Behavior problems in children are broad term to describe a wide range of problems encountered while rearing up a child. These include sleeping problems, developmental disorder, mental retardation, psychosocial disorders, Tics and habit disorders, anxiety disorders, gender identity disorder and eating disorder. Every child develops individual behaviors depending upon the environment. The definition of normal behavior may differ depending on country, race, family etc. Then, how we measure behavior problems in children? Do not worry; researches developed some tools, which use some criteria. Abnormal behavior can be measured using those criteria. In this discussion, we are going to outline some common behavior problems in children, how to identify it and some modes of treatment. Most of the children who develop behavioral problem have history of family problems, separation and marital problems of their parents and others have history of child abuse or neglect by parents or caregiver, overindulgence, chronic illness and loss events.
Sleep Problems in Children
Sleep problem is one of the common behavior problems in children. Sleep problem can be insomnia or excess sleep. Average sleep duration in newborn is about 14 to 15 hours. They stay awake for 1-2 hours after a 1-3 hours sleep. Many parents think it is problematic. Child who cannot be consoled may have problems like gastro-esophageal reflux, formula intolerance etc. Behavioral insomnia of childhood is a real problem in infant and toddlers. The child when awake at night, do not find settings same as before sleep and cannot sleep again. Many children or their parents cannot maintain bedtime rules and sleeplessness occurs. Many child complain of sleepwalking, sleep paralysis, sleep terrors, nighttime fears/nightmares, nocturnal enuresis, body rocking, head banging and these are termed as parasomnia. Many others suffer from some disease like restless leg syndrome, obstructive sleep apnea and cannot sleep. These diseases need specific treatment. For other aspects of sleep, you should follow some rules.
Parents should have a fixed bedtime or a bedtime routine. Either it is school night or non-school night wake up time and bedtime must be same. You should allow only about one hour difference in those times. Children should avoid playing high energy expending game or work and watching television, computer games etc. stimulating activities just before bed. An hour before there should be a tranquil environment. If your children are hungry, they cannot sleep. Heavy diet before sleep is also a bad idea. You should avoid caffeinated sodas, coffee, tea, and chocolate before bed. Make sure your child have activities outside or regular exercise. The sleeping room of your child should be quiet and dark or semi dark and temperature of the room should be comfortable. Never punish your child in bedroom. Television should be out of your child’s bedroom. Reassurance, patient education and above measures solves most of the sleep problems. In other cases of parasomnia, you should arrange enough safety measures. Use gates in doorways and at the top of staircases, lock outside doors and windows before sleep, and install parent notification systems such as bedroom door alarms. As a behavioral intervention, parents can wake the child every night about 15 to30 minutes before the time when first parasomnia attack happened. Patient with frequent or severe episodes, high risk of injury, violent behavior or serious disruption to the family need drug therapy. The primary pharmacologic agents used are potent slow wave sleep suppressants such as Fenfluramine, benzodiazepines and tricyclic antidepressants. Antidepressants like tricyclic antidepressant and serotonin reuptake inhibitors may be used to control cataplexy, hypnogogic hallucinations, and sleep paralysis. For narcolepsy or hypersomnia, along with these psycho-stimulants modafinil can be used.
Habit and Tic Disorders
These are the most frequently noticed behavior problems in children. Almost all children show some repetitive activity that have no functional value, have no gain of child, no driving force, may have soothing effect and markedly interferes with normal activities of child or results in self-inflicted bodily injury that requires medical treatment. This are termed as habit disorder. If the behavior persists for more than 4 weeks, it is a pervasive developmental disorder. Teeth grinding may start around 5 years and it reduces child’s anxiety. Thumb sucking and nail biting is common child habit disorder. Many child show habits of air swallowing, banging of head, moving body parts or rocking whole body and hitting or biting themselves. In Trichotillomania, the child repetitive pulls of hair, which causes loss of hair. It appears at age about 13 years and there is a sense of tension before pulling hair and sense of relief after pulling hair. A tic is a sudden onset, rapidly occurring, recurrent, non-rhythmic, stereotyped voluntary movement or vocalization. Tics occur every day or with gaps and many times a day. Tics may occur more than 4 weeks to more than 1 year. The age of onset is about 18 years. Tics due to stimulants or disease like Huntington’s disease are not included here.
Habit disorders go away if extra attention is not given to it. Therefore, do not make child worried about it. If there is associated distress in the child or family, social isolation and history of physical injury, treatment is necessary. Various behavior therapy approach is effective. Habit reversal strategy, relaxation therapy, monitoring by parents, use of reinforcements, competing responses, praise for good practice and no praise for negative practice and the use of aversive tasting substances (for thumb sucking or nail biting) have quite good response. Selective serotonin uptake inhibitors may needed in obsessive disorders or anxiety disorders. For tic disorder, Haloperidol, Pimozide, Risperidone and Clonidine found to be effective.
