COMMON BEHAVIOURAL PROBLEMS

BEHAVIOUR is the action or reaction of something under specified circumstances.

COMMON BEHAVIOURAL PROBLEMS

Any behavior that disturbs the individuals ability to function adequately, will constitute a behavior problem.

WHAT IS A BEHAVIOURAL PROBLEM?

INFANCY

Feeding problemColic Stranger anxiety Breath holding spells Temper tantrum

TYPES OF BEHAVIOURAL PROBLEMS IN RELATION TO

AGE GROUP

MID-CHILDHOOD

StutteringPicaSleep problemEnuresisEncopresis

Cont…..

PRESCHOOL CHILD

Hyperactive or restless childHead banging/Body rockingThumb suckingNail bitingMasturbationLack of clarity in speech

Cont….

Jealousy /sibling rivalryJuvenile delinquency

ADOLESCENCE

FEEDING PROBLEMS

UNDERFEEDING

Caused by improper feeding techniques such as decreased frequency or duration of feeding,Inadequate quantity or quality of feeding Early introduction of top feedingNipple confusion.Brest problems.Improper burpingAbnormal mother infant bondingChronic systemic illness in infant

FEEDING PROBLEMS

OVERFEEDING

Caused by parents 'ignorance about nutritional requirement of the children.Upwelling of the mother to Brest feed and reliance on bottle feed.

Cont…….. 3

•Parents should be counseled regarding daily dietary allowance•Teach the parents about feeding technique and type of food to be used.•Adequate and expulsive Brest feeding can over come the problem of over feeding.

NURSING MANEGEMENT

HEAD BANGING

HEAD BANGING

This involve rhythmic hitting of the head against a solid surface often the crib mattress.This occur in 5-6% of children during infancy and toddler years.This is common at bedtime before going to sleep or after a child wakes during night or in the morning.

Cont……….

Head banging typically occurs with the child lying face down – banging the head down into a pillow or mattress. In the upright position, the head is banged against the wall or headboard repeatedly.

Head banging usually disappear within 18 months, and might do so in as little as weeks or months.

Banging can result in callus formation . abrasions and contusion can occur at the site

Reassurance of the parents that head banging alone is not a sign of developmental disability Significant injury is unlikely .Padding of the heard surface can decrease the chance of injury.Parents should ignore the behavior as attention in the form concern or punishment can reinforce it.

NURSING MANAGEMENT

•Colic is characterized by intermittent episodes of abdominal pain or severe crying in young infants who are otherwise well.

•It is usually begins at 1-2 weeks of age and can persist till 3-4 months of age.•The crying usually occurs in the late afternoon or evening.

COLIC

The diagnosis is conformed when the infant cries for more than 3hours per day for more than 3day per week for more than 3 weeks.

DIAGNOSIS

The attack usually begins suddenly with a loud cry. Crying occurs continuously and may last for many hours.Face become red and the legs are drawn up on the abdomen.The abdomen become tense .The attack terminates when infants is completely exhausted.

CLINICAL FEATURES

colic start happening with in few weeks after birth, reach a peak by 4-6 weeks and subside by 3-4 months of age.

CONTD…….

COUNSELING is the most effective method for helping parents cope successively with their infant’s crying. Nurse should ensure the parents that your child id not sick so as to unburden them. The parents should be told that all young infants are irritable and fussy and cry to some degree on an average of 2-3 hrs per day.

MANAGEMENT

Stranger’s anxiety

By about 6-7 months, the infant can differentiate between the primary care giver and others. thus at this develop fear of unfamiliar people or strangers. The infant, when approached by some unfamiliar person, turns away, even cry or runs towards the primary caregiver. This is known as the Strangers reaction.

CONT…….. 3

Infant is managed with relaxation technique such as slowly exposing them to the stranger, initially from the distance. Reassurance of parents is required as this behavior is gradually declines. If the behavior persists than the child should be referred to psychiatrist to evaluate for associated anxiety disorder.

NURSING MANAGEMENT

•Reassure your child.  If toddler seems scared, upset, or wary when other adults approach her (pressing her face to your leg may clue you in), do your best to reassure her that everything is okay .

•Stay within arm’s reach.  When toddler stranger anxiety sets in, it’s key to make it clear to your child that she’s “safe” by holding her or staying close to her. And be sure to give her lots of love and affection as she gets acclimated (or re-acclimated) to the new (or familiar) face.

Cont…….. 5

Coach your friends and family.

•Let everyone know that your toddler needs a little time to warm up to people.

• Explain that it’s best not to rush in and pick her up or demand hugs and kisses the minute they see her Instead, tell them to play it cool for a bit, and then maybe, after your toddler seems comfortable, offer her a favorite toy to entice her to connect with them.

Cont……..

