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Pediatric Behavioral Problems - PE 5.1 to 5.10

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PE 5.1 - THUMB SUCKING

Definition

Epidemiology

• One of the most common habit disorders in children
• Normal and almost universal in infants below 2 years
• Affects boys = girls in early years; more girls persist beyond age 4
• Prevalence: ~45% at age 2, declining to ~5-10% by school age

Etiology / Predisposing Factors

• Normal developmental behavior - satisfies the rooting and sucking reflex
• Unmet oral needs (inadequate breastfeeding time)
• Anxiety, boredom, fatigue, hunger
• Comfort-seeking behavior and stress relief
• Genetic tendency in some families

Clinical Features

• Sucking of thumb (most common), index finger, or multiple fingers
• Usually occurs during sleep, boredom, or emotional stress
• Complications (if persistent beyond 4-5 years):
  • Dental malocclusion: anterior open bite, overjet
  • Narrowing of the hard palate (high arched palate)
  • Prognathism (protrusion of upper teeth)
  • Callus formation or skin irritation on thumb
  • Social embarrassment in school-age children
  • Speech difficulties (lisping)

Diagnosis

• Primarily clinical; based on history and observation
• No special investigations required
• Assess for underlying emotional problems or anxiety

Management

• Reassure parents that habit is self-limiting in most cases
• Most children stop spontaneously before school age

• Positive reinforcement - reward child when not sucking
• Substitution - give a toy or activity to keep hands busy
• Gentle reminders (not scolding or punishment)
• Bitter-tasting preparations painted on the thumb (e.g., bitter gourd extract, commercial bitter nail polish)
• Thumb guard / glove / bandage at night
• Habit-breaking appliances (by orthodontist): palatal crib, bluegrass appliance

• Avoid negative attention (scolding makes it worse)
• Address any underlying anxiety or emotional stressors
• Refer to orthodontist if malocclusion develops

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PE 5.2 - FEEDING PROBLEMS

Definition

Classification (DSM-5 related)

1. Pica
2. Rumination disorder
3. Avoidant/Restrictive Food Intake Disorder (ARFID) - formerly "feeding disorder of infancy or early childhood"

Types of Feeding Problems

Etiology

• Gastroesophageal reflux (GERD) - most common organic cause in infants
• Oral motor dysfunction, cleft palate
• Food allergies/intolerances
• Cardiac disease (fatigue during feeding)
• Neurological disorders (cerebral palsy)
• Chronic illness, constipation

• Poor feeding environment (distractions, force-feeding)
• Negative food experiences (choking, vomiting)
• Parental anxiety about feeding
• Learned food refusal
• Developmental stage (toddler autonomy)

Clinical Features

• Refusal to eat or prolonged mealtimes (>30 min)
• Limited food variety
• Gagging or vomiting at mealtimes
• Distress during feeding (child and/or parent)
• Poor weight gain or growth faltering
• Nutritional deficiencies (iron, zinc, vitamins)

Diagnosis

• Detailed feeding history: what, how much, how often, feeding environment
• Growth assessment (weight, height, head circumference)
• Dietary diary
• Screen for organic causes if indicated:
  • Barium swallow (dysphagia)
  • pH monitoring (GERD)
  • CBC, serum iron, zinc levels

Management

• Address organic causes first
• Structured mealtimes (same time, place, duration)
• Family meals together
• Positive mealtime environment (no screens, no distractions)
• Avoid force-feeding

• Systematic desensitization (gradual exposure to new foods)
• Positive reinforcement for trying new foods
• Offer small portions; do not make the child finish everything
• Parent modeling (eating the same food)

• Oral nutritional supplements if growth faltering
• Vitamin/mineral supplementation as needed

• Dietitian, speech-language therapist (for oral motor issues)
• Child psychiatrist/psychologist if behavioral component is severe
• Pediatric gastroenterologist for organic causes

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PE 5.3 - NAIL BITING (Onychophagia)

Definition

Epidemiology

• Very common habit disorder
• Prevalence: ~30-60% of school-age children and adolescents
• Peaks between 10-18 years
• More common in boys
• Often familial
• Classified as a body-focused repetitive behavior (BFRB)

