B.

Sc NURSING THIRD YEAR

CHILD HEALTH NURSING
UNIT VI
MANAGEMENT OF BEHAVIOURAL AND
SOCIAL PROBLEMS IN CHILDREN
subtopic: Management of common
behavioural disorders

Prepared By
Mrs. Angel, MSc. N
BTNC
Learning Objectives
By the end of the class the students will be able
to:
define behavioural disorders
enlist the causes of behavioural disorders
enumerate the types of behavioural disorders
explain the assessment for common behavioral
disorders.
elaborate behavioural disorders
describe the nursing care
OVERVIEW
 Introduction.

 Definition

 Causes of behavioural disorders

 Types of behavioural disorders

 Assessment of common behavioural

disorders.

 Description of behavioural disorders

 Conclusion
TERMINOLOGIES
• BEHAVIOUR
The way in which one acts or conduct
oneself, especially towards others.
• COUNSELLING
The act of exchanging opinions and
ideas and consultation.
• THERAPY
Treatment intended to relieve or heal a
disorder
.
INTRODUCTION
A young person is said to have a behaviour
disorder when he or she demonstrates behaviour
that is noticeably different from that expected in
the school or community.
“A child who is not doing what adults
want him to do at a particular time”.
DEFINITION
When children cannot adjust to a complex
environment around them, they become unable
to behave in the socially acceptable way
resulting in exhibition of peculiar behaviours and
this is called as behavioural problems.
CAUSES FOR BEHAVIORAL DISORDERS
 Faulty Parental Attitude
 Inadequate Family Environment
 Mentally and Physically Sick or
Handicapped Conditions
 Influence of Social Relationship
 Influence of Mass Media
 Influence of Social Change
Categorization of Common Behavioral
Problems

HABIT SLEEP SEXUAL

PROBLEM PROBLEMS PROBLEMS

SPEECH EATING ANTISOCIAL

PROBLEMS DISORDERS PROBLEMS

PERSONALITY SCHOLASTIC
PROBLEMS PROBLEMS
TYPES OF BEHAVIORAL PROBLEMS IN
CHILDREN
Behavioral disorder results due to deprivation in
any one of the area mentioned below :-
1. Emotional Deprivation.
2. Physical Deprivation.
3. Social Deprivation
4. Other forms.
1. EMOTIONAL DEPRIVATION
It occurs when a child is criticized, neglected,
ignored or abused by primary caregiver. Behavioral
problems resulting from emotional deprivation are :-
Temper tantrum
Breath holding spells
Jealousy
Insomnia
Nightmares/ night terrors
Somnolence
Masturbation or Homosexuality
Bruxism
2. PHYSICAL DEPRIVATION
A physically deprived child has profound effects
on developing brain. Behavioural disorders
coming under this are :-
Enuresis (Bed wetting)
Encopresis
Tics
Nail Biting
Pica
Thumb Sucking
Attention Deficit Hyperactive
Disorder
[Link] DEPRIVATION

It is the reduction of culturally normal interaction

between individual and society, It includes :-
Juvenile Delinquency
School Phobia
Stealing
Repeated Failures
Lying
Aggressiveness/Destructiveness
4. Other forms

 Sibling Rivalry

 Speech Disorder
ASSESSMENT OF COMMON BEHAVIORAL
PROBLEMS
 Assess whether child is happy or difficult to
manage.
 Child’s response to new situation.
 Excessive demand of attention.
 Problems of toilet and bladder.
 Habit of nail biting, thumb sucking, pica etc...
DISORDERS CAUSED BY EMOTIONAL
1. TEMPERTANTRUM
Temper tantrum is a sudden outburst or violent
display anger, frustration and bad temper as
physical aggression or resistance such as rigid
body, biting, kicking, throwing objects, hitting,
crying, rolling on floor, screaming loudly, banging
limbs, etc.
SYMPTOMS
 Loud cry
 Shouting
 Kicking
 Biting
 Head Banging
 Screaming
 Throwing and breaking objects
 Inflicting self injury.
Management