BREATH HOLDING SPELL

A breath holding spell is an involuntary pause in breathing, sometimes accompanied by loss of consciousness. It usually occurs in response to an upsetting or surprising situation.

BREATH HOLDING SPELL

•A small number of children have severe spells.

• Usually the spells stop by the time a child reaches ages 6 – 8years.

•Breath holding is seen in some normal children from as early as age 2 months, but it can start as late as 2 years old.

CAUSES

•Although they often occur with tantrums, breath holding spells are not thought to be a willful act of defiance.•Children with iron deficiency anemia may also have increased episodes of breath holding.

CONT…….. 4

•Breath holding spells appear to be a response to fear, pain, a traumatic event.

•The sudden reaction can cause the nervous system to temporarily slow the heart rate or breathing, causing breath holding and color changes.

CONT………. 5

Symptoms

•Bluish discoloration of the skin caused by lack of oxygen (cyanosis) or loss of skin color (pallor)

•Crying and then stopping breathing (apnea)

•Momentary unconsciousness or faintingShort seizure-like movement (one to two jerks)

CONT……… 6

No treatment is usually necessary. Avoiding situations that provoke temper tantrums can help reduce the number of spells your child .Placing a cold cloth on your child's forehead during the spell may shorten the episode.Breath holding spells that do not cause the child to become unconscious are best ignored, in the same way temper tantrums are ignored.

TREATMENT

•If your child has an iron deficiency, should start iron replacement treatment.

•When a spell occurs, be sure that your child is in a safe place where he or she won't be hurt during a fall or a brief seizure.

•After the spell, try to be calm and avoid giving too much attention to the child, because this can reinforce the behaviors that lead to the breath holding spells.

CONT……...

The biggest risk is injury, especially head injury, due to a fall during a spell.

Possible Complications

•Reassurance of the parents that spell will not harm the child.•Protect child during a spell, lay the child on the floor and keep his or her arms, legs, and head from hitting anything hard or sharp•Try to distract him or her before the behavior reaches the point that typically provokes a spell.

NURSING MANAGEMENT

When Your child may stop breathing for up to 1 minute (60 seconds) during a spell. If your child doesn't wake up quickly and start breathing again than seek MEDICAL HELP.

SEEK MEDICAL HELP

THUMB SUCKING

Thumb-sucking is normal in babies and young children. A natural sucking instinct leads some babies to suck their thumbs during their first few months of life, or even before birth. Babies may also suck on their fingers, hands.

Why do babies suck their thumbs?

Babies have a natural urge to suck, which usually decreases after the age of 6 months. But many babies continue to suck their thumbs to soothe themselves. Thumb-sucking can become a habit in babies and young children who use it to comfort themselves when they feel hungry, afraid, restless, sleepy, or bored.

•Thumb-sucking is normal in babies and young children. •A natural sucking instinct leads some babies to suck their thumbs during their first few months of life, or even before birth.• Babies may also suck on their fingers, hands, or items such as gloves

CONT…….. 3

4

Alveolar Prognathism - Caused by thumb sucking and tongue thrust

Teething problems Respiratory problems Gastro-intestinal problemsPalate changesTeeth pushed forwardBuck teethDental bite problems

COMPLICATIONS

This is a habit of biting or eating nails most of the time. it is usually diagnosed after 3 yrs of age. it is more common in girls than in boys. This is found in all socio-economic classes. The peak age for the development of this disorder is 5-7 yrs or 13-15 yrs Nail biting may be a learned behavior.

NAIL BITING

•DEVELOPMENTAL CAUSES This disorder is common in the biting stage and teething stage as a gratifying oral habits.

•EMOTIONAL FACTORS These include tension, anxiety, parental neglect, strictness, stress of exams and excessive fear.

CAUSES 3

•Teething problems•Respiratory infections•Gastro intestinal tract infection.•Cosmetic  problems infection in the bone (osteomyelitis) of his finger tip.

COMPLICATIONS

No therapeutic measures are needed. most children grow out of this habit by the age of 5 or 6 years.Try to remove the precipitants.Use various behaviour modification technique such promise of a reword to correct the faulty behavoiur.Keep the child normally busy during the day time.suggest an alternative activity such as playing with play dough or wiggling his fingers around.  Use of play therapy is beneficial in the management of the disorder

NURSING MANAGEMENT

•Identify the cause of nail biting and try to remove that cause.•Identify the precipitant and try to remove them•The environment should be free of tension and fear for the proper development of the child.•Give proper explanations to the child.•Distract the mind of the child by play therapy.

Cont………

TEMPER TANTRUM

What are temper tantrums? A temper tantrum is a sudden, unplanned display of anger. It is not just an act to get attention. During a temper tantrum, children often cry, yell, and swing their arms and legs. Temper tantrums usually last 30 seconds to 2 minutes and are most intense at the start.

Parental factors These include over protection of the child, and inconsistent behavior of the parents.

