BEHAVIOURAL PROBLEMS

INTRODUCTION:
Infancy and childhood are important in determining the future behavior and character of the
children. Childhood is the period of dependency. Gradually, children learn to adjust in the
environment. But when there is complexity around them, they cannot adjust with those
circumstances. Then they became unable to behave in the socially acceptable way and
behavioral problems develop with them. Every child should have tender loving care and
sense of security about protection from parent and family members. They should have
opportunity for development of independence, trust, confidence and self-respect. The child
should get scope for self- expression and recreation. Parent should be aware about
achievements of their children and express acceptance of positive attitude within the social
norms.
DEFINITION:
Behavioral problems are viewed as discrepancy between the child behavior and demands
placed on him by his parents, teachers and colleagues.
CAUSES OF BEHAVIOURAL PROBLEMS:
Behavioral problems are caused by multiple factors. The important contributing factors are:
 Faulty Parental Attitude (Overprotection, dominance, broken family)
 Inadequate Family Environment (Poor-economic Status, Cultural Pattern)
 Mentally & Physically Sick or Handicapped Conditions (Children with sickness and
disability)
 Influence of Social Relationship (Disturbed Relationship with neighbors, school
teachers, school mates)
 Influence of Mass Media (Television, Radio, Periodicals)
 Influence of Social Change (Violence, Unemployment, economic insecurity).
Common behavioral problems in Children:
 Feeding problems- Food fad, food refusal, overeating, vomiting, impaired appetite,
pica, etc.
 Habit disorders- thumb sucking, nail biting, encopresis, tics, breath holding spell,
rolling.
 Speech problems- unclear speech, delayed speech, dyslalia, stammering or stuttering
 Sleep problems- sleep walking (somnambulism), sleep talking, night terrors.
 Educational difficulties- school phobia, truancy, repeated failure, school absentism.
 Adjustment problems- disobedience, misconduct, temper tantrum
 Emotional problems- negativism, jealousy, shyness, fear, anger
 Anti-social problems-Delinquency, destructive attitudes, kleptomania
 Sexual problems- Masturbation, precocious sexuality, homosexuality, sexual assault.
 These behavioral problems may find to all children, but some problems are specific to
particular age group.
Types of Behavioral Disorders:
Behavioral disorders can be classified as-
 Habit disorders
Thumb sucking
Nail biting
Tics
Enuresis
Encopresis
Stealing
Telling lie
 Speech disorders
Stammering/stuttering
Phonation and articulation problems
 Eating disorders
Pica
Anorexia nervosa
Bulimia nervosa
 Sleeping disorders
Somnambulism
Somniloquy
Night mares/ night terrors
 Personality disorder
Juvenile delinquency
Temper tantrums
Shyness
BEHAVIORAL PROBLEMS OF INFANCY
Manifestations of behavioral problems during infancy are found as resistance to feeding or
impaired appetite, abdominal colic, stranger anxiety, resistance to parental interference to
explore environment and vomiting as attention seeking behavior in disturbed parent-child
relationship.
RESISTANCE TO FEEDING/ IMPAIRED APPETITE
During infancy feeding problems often develop at the time of weaning. Infant may refuse
new foods due to dislike of taste or due to dislike of taste or due to separation anxiety from
mother. It may be due to forced feeding by the mother or may be due to indigestion of new
food and abdominal colic. The infant may have painful ulcer in the mouth or sore throat
causing difficulty in swallowing. There may be nasal congestion or any other pathological
cause which need to be excluded.
Mother usually become frustrated and anxious with this situation, so they need reassurance
and guidance in rescheduling the feeding time and change of food items. Problems like
mouth ulcer, sore throat, nasal congestion or any other conditions to be treated accordingly.
Mother should be encouraged to provide tender loving care to her infant and to avoid
separation.
ABDOMINAL COLIC
Abdominal colic is an important cause of crying in the children. Some infants may cry
continuously for variable periods. This period usually starts within the first week after birth,
reaches at peak by the age of 4 to 6 weeks and improves after 3 to 4 months. The infants may
cry loudly with clenched fists and flexed legs.
The cause of the abdominal colic is not clearly understood. It occurs commonly in overactive
infants who are overstimulated by parents. It can be due to hunger, or improper feeding
technique or physiological immaturity of the intestine or cow’s milk allergy or aerophagy.