Etiology

• Anxiety, tension, boredom, frustration
• Habit formation (automatic, unconscious behavior)
• Genetic predisposition
• Imitation (family members who bite nails)
• Associated with ADHD, OCD, other anxiety disorders

Clinical Features

• Short, ragged, bitten nails
• Tender, bleeding, or inflamed cuticles
• Paronychia (bacterial/fungal nail fold infection)
• Dental problems (wear of incisors)
• Transmission of gut parasites (pinworms) via nail-to-mouth route
• Social embarrassment
• In severe cases: subungual hematoma, permanent nail damage

Diagnosis

• Clinical diagnosis based on appearance
• Rule out paronychia or skin infection
• Screen for underlying anxiety/OCD if severe

Management

• Most cases resolve spontaneously by late adolescence
• Parental awareness - avoid drawing negative attention

• Habit Reversal Training (HRT): Most effective evidence-based method
  • Awareness training
  • Competing response (e.g., making a fist when urge arises)
  • Motivation enhancement
• Stimulus control: Avoid triggers (stress, boredom)
• Keeping nails neatly trimmed and filed regularly
• Positive reinforcement for nail growth

• Bitter-tasting nail polish (aversion therapy)
• Bandages on fingertips
• Gloves at night

• Anxiolytic therapy if significant anxiety disorder present
• Refer to psychologist/psychiatrist if associated with OCD or ADHD

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PE 5.4 - BREATH HOLDING SPELLS (BHS)

Definition

Epidemiology

• Occurs in 4-5% of children <8 years of age
• Peak age: 6 months to 5 years (most common at 1-2 years)
• Onset: as early as 6 months; may start in up to 15% of cases <6 months
• Resolves spontaneously by age 5-6 years in most
• Positive family history in ~25%
• Slightly more common in boys
• Associated with iron deficiency anemia

Types

Pathophysiology

• Cyanotic BHS: Neurally mediated syncope. The child cries, then holds breath at end of expiration → hypoxia → loss of consciousness
• Pallid BHS: Exaggerated vagal response → cardiac inhibition (asystole) → hypoxia → LOC. Form of reflex anoxic seizure
• Both are forms of neurally mediated (vasovagal) syncope

Clinical Features

1. Precipitating event (anger, frustration, pain)
2. Child begins to cry intensely
3. Breath holding at end of expiration
4. Cyanosis develops (perioral → generalized)
5. Loss of consciousness (brief, seconds to <1 minute)
6. Postictal period minimal; child regains consciousness quickly
7. Occasionally: brief tonic-clonic movements (anoxic convulsions)

1. Minor injury or sudden fright
2. Brief or absent cry
3. Child becomes pale and limp
4. Loss of consciousness
5. Brief tonic activity may occur

Diagnosis

• Clinical diagnosis - characteristic history is sufficient
• Investigations generally not needed unless atypical:
  • CBC (to rule out iron deficiency anemia)
  • ECG (for pallid BHS - to rule out prolonged QT)
  • EEG only if seizure disorder suspected
• BHS is not associated with epilepsy and does not lead to brain damage

Differential Diagnosis

• Epileptic seizures (seizure usually not triggered by emotional event; no cyanosis before onset; post-ictal confusion)
• Reflex anoxic seizure
• Cardiac arrhythmia (rare)
• Hypoglycemia

Management

• Place child in lateral position (recovery position) to maintain airway
• Do not give mouth-to-mouth resuscitation (it may worsen vagal tone)
• Ensure child is safe from injury
• Episode usually self-terminates within 1 minute
• Cold cloth/water on face may abort some spells (vagal stimulation reversal)

• Parental reassurance - most important! Explain benign, self-limiting nature
• Educate parents to remain calm during spells
• Avoid reinforcing behavior (attention, secondary gain)
• Consistent discipline; avoid giving in to child's demands post-spell
• Iron supplementation: Treat iron deficiency anemia; iron therapy (ferrous sulfate) has been shown to reduce spell frequency even in children without frank anemia
• No anticonvulsants needed (BHS is not epilepsy)

• Atropine (0.01 mg/kg oral) - for pallid BHS with documented cardiac asystole
• Piracetam - used in some studies to reduce cyanotic BHS frequency

