Pediatric Behavioral Problems – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

Behavior that disrupts ≥1 areas of psychosocial functioning but not seriously enough to receive an official DSM-IV diagnosis; most commonly reported behavioral problems are

  • Noncompliance: Purposeful refusal (active/passive) to do what is requested by parent or other adult authority figure
  • Temper tantrums: Loss of internal control believed to be provoked by overtiredness, physical discomfort, or fear that leads the child to exhibit behaviors such as crying, whining, breath holding, or in extreme cases, acts of aggression
  • Sleep disorders: Sleep patterns that are distressing to parents, child, or physician; this can be further broken down into 2 categories based on polysomnograph:
    • Primary sleep disorders have abnormal polysomnograph. Examples include sleepwalking and night terrors.
    • Secondary sleep disorders have normal polysomnograph and are the most common sleep disorders. Examples include night awakenings and bedtime resistance.
  • Nocturnal enuresis: Enuresis that occurs only at night in children >5 years of age with no medical problems
    • Primary: Nocturnal enuresis in a child who has never been dry at night
    • Secondary: Nocturnal enuresis in a child who has been dry at night for at least 6 months

Epidemiology

  • Noncompliance: More common in children <1 year of age, especially as they develop autonomy; boys have a modestly greater likelihood of being noncompliant. Noncompliant behavior decreases with age.
  • Temper tantrums: 70% of 18- to 24-month-old children; 75.3% of 3- to 5-year-old children; in children with severe tantrums, 52% have other non-tantrum-related behavioral/emotional problems (1).
  • Sleep disorders (secondary): 25% of children between 1 and 5 years of age and 20–30% of infants, toddlers, and preschoolers
  • Nocturnal enuresis:
    • At least 20% of children in the 1st grade wet the bed occasionally, and 4% wet 2 or more times per week; more common in boys than in girls (2):
      • Enuresis in boys aged 7 and 10 years is 9% and 7%, respectively.
      • Enuresis in girls aged 7 and 10 years is 6% and 3%, respectively.

Risk Factors

Genetics

  • Genetic components contribute to the pathogenesis of primary nocturnal enuresis. One locus was assigned to chromosome 13q (3).
  • Major genes are involved in a large proportion of enuresis families. Linkage results suggest that such a gene is located on chromosome 12q.
  • Nocturnal enuresis is a genetic and heterogeneous disorder. The associations between genotype and phenotype are complex and are susceptible to environmental influences (4).

Sleep disorder, Nocturnal enuresis, Children, ADHD, secondary nocturnal enuresis, primary nocturnal enuresis, acts of aggression, infants toddlers, emotional problems,

Diagnosis

History

  • Noncompliance: Complete history taken from parents and teachers; direct observation of child or child–parent interaction:
    • Criteria: Is problematic for at least some adults in child’s life, leading to stressful/difficult interactions for minimum period of 6 months
    • Reduces child’s ability to take part in structured activities
    • Creates stressful interactions and relationships with compliant children
    • Disrupts academic progress; places child at risk for physical injury
  • Temper tantrums: History with focus on development, family depression, or violence:
    • Criteria: May consist of stiffening limbs and arching back, dropping to the floor, shouting, screaming, crying, pushing/pulling, stamping, hitting, kicking, throwing, or running away (1)
    • Screening for depression with the Preschool Feelings Checklist (5)
  • Sleep disorders: Screening questions about sleep during well-child visit; complete history, including questions about snoring (6)
  • Nocturnal enuresis: Complete history specifically asking about urine output/fluid intake/bowel movements; consider asking parent to keep a voiding diary.

Physical Exam

  • Nocturnal enuresis: Physical exam should focus on abdomen, spine, genitalia, and perineum, followed by a neurologic exam. Specifically, evaluate for
    • Abdomen: Enlarged bladder, kidneys, or fecal masses
    • Spine: Dimpling or tufts of hair on sacrum
    • Genital urinary exam:
      • Males: Meatal stenosis, hypospadias, epispadias, phimosis
      • Females: Vulvitis, vaginitis, labial adhesions, ureterocele at introitus; wide vaginal orifice with scar or healed laceration may be evidence of abuse.
  • Rectal exam: Tone and constipation
  • Neurologic exam: Focused on the lower extremities

Diagnostic Tests & Interpretation

Lab

Initial lab tests

For nocturnal enuresis: Urinalysis and urine culture

Follow-Up & Special Considerations

Sleep studies should be performed in children if there is a history of snoring and daytime attention-deficit hyperactivity disorder (ADHD)–type symptoms.