Child personality The disorder is common in active energetic, determined, resistant children and incase of feeling of insecurity.

Other causes Includes sibling jealousy, physical illness, psychosocial problem, problem in family, lack of play and organic disease.

ETIOLOGY/CAUSES

•screaming •hammering •stemping feet•thrashing arms •kicking •thrushing on the floor •strikes people •throws things•oversenstive

CLINICAL FEATURES

£This disorder ceases with age.£A through physical examination should be carried out to explore any organic disease and treated as early as possible.£Look for any faulty habits regarding, eating, sleeping, elimination and these must be corrected.£If there is lake of play opportunity, than ample opportunity for play should be provided.

MANAGEMENT

No therapeutic measure are needed.Most children grow out of this by the age of 5to6 years.Try to remove the precipitants Use various behaviour modification techniques such as promise of a reward to correct the faulty behaviour. Keep the child normally busy during day time.Use of play therapy and individual therapy is beneficial in the management of this disorder.

NURSING MANAGEMENT

Sometimes temper tantrums last longer and are more severe. The child may hit, bite, and pinch. These violent tantrums, in which children harm themselves or others, may be a sign of a more serious problem.Temper tantrums are most common in children ages 1 to 4 years. But anyone can have a tantrum-even an adult.

Cont……

Remove the underlying cause of tamper tantrum such as insecurity over protection, faulty parental attitude.cut down opportunity resistance.Do not scold the child during tamper tantrum.Child must be reassured with given explanations

Cont…….

child must be reassured with given explanations, why his demands are nit satisfied, the unreasonable demand must be made clear to him.The children learn that he just can not dominate his environment by his or her tantrum.

CONT……

Tic is a problem in which a part of the body moves repeatedly, quickly, suddenly and uncontrollably. Tics can occur in any body part, such as the face, shoulders, hands or legs. It is a disorder of movement in children .it is prevalent in 12 to 20%children,the peak yrs for this disorder 5-7 yr. It is more common in boys than in girls.Facial tics are commonest followed by neck, eye or leg tics.

TIC DISORDER

Genetic factors 10 to 15%children with this disorder having family history Emotional factors Such as ambitious, over expecting parents, over protecting parents and neglect contribute to development of this disorder.

Other causes Central nervous system defects ,increased dopamine activity, metabolic disorder anger, tension, frustration and viral infections

ETIOLOGY

GrimacingYawningGrunting Sighing BlinkingWrinklingScratching noseThigh rubbing.

CLINICAL FEATURES

A holistic approach is recommended for the treatment of tic disorders. A multidisciplinary team should work together with the affected child's parents and teachers to put together a comprehensive treatment plan. Treatment should include the following:Educating the patient and family about the course of the disorder in a reassuring manner.

TREATMENT

Completion of necessary diagnostic tests, including self-reports (by child and parents); clinician-administered ratings; and direct observational methods.Comprehensive assessment, including the child's cognitive abilities, perception, motor skills, behavior and adaptive functioning.

Cont…..

Collaboration with school personnel to create a learning environment conducive to academic success.Therapy, most often behavioral or cognitive-behavioral, though other modalities may be appropriate.If necessary, evaluation for medication.

CONT

For the treatment of this disorder, drugs such as haloperidol, pimozide, clonidine,nifedipine are use in low doses.Several behavior modification techniques such as self training ,relaxation techniques and biofeedback are used to correct theFaculty behavior of the child must be treatedany situation and difficultiesAny physical problems should be treated.

MANAGEMENT

As the name indicates excess of activity. This is commonly characterized by Fails to concentrate on work.Acts before thinking Shifting quickly from one activity to anther.Inability to sit quietly

HYPERACTIVE CHILD

•Reward child for only small amount of work and then gradually helping them to increase attention span.•These children are hard on toys. Toys should be durable and which do not hurt child.Maintain peace and quiet time may be ever for a short period. the child should be encouraged to sit or lie down. parents might read a book holding the child on the lap.

WHAT TO DO

•Have strict regime with clear cut rules, definite assignment and direction is preferable even for routine activities like going to bathroom and sharpening.•Do not over control or overprotect the child

Cont…

•Do not over control or over protect the child•Child should not be allowed to take excessive tea, coffee, chocolate and synthetic drinks.•Do not keep valuables, breakable or dangerous objects within easy reach of children as they are more prone to accidents.•Do not threaten, forbid or correct the child as after a while child gets use to the shouting that he does not pay attention to the words.

Do not’s

It is the inability to maintain urinary control during sleep. •Primary enuresis  refers to inability to maintain urinary control from infancy. 

•Secondary enuresis  is a relapse after control has been achieved.

