Behavioral disorders – Development of behavior in children is a complex process, influenced by inherent temperament as well as exogenous influences like family and social environment.  Consequently, all children, like all adults, have unique behavioral traits, usually within the acceptable limits of deviance. It is important to differentiate these benign behavioral disorders from organic brain disorders or psychopathic disorders, which require more detailed evaluation, expert referral and intensive management.

Behavioral disorder

The term “Behavioral disorders” denote “a spectrum of abnormal behavior patterns in children, ranging from transient, minor and essentially benign habit disorders to chronic and debilitating psychiatric illnesses’ Although termed as disorders, many of these problems are mere aberrations in normal behavior, which may disappear with age.

Common behavioral disorders in Children

A) Vegetative

• Eating disorders: Pica, Rumination, Anorexia nervosa

• Elimination disorders: Enuresis, Encopresis

• Sleep disorders: Night-terrors, Somnambulism

B) Habit

• Benign: Bruxism, Ticks, thumb sucking/nail biting

• Organic: Gil/es de ía tourette syndrome

• Speech disorders: Stuttering, Stammering

C) Disruptive or antisocial

• Benign: Breath holding spells, Temper tantrums

• Conduct disorders: Lying, Stealing, Truancy

• Juvenile delinquency

• Sexual disorders: Masturbation, Homosexuality

D) Personality (Emotional)

• Anxiety neurosis

— Phobias: School phobia, social phobia

— General anxiety disorder

— Obsessive-compulsive disorder

— Post-traumatic stress disorder (PTSD)

• Affective (mood)

— Depression, suicide/attempted suicide

— Dysrrhythmic disorder

— Bipolar disorders (Cyclic mood changes)

E) Psychosomatic behavioral disorders

• Psychosomatic: Diabetes, Asthma, Ulcerative colitis

• Conversion reactions: Hysteria

• Fictitious: Munchansen by proxy syndrome

G) Pervasive development (Psychosis)

• Autistic disorders: Autism, Asperger disorder

• Attention deficit-hyperactivity disorder (ADHD)

• Others: Rett syndrome, childhood schizophrenia

Management of pica includes —

a) Treatment of predisposing and complicating factors e.g. iron deficiency anemia, helminthiasis & lead poisoning;

b) Parental counseling regarding — i) benign and self- limiting nature of problem, ii) need to provide emotionally stimulating environment to child and iii) supervision to keep the potentially dangerous substances out of the reach of child;

c) behavioral disorders strategies e.g. positive reinforcement, occasional negative reinforcement or mild aversion therapy.

Rumination is a rare but severe vegetative disorder in infants (3-12 months), characterized by self-induced or spontaneous regurgitation of food after feeding. It is more common in males and emotionally deprived children, often leading to severe failure to thrive and occasionally death.

Enuresis is the commonest vegetative (elimination) behavioral disorders, characterized by repeated involuntary passage of urine, beyond the normal age for toilet training and bladder control. Although the day and night-time bladder control is usually achieved by — 18 and 30 months respectively, occasional bedwetting is not uncommon till 9-10 years. Depending on the time of occurrence, it is termed as nocturnal enuresis (only during sleep) or mixed (nocturnal as well as diurnal). Isolated diurnal enuresis is extremely rare.

Diagnostic criteria of behavioral disorders: As per DSM IV criteria, enuresis is defined as ‘repeated involuntary or intentional voiding of urine into bed and clothes beyond 5 years of age, with —

a) Frequency of atleast twice a week for atleast 3 consecutive months, or

b) Presence of significant emotional, social or academic impairment, and

c) Without being the effect of a substance, drug or medical condition e.g. urinary tract infection.

Incidence of enuresis varies with age, estimated to be …10-15% at five years and -. 2-3% at ten years.

Etiology of behavioral disorders: Enuresis may be classified as primary, in which the child has never achieved bladder control or secondary, in which the enuresis has re-started after a dry period of atleast   1 year. Over 75% cases are primaiy.

Primary enuresis is mostly functional in origin, due to delayed maturation in bladder functions. It is more common in boys (3:1) and children with similar family history. Various factors of behavioral disorders, attributed in causation of primary enuresis include — a) Premature (<18 months) or coercive attempts for toilet-training, b) abnormal sleep- awake cycle, c) lack of normal nocturnal surge in ADH secretion, d) inadequate bladder capacity e) mental subnormality and f) emotional deprivation. Organic primary enuresis is rare (<5%), seen in children with neural tube defects or congenital urinary tract malformations.

Secondary enuresis behavioral disorders is usually due to — i) recent emotional stress in family or school e.g. family-conflict, birth of a sibling, change in school etc., or more likely, ii) underlying organic pathology. Important organic causes for secondary enuresis include — a) urinary tract infections, b) obstructive uropathy, c) diabetes mellitus or insipidus, d) neurogenic bladder, and e) seizure disorders. Involuntary passage of urine may be the only indicator of nocturnal unobserved convulsion.

Diagnostic evaluation of these cases includes — Detailed history, specially related to age of onset (primary vs. secondary), the time of enuresis (nocturnal, mixed), similar family history, coexisting problems e.g. dysuria, encopresis, general development and behavioral disorders profile of the child as well as family.

Clinical examination to exclude organic etiology, including palpation for enlarged kidneys or full bladder, examination of external genitals and urinary stream, spinal examination for spina bifida, and complete neurological evaluation.

Investigations should begin with routine urine analysis/culture to exclude UTI, followed by other relevant investigations e.g. renal function tests, spinal Xrays, urinary tract imaging and urodynamic studies.

