objectives

• Behavioral problems in children definition

and classification
Nocturnal enuresis (NE) :
• Physiology of normal bladder control in
children
• Definition and classification of NE
• Epidemiology and Pathogenesis of NE
• Management options of NE

6/7/2018 2
 Behavioral disorders
definition
When children cannot adjust to a
complex environment around them,
they become unable to behave in the
socially acceptable way resulting in
exhibition of peculiar behaviours and
this is called as behavioural problems.

6/7/2018 3
 causes
• Faulty Parental Attitude

• Inadequate Family Environment

• Mentally And Physically Sick or

Handicapped Conditions

• Influence of Social Relationships

• Influence of Mass Media

6/7/2018 4
 AGE
CLASSIFICATION
OF BEHAVIOURAL
DISORDERS
NATURE

5
 Classification of behavioral
disorders
Age Nature
• Infancy • Movements
• Childhood • Habits
• Adolescence • Toileting
• Speech
• Sleep
• School
• Eating
6/7/2018 6
INFANCY
– Impaired appetite or Resistance to
feeding
– Abdominal Colic
– Stranger Anxiety

7
CHILDHOOD
• Temper tantrums • Attention Deficit Hyper
• Breath holding spell Activity Disorder (ADHD)
• Thumb sucking • Conduct Disorder
• Nail biting • Speech Problems
• Enuresis or Bed wetting – Stuttering
• Encopresis – Cluttering
• Pica – Delayed Speech
• Tics or Habit spasm • Sleep Disorders
• School Phobia – Sleep walking
• Autistic spectrum – Sleep talking
disorders – Bruxism
8
 ADOLESCENCE
• Masturbation
• Juvenile Delinquency
• Substance Abuse
• Anorexia Nervosa
• Homosexuality

9
10
Problems of Movements
• Head Banging
• Breath holding Spells
• Temper tantrums
• Tics

Problems of habit
• Thumb sucking
• Nail biting
• Pica
• Trichotillomania 11
Problems of Toilet Training
• Enuresis
• Encopresis

Problems of Speech
• Stuttering
• Elective mutism

Problems at School
• School Phobia
12
Sleep Disorders
• Somnambulism
• Nightmares

Eating Disorders
• Anorexia Nervosa
• Bulimia Nervosa
• Pica

13
Nocturnal
Enuresis

14
 NORMAL VOIDING AND TOILET
TRAINING
▒ The infant has coordinated, reflex
voiding as often as 15 to 20 times per
day
▒ At 2-4 yr, toilet training begins
▒ When grow up;
Average bladder capacity (Ounces)
= Age (yr)+ 2
( Up to the age of 12-14 yr )

6/7/2018 15
 NORMAL VOIDING AND TOILET
TRAINING (Cont.)

• Girls typically acquire bladder control before

boys, and bowel control is typically achieved
before urinary control.
• By 5 yr of age, 90-95% are nearly completely
continent during the day and 80-85% are
continent at night

6/7/2018 16
 Steps of normal conscious
bladder control

• To achieve normal conscious bladder

control, several steps must occur:
1.Awareness of bladder filling
2.Cortical inhibition (suprapontine
modulation) of reflex (unstable)
bladder contractions

6/7/2018 17
Steps of normal conscious
bladder control (cont.)

3.Ability to consciously tighten the

external sphincter to prevent
incontinence
4.Normal bladder growth
5.Motivation by the child to stay dry.

6/7/2018 18
19
 Nocturnal enuresis

Definition
• The occurrence of involuntary voiding
at night at 5 yr, the age when
volitional control of micturition is
expected.

6/7/2018 20
 Nocturnal enuresis (cont.)

• Enuresis may be
1. Primary (75%)
Nocturnal urinary control never
achieved
2. Secondary (25%)
The child was dry at night for at
least a few months and then enuresis
occurs .
•
6/7/2018 21
 Nocturnal enuresis (cont.)

* 75% of children with enuresis are

wet only at night
* 25% are wet day and night.
This distinction is important because
the pathogenesis of the two patterns
is different.

6/7/2018 22
 Epidemiology
• Approximately 60% of children with
nocturnal enuresis are boys.
• Family history is also important and is
positive in 50% of cases.
• Although primary nocturnal enuresis may
be polygenetic, candidate genes have been
localized to chromosomes 12 and 13.

6/7/2018 23
 Epidemiology (cont.)

• If one parent was enuretic, each child has

a 44% risk of enuresis;
• If both parents were enuretic, each child
has a 77% likelihood of enuresis.

6/7/2018 24
 Epidemiology (cont.)

• Nocturnal enuresis without overt daytime

voiding symptoms affects up to 20% of
children at the age of 5 yr
• It ceases spontaneously in approximately
15% of involved children every year
thereafter.
• Its frequency among adults is less than 1%.

6/7/2018 25
 Pathogenesis of primary
nocturnal enuresis
Is multifactorial and includes the
following:

1. Delayed maturation of the cortical

mechanisms that allow voluntary control
of the micturition reflex.
2. Sleep disorder-enuretic children, who
are classically described as being deep
sleepers, although no specific sleep
pattern has been described. Enuresis can
occur in any stage of sleep .

6/7/2018 26
 Pathogenesis of primary
nocturnal enuresis (cont.)

3.Reduced antidiuretic hormone production

at night, resulting in an increased urine
output, which explains why children with
enuresis often are described as "soaking
the bed."
4.Genetic factors, with chromosomes 12 and
13q the likely sites of the gene for
enuresis; family history is often positive
in enuretic children, as described earlier.