ENURESIS

anxiety stress urinary tract infections a small bladder, abnormal urethral valves in males, spinal cord abnormalities, slow development of the central nervous system i.e. nerves that control the bladder mature slowly leading to inability to recognize a full bladder, hormonal factor

CAUSES

•UTI•Individual feel ashamed or embarrassed•Individual wish to avoid situations that lead to embarrassment such as camps or over night visits to relatives and friends

COMPLICATIONS

PARENTAL COUNSELLING

•Remove psychological factors leading to this problem such as separation from parents, parental neglect marital disharmony,excessive punishments, criticism in front of others etc.•The toilet training should be given properly.•It should not be too lax nor be too strict.•Toilet training can be delayed to 5 years In case of mentally retarded children.

MANAGEMENT

Mower and mower devised an apparatus in 1938 consisting of an alarm buzzer which could be set off by the discharge of urine onto a detector circuit and child wakes up from the sleep to pass the urine at right place.

BEHAVIOUR MODIFICATION

DRUGS Drugs such as oxybutemine 2.5-5mg,2-4 times a day or imipamine 25-50 mg can be used at bed time.

SITUATIONAL MANIPULATION Wake the child during the course of sleep in night to pass urine. Restrict fluids such as water, milk juice soup at least 1-2 hrs before sleep.

Is involuntary fecal soiling in children who have usually already been toilet trained. Children with encopresis often leak stool into their undergarments.

ENCOPRESIS

The estimated prevalence of encopresis in four-year-olds is between one and three percent. The disorder is thought to be more common in males than females, by a factor of 6 to 1.

PREVALENCE

.

•Repeated passage of feces into inappropriate places (e.g., clothing or floor) whether voluntary or unintentional•At least one such event a month for at least 3 months•Chronological age of at least 4 years (or equivalent developmental level)•The behavior is not exclusively due to a physiological effect of a substance (e.g., laxatives) or a general medical condition.

DIAGNOSIS

Continuous type In this type the child is never trained, aggressive, overactive, shameless, child low socio-economic family.

Discontinuous type In this type the child is once toilet trained but soils later in response to stress, a neurotic, ashamed child .it is also called reactive encopresis.

TYPES

CAUSESGenetic factors

Organic causes

Emotional factors

Cont….

Clinical features

Frequency of soiling varies from once to several times a day.It occur in school he child is tense Child is prone to anxiety reactions.Poor self esteem.Withdrawn and stubborn childLess time spent with peer group.

Defect in speech characterized by Hesitation

Stumbling

Spasmodic repetition with pause

STUTTERING

Genetics

•Other speech and language problems or developmental delays.•Differences in the brain's processing of language

Causes

The parents of young child with primary stuttering should be reassured and advised. Parents should be told that the speech is non-fluent between the ages of 2-5 years. They should not show undue concern and accept his speech without pressurizing him to repeat or making him conscious of his handi cappedness.

Management

The older children with secondary stuttering should be given emotional support and referred to speech therapist.

Cont….

•Juvenile Delinquency involves wrong doing by a child or a young person who is under an age specified by the law of the place concerned.

•From the legal point of view, a juvenile delinquent is a person who is below 16 years of age (18 years in case of a girl) who indulges in an antisocial activity.

JUVENILE DELINQUENCY

1.Social causes

2.Psychological causes

3.Economic causes

ETIOLOGY

Child must keep under the supervision of a therapist or nurse whose job is to help him get established in normal life. Psychological therapies like play therapy, finger-painting, psychodrama etc.

Management

It originates because of child’s desire to his mother’s only beloved. this desire is so possessive that it tolerates no rivals when brother or sister arrives, and child competes with them for their exclusive love of parents

JEALOUSY/SIBLING RIVALRY

•These attacks whether physical or verbal must be stopped because they harm both but to protect the physical safety of the younger child. •We do not insult or punish the older child.•The approach should be towards reduction of the jealousy.•This can be done by the mother whenever she is handling the younger children.

What to do

•While attending to the younger child inpresence of the older one, she should involve older child by saying e.g. let us now play with the child•Attempt to settle inter parental tensions outside the child’s presence.

Cont…

•Avoid nagging the child with continuous “do nots”•The mother should not treat the younger child with undue favors and deny same to the older child.

DONOT’S

•It is the habit of eating non-eatable substances such as mud, plaster, paper, clay etc.•It is normal in infants up to 2 years•It is more common in boys than girls.•The peak age for development of this disorder is 20-26 months.•The prevalence of this disorder falls with age.

PICA

•Cultural factors

•Organic causes

•Emotional factors

CAUSES

•Worm infestation•Cholera•Typhoid•Constipation •Poisoning

COMPLICATIONS

•Identify the cause of pica and try to remove the cause.•Identify and remove the precipitantsIf the cause is any organic disease, then refer the patient to child specialist.•Ask the parents to change their attitude towards the child.•Ask the parents to scold the child.•Oral substitutions can be used.•Give proper explanations to child.

NURSING MANAGEMENT