Excessive carbohydrate in food may lead to intestinal fermentation and accumulation of gas
which may cause abdominal distension and pain.
Abdominal colic of the baby increases anxiety and tension of the mother. She required
explanation and help for solving the problem. Baby should be placed in upright position and
burping can be done to remove swallowed air. Psychological bonding with infant to be
improved. Presence of any organic cause to be excluded and necessary management to be
arranged. Antispasmodic drugs may be administered to relief the colic. Frequent small
amount feeding and modification of feeding technique are very important.
STRANGER ANXIETY
Mother is the significant person during infancy or satisfaction of needs, feeling of comfort,
pleasure and security. The infant does not belief any other persons except mother, because
they have trust relationship with mothers only. In absence of mother, if any new person
approaches, the child will start crying due to feeling of insecurity, fear and anxiety. This
crying may upset the parent, but it is an indication that parent have done a great job in the
emotional development of the infant by deep mother-child or parent-child bondage.
Separation anxiety is a vital step of emotional development and may continue upto 13 to 15
months of age. This anxiety usually reduced when the strangers gradually approach from
distance in a familiar place specially in presence of the mother or father. In absence of
parents, loving concern of the stranger is very important.
BEHAVIORAL PROBLEMS OF CHILDHOOD
Common behavioral problems of childhood are temper tantrum, breath-holding spell, thumb
sucking, nail biting, enuresis, encopresis, pica, tics, speech problems, sleep disorders, school
phobia, etc.
TEMPER TANTRUM
Temper tantrum are a child’s response to physical or emotional challenges by attention
seeking tactics like yelling, biting, kicking, pushing, throwing objects, hitting and head
banging. Tantrums typically begin at 18-36 months of age and gradually subside by the age
of 3-6 years. Parents are counseled to handle this behavioral problem strategically, by staying
calm, firm and consistent so that the child is unable to take advantage from such behavior.
The child should be protected from injuring himself or others. Distraction and time out
techniques are useful.
BREATH HOLDING SPELLS
Breath-holding spells are reflex events typically initiated by a provocation that causes anger,
frustration, or pain making the child cry. The crying stops at full expiration, the child
becomes apneic and cyanotic. In some cases, the child may become unconscious. In
prolonged events, brief tonic clonic movements may happen. Breath holding spells are rare
before 6 months of age, peak at 2 years and abate by 5 years of age. The differential diagnosis
includes seizures and cardiac arrhythmias.
The essential component of management is parental reassurance. The family should be
advised to be consistent in handling the child, to remain calm during the event, turn him side
ways so that secretions should drain and avoid picking the child up (since this decreases
blood flow to the brain). The family should avoid exhibiting undue concern nor give into the
child’s demands, if the spell was provoked by anger or frustration.
THUMB SUCKING
Thumb sucking or finger sucking is a habit disorder due to feeling of insecurity and tension
reducing activities. It may develop due to inadequate oral satisfaction during early infancy as
a result of poor breast feeding.
Definition: Thumb sucking is defined as non- nutritive sucking of fingers or thumb.
Age of occurrence: Thumb sucking is common in oral stage (0-1 year) as the babies have a
natural urge to suck. This usually decreases after the age of 6 months. Many babies continue
to suck their thumb to soothe themselves. Most children stop thumb sucking between 3-6
years of age.
Causes of thumb sucking:
Parental causes
 Over protection by parents
 Neglect by parents
 Strictness of parents
 Disharmony between parents
Due to teachers
 Excessive strictness
 Excessive punitive attitude of teachers
Due to siblings and friends
 Excessive competition
 Separation from close friend or sibling
Other causes
 Loneliness and boredom
 Tiredness
 Frustration and anxiety
 Separation from parents.
Problems caused by Thumb sucking:
Thumb sucking in children continues beyond 4 years of age then complications may arise as
malocclusion and malalignment of teeth, swallowing. It may cause deformity of thumb, facial
distortion and speech difficulties with consonants D and T. if it continues up to 5 years of age
or above it indicates emotional stress. If the child develops thumb sucking at the age of 7 or 8
years, it indicates a sign of stress.
Management:
Usually thumb sucking can be managed at home and includes parents setting rules and
providing distractions. Many experts recommended ignoring thumb sucking in children as
most children stop it on their own. The following measures should be adopted by parents.
