1. CAUSES OF BEHAVIORAL PROBLEMS IN CHILDREN Faulty Parental
Attitude Inadequate Family Environment Mentally and Physically Sick
or Handicapped Conditions Influence of Social Relationship
Influence of Mass Media Influence of Social Change
2. COMMON BEHAVIORAL PROBLEMS IN CHILDREN Feeding problems
Habit disorders Speech problems Sleep Problems Educational
difficulties Adjustment problems Emotional problems Antisocial
problems Sexual problems
3. BEHAVIORAL PROBLEMS OF INFANCY Resistance to Feeding or
impaired Appetite Abdominal Colic Stranger anxiety (separation
anxiety)
4. Temper tantrum Temper tantrum is a sudden outburst or
violent display anger, frustration and bad temper as physical
aggression or resistance such as rigid body, biting, kicking,
throwing objects, hitting, crying, rolling on floor, screaming
loudly, banging limbs, etc.
5. Management of Temper tantrum Professional help from child
guidance clinic. Parent should be made aware about the beginning of
temper tantrum and when the child loses control. Parent should
provide alternate activity at that time. Nobody should make fun and
tease the child about the unacceptable behavior. Parent should
explain the child that the angry feeling is normal but controlling
anger is an important aspect of growing up. The child should be
protected from self injury or from doing injury to others.
6. Contd Physical restraint usually increase frustration and
block the outlet of anger. Frustration can be reduced by calm and
loving approach. Over indulgence should be avoided. After the
temper tantrum is over the child's face and hands should washed and
play materials to be provided for diversion. The child's tension
can be released by vigorous exercise and physical activities.
Parents must be firm and consistent in behavior.
7. Breath holding spell It may occur in children between 6
months to 5 years of age. It is observed in 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.
8. Contd. Loss of consciousness, twitching and tonic-clonic
movements may also be found. The child may become limp and look
pallor and lifeless. Heart rates become slow. There may be spasm of
laryngeal muscles. This attack lasts for 1 to 2 minutes, then
glottis relaxed and breathing resumed with no residual
effects.
9. Management Identification and correction of precipitating
factors (emotional, environmental) are essential approach.
Overprotecting nature of parents may increase unreasonable demand
of the child. Punishment is not appropriate and may cause another
episode. Repeated attacks of spells to be evaluated with careful
history, physical examination and necessary investigations to
exclude convulsive disorders and any other problems.
10. Thumb sucking Complications malocclusion and malalignment
of teeth difficulty in mastication and swallowing. deformity of
thumb facial distortion speech difficulties with consonants (D
& T), GIT infections.
11. Management Parents and family members need to 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 the bored time or engaging the thumb or finger
for other activity, keep the hand busy. The child should not be
scolded for the habit. Consultation with dentist or speech
therapist Hygienic measures to be followed and infections to be
treated promptly.
12. Nail biting Nail biting is a bad oral habit especially in
school age children beyond 4 years of age. 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 a nail
biter. It is caused by feeling of insecurity, conflict and
hostility. It may be due to pressurized study at school or home or
due to watching frightening violent scene.
13. Management Identify the cause of nail biting with the help
of a psychologist and the steps to be taken to remove the habit.
The child should be praised for well kept hand by breaking the
habit to maintain the self confidence. The childs hands to be kept
busy with creative activities or play Punishment to be avoided
Parents need reassurance to accept he situation and the child to
overcome the problem.
14. Enuresis or bedwetting Enuresis is the repetitive
involuntary passage of urine at inappropriate place especially in
bed, during night time beyond the age of 4 to 5 years. It is found
in 3 to 10 percent school children
15. Common causes small bladder capacity improper bladder
training deep sleep with inability to receive the signals from
distended bladder to empty it. The emotional factors hostile or
dependent parent child relationship dominant parent punishment
sibling rivalry emotional deprivation due to insecurity and
parental death
16. Contd The other factors child emotional conflict and
tension desires to gain care and attention of parents as in
infancy. Environmental factors dark passage to toilet or cold or
fear of toilets toilet at distance from bedroom may cause bed
wetting at night. The associate organic cause may present e. g.
spina bifida, neurologic bladder, juvenile DM, seizure
disorders
17. Types Primary secondary
18. Management Non-organic causes to be managed primarily with
emotional support to the child and parents along with environmental
modification. The child needs reassurance, restriction of fluid
after dinner, voiding before bed time and arising the child to
void, once or twice, three to four hours later. Interruption of
sleep before the expected time of bed wetting is essential. The
child should be fully waken up by the parent and made aware of
passing of urine at night. The child can assume responsibility for
changing the bed cloths. Parents should not be worried about the
problem.
