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Behavioral Problems, Pediatric
William G. Elder, PhD
image BASICS
DESCRIPTION
Behavior that disrupts at least one area of psychosocial functioning. Commonly reported behavioral problems are as follows:
  • Noncompliance: active or passive refusal to do as requested by parent or other authority figure
  • Temper tantrums: loss of internal control provoked by overtiredness, physical discomfort, or fear that leads to crying, whining, breath-holding, or in extreme cases, aggressive behavior
  • Sleep problems: sleep patterns that are distressing to caregivers or child; difficulty going to sleep or staying asleep at night, nightmares, and night terrors
  • Nocturnal enuresis: enuresis that occurs only at night in children >5 years of age with no medical problems
    • Primary: children who have never been dry at night
    • Secondary: children dry at night for at least 6 months
  • Functional encopresis: repeated involuntary fecal soiling that is not caused by organic defect or illness
  • Problem eating: “picky eating,” difficult mealtime behaviors
  • Normative sexual behaviors: developmentally appropriate behaviors in children in the absence of abuse
  • Thumb-sucking: an innate reflex that is self-soothing; may be protective against sudden infant death. If persists, past eruption of primary teeth can affect teeth alignment and mouth shape.
EPIDEMIOLOGY
  • Noncompliance: may manifest as children develop autonomy; males have a modestly greater likelihood of being noncompliant; decreases with age.
  • Temper tantrums: 70% of 18- to 24-month-old children; 7% of 3- to 5-year-old children; in children with severe tantrums, 52% have other behavioral/emotional problems (1).
  • Sleep problems
    • Night waking in 25-50% of infants 6 to 12 months; bedtime refusal in 10-30% of toddlers
    • Nightmares in 10-30% of preschoolers; peaks between ages 6 and 10 years
    • Night terrors in 1-6.5% early childhood; peaks between ages 4 and 12 years
    • Sleepwalking frequently in 3-5%; peaks between ages 5 and 8 years (2)
  • Nocturnal enuresis
    • At least 20% of children in the 1st grade wet the bed occasionally; 4% wet ≥2 times per week.
    • At 10 years of age, 9% in boys, 3% in girls (3)
  • Functional encopresis
    • Rare before age 3 years, most common in 5- to 10-year-olds; more common in boys (4)
  • Problem eating
    • Prevalence peaks at 50% at 24 months of age; no relation to sex/ethnicity/income (5)
  • Normative sexual behaviors
    • Rare in infancy, except hand to genital contact
    • Increased in 3- to 5-year-olds; less observed in >5-year-olds because more covert (6)
  • Thumb-sucking: decreases with age; most children spontaneously stop between 2 and 4 years.
COMMONLY ASSOCIATED CONDITIONS
  • Noncompliance: if exceeds what seems normative, rule out depression, compulsive patterns, adjustment disorder, inappropriate discipline
  • Temper tantrums: difficult child temperament, stress
  • Sleep problems: often with inconsistent bedtime routine or sleep schedule, stimulating bedtime environment; can be associated with hyperactive behavior, poor impulse control, and poor attention in young children (2). Acute or chronic anxiety is associated with insomnia.
  • Enuresis: secondary often with medical problems, especially constipation, and frequent behavior problems, especially ADHD
  • Functional encopresis: enuresis, UTIs, ADHD
  • Normative sexual behaviors: family stressors such as separation or divorce (6)
image DIAGNOSIS
PHYSICAL EXAM
  • Nocturnal enuresis
    • Physical exam of abdomen for enlarged bladder, kidneys, or fecal masses; rectal exam if history of constipation; back for spinal dysraphism seen in dimpling or hair tufts
    • Neurologic exam: focus on lower extremities
    • Genitourinary exam
      • Males: meatal stenosis, hypospadias, epispadias, phimosis
      • Females: vulvitis, vaginitis, labial adhesions, ureterocele at introitus; wide vaginal orifice with scar or healed laceration may be evidence of abuse.
  • Functional encopresis
    • Height and weight; abdominal exam for masses or tenderness; rectal exam for tone, size of rectal vault, fecal impaction, masses, fissures, hemorrhoids; back for signs of spinal dysraphism seen in dimpling or hair tufts (4)
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • For nocturnal enuresis: urinalysis (dipstick test OK); if abnormal, consider urine culture.
    • For secondary enuresis: serum glucose, creatinine, thyrotropin (8)[C]
    • Urinary tract imaging and urodynamic studies if significant daytime symptoms with history or diagnosis of UTI or history of structural renal abnormalities (8)[C]
  • For functional encopresis: tests for hypothyroidism or celiac disease if poor growth or family history; urinalysis and culture if enuresis or features of UTI (4)
    • Spine imaging if evidence of spinal dysraphism or if both encopresis and daytime enuresis; barium enema if suspect Hirschsprung disease
Follow-Up Tests & Special Considerations
Sleep disorders: Sleep studies may be performed in children if there is a history of snoring and daytime ADHD-type symptoms (2).