Diagnostic Procedures/Surgery

  • General screening tools: Child Behavioral Checklist
  • Pediatric Symptom Checklist (www. brightfutures.org/mentalhealth/pdf/professionals/ped_symptom_chklst.pdf)
  • NICHQ Vanderbilt Assessment (ADHD screen; www.myadhd.com/vanderbiltparent6175.html

Pathological Findings

Certain tantrum behaviors are more likely to be indicative of a serious illness such as major depression or other DSM-IV diagnosable disorders such as ADHD, oppositional defiant disorder (ODD), etc. These behaviors include (5)

  • Self-injurious behaviors
  • Slow recovery time from tantrums
  • More tantrums in the home than outside the home
  • More aggressive behaviors toward others, including oral aggression

Treatment

  • General: Educate parent about the specific behavioral problem (2).
  • Noncompliance: In the case of extreme child disobedience, consider parent training programs. Child may need to be screened for ADHD, ODD, or conduct disorder (CD).
  • Temper tantrums: Remind parent(s) that this is a normal aspect of childhood.
    • If tantrum is set off by external factors such as hunger or overtiredness, then correct.
    • Other methods for dealing with a tantrum include 1 of the following:
      • Ignoring the tantrum
      • Removing the child and placing him or her in time-out (1 minute for each year of age)
      • Holding child/restraining child until he or she calms down
      • Giving child clear, firm, and consistent instructions as well as enough time to obey
  • Sleep disorders: Aside from parent education, other interventions include
    • Extinction: Child goes to bed at designated time, and cries/tantrums are ignored while monitoring child for safety.
    • Graduated extinction: Parent ignores cries/tantrums for specified period. Parent can check at a fixed time or check at increasing intervals.
    • Studies show that parent education and extinction are the most effective approaches (6).
  • Nocturnal enuresis:
    • Bedwetting alarm: Continue for at least 2–3 months.
    • Little evidence from clinical trials, but good empirical evidence for behavioral training, including positive reinforcement (small reward for each dry night), or responsibility training (if old enough, child is responsible for changing or washing sheets), encouraging daily bowel movements, and frequent bladder emptying during the day (2).
    • If behavioral therapy fails: Desmopressin if child >6 years of age.
    • If behavioral and medical therapy fail, then refer to a specialist.

Medication

Most pediatric behavioral issues respond well to nonpharmacologic therapy.

  • Sleep disorders:
    • For certain delayed sleep onset disorders, after behavioral methods are exhausted, melatonin at low doses can be tried while behavior modification is continued (7). However, this is not approved by the Food and Drug Administration (FDA) for pediatric patients.
    • Melatonin has been used in pediatric patients in doses of 0.5–10 mg PO given at night.
  • Nocturnal enuresis (also see topic Enuresis):
    • If behavioral therapy fails: Desmopressin is the only medicine approved as 1st-line therapy if child >6 years of age.
      • As of 2007, the FDA recommends against use of intranasal formulations in children owing to reports of severe hyponatremia resulting in seizures and death in children using intranasal formulations of desmopressin.
      • Oral desmopressin (DDAVP): Dose-dependent; begin with 0.2-mg tablet taken at bedtime on empty stomach; may titrate to 0.6 mg
      • Maximally effective in 1 hour; cleared within 9 hours
      • Give nightly for 6 months; then stop for 2 weeks for test of dryness.
      • Suspend dose in children who experience acute condition affecting fluid/electrolyte balances (i.e., fever, vomiting, diarrhea, vigorous exercise).
      • Potential risks include water intoxication with hyponatremia.
      • 10–60% success; safe even when used for >12 months; high relapse rate after discontinuation without a structured withdrawal program

Additional Treatment

Issues for Referral

A patient who exhibits self-injurious behaviors, slow recovery time from tantrums, more tantrums in the home than outside the home, or more aggressive behaviors toward others (including oral aggression) may require referral to a neurodevelopmental or psychiatric specialist.