Prognosis

• Spontaneous resolution by 5-6 years in most children
• ~20% may develop neurocardiogenic syncope in adult life (pallid type)
• No association with epilepsy or developmental delay

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PE 5.5 - TEMPER TANTRUMS

Definition

Epidemiology

• Extremely common in toddlers aged 1-4 years (peak: 2-3 years = "terrible twos")
• Affects ~80% of 2-year-olds and ~48% of 4-year-olds
• Equal in boys and girls (boys may be slightly more severe)
• More common in children with developmental delay, ADHD, language delays

Etiology

• Expression of emerging autonomy and independence
• Child's desires exceed their ability to communicate
• Frustration at inability to control environment
• Immature emotional regulation

• Fatigue, hunger, illness
• Change in routine
• Parental restriction of desired activity
• Overstimulation

• Frequency >5 per day
• Duration >15 minutes per tantrum
• Aggressive behavior toward people or objects
• Persisting beyond age 4-5 years
• Associated with self-injurious behavior
• Occurring in older children (school age)

Clinical Features

• Mild: Whining, crying, pouting
• Moderate: Screaming, throwing objects, stomping feet, falling to floor
• Severe: Breath-holding, head banging, biting, kicking, self-injury
• Usually lasts 2-5 minutes
• Child may be inconsolable during tantrum
• Resolution often rapid; child returns to normal behavior
• May occur in public, causing parental embarrassment

Diagnosis

• Clinical assessment; detailed behavioral history
• Developmental assessment
• Rule out:
  • Language/communication delay
  • Autism spectrum disorder
  • ADHD
  • Hearing impairment
  • Underlying pain/medical illness

Management

• Maintain regular routines (sleep, meals)
• Offer limited choices (child feels in control)
• Anticipate triggers (hunger, fatigue) - plan outings accordingly
• Praise and reward appropriate behavior

• Stay calm - parental composure is key
• Ensure child safety
• Ignore the tantrum when it is attention-seeking behavior (extinction)
• Do not give in to demands (this reinforces the behavior)
• Do not engage in lengthy explanations or negotiations
• Remove the child from the situation if in a public place
• Offer comfort if the tantrum is from fear or pain

• Do not punish after the tantrum has ended
• Discuss briefly and calmly once the child is calm
• Re-engage child in a positive activity

• Used for children >2 years
• 1 minute per year of age
• Quiet, boring space
• Consistent application

• Explain normal developmental nature
• Educate on consistent limit-setting
• Avoid inconsistent responses (sometimes giving in)

• Tantrums are extreme, prolonged, or associated with developmental concerns
• Family is struggling significantly
• Signs of conduct disorder

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PE 5.6 - PICA

Definition

Epidemiology

• More common in young children (12 months to 5 years)
• Increased prevalence in intellectual disability, autism spectrum disorder
• Occurs in both sexes; more in institutionalized populations
• Also seen in pregnancy (geophagia, amylophagia in some cultures)

Substances Ingested (by age)

Etiology

• Nutritional deficiency: Iron deficiency, zinc deficiency (most important and treatable cause)
• Sensory-seeking behavior (autism, intellectual disability)
• Environmental deprivation, neglect, poverty
• Cultural practices (geophagia in some regions)
• Psychological stress, anxiety
• No specific biological abnormality identified in most cases

Clinical Features

• Persistent ingestion of non-food items
• Complications:
  • Lead poisoning (from lead-based paint) - encephalopathy, anemia
  • Iron deficiency anemia (ingestion of clay/starch)
  • Zinc deficiency (clay ingestion)
  • Intestinal parasites (soil/feces ingestion - ascariasis, toxocariasis)
  • Intestinal obstruction (hairballs/bezoars, stones)
  • Dental injury
  • Infections (bacterial, parasitic)
  • Poisoning (depending on substance)

Diagnosis

• Clinical diagnosis: history of persistent ingestion of non-food items
• Investigations to assess for complications:
  • CBC, serum ferritin (iron deficiency)
  • Serum zinc, lead levels
  • Stool examination (parasites)
  • Abdominal X-ray (if obstruction suspected)
  • KUB X-ray (radio-opaque foreign body)
• Assess for autism, intellectual disability, neglect

