopedic, and psychological problems. - Risk of malocclusion of developing dentition, - Malocclusion of jaw and digital deformity - Some children may develop speech difficulty for consonants like D and T. - Can affect permanent teeth eruption, teeth alignment and shape of the mouth, in later childhood.

23. TREATMENT Indications • Persistent thumb sucking after 4–5 years age • Presence of dental problems due to the behavior. • Treatment is not indicated when thumb-sucking is infrequent or when it acts as a temporary adaptive coping strategy. Strategies (1) Planned Ignoring; (2) Giving Attention To More Positive Aspects Of The Child’s Behavior; (3) Monitoring Followed By Rewards Or Incentives For Sucking-free Days (Positive Reinforcement). (4) Use of bitter agents on thumbs or tying a cloth on thumb should not be considered as a first-line approach.

24. Parental Counseling • • Parents should be counseled regarding the self-remitting nature. Children with thumb-sucking should not be punished for this act. Punishment would only reinforce this habit. A positive feedback is helpful when the child is not sucking. Child who looks depressed should be referred for psychological evaluation. The child should be praised and encouraged if he tries to indulge in activities other than thumb-sucking • • •

25. Breath-holding Spells INTRODUCTION • Breath-holding spells are paroxysmal self-limiting events usually consisting of multiple (three or more) episodes of the following sequence: (a) provocation, followed by (b) crying to a point of noiselessness and accompanying change of color, and (c) ultimately, a loss of consciousness with an associated alteration in body tone. • These episodes occur in up to 10% of healthy children between the age of 6 months and 6 years. • The episodes are involuntary in nature and occur during expiration.

26. EPIDEMIOLOGY • Constitute 4–18% of all the psychosomatic disorders seen in children • Male-to-female ratio of 3:1. • Most common psychiatric disorder in among 0–3 year old • Prevalence of 5.9%. • No difference in prevalence among rural, urban, and slum children.

27. ETIOLOGY • Breath-holding spell is a neurobehavioral problem and categorized as a nonepileptic paroxysmal disorder. • Recent research implicates a genetically-mediated dysregulation of autonomic nervous system reflexes. • These spells do not result due to a disciplinary conflict between parents and the child. CLASSIFICATION • Cyanotic type in which the face turns blue; this is precipitated by anger or frustration. • Pallid type where face is pale; usually provoked by sudden fright or pain. • Mixed—there is no clear distinction between cyanosis or pallor, or a conflicting history is given by the parents.

28. CLINICAL FEATURES • • • Typical age of onset is between 6 and 18 months. Frequency ranges from multiple episodes daily to as few as one per year Gradually increases in frequency during the second year followed by gradual decrease to nil by 6 years. initiation of a tantrum Child holds his breath followed by limpness becomes rigid and attains opisthotonic posture expiration after a bout of crying Normal breathing and alertness is resumed within a minute

29. DIFFERENTIAL DIAGNOSIS  Epilepsy: ˗ A breath-holding spell is predisposed by anger, frustration, or fright. The child becomes completely normal after the attack. An epileptic fit has no such predisposing factor and the child remains in a postictal stage, with short-lasting altered sensorium or drowsiness after the attack. ˗ Cyanosis occurs earlier in breath-holding spell but in epilepsy it occurs after the seizure. ˗ (EEG) is normal in majority of children with breath-holding spell.  Hypercyanotic spell (Tet spells): ˗ Presence of clubbing, auscultation findings, cyanosis for a long time, favors hypercyanotic spell, ˗ Cyanosis is also present before and after the attack, while there is no cyanosis before or after a breath-holding spell. ˗ Child never develops neurological deficits after the breath-holding spells.