In general, parents advised to:

 Set a good example to child
 Pay attention to child
 Spend quality time
 Have open communication with child
 Have consistency in behavior
Management
•During temper tantrum:
 Parents to ignore child and
once child is calm, tell child
that such behavior is not
acceptable
 Verbal reprimand should not
be abusive
 Never beat or threaten child
 Impose “Time Out” -if
temper tantrum is
disruptive, out of control and
occurring in public place.
2. BREATH HOLDING SPELLS

These are brief periods for which young children

stop breathing for 1 minute.

These spells often causes a child to lose
consciousness.
It is of 2 types:
Cyanotic Spell

Pallid Spell
Cyanotic Spell :- It is caused by a change in

child’s usual breathing pattern, usually in

response to feeling angry or frustrated.
Pallid Spell :- It is caused by slowing of child’s

heart rate usually in response to pain.

SIGN AND SYMPTOMS
 Fainting
 Stiff body
 Too fast or too hard breath
 Long pause before child takes another
breath
 Red or blue purple lips
 Intense/single or no cry at all
Management – General:
 No treatment is usually needed
 Iron supplements to children with iron
deficiency
During a spell :
 Make sure your child is in a safe place where
he or she will not fall or be hurt.
 Place a cold cloth on your child's forehead
during a spell to help shorten the episode.
 After the spell, try to be calm.
 Avoid giving too much attention to the child, as
this can reinforce the behaviors that led to the
event.
 Avoid situations that cause a child's
tempertantrums.
3. JEALOUSY
Jealousy is a normal response to actual, supposed or
threatened loss of affection.
e.g. During the birth of an additional family member
lots of new feelings are generated in older child.
SYMPTOMS
Aggressive nature

Roughly handling of new baby

Children may act naughty to get attention

Gets detached and may become over affectionate

MANAGEMENT
 Never punish the child for his feeling of jealousy.
 Teach the child to deal effectively with his
emotions.
 Parents should treat child equally and avoid
comparison.
 Professional help can be taken in complicated
cases.
SLEEP DISORDERS
4. SOMNILOQUY

It is a sleep disorder that refers to talking aloud

while asleep.

It can be quite loud ranging from simple

mumbling sounds to loud shouts.
SYMPTOMS

 Talking irregularly and giving gaps like normal

conversation.

 Child gives good facial expression in sleep

also.
MANAGEMENT
Sleep along with the child and assure that
parents are with him/her.
Satisfy the child’s needs.
Resolve conflicts with other children.
Try to make good relationship with child.
Do not show movie or tell story before sleeping.
6. SOMNABULISM
It is a phenomenon of combined sleep and
wakefulness. In this sleep walking occurs at a state
of low consciousness and child performs activities
that are usually performed in full consciousness.
SYMPTOMS
Activities like:
Sitting up in the bed.
Walking to the bathroom and cleaning it.
Initiating hazardous activities like cooking,
driving and grabbing hallucinated objects.
Homicide
MANAGEMENT

 Lock the doors and windows of the room in which

child is sleeping.
 Remove all dangerous and hazardous objects,
 Give small dose of Diazepam in advanced cases.
 Consult physician if uncontrollable.
7. NIGHTMARES AND NIGHT TERRORS
NIGHTMARES:- In this the child gets awakened
due to a frightening bad dream but the child is
conscious about the surrounding.
NIGHT TERRORS:- In this the child gets
awakened during sleep and sits up screaming
and terrified to recognize the surroundings and
after sometimes sleeps again.
SYMPTOMS
Child suddenly awakes during sleep periods.
Child gets frightened and may not be fully alert.
Child describes frightening dreams in detail
He seeks and responds to comfort given by
parents.
May resist return to bed because of fear of
recurrence.
Management
Give reassurance to the child by holding him.
Speak in very soothing tone that there is nothing
wrong.
Discuss the dream images with the child and work
together to change the outcome
Have the child to go to bed in same time everyday.
Avoid scary books or movies before sleeping
8. INSOMNIA

It is a sleep disturbance in which children have

trouble falling asleep or staying asleep at night.
SYMPTOMS
 Difficulty falling asleep or staying asleep or

waking up too early in morning.

 Being sleepy during the day.

 Irritability

 Mood swings

 Decreased attention span

MANAGEMENT
 Provide a comfortable sleep environment.
 Set bedtime to obtain usual timing of sleep.
 Provide deep breathing, positive mental
imaginery while lying in bed and other
relaxation technique.
9. MASTURBATION AND HOMOSEXUALITY
Masturbation:- It is the stimulation and

manipulation of one’s own genitals in order to

achieve orgasm.
Homosexuality:- It is the sexual attraction
between the members of same sex or gender.
MANAGEMENT
Parents should not scold or show negative attitude
towards child’s behaviour.
Advice and educate the child in a non threatening
way about acceptable behaviour in public.
As intellectual development progress incidence of
masturbation declines in preschoolers.
[Link]
It is excessive grinding or clenching of teeth while
sleeping which is not related to normal function
of eating or talking.
SYMPTOMS
Excessive teeth wear.

Tooth fractures

Hypersensitive teeth

Grinding or tapping noise during sleep

Cheek/lip Biting

Tenderness, pain or muscle fatigue

Headache particularly in temples

MANAGEMENT

Repairing of damaged teeth.

Dental restoration like crown

filling.
DISORDERS CAUSED BY PHYSICAL
DEPRIVATION
1. ENURESIS
Enuresis refers to bed wetting after the
age of 5 years. It is common pediatric
problem in which repeated involuntary
urination takes place at an age in which
voluntary bladder control should have
established.
It is of 2 types :-
PRIMARY ENURESIS :- In this child is

never dry at night and occurs as a result of

rigid bladder training by parents who are
over anxious.
SECONDARY ENURESIS :- It is
characterized by initial control of bladder
that later gets disrupted by stressful
environment.
SYMPTOMS
Repeated voiding of urine into bed or
clothes.
Soiling themselves.

MANAGEMENT
Do not give excess fluid to child after 6-7
pm
Make the child void before going to bed
Do not give strict bladder and bowel
training
Wake up the child once or twice at night
to void
Reward the child for dry nights
2. ENCOPRESIS
It is repeated voluntary or involuntary passage of
feces of normal or near normal consistency in
places not appropriate for that purpose.
CAUSES
Subconscious anger
Child with emotional problem
Psychosocial stress like entering
new school
MANAGEMENT
Do not give too strict toilet training.
Educate parents that toilet training is a
developmental process which happens in time.
Provide minerals and vitamins if deficiency
occurs.
Give family counselling about the problem.
3. TICS
A tic is a nonvoluntary body movement or
vocal sound made repeatedly or suddenly.
They appear to be a manifestation of
discharge of tension.

It is of following types :-
SIMPLE TICS- It involves only few muscles

or sounds that are not words.

E.g. Nose wrinkling, facial grimace, jerking
the neck and shrugging the shoulders.
COMPLEX TICS- It involves multiple
group or muscles or complete words
or sentences. Eg. Making same motions
with hands repeatedly, Touching or
smelling an object repeatedly and
holding body in unusual position.

SENSORY TICS- In this repeated

unwanted or uncomfortable sensation
arise. E.g. Repeated feeling of blinking
the eyes.
PHANTOM TICS- It is the least common
type. In this out of body variation takes place
and the person feels a sensation in other
people or object,
E.g. The person experiences relief by touching or
scratching the object involved.
MANAGEMENT
Tics should be ignored by caregivers while
working with these children
Allow the child to discuss concerns related to
school and family.
Refer child for medical evaluation if tic does
not decrease.
5. NAIL BITING
Nail Biting is a common habit of childhood. It is
usually an overt evidence of anxiety in older
children.
Sometimes thumb suckers change to nail
biters as they grow older.
SYMPTOMS
Biting nails of all the fingers.
The cuticle, skin margins, and surrounding
tissue of the nail gets affected.
Nail cutting is painful and the child may use
this as a form of self punishment.
MANAGEMENT
Assess the psychological environment of the

child.
Do not scold or punish the child for it.

Use a bitter substance applied for nails.

Keep child’s hand soft by applying

lotion or warm oil.

6. PICA

• Repeated or chronic ingestion of non-nutritive

substances.
E.g. Clay, sand, plaster from walls.
 It is frequent in first year of life but may be seen in

grown ups as well.

Types

Geophagia Eating of mud, soil, clay,

chalk, etc.
Pagophagia Consumption of ice
Hyalophagia Consumption of glass
Amylophagia Consumption of starch
Xylophagia Consumption of wood
Trichophagia Consumption of hair
Urophagia Consumption of urine
Coprophagia Consumption of feces
SYMPTOMS
 Lack of appetite.
 Lots of hair collection in stomach.

 Intestinal and parasitic infection.

Minerals and vitamin deficiencies.

MANAGEMENT
Provide treatment of worm infestations.

Provide psychotherapy.

Proper supervision of parents is necessary.

7. THUMB
SUCKING
Sucking is the infant’s chief pleasure
through which they get love, affection and
satisfaction.
Infants do thumb sucking if they lack oral
satisfaction.
CAUSES OF THUMB SUCKING
Infants deprived of sucking and breast
feeding
Manifestation of feeling of insecurity
Lack of bonding between parent and child
Sign of boredom, stress and isolation
Adverse Effects
 Malocclusion – open bite
 Mastication difficulty
 Speech difficulty ( D and T )
 Lisping
 Paronychia and digital
abnormalities
MANAGEMENT
Parents should not show anxiety till
the child is 4 years old.
Always praise and encourage the
child which helps to give up thumb
sucking.
• Reassure parents that it’s transient.
• Improve parental attention / nurturing.
• Bitter salves, thumb splints, gloves
may be used to reduce thumb
sucking.
SOLUTION TYPE HOW IT WORKS EXAMPLES HOW IT FAILS

Behavioural Depends on child‟s Rewards & Child loses control

willingness to stop punishments, when sleeping or in
stories subconscious state

Aversive Use of pain or Applying foul Creates more

discomfort to tasting liquids stress and pain to
discourage the child / can even
habit worsen…

Mechanical Mechanical Bandages around Restrict

impediments to the elbows, socks over movements, can
process the fingers, fabric be removed, not
gloves, etc hygienic

T Guards Remove the Thumb guards, Can not remove,

pleasure finger guards hygienic, do not
associated by restrict movement,
eliminating suction 95% success rate
8. ATTENTION DEFICIT HYPERACTIVITY
DISORDER

It is a condition that affects the behaviour of children

which is marked by persistent inattention,
hyperactivity and impulsivity.
ETIOLOGY

• Genetic Factors
• Biochemical Theory
• Pre, Peri and Postnatal Factors
• Environmental Influences
• Psychosocial Factors
TYPES

CLASS I: CLASS II:

INATTENTION
+ CLASS III:
HYPERACTIVITY HYPERACTI VITY
+ + INATTENTION
IMPULSIVENESS. IMPULSIVENESS

Mable_Ma 62
ria
CLINICAL FEATURES
• Sensitive to stimuli, easily upset by
noise, light, temperature and other
environmental changes.
• At times the reverse occurs and the
children are flaccid and limp, sleep more
and the growth and development is slow
in the first month of life.
• General coordination deficit.
• Short attention span, easily distractable.
• Failure to finish tasks
• Impulsivity.
• Memory and thinking deficits.
• Specific learning disabilities.
DIAGNOSIS

• Complete medical evaluation.

• A psychiatric evaluation.

• Detailed prenatal history and early

developmental history.
• Direct observation, teacher’s school
report, parent’s report.
TREATMENT

 Pharmacologic

 Non Pharmacologic

- Psychologic Therapies
• Behaviour therapy

• Cognitive Behaviour Therapy

• Biofeedback
MANAGEMENT
Parents can create small manageable goals

for their child like sitting in chair for 10 min

and giving rewards for its completion.
Sleeping for extra half hour helps in dealing

with restlessness
Start practicing good health habits

Make sure that child gets plenty

of opportunities to play.
NURSING INTERVENTION
• Develop a trusting relationship with the
child.
• Ensure safe environment.
• Offer recognition for successful attempts
and positive reinforcement.
• Provide information and materials related to
the child’s disorder and effective parenting
techniques.
• Explain and demonstrate positive parenting
techniques
• Coordinate overall treatment plan with
schools, collateral personnel and the family.
DISORDERS CAUSED BY SOCIAL
DEPRIVATION
1. JUVENILE DELIQUENCY
Juvenile Deliquency is defined as an individual
under the age of 16 who fails to abide the laws.
CHARACTERISTICS OF JUVENILE
DELINQUENCY

The behaviour is marked by violation of law,

persistent mischieviousness, antisocial behaviour,
disobedience etc.
INTERVENTIONS
Delinquent court seeks to provide protection

and safety of public and of the minor who has

come in contact with court.
Special facilities like juvenile correction homes

are there which provides safety and

supervision of delequent child.
Family should act as role models and support

their child always.

Prevention

Prevention of juvenile delinquency is possible by

elimination of contributing factors.

Healthy parent child relationship, tender loving care

in the family, fulfillment of basic needs, educational

opportunities, facility for sports exercise and
recreations, healthy teacher taught relationships, etc.
are important aspects of prevention.
Contd…
Delinquent child needs sympathetic attitude with
necessary guidance and counseling for
modification of behavior.

The child should be referred to child guidance

clinic for necessary help. A team approach is
necessary in management of this condition
including social workers, psychologists,
pediatricians, community health nurse, school
teachers, family members and parents.

 Modification of social environment and

rehabilitation of delinquent child should be
promoted.
2. SCHOOL PHOBIA
DEFINITION
School phobia is also known as school refusal
or school avoidance.

Children who resist going to school or who

demonstrate extreme refusal to attend school
for a sustained period of time are said to have
school phobia.

They demonstrate signs like leg pain,

headache, nausea, vomitting etc.
MANAGEMENT

 Treatment depends upon the cause.

 Examine the relationship of child and

teacher with the peer group.

 Reward the children for going to school

in daily basis.
 Professional child consultation is needed

in severe problem.
OTHERS
1. SPEECH PROBLEMS.
i) Stuttering or Stammering
It is fluency disorder beginning between 3-5 years
probably due to inability to adjust with
stress.
It is characterized by interruptions in the flow of
speech, hesistations, spasmodic repetitions
etc.
ii) CLUTTERING
Cluttering is characterized by unclear and
hurried speech in which words trumble over
each other.
These are awkward movement of hand feet
and body.
These children therapy.

iii) DYSLALIA

It is the disorder of difficulty in articulation

which is caused by abnormalities in jaw
and palate
MANAGEMENT
Speech disorders are managed by:

Behavior modification and relaxation

therapy.
Reassure the child and help in breath
control exercise.
Speech therapy
LEARNING DISORDERS
 “These disorders are characterized by
academic functioning that is substantially
below that expected given the person’s
chronological age, measured intelligence,
and age- appropriate education” (APA)
 Must be distinguished from difficulties
arising from lack of opportunity, poor
teaching, and/or cultural factors
 Types of Learning Disorders
– Reading Disorder
– Mathematics Disorder
– Disorder of Written Expression
– Learning Disorder Not Otherwise Specified
Learning Disorders - Assessment
 Administer an individually administered
standardized intelligence test
 Administer an individually administered
standardized academic achievement test
 Compare the child’s IQ score with the
child’s achievement standard score
 A significant discrepancy between these
two scores is indicative of a learning
disorder
Learning Disorders - Reading
 Reading Disorder ~ Dyslexia
– Reading achievement is substantially
below that expected
– Equal among males and females
– Prevalence ~ 4% of school-aged
children
– Etiology
 Tends to be more prevalent among family
members
 Possibly related to subtle deficits in
particular cortical regions of the brain
specifically associated with oral
language, encoding, and working
memory
Learning Disorders - Reading
 Treatment
– Modifications in school
 Extra time on written tests
 Marking but not downgrading spelling errors

 Oral exams for severely impaired dyslexics

– Individual tutoring in phonics based approach

to reading
– Older dyslexics may need help with reading
comprehension strategies and study skills
– Caregivers take on the role of advocate,
facilitator of appropriate interventions, and
source of emotional support
Learning Disorders - Mathematics
• Mathematics Disorder
– Skills potentially impaired in Mathematics Disorder
 Linguistic Skills ~ understanding or naming

mathematical terms, operations, or concepts and

decoding written problems into mathematical
symbols
 Perceptual Skills ~ recognizing or reading
numerical symbols or arithmetic signs and
clustering objects into groups
 Attention Skills ~ copying numbers or figures

correctly, remembering to add in carried numbers,

and observing operational signs
 Mathematical Skills ~ following sequences of

mathematical steps, counting objects and learning

multiplication tables
Learning Disorders - Mathematics
 Prevalence ~ estimated at 1% of school-
aged children
 Treatment
 Utilize graph paper to address perceptual
difficulties
 Highlight arithmetic sign to address attention

difficulties
 Extra tutoring to address deficits in

mathematical skills and linguistic skills

– Additional instruction/tutoring with focus on
problem solving activities
– including word problems
– addresses social skills deficits as well
Learning Disorders – Writing
– Difficulties in the individual’s ability to
compose written texts as evidenced by
 Grammatical or punctuation errors

within sentences
 Poor paragraph organization

 Multiple spelling errors

 Excessively poor handwriting

– Diagnosis typically not provided if deficits

in only spelling or only poor handwriting
Learning Disorders - Writing
 Etiology
– Possible neurological deficits in the central
information processing centers of the brain
– Most children with a disorder or written
expression have relatives with the disorder
 Treatment
– Positive response to remedial treatment ~
intensive, continuous, individually tailored,
one-to-one expressive and creative writing
therapy (provided in school)
– Psychological treatment of secondary
emotional and behavioral problems
NURSING RESPONSIBILITIES

Assessment of specific problem of the

child by appropriate history and detection
of the responsible factors.
Informing the parents and making them
aware about the causes of behavioural
problems of the particular child.
Assisting the parents, teachers and family
members for necessary modification
of environment at home school
and community.
Encouraging the child for behaviour
modification, as needed
Contd…
Promoting healthy emotional development of
the child by adequate physical,
psychological and social support.
Creating awareness about psychosocial
disturbances which may lead to behavioural
problems during developmental stages.
Providing counselling services for children
and their parents to solve the problems,
whenever necessary and for tender loving
care of the children.
Contd….
Participating in the management of the problem
child, as a member of health team along with
pediatrician, psychologist and social worker.
Organizing Child guidance clinic.

Referring the children with behavioral problems

for necessary management and support to
better health care facilities, child guidance clinic,
social welfare services and support agencies.
References
Hockenberry, M., & Wilson, W. (2008).
Essentials of Pediatric Nursing, (7th ed).
Missouri. Mosby Publications.

James, S.R., & Ashwill, J.A. (2007). Nursing

Care of Children, Principles and Practice,
Pennsylvania. Saunders Elsevier Publicatons.

Townsend ,M.C., (2010).psychitric mental

health nursing concepts of caring in evidenced
based practice 5th ed , jaypee brothers.

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