Behavioral Pediatrics PDF - MUCM Semester 5

BEHAVIOURAL PAEDIATRICS Paediatrics Semester 5 MUCM LEARNING OBJECTIVES • Know the common behavioural health problems in children and adolescents • Understand the clinical features or presentation • Multi-disciplinary approach to management • HEADSS screening tool for adolescents DEFINITION ▪...

BEHAVIOURAL PAEDIATRICS Paediatrics Semester 5 MUCM LEARNING OBJECTIVES • Know the common behavioural health problems in children and adolescents • Understand the clinical features or presentation • Multi-disciplinary approach to management • HEADSS screening tool for adolescents DEFINITION ▪ BEHAVIOUR : Refers to actions or reactions of an object or organism usually in relation to environment. ▪ BEHAVIOURAL PROBLEMS : Include disorders that represent significant deviation from normal behaviour. BEHAVIOURAL PAEDIATRICS ▪ Have significant negative impacts on the individual, the family and the society. ▪ Commonly associated with poor academic, occupational, and psychosocial functioning. ▪ Important to be aware of the range of presentation, prevention and management of the common problems in children and adolescents. CATEGORISATION OF BEHAVIOURAL PAEDIATRCS No No 1. Sleep problems 5. Scholastic problems 2. Speech problems 6. Sexual problems 3. Habit problems 7. Personality problems 4. Eating problems 8. Antisocial problems IMPORTANT CONDITIONS 1. 2. 3. 4. 5. 6. 7. 8. Conduct disorder Emotional problems Mixed disorders of conduct and emotions Hyperkinetic or Attention Deficit Hyperactivity Disorder Disorder of social functioning Tic disorders Pervasive developmental disorder (Autism Spectrum Disorder) Miscellaneous - encopresis/enuresis - sleeping and eating disorder ETIOLOGY FACTORS Constitutional • • • • Hereditary Intelligence Coping mechanism Temperament Environmental • Family • Schooling • Community Physical Illness • Diabetes • Asthma • Etc COMMON TYPES OF BEHAVIOURAL PAEDIATRICS EVENING/INFANTILE COLIC ▪ Intermittent episodes of abdominal pain and severe crying in normal infants ▪ Crying in late afternoon or evening ▪ Infant cries > 3 hrs per day > 3 days per week > 3 weeks ▪ Begins with a loud cry, crying continuous ▪ Face becomes red and legs drawn up on the abdomen ▪ Abdomen becomes tense ▪ Attack terminates after exhaustion or passage of flatus or faeces Abdominal bloating Acute gastric and intestinal pain Trapped stomach & intestinal gas Allergic reaction CAUSES AND SYMPTOMS Intense & Prolonged crying Sleeplessness & Exhaustion Stressed Out Parents Colic Immature GIT/CNS Acid reflux Over stimulation Gas producing foods Air intake from Feeding/Crying INFANTILE COLIC Management: ▪ During the episode : Hold baby erect or prone Avoid drugs ▪ Counselling-coping with the parents Reassure the parents that infant is not sick They need to soothe more with repetitive sound and stimulate less BREATH HOLDING SPELLS ▪ Occurs in children between 6 months to 5 years of age. ▪ Involuntary pause in breathing sometimes accompanied by loss of consciousness. ▪ It is observed in response to frustration or anger. ▪ Children with iron deficiency anaemia have increased episodes. BREATH HOLDING SPELLS ▪ Starts with violent crying, hyperventilation and sudden cessation of breathing cyanosis and rigid. ▪ Become limp, pale and lifeless ▪ No treatment is usually required. ▪ Iron supplements TEMPER TANTRUMS ▪ Sense of autonomy is developed by 18 months to 3 years old ▪ Child display defiance, negativism/oppositionist by having temper tantrums. ▪ Normal part of child development. ▪ Gets reinforced when parents respond to it by punitive anger. ▪ Child wrongly learns that temper tantrums are