CHAPTER 13

Common Behavioral and Psychiatric Disorders Among Children

DEFINITION

• Behavioral disorders are defined as persistent and repetitive patterns of disruptive behaviors, in children that last for at least 6 months and violates societal norms .

PATTERNS OF BEHAVIORAL DISORDERS

• Internalizing (behavioural disorders due to depression and anxiety such as thumb sucking, temper tantrums).
• Externalizing (disruptive behaviours such as attention deficit hyperactivity disorder, juvenile delinquency).

Habit Disorders

• Thumb sucking
• Nail biting

Speech Disorders

• Stammering/stuttering
• Phonation and articulation problems

Eating Disorders

• Pica
• Anorexia nervosa

Sleep Disorders

• Night mares/night terrors
• Somnambulism
• Somniloquy

Personality Disorders

• Temper tantrum
• Juvenile delinquency

Academic Disorders

• Learning disability

HABIT DISORDERS

• Enuresis
• Children usually acquire bladder control normally by the age of 21/2-3 years.
• It's abnormal if it is not acquired beyond 4-5 years of age.

Definition

• Enuresis is defined as the involuntary, repeated voiding of urine into bed or clothes; in children aged 5 years or older, in whom normal bladder control is usually acquired.

Types of Enuresis

• Primary enuresis
• Secondary enuresis

• Based on the timing of bed wetting

• Daytime (Diurnal) enuresis
• Nighttime (nocturnal) enuresis

Causes of Enuresis

• Organic causes
• Abnormal circadian rhythm of antidiuretic hormone secretion

Management

• Parents and children should be reassured that it’s a common problem.
• Don’t scold, beat, threaten or criticize the child for bed-wetting.

Bed wetting alarm

Encopresis

Definition

• Encopresis is defined as a disorder characterized by repeated involuntary or intentional stool evacuation in inappropriate places in children over the age of four.

Types

• Non-retentive encopresis
• Constipation-associated encopresis or overflow encopresis

Causes

• Chronic constipation due to poor bowel habits and poor dietary pattern
• Unhygienic toilets, dim lights at toilet corridor.

Management

• Breaking the habit of forming hard stool by means of adding more roughage to the diet
• Emptying the colon of stool if there is a hard stool. Suppositories and laxatives are of choice at first.

Shyness and Nervousness

• Shyness is a personality trait where a child may feel uncomfortable or self-conscious in social situations.
• Nervousness, on the other hand, is a temporary emotional response to specific situations, such as speaking in front of a class or taking a test.

Table 1: Causes, Signs And Symptoms, And Management Strategies For Shyness And Nervousness In Children

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Refer To Book

Page No. 234 And 244

Nail Biting

Definition

• Nail biting or Onychophagia is a common oral compulsive, self-injurious disorder of putting one or more fingers in the mouth and biting on nails with teeth without any preference for any of the fingernails.

Causes

• Boredom
• Working on difficult problems

Complications

• Ungual and oral infection.
• Paronychia (infection of soft tissues surrounding nail bed).

Management

• Provide a sympathetic and loving home environment for the child.
• Allow the child to express his cause of anxiety in a positive approach to boost self-confidence.

Thumb Sucking

• Definition

• Thumb sucking is defined as a non-nutritive behavior that serves as an adaptive function by providing stimulation or self-soothing.

Causes of Thumb Sucking

• Maturational Process
• Use of Regression as Defence Mechanism

Consequences of Thumb Sucking

• Deformity of nails and chronic paronychia .
• Blisters in the affected thumb due to vigorous sucking .
• Malocclusions of teeth leading to cosmetic defects.

Fig:- Deformity of nails

Periarticular tumor near the metacarpophalangeal joint of the thumb.

Malocclusions such as anterior open bite of teeth happens if the habit persists during permanent teething.