Do’s
 Divert the child’s attention. Engage him in play activities.
 The hands and fingers of the child should be kept busy in some interesting activity
like drawing.
 Offer praise and rewards to the child for not sucking thumb.
 Distract the child when he feels bored.
 Put gloves on child’s hands or wrap the thumb with a cloth or bandage.
 A non-toxic bitter tasting substance can be applied on child’s thumb so that he may
not suck it.
 Take help of elder children for explanation to younger sibling.
 Encourage the child to socialize.
 If the child is sucking thumb due to anxiety or distress, address the cause of
discomfort. Talk the child and reassure him.
Don’ts
 Do not scold the child or punish or forcefully remove thumb from the mouth.
 Do not tie the child’s thumb and fingers.
 Do not nag, scold or beat the child.
 Do not leave the child repeatedly cold, wet or hungry.
NAIL BITING
Nail biting or Onychophagia is a bad habit especially occur in school age children beyond 4
years of age. It is a common oral compulsive habit in children and adults. It is just a way of
coping with stress or comforting self.
Causes of nail biting:
Child may bite nails because of many reasons
 To relieve stress or anxiety
 Because of habit
 Because of nervousness
 Lack of confidence
 Feeling shy
 Feeling of insecurity
 Fear
 Tiredness
 Constant nagging
 Pressurized study at home & school,
 Etc.
Management:
 The most common treatment, which is cheap and widely available is application of a
clear, bitter tasting nail polish to the nails. The bitter flavor discourages nail biting.
 Address the child’s anxieties. Make the child speak about his/her worries.
 Don’t nag or punish the child.
 Keep the fingernails of child neatly trimmed, to cut down on the temptation to bite.
 Keep the child’s hands clean to cut down on ingestion of germs.
 Don’t pressurize the children to stop biting nails, as this adds to their stress.
 Reassure the child with love and affection.
 Discuss with the child about unacceptable habits and how to break them.
 Help the child become aware of this bad habit.
 Suggest a substitute actively like car rides or holding a smooth stone in free hand
while reading or writing and then make the child practice the alternative habit daily.
 In case, all these simpler measures fail then behavior therapy is beneficial. Habit
reversal training, which seeks to unlearn habit of nail biting and possibly replace it
with more constructive habit, has shown its effectiveness. In addition to habit reversal
training, stimulus control therapy is used to both identify and then eliminate the
stimulus that triggers biting urges.
ENURESIS/BET-WETTING
Enuresis is the repetitive involuntary passage of urine at in appropriate place especially at
bed, during night time, beyond the age of 4-5 years. It is found in 3 to 10 percent school
children. Enuresis may be primary or secondary.
 Primary enuresis refers to the condition in which children have never been
successfully trained to control urination. There may be delayed in maturation of
sphincter control.
 Secondary enuresis refers to the condition in which children have been successfully
trained, but revert to bed wetting in response to some stress. It may be due to parent
child maladjustment.
Another classification is on the basis of time of bed wetting:
 Nocturnal enuresis: It means bed wetting during night time.
 Diurnal enuresis: It means bed wetting during day time.
 Mixed enuresis: It includes a combination of both nocturnal and diurnal enuresis.
The causes of enuresis are small bladder capacity, improper toilet training and deep sleep
with inability to receive the signals from distended bladder to empty it, neurological
developmental delay, genetics, emotional factors, etc.
Management of enuresis depend upon the specific factors. Assessment of exact cause is very
essential by through history, clinical examination, and necessary examination. The child need
reassurance, restriction of fluid after dinner, voiding before bed time and arising the child to
void. Once or twice, three or four hours later. The child should be fully wakening up by the
parent and aware of passing of urine at night. Parent should encourage and reward the child
for dry nights. Drug therapy with tricyclic antidepressant is useful. 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.
ENCOPRESIS
Encopresis is the passage of feces into appropriate places after the age of 5 years, when the
bowel control is normally achieved. It is a more serious form of emotional disturbances due
to unconscious anger, stress or anxiety. It can be primary or secondary encopresis like bet
wetting. Associated problems are chronic constipation, parental overconcern, over aggressive
toilet training, toilet fear, poor school attendance and learning difficulties may be found with
encopresis.