30. TREATMENT • Immediate measures: Prevent injury. Help the child lie flat. If loss of consciousness occurs, Protect against aspiration. Maintain patent oral airway. Do not shake the baby, splash water or put anything in the mouth. • Long-term measures: Treat with oral iron (4–6 mg/kg/day) for 6–8 weeks. • Attacks can be averted by behavioral modification. • Parental education: Parents should be reassured that breath-holding spell does not cause irreversible hypoxia, brain injury, , and subsequent cognitive impairment development. Avoid excessive rules and restrictions. Try to remove unnecessary frustrations. • Refer if the child is <3 months, unconsciousness lasts for more than 1 minute, attacks are too frequent, or seizure disorder or hypercyanotic spell is suspected.

31. IN A NUTSHELL Breath-holding Spells 1. Breath-holding spells are characterized by multiple episodes of “excessive cry followed by cessation of breath” following some provocation event. They typically occur between 6 months and 5 years of age. 2. Breath-holding spells should be differentiated from hypercyanotic spells which are characteristic of congenital cyanotic heart disease.. 3. Breath-holding spell is a clinical diagnosis and does not require EEG or neuroimaging. 4. Iron therapy is effective in management

32. Temper Tantrum • Occurs between the age of 18 months to 3 years, • Child begins to develop autonomy negativism • They do things opposite to what has been requested or opposite of their own desire (oppositionalism). • When they cannot express their autonomy, they become frustrated and angry. • Frustration manifests with physical aggression or resistance such as biting, crying, kicking, throwing objects, hitting, and head banging. • This behavior subsides between 3 and 6 years. • Parental anger and frustration may reinforce the defiance of the noncompliant child and aggravate the problem further.

33. RIDD Strategy for Management Prevent common triggers like hunger, fatigue, injury, and illness. RIDD is a strategy that can help in managing tantrums. • R: Remain calm during the attack, and redirecting and distracting the child • I: Ignore the tantrum • D: Distract the child, you can leave the room and let the child settle down by keeping a distant eye on the child to ensure safety • D: Do say “yes” to acknowledge the physical demands of the child but do not give into the demands

34. TREATMENT • At the time of the tantrum, parents should turn away briefly (to give the child time and space to recover). Later be explain that such behavior is not acceptable. • Consequences should be provided immediately after every occurrence, and should be constant across all time periods and settings. • Parents should provide ample amount of praise for positive behavior. Set limit regarding what is acceptable and not acceptable. • Parents should be calm, loving, firm and consistent; and such behavior should not allow the child to take advantage of gaining things. • Time-out may be used (1 minute/year of age).

35. IN A NUTSHELL Temper Tantrum 1. It occurs with lack of expression of their autonomy causing frustration and anger. 2. A detailed clinical history and physical examination helps you to differentiate from developmental disorders. 3. Management depends on prevention of extreme and recurrent attacks of temper tantrums by preventing common triggers such as hunger, fatigue, injury and illness. 4. RIDD is a strategy that can help in managing tantrums.

36. Pica • Defined as “the repeated and chronic ingestion of non-nutritive substances including mud, plaster, charcoal, chalk, paint, earth, clay, etc., for a period of at least 1 month. ETIOLOGY • Cause of pica is unknown. • Various nutritional, neuropsychiatric, cultural, and psychological theories are proposed. • Children between 18 and 24 months often try to eat nonfood items. • Persistence after 2 years of age needs attention and workup for lead toxicity, iron- deficiency anemia, and parasitic infections. • Pica is more prevalent among children with intellectual disabilities, and those with lack of parental supervision.

37. CLINICAL FEATURES Children with pica can present with inherent toxicity; intestinal obstruction (such as that occurring with trichophagia, or hair eating); nutritional deprivation; parasitic infestations; and dental injury. DIAGNOSIS As per DSM-5, pica is diagnosed by the presence of: • Repeated eating of non-nutritional and nonfood substances, e.g., gum, hair, dirt, paint, chalk, clay, paper, soap, wool, strings, for at least a month • The eating behavior is not normal and is inappropriate to the patient’s development • The severity of eating behavior warrants additional attention if it occurs in presence of another illness, e.g., intellectual disability, or autism.