Complementary and Alternative Medicine

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  • The EPA portion of omega-3 fatty acids has been shown to be useful in treating depression and mood disorders in the pediatric population (8). For patients >8 years of age, 1 g of fish oil is recommended daily, <8 years old, 700 mg/d is recommended.
  • For irritability, there is some limited evidence for calcium at 400–800 mg/d and magnesium at 200–400 mg/d, B complex vitamins at 50 mg/d, vitamin C at 1,000 mg/d if younger than 8 years of age and 500 mg/d if over 8 years of age (8)[C].

Ongoing Care

Diet

  • Nutrition is very important in behavioral issues. Avoiding high-sugar foods and providing balanced, whole meals has been shown to decrease aggressive and noncompliant behaviors in children.
  • Eliminate caffeine and increase protein.

Patient Education

  • A few examples of parent training programs are
    • The Oregon Social Learning Center program: www.oslc.org
    • Forehand and McMahon program: Helping the Noncompliant Child (ages 3–8 years): www. strengtheningfamilies.org/html/programs_1999/02_HNCC.html
    • The BASIC program by Webster-Stratton: www.incredibleyears.com
  • Also check local community organizations for parenting classes.

References

1. Potegal M, Davidson RJ. Temper tantrums in young children: 1. Behavioral composition. J Dev Behav Pediatr. 2003;24:140–7.

2. Robson WL. Clinical practice. Evaluation and management of enuresis. N Engl J Med. 2009;360:1429–36.

3. Arnell H, Hjälmås K, Jägervall M, et al. The genetics of primary nocturnal enuresis: inheritance and suggestion of a second major gene on chromosome 12q. J Med Genet. 1997;34:360–5.

4. von Gontard A, Schaumburg H, Hollmann E, et al. The genetics of enuresis: a review. J Urol. 2001;166:2438–43.

5. Belden AC, Thomson NR, Luby JL. Temper tantrums in healthy versus depressed and disruptive preschoolers: defining tantrum behaviors associated with clinical problems. J Pediatr. 2008;152:117–22.

6. Mindell JA, Kuhn B, Lewin DS, et al. Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep. 2006;29:1263–76.

7. Gringras P. When to use drugs to help sleep. Arch Dis Child. 2008.

8. Shannon S et al. Integrative approaches to pediatric mood disorders. Altern Ther Health Med. 2009;15(5):48–53.

Additional Reading

Albrecht SJ, Dore DJ, Naugle AE. Common behavioral dilemmas of the school-aged child. Pediatr Clin North Am. 2003;50:841–57.

Brown P, Schnall JG, Hallgren JD. When (and how) should you evaluate a child for obstructive sleep apnea? J Fam Pract. 2007;56:317–20.

Caldwell PHY, et al. Bedwetting and toileting problems in children. JAMA. 2005;182:190–5.

Kalb LM, Loeber R. Child disobedience and noncompliance: a review. Pediatrics. 2003;111:641–52.

Luby JL, Heffelfinger A, Koenig-McNaught AL, et al. The Preschool Feelings Checklist: a brief and sensitive screening measure for depression in young children. J Am Acad Child Adolesc Psychiatry.2004;43:708–17.

Miller JW. Screening children for developmental behavioral problems: principles for the practitioner. Prim Care Clin Office Pract. 2007;34:177–201.

Thiedke CC. Sleep disorders and sleep problems in childhood. Am Fam Physician. 2001;63:277–84.

See Also (Topic, Algorithm, Electronic Media Element)

Enuresis

Codes

ICD9

  • V40.3 Other behavioral problems
  • 312.9 Unspecified disturbance of conduct

Snomed

277843001 Problem behavior (finding)

Clinical Pearls

  • Most commonly reported pediatric behavioral problems are noncompliance, temper tantrums, sleep disorders, and nocturnal enuresis.
  • Well-child visits provide opportunities to systematically screen for these common conditions.
  • Parental education is a key component of treatment.
  • Nutrition is an important factor in behavior disorders and should be screened at the well-child visit.

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