reasonable response to frustration TEMPER TANTRUMS Precipitating Factors: ▪ Hunger ▪ Fatigue or Lack of sleep ▪ Innate personality of child ▪ Ineffective parental skills ▪ Over pampering ▪ Dysfunctional family/family violence ▪ School aversion TEMPER TANTRUMS Management: ▪ Parents are advised to set good examples to child ▪ Pay attention to child ▪ Spend quality time ▪ Have open communication with the child During temper tantrums: ▪ Parents to ignore child and once child is calm, tell child that such behaviour is not acceptable. ▪ Verbal reprimand should not be abusive. ▪ Never beat or threaten child. ▪ Impose Time Out if temper tantrum is disruptive THUMB SUCKING ▪ Common habit ▪ Most stopped by 2 - 5 years of age. ▪ Resumption or Continuation of habit suggests that child is suffering from stress or insecurity. ▪ Complications: malocclusion or misalignment of teeth, difficulty in mastication and swallowing. ▪ It may cause facial distortion, deformity of thumb and speech difficulties. MANAGEMENT: ▪ Self-remitting nature ▪ Improve parental attention ▪ Teach parent to ignore and give more attention to positive aspect of child’s behaviour. ▪ Child should be praised and encouraged if child indulges in activities other than thumb sucking. ▪ Use of bitter agents, tying a cloth on thumb, thumb splints or gloves or thumb T guards. NAIL BITING ▪ Common disorder among children, adolescents and also adults. ▪ It is most common in 10-14 years but can occur as early as 4 years. ▪ Biting all ten fingernails, cuticle and soft tissue leads to bleeding, infection and inflammation. ▪ A manifestation of emotional insecurity. MANAGEMENT: NAIL BITING ▪ Behavioural reinforcement such as positive reinforcement. ▪ Relaxation exercises ▪ Positive emotional support. HEAD BANGING ▪ Rhythmic hitting of the head against a solid surface often the crib mattress ▪ 5-20 % of children – infancy and toddler years ▪ Benign and self-limiting ▪ Can result in callus formation, abrasions and contusions HEAD BANGING Management: ▪ Assurance- significant injury is unlikely ▪ Teach parents to ignore as concern and punishment can reinforce it. ▪ Padding TICS ▪ Sudden, Repetitive, Nonrhythmic, Motor movement or Vocalisation involving discrete muscle group. ▪ Motor tics can be found as lip smacking, tongue thrusting, eye blinking, grimacing, shoulder jerking and twitching of fingers. ▪ Vocal tics are found as throat clearing, barking, sniffing, coughing etc. TICS Management: ▪ Parents should be counselled that the disorder may spontaneously resolve. ▪ Behaviour therapy - habit reversal training. ▪ Relaxation exercises have proven efficacy. ▪ Medications to control severe symptoms- haloperidol ENURESIS (BED WETTING) ▪ More than 85 % children will have complete Diurnal and Nocturnal Control of Voiding of Bladder by 5 years of age. ▪ Enuresis occurs if a child has normal nearly complete evacuation of bladder at wrong place and time at least 2 x a month after 5 years of age. ENURESIS Primary: Bed wetting in children who have never been dry for extended periods Secondary: Onset of wetting after a period of established urinary continence ENURESIS Causes: ▪ Neurological developmental issues eg tethered cord syndrome ▪ Infection-urinary tract infection ▪ Physical abnormalities- smaller bladder than normal ▪ Insufficient anti diuretic hormone production ▪ Others : Stress, Psychological, Caffeine, Improper toilet training Alcohol abuse INVESTIGATIONS ▪ Full medical history (toilet training, parents attempts at coping with problem) ▪ Time, duration, total incidence etc. ▪ Genital and neurological examination. ▪ Urine examination for albumin, sugar, microscopy, specific