Management

• Iron supplementation (ferrous sulfate 3-6 mg/kg/day) - correcting iron deficiency often resolves pica
• Zinc supplementation if deficient

• Remove access to ingested substances (child-proof the environment)
• Supervise the child closely

• Positive reinforcement for not ingesting non-food items
• Habit reversal training
• Aversive conditioning (in severe/resistant cases, under specialist supervision)

• Chelation therapy for lead poisoning (DMSA/EDTA)
• Antiparasitic treatment
• Surgical intervention for obstruction

• Family support, parenting education
• Address neglect, poverty, emotional deprivation

• Child psychiatrist/psychologist for persistent cases
• Occupational therapist for sensory-based pica
• Gastroenterologist for complications

Prognosis

• Resolves spontaneously in most children by adolescence
• Persistent in autism and intellectual disability
• Pica of pregnancy is limited to pregnancy

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PE 5.7 - FUSSY INFANT (Infant Colic / Excessive Crying)

Definition

• Crying for >3 hours/day
• On >3 days/week
• For >3 weeks
• In an otherwise healthy, well-fed infant

Epidemiology

• Affects ~10-25% of infants
• Onset: typically 2-4 weeks of age
• Peak: 6 weeks of age
• Usually resolves by 3-4 months of age
• Equal in breastfed and formula-fed infants
• No gender predilection

Etiology (multifactorial, largely unknown)

• Immature gut motility and coordination
• Gas pain, intestinal spasms
• Lactose intolerance / cow's milk protein allergy
• GERD

• Immature central nervous system
• Hypersensitivity to stimuli

• Parental anxiety and tension (transmitted to infant)
• Difficult temperament
• Poor feeding technique

• Hunger (inadequate milk supply)
• Overstimulation
• Fatigue

Clinical Features

• Intense, high-pitched crying, often in late afternoon/evening
• Legs drawn up, abdomen distended, clenched fists
• Face flushed, back arched
• Difficulty consoling
• Infant appears healthy and thriving between episodes
• Normal weight gain

Diagnosis

• Fever, vomiting, diarrhea (infection)
• Blood in stool (cow's milk protein allergy, intussusception)
• Bilious vomiting (intestinal obstruction)
• Abdominal distension

• Careful head-to-toe exam (hair tourniquet on toe/finger, corneal abrasion, otitis media, hernia, fracture)
• Abdominal palpation
• Neurological assessment

Management

• Explain self-limiting nature; resolution by 3-4 months
• Acknowledge parental frustration and exhaustion
• Emphasize that it is not their fault

• Ensure adequate latch and breastfeeding technique
• Trial of hypoallergenic/hydrolyzed formula if cow's milk protein allergy suspected
• Burping after feeds
• Avoid overfeeding

• Rhythmic motion (rocking, car rides, baby swings)
• White noise, gentle music
• Swaddling
• Skin-to-skin contact
• Non-nutritive sucking (pacifier)
• Reducing stimulation

• Maternal dietary modification (avoiding cow's milk, cruciferous vegetables) in breastfed infants
• Simethicone drops - widely used but evidence limited
• Probiotic Lactobacillus reuteri - some evidence for breastfed infants with colic

• Simethicone: Not proven superior to placebo but widely used
• Dicyclomine: Anticholinergic - effective but NOT recommended in infants <6 months (apnea risk)
• Avoid herbal teas, glucose water

• Never shake a baby (Shaken Baby Syndrome risk)
• It is safe to put baby down in a safe place and take a break

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PE 5.8 - ENURESIS

Definition

Epidemiology

• Affects ~15-20% of 5-year-olds
• Spontaneous resolution rate: ~15% per year
• By age 15: <2% still affected
• Boys > Girls (2:1)
• Positive family history in 70-75% (autosomal dominant inheritance with variable penetrance)

Etiology

• Genetic factors (strongest factor)
• Maturational delay of bladder control
• Nocturnal polyuria: Inadequate vasopressin (ADH) secretion at night
• Reduced functional bladder capacity
• Deep sleep / difficulty arousing from sleep
• Associated conditions: ADHD (frequently comorbid), constipation, sleep-disordered breathing