Intraoral cemented modified bluegrass appliances

Tics Disorders

• Definition

• Tics are defined as “sudden, rapid, recurrent, nonrhythmic motor movement (motor tics) or vocalization (vocal or phonic tics)”

Types

• Simple
• Simple motor tics
• Simple phonic (vocal) tics

• Complex

• Complex motor tics
• Complex phonic (vocal) tics

Causes

• Structural and functional neurological abnormality
• Abnormal distribution of neurotransmitters
• Anxiety
• Attention deficit hyperactivity disorder (ADHD, depression)

Management

• Pharmacological management
• Cognitive behaviour therapy

PERSONALITY DISORDERS

• Temper Tantrum
• Definition

• An inability to control emotions stemming from frustration or difficulty expressing the particular need or desire.

Causes

• Physiological triggers such as fatigue, hunger, sleep or illness.
• Desire for parental attention and a strong will of independence.

Clinical Manifestation

• Crying, screaming, shouting, biting others, and spitting
• Lowering the body/falling to the floor
• Holding breath, biting self, nondirected kicking

Prevention and Management

• Establish a daily routine for the child and stick to the routine as much as possible.
• Praise the child and give extra attention for good behavior.

Stealing and Lying

• Stealing (taking something without permission what does not belong to oneself) and lying (purposefully telling an untruth) are socially inappropriate behavior usually found in children under seven years of age.

Causes

Management

• Try and correct mistakes at an early stage by a face to-face communication with the child to listen to their reasons.
• Consider counselling if stealing and lying activity persists and can’t be resolved with parental involvement.

Aggressiveness

• Definition
• Aggressive behavior is referred to any hostile behavior that is carried out by a child with the intention of causing harm to peers, siblings or adults.

Types

• Impulsive
• Predatory
• Cognitive/disorganized

Risk Factors

• Neurobiological
• Environmental factors
• Parenting factors

Management

• Pharmacotherapy

• In children with developmental delay, physical causes for agitation are to be avoided as much as possible such as hunger, constipation, infection, and pain.

Juvenile Delinquency

• Juvenile delinquency is an umbrella term that includes a broad spectrum of behavioral abnormalities and are considered as against social norms.

Definition

• Juvenile delinquency refers to an adolescent who breaks the law or engages in any criminal behaviour which is considered as illegal, and socially unacceptable and the actions are proved to be dangerous to the society and for him or her.

Pattern of Antisocial Behaviours

• Destructiveness and violence
• Constant disobedience
• Truancy at school

Risk Factors

• Intrauterine factors
• Biological factors
• Social environment

Management

• Trauma-focused emotion regulation intervention (TARGET)
• Multisystemic therapy (MST)
• Remedial education and vocational training

School Phobia

• Definition

• School phobia (also known as Scolionophobia) is an overwhelming fear of school and the child refuses to go to school on a regular basis or has problems staying in school.

Causes

• Actual physical harm by peers.
• A perceived fear of the teacher or conflicted relationship with teacher.
• Anxieties over toileting in a public bathroom.

Clinical Manifestations

• Frequent requests to call home.
• Refusal to engage with peers or participate in social activities.
• Willingness to complete work at home.

Management

• Dialectical behaviour therapy (DBT)
• Exposure-response therapy (ERP)
• Medication

ACADEMIC DISORDERS

• Learning Disability
• Definition

• A disorder affecting one or more basic psychological processes involved in understanding or using spoken or written language, leading to difficulties in listening, thinking, speaking, reading, writing, spelling, or mathematics, and not caused by sensory, motor, intellectual, emotional, cultural, or economic factors.

Risk Factors for Developing Learning Disability

• Intracranial bleeding, prematurity, hypoxic-ischemic encephalopathy, repeated hypoglycemia of newborns.
• Sibling of a learning disabled child has a 45% chance of recurrence.
• Frequent changing of school, illiterate home background, a school which provides very little personal attention.

Types of Learning Disabilities

Dyslexia

• Dyslexia also known as reading disabilities is characterized by a significant impairment in reading acquisition.