gravity and culture. ▪ Tests for diabetes mellitus, diabetes insipidus , chronic renal failure. ▪ If evidence of UTI, he should be evaluated with USG, voiding cystourethrogram and urodynamic studies. MANAGEMENT ▪ Education for parents and giving information on enuresis ▪ Remind child to empty bladder 2 nd hourly. ▪ Teach bladder stretching exercises ▪ Reward system for dry nights. ▪ Treat constipation. ▪ Discourage fluid intake after 5 pm ▪ Bed wetting alarm ▪ Medications- desmopressin, oxybutynin, tricyclic antidepressants (imipramine) ENCOPRESIS ▪ Repeated involuntary or intentional passage of faeces in inappropriate places (clothing or floor). ▪ Event must occur once a month for at least 3 months and chronological age or developmental age of child must be at least 4 years. ▪ Primary encopresis: never achieved faecal continence by 4years of age ▪ Secondary encopresis: faecal incontinence in child over 4 years of age after a period of established faecal continence . ENCOPRESIS CAUSES : ▪ Birth of new sibling ▪ Moving to new house ▪ Changing of school ▪ Unfamiliar toilet facility ▪ Anal fissures ▪ Emotional problems ▪ Busy schedule ▪ Disturbed mother and child relationship ENCOPRESIS Management: ▪ History ▪ Physical assessment ▪ Help the child to sit in toilet at routine intervals ▪ Diet management with high fibres ▪ Administer enema, suppository if prescribed ▪ Behaviour therapy ▪ Family counselling EATING DISORDER - PICA ▪ Disorder of eating non-edible substances such as clay, paints, chalk, pencil, plaster from wall, earth, scalp hair. ▪ Normal up to age of 2 years ▪ Persistence may be a manifestation of parental neglect or supervision or lack of affection. EATING DISORDER - PICA ▪ Common in poor socioeconomic family, in malnourished and mentally subnormal children ▪ Screening indicated for Iron deficiency anaemia Worm infestations Lead poisoning Family dysfunction ▪ Treat cause accordingly ▪ Usually remits in childhood EATING DISORDER - ANOREXIA NERVOSA Psychosomatic disorder characterised by self-starvation intense fear of gaining weight and a distorted body image Causes: Genetic role Neurobiological factors Nutritional factors Psychological factors Social and environmental factors ANOREXIA NERVOSA Sign / symptoms: Diagnosis: ▪ Loss of menstrual periods ▪ History taking ▪ Extreme concern with body ▪ Family history weight and shape ▪ Feeling of being fat despite dramatic weight loss ▪ Fear of weight gain ▪ Denial of hunger ▪ Excessive exercise regimen ▪ Risk of heart failure, kidney failure, bone problems ▪ Check for fluid and electrolytes ▪ Psychiatric consultation ▪ Hormonal assessment ANOREXIA NERVOSA MANAGEMENT: ▪ Diet management ▪ Behaviour therapy Address thoughts, feelings and beliefs concerning food and body image and devise strategies to change behaviour. ▪ Encourage family support ▪ Treat any physical complications and associated mental health problems BULIMIA NERVOSA ▪ Characterised by episodes of binge eating followed by inappropriate methods of weight control ( vomiting/purging) ▪ No definite cause Complications: ▪ Dental cavities, sensitivity to hot, cold food ▪ Swelling and soreness in salivary glands ▪ Stomach ulcer ▪ Rupture of stomach and esophagus ▪ Electrolyte imbalance ▪ Dehydration BULIMIA NERVOSA ▪ Purging type: during episode of bulimia nervosa, person is regularly engaged in self induced vomiting or misuse of laxatives ▪ Non purging type: during episode, person is engaged in activities other than above mentioned like excessive exercise Management: ▪ Behaviour modification techniques - individual, group or family counselling ▪ Antidepressant drugs ▪ Support groups- overeaters anonymous