19. Parents should encourage and reward the child for dry
nights. Punishment and criticism may lead to embarrassment and
frustration of the child. Bladder stretching during daytime to be
done to increase holding time of urine, using positive
reinforcement and delaying voiding for some time. Drug therapy with
tricylic antidepressant (Imipramine) is useful.
20. Condition therapy by using electric alarm bell mattress is
a effective and safest method, when the child wakes up as soon as
the bed is wet. Supportive psychotherapy is important for child and
parent. Changes of home environment to remove the environmental
causes are essential.
21. Encopresis Encopresis is the passage of feces into
inappropriate places after the age of 5 years, when the bowel
control is normally achieved It can be primary or secondary
encopresis Associated problems are chronic constipation, parental
overconcern, over aggressive toilet training, toilet fear,
attention deficit disorders, poor school attendance and learning
difficulties
22. Management history of bowel training use of toilets and
associated problems. needs help in establishment of regular bowel
habit, bowel training, dietary intake of roughage and intake of
adequate fluid. Parental support reassurance and help from
psychologist for counseling of child and parents may be essential
in persistent problems.
23. Geophagia or pica Pica is a habit disorder of eating
non-edible substances such as clay, paints, chalk, pencil, plaster
from wall, earth, scalp hair, etc. it may be due to parental
neglect, poor attention of caregiver, inadequate love and
affection, etc. It is common in poor socioeconomic family and in
malnourished and mentally subnormal children.
24. associated problems intestinal parasitosis lead poisoning
vitamins and minerals deficiency trichotillomania Trichobezoar
25. Management psychotherapy of the child and parents.
Associated problems should be treated with specific management
26. 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.
27. Motor tics can be found as eye blinking, grimacing,
shrugging shoulder, tongue protrusion, facial gesture, etc. Vocal
tics are found as throat clearing, coughing, barking, sniffing,
etc
28. A special type of chronic tics - 'Gilles de la Tourette's
Syndrome characterized by multiple motor tics and vocal tics a
genetic disorder with onset at around 11 years of age. It requires
for special management with behavior therapy, counseling 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.
29. Speech Problems Stuttering and stammering Cluttering
Delayed speech Dyslalia
30. Stuttering and stammering Stuttering or stammering is a
fluency disorders begin 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
specialty of initial consonants
31. Cluttering 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.
32. Delayed speech Delayed speech beyond 3 to 3.5 years can be
considered as organic causes like mental retardation, infantile
autism, hearing defects or severe emotional problems. The exact
cause must be excluded for necessary interventions.
33. Dyslalia Dyslalia is the most common disorder of difficulty
in articulation. It can be caused by abnormalities of teeth, jaw or
palate or due to emotional deprivation. Treatment of the structural
abnormalities and speech therapy should be done adequately. In
absence of structural problems, the responsible emotional disorders
or factors should be ruled out. The child needs counseling. The
parents should be informed about the modification of family
environment and correction of deprivation.
34. Sleep 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, night terrors, sleep walking (somnambulism), sleep
talking (somnoloquy), bruxism (teeth grinding), etc.
35. Management In all these problems, 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 not be allowed at night. Parents should allow
relax 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. consultation with doctors and
psychologists for specific drug therapy and psychotherapy.
36. School phobia 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.
37. Contributing factors of school phobia Anxiety about
maternal separation Over indulgent Over protective and dominant
mother Disinterested father Intellectual disability of the students
and uncongenial school environment like teasing by other students,
poor teacher-student relationship, unhygienic environment, fear of
examination, etc.
38. Management habit formation for regular school attendance
play session and other recreational activities at school
improvement of school environment and assessment of health status
of the child to detect any health problems for necessary
interventions. The most important aspect to manage this problem is
family counseling to resolve the anxiety related to maternal
deprivation.
39. Attention deficit disorders Attention deficit disorders
(ADD) are learning disabilities can be related to CNS dysfunction
or due to presence of psycho educational determinants. It is
usually associated with hyperactivity and known as hyperactive
attention deficit disorders. These children are lagging behind in
intellectual and learning abilities with alteration of behavior
patterns.
40. causes The cause of this problem is not understood clearly
predisposing factors o prematurity or low birth weight o brain
damage due to infections or injury o interaction between genetic
and psychosocial factors.