The commonly found signs and symptoms of dyslexia are:

• Inaccurate reading due to problem in word recognition, i.e., omission of letters, syllables, words or word endings.

Dysgraphia

• This is usually apparent in the 1 or 2 standards, when children are required to write.

The commonly observed difficulties are:

• Slow writing, avoiding writing.
• Thought block while writing.

Dyscalculia (Mathematical Disability)

• Mathematical disability or dyscalculia is evident when the child starts mathematical calculations in 2nd or 3rd standard of the school.

They present with:

• Inability to point out small/big, more/less, tall/short, fist/last when asked, take unusually longer time to solve a problem.
• Difficulty in keeping unit, tens and hundredths places. Difficulty in carrying over and borrowing.

Dyslalia (Expressive Language Disabilities)

• Speaking disorder is an impairment to express the thought process verbally.

These children show the following characteristics:

• Inability to express ideas and thoughts, stammering, use of incomplete sentences, speaking dysfluently.
• Avoidance of social communication.
• Use of the same simple words though not applicable.

Management

• Let the child to express his/her feelings in any suitable forms, such as writing, or drawing.
• Avoid comparing with others.
• Always summarize a lesson and explain any lesson with a list or pictures.
• Use simple words instead of complex ones and also break the long and complex sentences into smaller ones.

SLEEPING DISORDERS

• Alteration in sleep pattern than recommended hours of sleeping along with any unusual behavioral manifestations are called as sleep disorders.

Management

• Establish a set bedtime and bedtime routine and wake time for a child.
• Never allow the child to sleep hungry.
• Establish a routine of regular exercise for at least 30  mins a day.

SPEECH DISORDERS

• Stammering/Stuttering

• Stammering/stuttering is a speech disorder in which the flow of speech is disturbed by the prolongation of sound due to delayed uttering and involuntary repetition of sounds.

Causes

• Cleft lip,
• Cleft palate,
• Brain injury in childhood

Clinical Manifestation

• Hesitation,
• Repetition of words,
• Trembling

Management

• Parents should give sufficient time to children to express their thoughts.
• Don’t criticize as it might affect the self-confidence of the child and worsen the situation.

ATTENTION DEFICIT HYPERACTIVE DISORDER (ADHD)

• Definition

• Attention-deficit/hyperactivity disorder (ADHD) is a neurobehavioral disorder with an ongoing developmentally inappropriate pattern of inattention and/or hyperactivity and impulsivity that interferes with functioning or development.

Types of ADHD

• Predominantly inattentive
• Predominantly impulsive or hyperactive
• Combination of the above

Risk Factors

• Neurological
• Intrauterine
• Environmental factors

Complication

• Academic
• Occupational
• underachievement

Clinical Manifestations

• Inattentive symptoms
• Hyperactive symptoms

Management

• Parent training
• Community support groups
• Pharmacotherapy
• The tricyclic antidepressants (TCAs)

COMMON PSYCHIATRIC DISORDERS AMONG CHILDREN AND THEIR MANAGEMENT

• Childhood Schizophrenia

• Definition

• Childhood-onset schizophrenia (COS), a very rare and severe chronic psychiatric condition is defined by an onset of positive symptoms (delusions, hallucinations and disorganized speech or behavior) before the age of 13 years.

Risk Factors

• Familial factors
• Prenatal factors
• Comorbid neurodevelopmental disorders

Clinical Manifestations

• Positive symptoms appear to be linked to a dysfunction within the temporal lobe of the brain.
• Negative symptoms are linked to a dysfunction of the brain’s frontal lobe .

Management

• The pharmacological management is done preferably by atypical antipsychotics .
• Individualized therapy with children helps to reduce their symptoms by improving their coping strategy towards various stressors and challenges of living with schizophrenia.
• Teaching children social and academic skills

• Childhood Depression

• Definition

• Childhood depressive disorder is a common mental disorder which involves a depressed mood or loss of pleasure or interest in activities for a prolonged period of time.