6/7/2018 27
 Pathogenesis of primary
nocturnal enuresis (cont.)
5. Psychologic factors, often implicated in
secondary enuresis.
6. Organic factors, such as urinary tract
infection (UTI) or obstructive uropathy,
which is an uncommon cause of enuresis.
7. Sleep apnea (snoring) secondary to
enlarged adenoids.

6/7/2018 28
 Clinical Manifestations and
Diagnosis
• A careful history should be obtained,
especially with respect to fluid intake at
night and pattern of nocturnal enuresis.
• Children with diabetes insipidus, diabetes
mellitus, and chronic renal disease may
have a high obligatory urinary output and a
compensatory polydipsia.

6/7/2018 29
 Clinical Manifestations and
Diagnosis (cont.)

• The family should be asked whether the

child snores loudly at night.
• A complete physical examination should
include palpation of the abdomen and
rectal examination after voiding to assess
the possibility of a chronically distended
bladder.

6/7/2018 30
 Clinical Manifestations and
Diagnosis (cont.)

• The child with nocturnal enuresis should

be examined carefully for neurologic and
spinal abnormalities.
• There is an increased incidence of
bacteriuria in enuretic girls, and, if found,
it should be investigated and treated

6/7/2018 31
 Clinical Manifestations and
Diagnosis (cont.)
• Urinalysis should be obtained after an
overnight fast and evaluated for specific
gravity or osmolality, or both, to exclude
polyuria as a cause of frequency and
incontinence and to ascertain that the
concentrating ability is normal.
• The absence of glycosuria should be confirmed.

6/7/2018 32
 Clinical Manifestations and
Diagnosis (cont.)
• If there are no daytime symptoms and if
the physical examination and urinalysis are
normal, and culture is negative, further
evaluation for urinary tract pathology
generally is not warranted.
• A renal ultrasonogram is reasonable in an
older child with enuresis or in children who
do not respond appropriately to therapy.

6/7/2018 33
 Treatment
• The best approach to treatment is to
reassure parents that the condition is
self-limited and to avoid punitive measures
that may affect the child's psychologic
development adversely.

6/7/2018 34
 Treatment (cont.)

• Fluid intake should be restricted to

* 2 oz after 6 or 7 o'clock in the evening
if the child weighs less than 75 lb
* 3 oz if the child weighs 75 to 100 lb
* 4 oz if the child weighs more than 100 lb.

6/7/2018 35
 Treatment (cont.)
• The parents should be certain that the
child voids at bedtime.
• If the child snores and the adenoids are
enlarged, referral to an otolaryngologist
should be considered, because
adenoidectomy may result in cure of the
enuresis.

6/7/2018 36
 Active treatment

• Should be avoided in children younger than

age 6 yr because enuresis is extremely
common in younger children.
• The simplest initial measure is motivational
and includes a star chart for dry nights.

6/7/2018 37
 Active treatment (cont.)

• Waking children a few hours after they go

to sleep to have them void often allows
them to awaken dry, although this measure
is not curative.
• Some have recommended that children try
holding their urine for longer periods
during the day, but there is no evidence
that this approach is beneficial.

6/7/2018 38
 Active treatment (cont.)
• Conditioning therapy involves use of an auditory
alarm attached to electrodes in the underwear.
The alarm sounds when voiding occurs and is
intended to awaken children and alert them to
void.

• This form of therapy is considered curative and

has a reported success of 30-60%. Often the
alarm wakes up other family members and not the
enuretic child; persistence for several months is
necessary.

6/7/2018 39
 Active treatment (cont.)

• A vibratory alarm is available also.

• Conditioning therapy tends to be
most effective in older children.

6/7/2018 40
 Pharmacologic therapy
• Is intended to treat the symptom of
enuresis and is not curative.

• One form of treatment is desmopressin

acetate,
□ which is a synthetic analog of
antidiuretic hormone and reduces urine
production overnight.
□ It is available as a tablet, with a
dosage of 0.2-0.6 mg at bedtime.
Desmopressin acetate is effective in as
many as 40% of children.
6/7/2018 41
 Desmopressin acetate, (cont.)
□ If effective, it should be used for 3-6
mo, and then an attempt should be
made to taper it.
□ If tapering results in recurrent enuresis,
the medication may be started again at
the higher dosage.
□ No adverse events have been reported
with the long-term use of desmopressin
acetate.

6/7/2018 42
 Pharmacologic therapy
(cont.)
• Another pharmacologic agent is Imipramine,
which is a tricyclic antidepressant.
• This medication has mild anticholinergic and α-
adrenergic effects and may alter the sleep
pattern also.
• The dosage of imipramine is
- 25 mg in children age 6-8 yr
- 50 mg in children age 9-12 yr, and
- 75 mg in teenagers.

6/7/2018 43
 Pharmacologic therapy
(cont.)

• Reported success rates are 30-60%.

• Side effects include anxiety, insomnia, and
dry mouth. In addition, the drug is one of
the most common causes of poisoning by
prescription medication in younger siblings.
• Oxybutynin chloride
a pure anticholinergic agent, has been used
in some children with primary nocturnal
enuresis, but the response rate is low.

6/7/2018 44
 Summary
• At 2-4 yr, toilet training begins
• By 5 yr of age, 90-95% are nearly completely
continent during the day and 80-85% are
continent at night
• Enuresis may be Primary (75%)or Secondary
(25%)
• Family history is positive in 50% of cases.

6/7/2018 45
 Summary (cont.)
• If one parent was enuretic, each child has a 44%
risk of enuresis;
If both parents were enuretic, each child has a
77% likelihood of enuresis
• The best approach to treatment is to reassure
parents that the condition is self-limited
• The simplest initial measure is motivational
• Active treatment include
1. Conditioning therapy
2. Psychological therapy
3. Pharmacologic therapy

6/7/2018 46
 Thank you

6/7/2018 47