• Urinary tract infection (most common organic cause in girls)
• Diabetes mellitus (polyuria)
• Diabetes insipidus
• Psychological stress (birth of sibling, school problems, abuse)
• Constipation / fecal impaction
• Neurological causes (spina bifida, tethered cord)
• Obstructive sleep apnea

Clinical Features

• Bedwetting ≥2 times/week for ≥3 months in children >5 years
• Daytime urgency, frequency (diurnal enuresis)
• Associated dysuria, hematuria, polyuria (suggests organic cause)
• Assess impact on child's self-esteem, school performance, social life

Diagnosis

• Age of onset, frequency, primary vs. secondary
• Fluid intake pattern, especially evening
• Bowel habits (constipation common)
• Family history
• Psychological stressors (secondary enuresis)
• Sleep history (snoring - sleep apnea)

• Abdomen (bladder palpation, fecal loading)
• Spine (sacral dimple, tethered cord)
• Genital examination
• Neurological examination of lower limbs

• Urinalysis and urine culture (mandatory)
• Urine specific gravity (ADH deficiency)
• Blood glucose, electrolytes (if diabetes suspected)
• Ultrasound KUB (bladder wall, residual urine)
• Voiding diary (frequency, volume, timing)
• Spinal X-ray/MRI only if neurological cause suspected

Management

• Reassurance that it is common and self-limiting
• Fluid restriction in the evening (especially 2 hours before bedtime)
• Regular daytime voiding every 2-3 hours
• Double voiding before bed
• Eliminate caffeine
• Treat constipation
• Motivational therapy (star chart) - reward dry nights
• Lifting (taking child to toilet at parents' bedtime)
• Protective mattress covers
• Avoid punishment or blame

• Enuresis alarm (moisture sensor) - wakes child when voiding begins
• Conditioning therapy - most effective long-term treatment
• Requires 3-4 months of consistent use
• Cure rate ~70%
• Not effective in children <7 years or unmotivated families

• Desmopressin (DDAVP) - synthetic vasopressin analog
  • 0.2-0.4 mg oral tablet or 10-40 mcg intranasal spray at bedtime
  • Reduces nocturnal urine production
  • Fast-acting, useful for school trips/sleepovers
  • High relapse rate on stopping (60-70%)
  • Risk: hyponatremia - limit fluid intake when using
• Imipramine (tricyclic antidepressant)
  • 10-50 mg at bedtime (age-dependent)
  • Second-line; risk of cardiac toxicity in overdose
  • Mechanism: anticholinergic + antidiuretic + light sleep effect
• Oxybutynin - for overactive bladder / diurnal enuresis

• Alarm + desmopressin for refractory cases

• Diurnal enuresis (wetting when awake)
• Recurrent UTIs
• Abnormal ultrasound or urinalysis
• No response to standard treatment

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PE 5.9 - ENCOPRESIS

Definition

Epidemiology

• Prevalence: ~1-2% of school-age children (5-year-olds: ~1%)
• Boys > Girls (3:1-6:1)
• Comorbid enuresis in >40% of cases

Etiology

• Painful defecation (anal fissure, constipation) → voluntary stool withholding → worsening constipation → rectal distension → reduced rectal sensation → overflow incontinence
• Diet low in fiber and fluid
• Transitions: breast milk to formula, or to cow's milk
• Toilet training trauma
• Fear of using school/public toilets (loss of privacy)

• Toilet training fear
• Oppositional defiant disorder (deliberate soiling)
• Conduct disorder
• Response to stress (birth of sibling, school change, abuse)
• Sexual or rectal abuse (must be considered)

• Hirschsprung disease (key distinguishing feature: absence of encopresis in Hirschsprung's - child does not soil)
• Anal stenosis
• Hypothyroidism
• Spina bifida

Clinical Features

• Fecal soiling of underwear (often small amounts of liquid stool - overflow)
• Rarely aware of soiling
• Abdominal distension, bloating
• Recurrent abdominal pain
• Reduced appetite
• Poor weight gain in severe cases
• Social embarrassment, school avoidance, peer rejection

Diagnosis

• Onset, frequency, character of stools
• Previous toilet training history
• 5-7 day stool diary
• Diet history (fiber, fluid intake)
• Screen for sexual/rectal abuse
• Psychological stressors