Risk Factors

• Neurobiological
• Stressful life events

Clinical Manifestation

• Cyclothymia, a persistent instability of mood involving numerous periods of depression and mild elation.
• Lack of sleep or excessive sleeping almost every day.
• Depressed or irritable mood most of the day, almost every day.

Management

• Self-system therapy
• Emotion-Focused Therapy (emotion regulation therapy or Greenberg’s experiential therapy)

• Conversion Disorder

• Definition

• Conversion disorder is defined as a condition in which a child presents with symptoms of deficits in sensory, motor function suggesting a neurological .

Causes

• Neuropsychological mechanisms
• Comorbidity
• Clinical manifestations
• Motor symptoms (Most common)
• Sensory manifestations

Diagnosis

• Reciprocal contraction is palpable during attempts to use apparently paralysed muscle groups and normal tendon reflexes can be elicited in the face of flaccidity.

Management

• Graded physiotherapy programme
• Behaviour therapy (both positive and negative reinforcement).
• Anxiolytics and antidepressants are used for treatment of underlying depression and or anxiety.

• Post Traumatic Stress Disorder
• Definition

• Posttraumatic stress disorder (PTSD) is a mental disorder that may develop in some children and adolescents after exposure to a traumatic event

Epidemiology

• Various research studies have reported that up to 60% of children and adolescents are exposed to a potentially traumatic event (PTE).

Causes

• Actual or threatened death of a dear ones
• Sexual abuse
• Emotional maltreatment

Clinical Features

• Separation anxiety.
• Shame, guilt, low frustration tolerance.
• Hyperarousal, impulsivity, temper outbursts.

Management

• Eye movement desensitization and reprocessing therapy (EMDR)
• Multi-sensory therapy
• Creative therapy such as art therapy, dance therapy, drama therapy, writing therapy, expressive therapies are also in use for the management of PTSD.

Risk Factors

• Autistic Spectrum Disorders
• Definition
• Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social communication and the presence of restricted interests and repetitive behaviours.

• Neuropathologic
• Maternal exposure during pregnancy

Clinical Manifestations

• Avoids or does not keep eye contact.
• Repeats words or phrases over and over (Echolalia).

Management

• Psychosocial Therapies
• Occupational Therapy
• Pharmacotherapy

EATING DISORDER IN CHILDREN AND MANAGEMENT

• Eating disorders among children are umbrella term that includes various patterns of eating deviations.

Types of Eating Disorders

• Anorexia Nervosa
• Bulimia Nervosa
• Binge Eating

Pica

• Definition

• Pica is an eating disorder typically defined as the persistent, compulsive urge to eat non-nutritive, inedible substances for a period of at least one month at an age in which the behavior is developed mentally inappropriate (18–24 month) and is not related to the individual’s sociocultural customs and traditions.

Types

• Geophagia
• Pagophagia
• Urophagia

Causes

• Autism Spectrum Disorder
• Attention Deficit Hyperactivity Disorder
• Schizophrenia,

Management

• Blocking
• Skill-building
• Vitamins or supplements

Complications

• Chronic abdominal problems
• Malabsorption
• Intestinal obstruction

Large hair mass in Rapunzel syndrome reported by Khanna K, Tandon S, Yadav DK, et al. Rapunzel syndrome: a tail too long to tell! Case Reports 2018;2018:bcr-2018-224756.

Causes

• Eating disorders are genetic predisposition
• Family history of parents

Clinical Manifestations of Eating Disorders

• Features related to inadequate energy intake or malnutrition
• Features related to purging
• Features related to excess energy intake

Complications

• Malnutrition and widespread slowing of bodily functions.
• Electrolyte imbalance.
• Gastroparesis, chronic constipation.

Management of Eating Disorders

• Hospitalization
• Parent counselling

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