Management needs to be individualized for each case, depending on suspected causative factor. Organic causes, though rare, should be looked for and treated. Some broad recommendations for behavioral disorders management include:

a) Parental and child counseling regarding the nature, probable cause, correct approach towards toilet training and expected results of therapeutic interventions.

b) Bladder stretching exercises e.g. voluntary holding the urine as long as possible during day-time to increase bladder capacity and repeated starting/stopping the stream during micturation to increase sphincter tone.

c) Habit modifications e.g. early dinner (4 hours before sleep), restricted fluid intake after dinner, voiding before retiring, waking the child at night to pass etc.

d) behavioral disorders with positive reinforcement i.e. rewards for dry nights. Negative conditioning e.g. punishment or humiliation of the child by family members should be strongly discouraged. Psychotherapy e.g. play therapy and hypnosis may be used in some cases.

e) Conditioning devices e.g. bed-wetting alarms, are useful in refractory cases, with a success rate of 70%. In these devices, a sensor attached to the child’s underwear or mattress is stimulated as soon as she wets the bed, completing the electronic circuit and buzzing of alarm to wake up the child.

f) Pharmacotherapy, should be reserved for selected cases of >5 years age and non-responsive to behavioral modification.

Two commonly used drugs for behavioral disorders are – Imipramine, (P0 1-2 mg/kg/d) or Desmopressin acetate or DDAVP (nasal spray 10-40 jig/dose), both administered as single dose 2 hours before bed-time. Although initial efficacy is comparable (>50%), relapse rate is much higher with imipramine (90% vs. 70%). Treatment should continue for at least 4-6 months or atleast >4 weeks of consecutively dry nights, to minimize relapse.

Common side effects of imipramine includes dry mouth, irritability/insomnia and urinary retention while desmopressin nasal spray may cause nasal stuffiness, epistaxis and headache.

Giggling incontinence is an uncommon behavioral disorders in otherwise continent children, characterized by sudden, involuntary, uncontrollable micturation during giggling or laughing heartily. It is more common in girls. Although some children overgrow this problem, urodynamic studies are warranted in them to exclude organic problems.

Encopresis i.e. involuntary or intentional passage of feces in inappropriate places beyond the normal age of control, is less common than enuresis.

As per DSM IV criteria, Encopresis is defined as such acts in presence of following criteria —

a) Frequency of at least once a month for >3 months,

b) Persistence beyond 4 years of age, and

c) Not due to a substance, drug or medical behavioral disorders.

Incidence: Encopresis is more common in boys, with an estimated incidence of —1% at 5 years of age.

Etiology: Encopresis is classified as primary, when toilet training was never achieved (usually till 4 years); or secondary (regressive) when it re-appears in a child who was previously continent for   1 year.

Prima-v encopresis indicates a more serious emotional behavioral disorders than enuresis, often associated with suppressed anger and defiance to coercive toilet training, sexual abuse & negative defecation experiences.

Secondary encopresis is usually due to chronic constipation with overflow incontinence e.g. Hirschsprung’s disease, anal fissures, hypothyroidism, substance abuse etc. or associated with habitual over-use of laxatives.

Diagnostic evaluation of these children with behavioral disorders includes — a) detailed psychosocial history. b) per-rectal examination & neurologic evaluation to exclude organic causes, & c) relevant investigations e.g. thyroid function tests, anal manometry and barium studies for congenital megacolon.

Management of these behavioral disorders cases includes — a) treatment of constipation with laxatives or enema, b) prevention of fit rther constipation by high-fiber diet, c) voluntary toilet training – The patient should be encouraged to visit the toilet 10-15 mm after each meal to induce gastro-colic reflex, d) behavioral modification i.e. positive reinforcement (rewards) for better bowel control, and e) psychotherapy for precipitating and secondary psychological events.

Prognosis: Encopresis is more difficult to control than enuresis and often leads to secondary psychological problems e.g. loss of self-esteem, sense of guilt! depression and frequent school absenteeism.

Sleep behavioral disorders: Sleep pattern of a child depends on the age, behavioral pattern, frequency/duration of daytime naps and environment during bedtime. A newborn sleeps for >20 hours/day, which is gradually reduced to 8 hours by one year. Circadian rhythm i.e. day-night pattern of sleep begins to establish by 3 months and completes by 18-24 months.

Biological temperament and emotional stress e.g. separation anxiety, home/school fears, insecurity etc. are the most important causes of sleep problems in childhood, though important organic causes include — a) obstructive sleep apnea syndrome, b) organic brain disorders e.g. Attention deficit disorder or Autism, c) other e.g. Prader-Willi syndrome.

Common sleep behavioral disorders may be broadly divided into — a) insomnia or interrupted sleep, b) hypersomnia or narcolepsy, and c) abnormal sleep behavioral disorders e.g. Somnambulism, Nightmares or Night-terrors.

Night terrors are commonest sleep problems in preschool children, characterized by sudden arousal from sleep in disoriented state with screaming and signs of intense autonomic activity e.g. labored breathing, tachycardia, sweating and dilated pupils. Some children may sleep-walk (Somnambulism) for few minutes, before getting oriented or going back to sleep. History of a bad dream (nightmare) is often present.

Though occasional behavioral disorders are common, recurrent night-terrors indicate significant underlying phobia, anxiety or emotional trauma.

Narcolepsy is rare, characterized by excessive daytime sleepiness, cataplexy, sleep paralysis, hypnogogic hallucinations and poor school performance.

Check out this video which is nicely put to explain Behavioral disorders: