Behavioural disorders in children and their management

1. Pica

Pica is the persistent ingestion of non-nutritive substances such as plaster, charcoal, paint and earth for at least
1 month in a manner that is inappropriate for the develop mental level, and is sufficiently severe to warrant independent clinical attention.

◾It is a common problem in children less than 5 yr of age.
◾Causes for initialization of pica may include mental retardation, psychosocial stress (maternal deprivation, parental neglect and abuse) and other behavioral disorders. Poor socioeconomic status, malnutrition and iron deficiency are commonly associated with pica.
◾Children with pica are at an increased risk for lead poisoning, iron deficiency anemia and parasitic infestations.
Management- It consist behavior modification, alleviating the psychosocial stress and iron supplementation
if deficiency is present.

2. Breath Holding Spells

A breath-holding spell is an episode in
which the child stops breathing and
loses consciousness for a short period
immediately after a frightening or
emotionally upsetting event or a
painful experience.

The child stops breathing for upto one minute.

The crying stops at full expiration and the child becomes apneic (temporary cessation of breathing) and cyanotic or
pale. In some cases the child may lose consciousness, become hypotonic and fall. If the spell lasts for more than
a few seconds, brief tonic-clonic seizures may occur. Breath holding spells always revert on their own within several seconds, with the child resuming normal activity or falling
asleep for some time.

◾Age – Breath holding spells generally start at 6 months of age, peak at 2 yr and abate by 5 yr of age.

◾Diagnosis – Diagnosis is based on the the typical sequence of crying, cyanosis or pallor with or without brief loss of consciousness. The differential diagnoses include seizures, cardiac arrhythmias or brainstem malformation.

◾Management- After a thorough examination of the child, the parents
should be reassured. They are explained that the apneic
spells do not lead to brain injury or death. The family should be advised to be
consistent in their behavior with the child, remaining calm during the event.

Avoid picking up the child, since this decreases the blood flow to the brain and turn him to the side so that secretions can drain.

3. Autistic Disorder

Autistic disorder is classified as one of the pervasive developmental disorders, also called as autistic spectrum disorders, a cluster of syndromes that share marked abnormalities in the development of social and communicative skills.

Symptoms- ◾qualitative impairment in social interaction as manifested by two of the following: impairment in the use of multiple nonverbal behaviors (e.g. eye gaze, facial expression, body postures); failure to develop peer relationships; lack of sharing of enjoyment; and lack of social or emotional reciprocity;

◾qualitative impairment in communication in delay or lack of spoken language, marked impairment in the ability to initiate or sustain a conversation with others, stereotyped or repetitive use of language.

◾restricted, repititive and stereotyped Patterson of behaviour, interests and activities, repititive motor mannerisms such as rocking, hand flapping, finger flicking, preoccupation with parts of objects.

Diagnosis- Diagnosis is clinical with the use of diagnostic tools, such as-

• Autism Diagnostic Observational Schedule
• Autism Diagnostic Interview- Revised

Treatment- Primary management is through ‘intensive behavioural therapy’ starting before age of 3 year, focussing on speech and language development and good behavioural control.

Older children and adolescents may require psychotherapy and pharmacotherapy.

4. ADHD – Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder in children,
estimated to affect 3-5% of school-aged children, particularly boys. It is characterized by difficulty in paying
attention, difficulty in controlling behavior and hyperactivity.

Clinical features-

◾Inattentive behavior

• Early distraction by extraneous stimuli
• Often makes careless mistakes in schoolwork or other activities
• Often has difficulty sustaining attention in tasks or play
• Often forgetful in daily activities
• Does not seem to listen to what is being said to him
• Often fails to finish school work or other chores
• Daydreams, becomes easily confused, and move slowly
• Difficulty in processing information as quickly and accurately as others

◾Hyperactive behaviour

• Runs about or climbs excessively in situations where it is inappropriate
• Fidgets with hands and feet and squirms in seat
• Talks nonstop
• Has trouble sitting still during dinner, school, and story time
• Has difficulty doing quiet tasks or activities.

◾Impulsive behaviour

• Has difficulty awaiting turn in games or group situations
• Blurts out answers to questions
• Often interrupts conversations or other’ activities

3 subtypes are known-

1. Predominantly Hyperactive-impulsive
2. Predominantly inattentive
3. Combined hyperactive-impulsive and inattentive.

Diagnosis-

Through clinical interview of parents and use of behaviour rating scales. Physical examination through direct observation of the child and ruling out chronic systemic illnesses.

Management-

Combination of behavioural therapy and medications

Behavioural strategies include-

(i) clear and explicit instructions to the child about desirable and undesirable
behavior;. (ii) positive reinforcement of desirable behavior by praise or small tangible rewards; (iii) punishment strategies like verbal reprimand. (iv) extinction technique, ie. systematic ignoring of undesirable behavior; (v) providing a well-structured and organized routine for the child at home as well as school.

Medications include-

1. Stimulants, e.g. methylphenidate, amphetamine and their derivatives.
2. Atomoxetine, a selective norepinephrine reuptake inhibitor, and extended-release preparations of selective alpha adrenergic agonists.