• Growth parameters
• Umbilical girth (measure of abdominal distension)
• Abdominal palpation (fecal mass)
• Rectal examination (tone, fecal impaction, anal fissure)
• Spine examination
• Hirschsprung disease: Absence of stool in rectum on examination despite constipation

• Abdominal X-ray (fecal loading)
• Rectal biopsy (to rule out Hirschsprung disease if suspected)
• Thyroid function tests (hypothyroidism)
• Spinal MRI if neurological cause suspected

Management

• Explain the cycle of constipation → overflow soiling
• Remove shame and blame from child and parents
• Motivate family for long-term treatment

• Series of enemas (phosphate enema or saline enema) OR
• High-dose oral laxatives:
  • Polyethylene glycol (PEG/Movicol/Miralax) - first-line
  • Lactulose, sodium picosulfate
• Goal: complete evacuation of fecal impaction

• Polyethylene glycol - daily, to produce 1-2 soft stools/day
• Dietary modification: increased fiber (fruits, vegetables, whole grains), adequate fluid intake
• Target: at least one painless soft stool per day
• Continue for 6-12 months until habit established

• Toilet sitting routine: after meals (gastrocolic reflex), 10-15 minutes
• Reward charts (star chart) for toilet sitting and stool passage
• Positive reinforcement; no punishment
• Combine with laxative therapy (most effective approach - evidence grade A)

• For non-retentive encopresis or deliberate soiling
• Family therapy, individual therapy
• Treat underlying emotional issues

• With consistent treatment, majority achieve continence
• Relapses common; long-term follow-up needed

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PE 5.10 - CHILD GUIDANCE CLINIC (CGC): ROLE AND REFERRAL CRITERIA

Definition

Team Composition (Multidisciplinary Team)

Role of the Child Guidance Clinic

• Developmental assessment (milestones)
• Psychometric testing (IQ testing, personality assessment)
• Behavioral and psychiatric evaluation
• Family assessment
• School performance and social adjustment

• Individual therapy: Cognitive behavioral therapy (CBT), play therapy, behavioral therapy
• Family therapy: Addressing family dynamics, parenting skills training
• Group therapy: Social skills training
• Pharmacotherapy: Under child psychiatrist supervision (ADHD medications, antidepressants, etc.)
• Behavior modification programs

• Special education for learning disabilities
• Remedial teaching
• Vocational guidance for older children

• Parent counseling and guidance
• School counseling and coordination with teachers

• For children with developmental disabilities, autism, intellectual disability

• School mental health programs
• Parent education workshops
• Teacher training
• Mental health awareness programs

• Epidemiological studies on childhood behavioral disorders
• Training of pediatricians, nurses, and allied health workers

Referral Criteria to Child Guidance Clinic

• Temper tantrums persisting beyond age 4-5 years or extreme in nature
• Persistent thumb sucking beyond age 5 with dental/emotional concerns
• Persistent nail biting with self-injury or associated OCD/anxiety
• Severe breath holding spells not responding to reassurance

• Global developmental delay
• Specific learning disabilities (dyslexia, dyscalculia, dysgraphia)
• Language and speech delay
• Intellectual disability (mental retardation)

• Childhood anxiety disorders, phobias
• Depression in children
• Obsessive-compulsive disorder
• Post-traumatic stress disorder (PTSD)
• Adjustment disorders

• Autism Spectrum Disorder (ASD)
• Attention Deficit Hyperactivity Disorder (ADHD)

• Oppositional defiant disorder
• Conduct disorder
• Juvenile delinquency, aggression, stealing

• Persistent pica not responding to basic management
• Feeding disorder / ARFID with growth failure
• Anorexia nervosa, bulimia nervosa

• Enuresis not responding to alarm or desmopressin
• Encopresis with significant psychological overlay
• Psychosomatic complaints (recurrent headaches, abdominal pain without organic cause)

• Suspected child abuse (physical, sexual, emotional)
• Neglected children
• Children of mentally ill parents

• Children from severely dysfunctional families
• Parenting difficulties requiring professional support

Red Flags - Immediate Referral

• Any self-harm or suicidal ideation
• Psychosis (hallucinations, delusions)
• Severe aggression toward others
• Profound developmental regression
• Suspected child abuse or neglect

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Quick Summary Table

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