38. TREATMENT • Pica below 2 years does not need any intervention. • Children with pica are at increased risk of lead poisoning, iron-deficiency, bezoars, and parasitic infections. They should be investigated for these problems and if present, treated suitably. Deworming needs to be done, as worm infection is generally associated. • Education, guidance and counseling of the family. The reason for parental conflict and neglect needs to be looked into, if present. • Child should be given more affection and love. The child has to be kept occupied in other tasks and provided with environmental stimulation. • Prevent unsupervised access to mud/chalk/paint, etc.

39. IN A NUTSHELL Pica 1. Pica is an eating disorder defined as “the repeated and chronic ingestion of non- nutritive substances including mud, plaster, charcoal, chalk, paint, earth, clay for a period of at least 1 month. 2. Persistence of pica after 2 years of age needs attention and workup for lead toxicity, iron-deficiency anemia, and parasitic infections. 3. Parental education, guidance and counseling is mainstay of management.

40. Enuresis • Voluntary or involuntary repeated discharge of urine into clothes or bed, after a developmental age when bladder control should be established (usually 5 years), is labeled as enuresis. • Bedwetting is labeled as enuresis, only if urine is being voided twice a week for at least 3 consecutive months, or if it is causing significant distress in the child’s life. • Enuresis is divided into monosymptomatic and nonmonosymptomatic forms. ˗ Monosymptomatic: Enuresis without any lower urinary tract symptoms or bladder dysfunction; further classified into primary and secondary ˗ Nonmonosymptomatic: associated with other lower urinary tract symptoms such as weak stream, daytime incontinence, hesitancy, postmicturition dribble and urgency.

41. CLASSIFICATION Enuresis may be primary or secondary; or nocturnal/diurnal.  Primary enuresis: Repeated enuresis (twice a week for at least 3 consecutive months) night in a child >5 years, who has never been dry in night.  Secondary enuresis: The child had been dry for at least 6 months and again starts bedwetting. In such cases, look for the underlying causes.  Nocturnal and diurnal enuresis: Nocturnal and diurnal enuresis refers to voiding of urine during night-time and while awake, respectively. Diurnal enuresis is more common in girls, is usually due to micturition deferral (waiting till the last moment to pass urine, and then being unable to hold)  When both diurnal and nocturnal enuresis are present, abnormalities of the urinary tract or voiding disorders are likely.  Chronic constipation is an important risk factor for enuresis  Encopresis occurs in about 15% children with enuresis.

42. Multifactorial Etiology • Less than 3% cases have organic etiology such as obstructive uropathy or UTI. • There might be a delay in neurological maturation to control bladder sphincter; associated with mental retardation or spinal cord abnormalities. • Children who undergo training late (after 24 months) are prone to develop late nocturnal bladder control; recommended age to begin toilet training is around 12–18 months. • Physiologic factors: Hyposecretion of arginine vasopressin (AVP), decreased responsiveness to low urine osmolality, loss of circadian rhythm of ADH secretion, altered AVP receptor function in the tubule, diminished capacity to be aroused, and altered sleep architecture. • Genetic factors: If both parents have nocturnal enuresis, children have a 75% chance of being affected. • Around 15% of the 5-year-old have primary enuresis; approximately 15% enuretics resolve their symptoms each year and about 5% of 10-year-old and 1% of the adolescents remain enuretic.

43. DIAGNOSIS Rule out any underlying neurological disorder, diabetes mellitus, diabetes insipidus, chronic renal failure, and bacterial cystitis. • Routine urine examination including osmolality, microscopy, sugar, and culture. • A frequency void chart often helps to differentiate primary nocturnal enuresis from voiding dysfunction. The normal frequency of daytime void in a child is 4–7 times per day. A frequency of >8 times or at duration <2 hours is considered abnormal. • Ultrasonogram on full bladder to estimate bladder capacity. • Urodynamic study needed to assess bladder capacity and detrusor pressures in a child who has an abnormal frequency void chart.

