Behavioral Disorders 2022 PDF

Behavioral disorders By Dina EL Bayaa Lecturer of pediatrics Port said university , faculty of medicine  Learning objectives At the end of the session you will be able to:  Discuss toilet training  Explain the causes and management of nocturna...

Behavioral disorders By Dina EL Bayaa Lecturer of pediatrics Port said university , faculty of medicine  Learning objectives At the end of the session you will be able to:  Discuss toilet training  Explain the causes and management of nocturnal enuresis in children.  Differentiate between different types of eating disorders.  Demonstrate how to diagnose and treat pica in children Toilet Training Definition: toilet training is teaching the toddler to gain control of urine and bowel movements. Time to start toilet training Children develop at different rates, and you should only begin potty training when your child is ready At 2-4 years training begins. Early training (before age 1yr) should be discouraged. By the age of three years, nearly all children are able to control their bladder and bowels during the day. Girls achieve bladder control before boys and bowel control is achieved before urinary control Duration for a child to become trained An average time frame for success in toilet training is 3 to 6 months It is common, however, for children to continue to wet at night until they are five years old. By 6 years of age, most children do stay dry all night. Signs for good training The children understand and use the family term for filling their nappy. They hold themselves when they need to go to the toilet. Asking for a clean nappy immediately after filling it. Basic principles behind good toilet training A key factor for parents to recognize successful toilet training is readiness of the child.  Readiness is present if a child communicates to his parents before the passage of urine and stools and can withhold elimination for a brief period of time. Proceed slowly, and take signals from the child.  Never force the child. Give the child a feeling of active participation, control and independence.  Do not start at a high stress time, like around the time of moving house, or the birth of a new baby.  Take the child to the toilet at night before bedtime. When dry nappies are noted in the morning, try the child without nappies at night. Next, lead the child to the potty 1-3 times per day (regular times) end encourage them to sit. A “high-yield" time for sitting tends to be after meals. A few minutes should be enough. The child can look at books or play with a small toy while he or she sits. Praise the child for every step in the right direction and keep your attitude positive. Advise the parents to ask the child to use the potty/toilet next time. Nocturnal enuresis  Classification  l. according to timing : Nocturnal: Night time; Good prognosis Diurnal: Day & Night Bad prognosis. 2.according to onset Primary: No dry period before  Secondary: Dry period 6 months before 3.according to associated symptoms : Monosymptomatic: Only bed wetting. Polysymptomatic: Other symptoms; dysuria, frequency, urgency... Definition: It is repeated involuntary voiding during sleep after the expected age of control (=5 years) Incidence:  At the age of 5 years:20% At the age of 10 years: 5% At the age of 15 years: 1% Boys to girls 3:2. Children with enuresis usually have psychological problems. It ceases spontaneously in most cases.  Etiology 1- primary enuresis (80%): Maturation delay of bladder control Genetic factors: Family history is positive in 50%. decrease ADH production at night (nocturnal polyuria)  Sleep disorders Adenoid hypertrophy Secondary enuresis (20%) Pathological causes of enuresis: diabetes mellitus, diabetes insipidus, neurologic or spinal abnormalities or, (e.g. spina bifida), renal abnormalities with polyuria. Investigations: to rule out pathological causes Urine examination. Plain x ray to spinal column to detect spina bifida. Urodynamic study when there are symptoms of neurogenic bladder as urgency or hesitancy.  management Simple measures (children >4 year) Explain to the parent and child that the problem is common and beyond conscious control so punishment should be avoided. decrease Fluid intake in the evening  Urination before sleep  Waking the child up few hours after sleep to void.  Rewarding for dry nights   Drug therapy (children >6 year) a. Anticholinergic (increase the bladder capacity): Oxybutynin b. Desmopressin (synthetic vasopressin analogue): Single night dose  c. Enuresis alarms (conditioning therapy): Auditory or vibratory alarm is attached to a wetness sensor in the underwear (wake the child up for urination) Motivational therapy includes: Star chart for dry nights. Waking children by using an alarm clock once 2-3 hours after falling asleep to take him or her to the bathroom is indicated. Holding urine for longer periods during the day is not beneficial Conditioning therapy: the use of conditioning device (e.g. an alarm that rings when the child wets a special sheet) is helpful in training the child to improve bladder capacity and avoid enuresis. The devices awaken children and alert them to void. This form of therapy is considered curative in older children. Pharmacotherapy: Active treatment is avoided in children younger than six years. They have good initial response and they are usually used for 3-6 months. 1.Desmopressin acetate (synthetic analog of antidiuretic hormone),  reduce urine production overnight  is available as a tablet and a nasal spray  given at bedtime  used for 3-6 month then taper the dosage. If tapering results in recurrence of enuresis, the child should return to the higher dosage. 2. anticholinergic therapy (oxybutynin) is given particularly if there are diurnal symptoms. For therapy of resistant enuresis 3.Imipramine (tricyclic antidepressant, tofranil): 25 mg in children age < 6-8 yr 50 mg in children age >6-8 yr 75 mg in teenagers, before bed time orally. It should be stopped gradually. Eating disorders  Definition Eating disorders : are medical illnesses marked by severe disturbances in a person’s eating behaviors. Those with eating disorders often have an unhealthy obsession with food, body weight, and shape.  