41. Manifestations combinations of reading and arithmetic
disability impaired memory poor language and speech development
inappropriate understanding of spoken words. The child is usually
overactive, aggressive, excitable, impulsive and inattentive. They
may be easily frustrated, irritated and show temper tantrums.
Social relationship and adjustment are poorly developed.
42. Management done by team approach including pediatrician,
psychologist, psychiatrist, pediatric nurse specialist, school
health nurse, teachers, social workers and parents. behavior
modification, counseling and guidance of parents and appropriate
training and education of the child. Drug therapy can help to
improve the CNS dysfunction or other associated problems.
43. BEHAVIORAL PROBLEMS OF ADOLESCENCE
44. Masturbation Masturbation or genital stimulation by
handling the genitals 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 mostly engage with this practice.
45. Juvenile Delinquency Juvenile delinquency means indulgence
in an offence by child in the form of premeditated, purposeful,
unlawful activities done habitually and repeatedly. Usually
children belong to broken family or emotionally disturb family with
overcrowded unhealthy environment & having financial or legal
problems.
46. factors contributing: (a) Rapid urbanization and
industrialization (b) Social change and changing lifestyle (c)
Influence of mass media (d) Change in moral standards and value
systems (e) Lack of educational opportunities and recreational
facilities (f) Poor economy (g) Unsatisfactory conditions at
schools and colleges (h) Unhealthy student teacher relationship and
(i) Lack of discipline
47. Delinquent behaviors The juvenile delinquent behavior
includes lying, theft, burglary, truancy from school, run away from
home, habitual disobedience, fights, ungovernable behavior, mixing
with anti social gang, cruelty to animals, destructive attitude,
murder, sexual assault, etc. in broad sense, delinquency is not
merely a juvenile crime, it includes all deviations from normally
youthful behavior and anti social activities.
48. Prevention Prevention of juvenile delinquency is possible
by elimination of contributing factors. Healthy parent child
relationship, tender loving care in the family, fulfillment of
basic needs, educational opportunities, facility for sports
exercise and recreations, healthy teacher taught relationships,
etc. are important aspects of prevention.
49. Contd Delinquent child needs sympathetic attitude with
necessary guidance and counseling for modification of behavior. The
child should be referred to child guidance clinic for necessary
help. A team approach is necessary in management of this condition
including social workers, psychologists, pediatricians, community
health nurse, school teachers, family members and parents.
Modification of social environment and rehabilitation of delinquent
child should be promoted.
50. Substance abuse 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 the
given culture.
51. Preventive Measures Provision of adequate facilities for
recreation and entertainment Proper channelization of adolescents
into constructive activities Inculcation of dangers of drug abuse
among students, teachers and family members. Provision of mental
health programs and periodical psychiatric guidance facilities in
schools.
52. Strict implementation of drug control measures. Individual
and group health education about the ill effects of drug abuse.
Provision of emotional support to the older children to prevent
frustration, conflict, confusion and mental tension. Provide psycho
therapy, de addiction services and rehabilitation for addicted
children.
53. Anorexia Nervosa Refusal of food to maintain normal body
weight by reducing food intake, especially fats and carbohydrates.
The affected adolescent girls practice vigorous exercises for
weight reduction or induce vomiting by stimulating gag reflex to
maintain slim.
54. Etiology There is no specific cause for 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 lead to development of
immaturity, isolation and excessive dependence.
55. Manifestations Under nutrition Marked weight loss Bizarre
food intake patterns Dryness of skin Hypothermia Hypotension
Bradycardia Amenorrhea Constipation
56. Management Psychotherapy antidepressant drugs behavior
modification nutritional rehabilitation Parental counseling for
modification of parent child relationship Hospitalization may be
needed in complicated cases.
57. NURSING RESPONSIBILITIES BEHAVIORAL DISORDERS OF CHILDREN
Assessment of specific problem of the child by appropriate history
and detection of the responsible factors. Informing the parents and
making them aware about the causes of behavioral problems of the
particular child. Assisting the parents, teachers and family
members for necessary modification of environment at home school
and community. Encouraging the child for behavior modification, as
needed.
58. Contd. Promoting healthy emotional development of the child
by adequate physical, psychological and social support. Creating
awareness about psychosocial disturbances which may lead to
behavioral problems during developmental stages. Providing
counseling services for children and their parents to solve the
problems, whenever necessary and for tender loving care of the
children.
59. Contd. Participating in the management of the problem
child, as a member of health team along with pediatrician,
psychologist and social worker. Organizing Child guidance clinic.
Referring the children with behavioral problems for necessary
management and support to better health care facilities, child
guidance clinic, social welfare services and support agencies.