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.