Diagnostic Procedures/Other
  • Pediatric symptom checklist: https://brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf
  • National Initiative for Children's Healthcare Quality (NICHQ) Vanderbilt Assessment (ADHD screen): http://www.myadhd.com/vanderbiltparent6175.html
  • Child Sexual Behavior Inventory: Completed by female caregiver to assist with differentiation of normative versus abnormal behaviors particularly those related to sexual abuse: http://www.nctsnet.org/content/child-sexual-behavior-inventory-csbi
image TREATMENT
  • General: Educate caregiver about specific behavioral problem.
  • Parent management training programs and techniques are effective for many child behavior problems (9)[A].
  • Noncompliance: In the case of extreme child disobedience, consider parent training programs. Child may need to be formally screened for ADHD, obsessive-compulsive disorder (OCD), oppositional defiant disorder (ODD), or conduct disorder (CD).
  • Temper tantrums: Remind caregiver this is a normal aspect of early childhood.
    • Educate caregiver that tantrums are not attention-seeking; although they may reveal that the child needs more attention from caregiver. This attention should be developmentally appropriate and not occur when the child is tantruming but at other times and prior to the tantrum.
    • If tantrum is set off by external factors, such as hunger or overtiredness, then correct.
    • Other methods for dealing with a tantrum include one of the following:
      • Ignore the tantrum; remove the child and place him or her in time-out (1 minute for each year of age); hold/restrain child until calmed down; provide child with clear, firm, and consistent instructions as well as enough time to obey.
  • P.119

  • Sleep problems: Intervention consists largely of education of the caregiver who may need a roadmap for dealing with this difficult and distressing problem. Developmental stages; environmental factors and cues; caregiver emotions and reactions; and child fears, stress, and habits are all important factors in sleep onset and maintenance that should be explored and explained to the caregiver.
  • Specific recommendations may also consist of other interventions including the following (2)[A]:
    • Graduated extinction: Caregiver ignores cries for specified period; can check at a fixed time or increasing intervals.
    • “Fading”: gradual decrease in direct contact with the child as child falls asleep; goal is for the caregiver to exit the room and allow child to fall asleep independently.
    • Consider the “5S Intervention” for settling problems in toddlers (used to comfort infants in nurseries): swaddling, sucking, shushing, stomach/side position, and swinging.
    • If fearful, preferred routines or inert sprays or glitter spread by the child (while avoiding the eyes) may help the child feel more secure.
  • Nocturnal enuresis
    • Bedwetting alarm: first-line therapy for caregivers who can overcome objection of having their sleep disturbed; about 2/3 of children respond while using the alarm; if enuresis recurs after use, it will often resolve with a second trial (7)[A].
    • Decrease fluids an hour before bedtime.
    • Little evidence from clinical trials but good empirical evidence for behavioral training, including positive reinforcement (small reward for each dry night) or responsibility training (if developmentally able, child is responsible for changing or washing sheets), encouraging daily bowel movements, and frequent bladder emptying during the day
  • Functional encopresis
    • First disimpaction: PO with polyethylene glycol solution or mineral oil; if unsuccessful, manual mineral oil enemas
    • Maintenance therapy
      • Medical: osmotics, such as polyethylene glycol, fiber, lactulose; stimulants, such as senna or bisacodyl
      • Behavior modification: toileting after meals for 10 minutes 2 to 3 times a day, star charts, and rewards (4)[C]
  • Problem eating
    • Avoid punishment, prodding, or rewards. Offer a variety of healthy foods at every meal; limit milk to 24 oz/day and decrease juice (5)[C].
  • Normative sexual behavior: No treatment needed; caregivers may need encouragement not to punish or admonish child and to use gentle distraction to redirect behavior when in public setting.
  • Thumb-sucking: Recommendations to caregivers include praising children when not sucking their thumb, offer alternatives that are soothing (e.g., stuffed toys), provide reminders or negative reinforcement in the form of a bandage around or bitters on the thumb (5)[C].
MEDICATION
Most pediatric behavioral issues respond well to nonpharmacologic therapy:
  • Sleep disorders
    • For certain delayed sleep-onset disorders, after behavioral methods are exhausted, melatonin 0.5 to 10 mg PO can be tried while behavior modification is continued. Sleep latency is likely to be reduced. However, this is not approved by the FDA for children. Expect rebound insomnia. Daytime exposure to bright or sunlight should be assured before treatment.
  • Nocturnal enuresis
    • Desmopressin can decrease urine output to reduce enuresis episodes. Not before age 6 years; begin with 0.2 mg tablet nightly 1 hour before bedtime; titrate to 0.6 mg (8)[B]. However, use is questionable because its effects do not persist posttreatment (10)[A]. Intranasal formulations can cause severe hyponatremia, resulting in seizures and death in children. Behavioral interventions should be first-line treatment (7)[C].
ISSUES FOR REFERRAL
  • A patient who exhibits self-injurious behaviors, slow recovery time from tantrums, more tantrums in the home than outside the home, or more aggressive behaviors toward others may require referral to a psychologist or psychiatrist.