Management includes assessment and history of bowel training, use of toilets, and associated
problems. The child needs help in establishment of regular bowel habit, bowel training,
dietary intake, intake of adequate fluid. Parental support, reassurance and help from
psychologist for counseling of child and parents may be essential in persistent problems.
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 is normal up to the age of two years. If it persists
after the age of two years, it may be due to parental neglect, poor attention of caregiver,
inadequate love and affection, etc.
Types: The subtypes of Pica are characterized by the substance eaten, for example
 Amylophagia – Consumption of starch
 Coprophagy- Consumption of animal feces
 Geophagy- Consumption of soil, clay or chalk
 Hyalophagia- Consumption of glass
 Pagophagia- Pathological consumption of ice.
Children with pica may have associated problems of intestinal parasitosis, lead poisioning,
vitamins and minerals deficiency. These children may have problems like trichotillomania
(pulling out of scalp hair and swallow) and trichobezoar (a big palpable lump in the upper
abdomen due to collection of swallowed hair).
Management of this problem is done with psychotherapy of the child and parents. Associated
problems should be treated with specific management.
TICS/ 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 occurs mostly in
the school children for discharge of tension in maladjustment emotionally disturbed children.
The age of onset is 2-15 years.
Tics can be motor or vocal tics. Motor tics can be found eye blinking, facial grimacing, head
jerks or shoulder shrugs, facial gesture and usually last less than one second. Vocal tics are
found as throat clearing, coughing, sniffing, barking or hissing.
A special type of chronic tics is found as Gilles de la Tourette’s Syndrome’, characterized by
multiple motor tics ad vocal tics. Management like behavior therapy, counselling and drug
therapy with haloperidol group of drug. Parental assurance and counselling of the child and
parents usually useful to manage the simple motor or vocal tics.
SPEECH PROBLEMS
Speech disorders are common in childhood. These can be found as disturbances of voice
(pitch disorder), articulation (baby talk) and fluency. Causes like hearing defect, cleft palate,
cleft lip, cerebral palsy, dental malocclusions, facial and bulbar paralysis, etc. the emotional
deprivations are also very significant cause of speech disturbances. The common speech
problems related to emotional disorders are stuttering or stammering, cluttering, delayed
speech, dyslalia, etc.
STUTTERING/ STAMMERING
Stuttering or stammering is a fluency disorders begins 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 prolongations of
sounds specially of initial consonants. It is mostly found in boys with fear, anxiety and timid
personality. These children are usually rigid and have positive family history of language and
speech difficulty. Management includes behavior modification and relaxation therapy to
resolve the conflict and emotional stress, thus to improve self confidence in the child.
Stammer suppressors, psychotherapy and drug therapy may be needed for some children.
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.
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 inter-vations.
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 counselling. Parents should be informed about the modification of family
environment and correction of deprivation.
SLEEP DISORDER
Sleep disorders are common in children with anxiety, tension and overactivity. These
problems are present with or without physical symptoms of behavioral disorders. The
common sleep problems are difficulty to fall asleep, night mares, night terrors, sleep walking,
sleep talking, bruxism, etc.
The child should have light meals at dinner and pleasant stories or scene at home. No exiting
games and pictures and frightening stories (ghost, murder, accidents) should not allow at
night. Parents should not allow relaxed comfortable bed and emotionally healthy environment
to the child.
SCHOOL PHOBIA/ SCHOOL REFUSAL
School phobia is persistent and abnormal fear of going to school. It is common in all social
group. It is a 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.
The contributing factors of school phobia are anxiety about maternal separation,
overindulgent, over protective and dominant mother, disinterested father, intellectual
disability of the students. The child may complain about recurrent physical complains like
abdominal pain, headaches, which subside, if the child is allowed to remain at home. The
problems can be managed by habit formation for regular school students, play session and
other recreational activities at school, improvement of school environment and assessment of
health status to detect any health problems and family counselling to resolve anxiety related
to maternal separation.
ATTENTION DEFICIT DISORDER
Attention deficit disorders are learning disabilities can be related to CNS dysfunction or due
to presence of psychoeducational determinants. It is usually associated with hyperactivity and
known as hyperactive action deficit disorders. These children are lagging behind in
intellectual and learning abilities with alteration of behavior patterns. The cause is not
understood properly, but predisposing factors can be prematurity or low birth weight, brain
damage due to infections or injury and interaction between genetic and psychologic factors.