44. TREATMENT Treatment should be aimed at completely stopping the enuresis. After establishing the diagnosis of primary nocturnal enuresis, a treatment plan should be discussed. The child’s cooperation in the management plan is essential. Any serious attempt to treat the condition should begin only beyond 7–8 years of age as enuresis interferes with socialization and behavior in older children.

45. Nonpharmacological Treatment Nonpharmacological management is effective in 30% cases. 1. Behavioral treatment: First mode of therapy. Counsel and reassure. ˗ Ask the parents to maintain a diary record of dry nights; reward the child for such nights. ˗ Parents should provide emotional support to the child, avoid criticism, and change the bed sheets without child’s notice. ˗ Avoid punitive measures. ˗ Practice Positive reinforcement ˗ Early dinner and avoid any form of fluid at least 2–3 hours prior to sleep. ˗ Ask the child to void before going to sleep. ˗ Use an alarm clock to wake the child once 2–3 hours after falling asleep to void.

46. 2. Behavior conditioning: Done with use of alarms. The alarm rings as soon as voiding starts. It is helpful in training the child to improve bladder capacity and avoid enuresis. Approximately 50–70% improve on this. 3. Bladder training exercises: —(a) Hold urine as long as possible during the day; —(b) practice repeated starting and stopping the stream at the toilet bowl; and —(c) practice getting up from bed and going to the bathroom at bedtime before sleep. 4. Caffeine reduction

47. Drug Therapy for Enuresis Medications are indicated only in children older than 6 years who fail behavioral treatment. 1. Desmopressin acetate (DDAVP) • First modality of treatment; orally or intranasally • Start with 10 μg at bedtime, increase gradually by 10 μg/per week to a maximum of 40 μg per day. • If effective, give for 3–6 months. Success rate 40–60%, relapse rate 90%. 2. Oxybutynin • • Anticholinergic agent used above 6 years in enuresis nonresponsive to desmopressin Reduces uninhibited bladder contractions and useful in children manifesting with urgency 3. Imipramine (25, 50 mg tablets): 6–8 years (25 mg), 9–12 years (50 mg), >12 years (75 mg) once a day at bedtime. ˗ Tricyclic antidepressant which alters the arousal-sleep mechanism. ˗ Used as a third-line treatment modality if desmopressin, alarm therapy and anticholinergics fail ˗ Success rate 30–60%, relapse rate 90%.

48. IN A NUTSHELL Enuresis (Bedwetting) 1. Primary nocturnal enuresis is defined as repeated passage of urine in clothes/bed during night in a child >5 years of age. 2. Primary enuresis needs to be differentiated from secondary enuresis, where the child had been dry for at least 6 months, before starting bedwetting. 3. Behavioral modification, bladder training exercises, use of alarm systems, and desmopressin (DDAVP) either singly or in combination are the treatment modalities. 4. Relapse rate after any treatment is high.

49. Encopresis • Encopresis is repetitive, voluntary or involuntary, soiling or passage of stools in inappropriate places in children 4 years and older. • It is also termed as functional fecal incontinence. • Functional fecal incontinence or encopresis is defined as involuntary passage of stools after acquiring toileting skills, in the absence of overt neuromuscular anorectal dysfunction.

50. ETIOLOGY 1. Retentive: If encopresis is associated with functional constipation it is known as retentive. They have history of retentive posturing, history of hard or painful stools, excessive volitional stool retention, presence of large fecal mass in the rectum and history of passing large-diameter stool. 2. Non-retentive: If functional fecal incontinence occurs in the absence of symptoms and signs of functional constipation it is known as non-rententive. Diagnostic criteria for non-retentive functional fecal incontinence in a child >4-year-old (a) >1 month history of defecation in inappropriate locations; and (b) no evidence of fecal retention even after appropriate medical evaluation.