  • Children with chronic insomnia or anxiety that interferes with sleep should be referred to a psychologist or psychiatrist.
  • A child with loud nightly snoring, with observed apnea spells, daytime excessive sleeping, and neurobehavioral signs such as mood changes, ADHD-like symptoms, or academic problems should be referred for sleep studies (2).
  • With enuresis and obstructive sleep apnea symptoms, refer for sleep studies because surgical correction of airway obstruction often improves or cures enuresis and daytime wetting (8).
  • Must distinguish sexual behavior problems: Developmentally inappropriate behaviors—greater frequency or much earlier age than expected— becomes a preoccupation, recurs after adult intervention/corrective efforts. If abuse is not suspected, consider referral to a child psychologist. If abuse is suspected, must report to child protective services (6).
  • If disimpaction by either manual or medical methods is unsuccessful, consult gastroenterology or general surgery. Patients who show no improvement after 6 months of maintenance medical therapy should be referred to gastroenterology (4).
  • Thumb-sucking resistant to behavioral intervention and threatening oral development may be evaluated by a pediatric dentist for use of habit-breaking dental appliances (5)[C].
image ONGOING CARE
DIET
Nutrition is very important in behavioral issues. Avoiding high-sugar foods and caffeine and providing balanced meals has been shown to decrease aggressive and noncompliant behaviors in children.
PATIENT EDUCATION
  • Yale Parenting Center, Kazdin Method Sessions Webinars, $50.00 each. Cost http://yaleparentingcenter.yale.edu/kazdin-method-sessions
  • See Parent Training Programs: Insight for Practitioners at: http://www.cdc.gov/violenceprevention/pdf/Parent_Training_Brief-a.pdf
  • The Happiest Baby Guide to Great Sleep: Simple Solutions for Kids from Birth to 5 Years. Harvey Karp, MD New York, HarperCollins Publishers 2012, 384 pp.
  • Products
    • Nytone Bed Wetting Alarms: by order to: http://www.nytone.com/products/nytone-enuresis-alarm?gclid=CM7Cm97i5rcCFSJMgodW1wAgg
REFERENCES
1. Potegal M, Davidson RJ. Temper tantrums in young children: 1. Behavioral composition. J Dev Behav Pediatr. 2003;24(3):140-147.
2. Bhargava S. Diagnosis and management of common sleep problems in children. Pediatr Rev. 2011;32(3):91-98.
3. Robson WL. Clinical practice. Evaluation and management of enuresis. N Engl J Med. 2009;360(14):1429-1436.
4. Har AF, Croffie JM. Encopresis. Pediatr Rev. 2010;31(9):368-374.
5. Tseng AG, Biagioli FE. Counseling on early childhood concerns: sleep issues, thumb sucking, picky eating, and school readiness. Am Fam Physician. 2009;80(2):139-142.
6. Kellogg ND. Sexual behaviors in children: evaluation and management. Am Fam Physician. 2010;82(10):1233-1238.
7. Vande Walle J, Rittig S, Bauer S, et al. Practical consensus guidelines for the management of enuresis. Eur J Pediatr. 2012;171(6):971-983.
8. Ramakrishnan K. Evaluation and treatment of enuresis. Am Fam Physician. 2008;78(4):489-496.
9. Owen DJ, Slep AM, Heyman RE. The effect of praise, positive nonverbal response, reprimand, and negative nonverbal response on child compliance: a systematic review. Clin Child Fam Psychol Rev. 2012;15(4):364-385.
10. Glazener CM, Evans JH. Desmopressin for nocturnal enuresis in children. Cochrane Database Syst Rev. 2002;(3):CD002112.
Additional Reading
  • Gringras P. When to use drugs to help sleep. Arch Dis Child. 2008;93(11):976-981.
  • Gringras P, Gamble C, Jones AP, et al. Melatonin for sleep problems in children with neurodevelopmental disorders: randomised double masked placebo controlled trial. BMJ. 2012;345:e6664.
  • Miller JW. Screening children for developmental behavioral problems: principles for the practitioner. Prim Care. 2007;34(2):177-201.
  • Stein MT. Difficult behavior. In: Rudolph C, Rudolph A, Lister G, et al, eds., Rudolph's Pediatrics. 22nd ed. New York: McGraw-Hill, 2011:335-338.
  • Strachan E, Staples B. Masturbation. Pediatr Rev. 2012;33(4):190-191.
  • Zahrt DM, Melzer-Lange MD. Aggressive behavior in children and adolescents. Pediatr Rev. 2011;32(8):325-332.
Codes
ICD10
  • F91.9 Conduct disorder, unspecified
  • F91.1 Conduct disorder, childhood-onset type
  • F91.2 Conduct disorder, adolescent-onset type
Clinical Pearls
  • Well-child visits provide opportunities for systematic screening for these common conditions.
  • Parental education, including a review of age-appropriate discipline, is a key component of treatment.