Management is done by team approach including pediatrician, psychologist, psychiatrist,
pediatric nurse specialist, school health nurse, social workers and parents. The approaches
include behavior modification, counselling and guidance of parents and appropriate training
and education of children. Drug therapy can help to improve the CNS dysfunction or other
associated problems.

BEHAVIOR PROBLEMS OF ADOLESCENCE

Common behavioral disorders of adolescence are excessive masturbation, delinquency,
antisocial behavior, substance abuse, anorexia nervosa, etc.
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. Girls may
do it to a lesser degree, through the number of these practice is increasing in recent years.
Boys may masturbate in front of friends but girls are more private. Children may play with
each other’s genitals or a child may play alone with own. Management includes giving
special attention, facilities for recreation and diversion, sex education and counselling.
Parents should be explained to provide love, affection and attention to the older children with
specific concern about their feelings. Punishment threat can exaggerate the practice.
Excessive masturbation can cause sexual maladjustment in future.
JUVENILE DELINQUENCY
Juvenile delinquency means indulgence is an offence by a child in the form of premediated,
purposeful, unlawful activities done habitually and repeatedly. Usually, it belongs to broken
family or emotionally disturbed family with overcrowded unhealthy environment and having
financial or legal problems. The factors contributing problems are rapid urbanization and
industrialization, social change and change lifestyle, unhealthy student teacher relationship
and lack of discipline. Behavior include lying, run away from home, habitual disobedience,
fights, sexual assault, theft, burglary, truancy from school, etc.
Prevention of juvenile delinquency is possible by elimination of contributing factors. The
problem of delinquent behavior is now increasing in India and other countries. Preventive
measures to be emphasized by healthy family and school environment. Healthy parent child
relationship, tender loving care in the family, fulfillment of basic needs, educational
opportunities, facilities for sports, exercise and recreation, healthy teacher taught relationship,
etc. are important aspects of prevention. Delinquent child needs sympathetic attitude with
necessary guidance and counselling for modification of behavior. Child should be referred to
child guidance clinic for necessary help. A team approach is necessary in management of
this condition including social workers, psychologist, psychiatrists, pediatricians, community
health nurse, school teachers, family members and parents. Modification of social
environment and rehabilitation of the delinquent child should be prompted.
SUBSTANCE ABUSE
Substance abuse or drug abuse is a threatening social problem of school going and
adolescence age group. 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 patters within a given culture. The abused agents
are mainly tobacco, alcohol, sleeping pill, tranquillizers, mood elevators, stimulants, opiates,
cocaine, heroin, cannabis (bhang, ganja). Child have frustration, emotional conflicts and
disturbed family and school relationship. Preventive measures of substance abuse include
provision of adequate facilities for recreation, entertainment, especially in hostels. Proper
channelization of energies of the adolescents into constructive activities, strict
implementation of drug control measures, provision of mental health program and periodical
psychiatric guidance facilities in schools. The addicted children need psychotherapy,
deaddiction services and rehabilitation.
ANOREXIA NERVOSA
Anorexia nervosa is an eating disorder occurs most often in adolescent girls. The problem is
found a refusal of food to maintain normal body weight by reducing food intake, especially
fats and carbohydrates. The affected adolescent girls practice vigorous exercise for weight
reduction or induce vomiting by stimulating gag reflex to remain slim. The child thinks that
they are fat even though they are under weight. Anorexia means loss of appetite, but in this
condition the affected individual experience true hunger though they have absolute control
over their appetite. There is no specific organic cause of 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
dependance.
Management of the condition include psychotherapy, antidepressant drugs, behavior
modification and nutritional rehabilitation. Parent counseling for modification of parent child
relationship is essential. Hospitalization may be needed in complicated cases.
NURSING RESPONSIBILITIES
Nurses play a vital role for prevention, early identification and management of behavioral
disorders in children. Nurses themselves, need to have up to date knowledge and skill related
to the problems.
 Assessment of specific problems 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.
 Promoting healthy emotional development of the child by adequate physical,
psychological and social support.
 Creating awareness about psychological disturbances which may lead to behavioral
problems during developmental stages.
 Providing counseling services for children and their parents to solve their parents,
whenever necessary and for tender loving care of the children.
 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 child with behavioral problems for necessary management and support
to better health care facilities, child guidance clinic, social welfare services and
support agencies.

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