As a part of development process, child develops anxiety and fear. These anxiety when cause significant distress or impairs social functioning or academic performance, it is anxiety disorder. Generalized anxiety disorder, childhood-onset social phobia, school phobia, panic disorder, separation anxiety disorder, obsessive-compulsive disorder, specific phobia and agoraphobia are found in many children. Treatment of underlying psychiatric condition, family therapy, parental training, behavioral and cognitive therapy will bring good results, if treated properly.
Disruptive Behavioral Disorders
These are dangerous behavior problems in children. These behavior problems in children easily draw attention of those in their surroundings and need quick therapy to recover. In this type disorder, the child shows anger or behavior that is out of control of anyone. Many child have all the criteria and many have only few criteria. In oppositional defiant disorder, children loses temper times and then, argues with adults, denies obeying the elder and rules, often annoys people without reason, blames others for own mistake or misbehavior, simple matters annoy them quickly, become angry and resentful frequently and they are spiteful or vindictive very often. When any four of this negative, hostile behavior last for 6 months or more with significant impairment in social, academic or occupational function, it is oppositional defiant disorder.
Child with conduct disorder violates rule in a manner that causes harm or have the potential to harm others. Their parents may also sow no or little concern to others harm. They can do many things. First, they can charge people and animals physically in the form of bullying, fighting to others, carrying and using weapons, cruelty to animals, and sexual offence. They can also destroy others property by setting fire or using weapons to break and enter. They can show deceitfulness or can be thieves. They can tell lie obtains goods or favors, can lift away shops etc. Many often show serious rule violations such as running from home, taking no permission to stay out up to late night and not attending school. When more than three of these symptoms are present at least one year and impair the function at home, at school, or with peers, we diagnose it as conduct disorder.
The treatment of disruptive behavior is very simple. Behavior therapy approaches are most effective. Parents themselves can manage these disorders. We have to teach the parents about social learning principles and about how to develop a warm, friendly, helpful relationship with the child. Then they wil be able interact with child. They should also arrange a well-structured and promising household environment with clear and simple household rules. Parents should always praise or reward positive behavior and ignore negative ones followed by praise when the child abandons annoying behavior. Besides, parents must inform the child about the dangers of annoying behaviors. Social and emotional skill development training based on cognitive, behavioral, social or emotional risk factors is another target of treatment.
Conduct disorder needs multi-systemic therapy. The therapist and the family, school, and peer group must continuously intervene to train skills and develop competencies and rewarding adaptive behavior in the patient. Stimulants like selective serotonin reuptake inhibitors, sodium valproate and atypical antipsychotics often rewarding both for disease process and for comorbidities.
Autism and Pervasive Developmental Disorders
Here there is qualitative impairment in social interaction such as absence of nonverbal interactions, absence peer relations and absence of social reciprocity. They also have impairment in communication such as absence of speech, repetitive speech etc. They have a small world with few repetitive behaviors in same order, few interests and limited activities.
Treatment aims at increasing functional ability of the child to lead an individual life. To do so, a joint approach of speech therapist, psychiatrist, psychotherapist, physician, nurse and teacher is needed. These interventions tries to improve communication skills, social skills, skills for day to day life, playing skills and enjoyment in leisure activities, academic achievement and maladaptive behaviors. They may also get benefit from stimulants, clonidine, valproates and atypical antipsychotics depending on conditions.
Attention Deficit and or Hyperactivity Disorder
They have either inattention or hyperactivity for more than 6 months and to an extent that is inconsistent with particular age. Patient with inattention may show careless mistakes, absence of continued attention, failure to follow instruction, forgetfulness, easily distracted etc. However, who are hyperactive may have fidgets, going beyond the limit, avoiding leisure, excessive talk, problem in waiting turns etc. They can be treated with 10 to 12 sessions of behavior therapy. Psycho-stimulant medications like methylphenidate, amphetamine or various amphetamine and dextro-amphetamine may help them.
In case of adult, eating disorder is nearly synonymous with anorexia nervosa and bulimia but in child there are some bizarre disorders. Pica is an eating disorder where child persistently eat substances that do not have nutritious value for a time 1 month or more. Their eating is not appropriate to development level or cultural practices. Rumination is repeated regurgitation and chewing of regurgitated food. The child do not have any gastrointestinal illness and this last for a period of 1 month or more. For pica, it is important to treat nutrition deficiency and removal of toxicity. Response, reinforcements and redirection is good behavior therapy. Antidepressants sometimes help pica patients. As a behavior approach in rumination, reinforcements or aversive therapy is advocated.