may help. SPEECH PROBLEMS ▪ Stammering ▪ Stuttering ▪ Mutism ▪ Articulation disorder SPEECH DISORDER - STUTTERING ▪ Characterised by hesitation or stumbling and spasmodic repetition of some syllabus with pauses. ▪ Difficulty in pronouncing initial consonants and it is caused by spasm of lingual and palatal muscles ▪ Environmental and emotional stress Management: ▪ Do not remind the child the mistake and ridicule him ▪ Do not show undue concern and accept his speech ▪ Reassure parents ▪ Speech therapist SCHOOL PHOBIA Management: ▪ Habit formation ▪ Persistent and abnormal fear of going to school ▪ It is an emotional disorder ▪ Play session and other recreational activities at school ▪ Improvement of school environment ▪ Assessment of health status of the child ▪ Family counselling SLEEP DISORDERS Could manifest as : Management: ▪ Difficulty falling asleep / ▪ Stay with child Insomnia ▪ Don’t leave child unattended ▪ Somnambulism (sleep walking) ▪ Doors and windows to be kept closed ▪ Sleep talking ▪ Dangerous objects removed ▪ Night terrors / Night mares ▪ Pleasant stories or scene at bedtime ▪ Narcolepsy ▪ Provide emotionally healthy environment ATTENTION DEFICIT HYPERACTIVITY DISORDER Impulsivity ADHD Inattention Hyperactivity ATTENTION DEFICIT HYPERACTIVITY DISORDER ▪ Commonest neurodevelopmental disorder of childhood ▪ 3-5 % school aged children Causes▪ Genetic factor ▪ Maternal smoking and alcohol use during pregnancy ▪ Prenatal or postnatal exposure to lead ▪ Abnormal brain structures ATTENTION DEFICIT HYPERACTIVITY DISORDER ▪ Developmentally inappropriate ▪ Begin before 7 years of age ▪ Present for at least 6 months ▪ Present in 2 or more settings ▪ Must not be secondary to another disorder ATTENTION DEFICIT HYPERACTIVITY DISORDER Diagnosis: Management: Clinical interview and history Behaviour rating scales Physical examination Laboratory tests Neuropsychological evaluationintelligence and educational achievements Behaviour therapy Clear & explicit instructions to child about desirable & non desirable behaviour Positive reinforcement Verbal reprimand, non-verbal gestures or timeout Systematic ignoring of undesirable behaviour Extinction technique Medications- methylphenidate, amphetamine, atomoxetine CONDUCT DISORDER ▪ Frequent refusal to obey parents ▪ Tendency to use drugs ▪ Lack of empathy for others ▪ Aggressive to animals and others ▪ Frequent lying ▪ Keenness to start physical fights and using weapons ▪ Tendency to run away from home ▪ Suicidal tendencies ▪ Criminal behaviour OPPOSITIONAL DEFIANT DISORDER ▪ Easily angered, annoyed or irritated ▪ Frequent temper tantrums ▪ Argues frequently ▪ Refuses to obey rules ▪ Low frustration threshold ▪ Seem to blame others ANTI-SOCIAL – JUVENILE DELINQUENCY ▪ Unlawful activities done habitually and repeatedly Management: ▪ Elimination of contributing factors ▪ Healthy parent child relationship ▪ Child guidance clinic ▪ Modification of social environment ▪ Rehabilitation of delinquent child EMOTIONAL PROBLEMS ▪ Anxiety ▪ Phobias ▪ School Refusal ▪ Obsessive-Compulsive ▪ Adjustment Disorders ▪ Depression ▪ Post-traumatic stress disorder PSYCHOSOCIAL HISTORY – ADOLESCENT - HEADSS INTERVIEW H E E A D S S S Home Education / Employment, Peer group Eating disorder Activities Drugs / smoking / vaping Sexuality Suicide/depression Safety SUMMARY • All age groups can be affected with behavioural problems • Varied clinical features and presentation • Some conditions may be self-limiting • Others may be life-threatening if not diagnosed and managed properly • Multi-disciplinary approach to management • For adolescents’ history taking, remember your HEADSS THANK YOU