This can affect a person’s emotional, mental, and physical health.  causes Genetics (heredity), hormones, psychological factors, and social circumstances can contribute to eating disorders with these risk factors: Mental health conditions Negative self-image and weight stigma Eating problems during early childhood Social or cultural ideas about health and beauty Perfectionism Abuse or bullying  Types of eating disorders 1- Binge Eating Disorder Binge episodes (eating large quantities quickly) Eating even when not hungry and until uncomfortably full Eating in secret and feeling ashamed or guilty Frequently dieting, possibly without weight loss  2- anorexia nervosa Those with anorexia nervosa have : a distorted body image and an intense fear of gaining weight. People with this disorder obsess about food intake. see themselves as overweight even if they are underweight. They may diet or exercise excessively and lose more weight than is considered healthy for their age and height.  3- Bulimia nervosa Adolescents with bulimia nervosa use strategies after binge eating to avoid weight gain. These strategies include: Excess use of laxatives or diuretics Fasting Self-induced vomiting Intense exercise The difference between bulimia nervosa and binge eating disorder is that those with binge eating disorder may try these strategies occasionally, but it is not their regular pattern.  Treatment 1- Monitoring The healthcare team may monitor nutrition, weight, and lab work through direct observation and patient logs to prevent dehydration and life threating electrolyte disturbances 2-Nutritional Counseling Dietitians are an integral part of the healthcare team and provide education about nutrients and proper amounts of food based on an individual’s size, age, gender, circumstances, and needs.  3- Therapy Cognitive behavioral therapy (CBT) is an excellent tool in helping patients change their thoughts and behaviors about food and their body. Family-based treatment (FBT): In this model of treatment, the family is considered part of the solution to disordered eating. Support groups: This is a great way for patients and families to listen to and share with those who understand their struggle 4-Inpatient Medical Care A person with severe or life-threatening health complications may need to be hospitalized. These complications include: Severe dehydration Significant decrease in blood pressure or pulse Severe depression or suicidal ideations (thinking about committing suicide) Weight loss despite treatment Weighing less than 75% of their ideal body weight Treating Severe Malnutrition  Case scenario A 5 years old girl presented with abdominal pain and distention examination of stool shows long pink and round worms.blood count shows eosinophilia. Her mother told she has a habit of eating soil.  a) what is your diagnosis ? b)How will you treat the patient ? Pica  Definition: Repeated or chronic ingestion of non- nutritive substance as mud, clay, rocks, paper, ice, crayons, hair, paint chips, chalk, or feces (poop). Young kids often put non-food items (like grass or toys) in their mouths because they're curious about the world around them. But kids with pica sometimes they eat things that can lead to health problems. Risk Factors:  Developmental problems, such as autism or intellectual disabilities  Mental health problems, like obsessive- compulsive disorder or schizophrenia  Malnutrition or hunger, low levels of nutrients like iron or zinc might trigger specific cravings.  Stress: poverty, child abuse or neglect. Clinical manifestations: Iron-deficiency anemia Lead poisoning, from eating dirt or paint chips with lead Constipation or diarrhea, from eating things the body can't digest (like hair) Intestinal infections, from eating soil or poop that has parasites or worms Intestinal obstruction, from eating things that block the intestines Mouth or teeth injuries Investigations Check for anemia or other nutrition problems Serum lead levels Stool analysis for parasites X-rays or other imaging tests to find out what the child ate or to look for bowel problems, such as a blockage Treatment  Try to prevent kids from getting the non- food things they eat  Nutritional rehabilitation.  Psychotherapy, and antidepressant in depressed patient.  Iron therapy in cases with iron deficiency anemia. Breath holding spells Breath holding spell is a condition that mimic seizures. It can occur repeatedly within few hours or it can recur sporadically. The most possible etiology is autonomic dysfunction precipitated by iron deficiency. Breath holding spells are rare before 1 year of age, they peak at about 2 years of age and they disappear by 5 years of age. They are used by infants and toddlers in an attempt to control their environment and their care givers. Clinical manifestations Breath holding spell is characterized by initial cry (which may be absent) followed by stoppage of respiration (apnea) in the expiratory phase with cyanosis and /or pallor. Sometimes when prolonged it may end with loss of consciousness and seizures (generalized clonic jerks). The clinical manifestation is owing to cerebral anoxia. Types: Cyanotic type: the child undergoes marked cyanosis. Pallid type: usually occurs after occipital trauma which is followed by pallor. The initial cry is usually absent. There is bradycardia due to vagal stimulation. Mixed type when both cyanosis and pallor occur together. Treatment: Reassurance that the condition is self-limited, not life threatening, not related to epilepsy. Avoid mechanical methods to stop the attack as painful trauma, water emersion or mouth-to-mouth breathing. You can stop the attack before stoppage of breathing, but once breathing stopped the attack will be completed. Iron therapy gives complete recovery in the majority of cases. Oral atropine is beneficial particularly in the pallid type.