BEHAVIOURAL PEDIATRICS AND PEDIATRIC NURSING

Pediatric nursing involves taking the responsibility of care for children and families
throughout the lifespan. This task includes health promotion, illness care, health restoration,
and rehabilitation of the child health.

Pediatric nursing requires understanding the developmental aspects of children and physical
differences between children and adults. Pediatric nurses must also recognize the role that
families play in the child’s health and reflect family-centered care in practice.
I. DEFENITION OF NURSING

It is the unique function of a nurse that is to assist the individual, sick or well, in the
performance of those activities contributing to health or its recovery (or to peaceful death) that
he would perform unaided, if he had the necessary strength will, or knowledge and to do this in
such a 1way as to strength, will or knowledge, and to do this is such a way as to help him gain
independence as rapidly as possible

-Virginia Henderson, 1966

DEFINITION OF PEDIATRICS

Pediatrics can be defined as the branch of medical-science that deals with the care of the
children, from conception to adolescence, in health and illness. It is concerned with preventive,
curative, and rehabilitative care of children.

DEFINITION OF PEDIATRIC NURSING

Pediatric nursing is defined as the specialized area of the nursing practice concerning the care of
children during wellness and illness, which includes preventive, promotive, curative and
rehabilitative care of children.

DEFINITION OF BEHAVIOURAL PEDIATRICS

Developmental behavioral pediatrics is a unique sub speciality that focuses on a child’s strengths
and challenges within the context of the family using a bio-psycho-social perspective.

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II. PRINCIPLES OF BEHAVIOURAL PEDIATRICS

In the development of planning resource a number of underlying principles and beliefs

1. UNDERSTAND THE FUNCTION OF BEHAVIOR

Our behaviors have specific functions. So, in order to modify behavior with applied behavior
analysis, its important to understand the purpose of behavior.

Hundreds or even thousands of different behaviors everyday. Most behaviors can be broken
down in to four main categories.

a) Escape or Avoidance. This is behavior that attempts to prevent the child from doing
something he or she doesn’t want to. Examples would be the child who runs away because he or
she doesn’t want to take a bath or the child who throws food because he or she doesn’t want to
eat it.
b) Attention-seeking. Attention-seeking behavior is behavior intended to get the attention of
the parent or another child or anyone in the vicinity. The child that does comical things intended
to make the parent laugh in order to avoid doing chores is doing a combination of attention-
seeking and escape/avoidance. A crying child is displaying simple attention-seeking behavior
that is designed to elicit the attention of the adult.
c) Sensory Stimulation or the Opposite. This behavior stimulates the senses. One child’s
preference for thrilling or fast sports is a method of sensory stimulation. Another child may rock
for hours in a self-soothing behavior that de-stimulates the senses.
d) Seeking Access to Tangibles or Activities. This behavior is like the opposite of escape or
avoidance. The child engages in this behavior in order to get or do something that he or she
wants. Examples are the child who whines at the grocery stores to get the parent to buy some
candy (negative behavior) or the child who gets dressed promptly in order to go outside and play
(positive behavior).

Once we understand the goals of different behaviors it becomes easier to modify them. Some of
the behaviors that we aim to teach a child with Autism Spectrum Disorder are appropriate table
behaviors, toileting behaviors, social interaction behaviors, and sleep and bedtime behaviors.

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2. UNDERSTANDING COMES FROM OBSERVATION OF ABCs

In behavior analysis , ABC data is typically the preferred method used when observing a
behavior. This involving directly observing and recording situational factors surrounding a
problem behaviors using an assessment called ABC data collection. An ABC data form is an
assessment too used to gather information on a certain problem behaviors or behaviors being
exhibited by a child ABC refers to,

Antecedent---The events , actions or circumstances that occur immediately before a behavior.

Behavior---The behavior in detail.

Consequences---The action or response the immediately follows the behavior.

3. CONSEQUENCE SHOULD BE CONSISTENT AND IMMEDIATE

A consequence is something that happens after your child behaves in a particular way. A
consequence can be positive or negative.

a) Positive and negative consequences

Only work if they are given consistently. If you only take away your child’s video games
two out of every three times he hits his brother, he won't learn.

Give child a negative consequence each and every time he breaks a rule. Consistency is the key
to helping child learn that he can't get away with bad behavior. Make sure you stick to
consequences as well. If you take away a privilege for the whole day, don't give in early.
Commit to doing what you say and saying what you mean and your child's behavior will
change.

b) Give Plenty of Positive Attention

A healthy relationship with child is a necessary foundation for discipline. If child loves and
respects you, consequences will be much more effective. Aim to give your child 15 minutes
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 of positive attention each day. The more you invest in time-in, the less time your child will
spend in time-out.

c) Give Immediate Consequences

The best consequences are immediate. Taking away child’s overnight with Grandma that is
planned for next week is not likely to be as effective as taking away his electronics right now.

Immediate consequences ensure kids remember why they got into trouble in the first place. If it’s
delayed by a week, they’re more likely to forget what rule they violated.

There may be times, however, that it’s not possible to give immediate consequences. If you find
out your child got into trouble on the bus three days ago, the consequence will obviously need to
be delayed. Or, if he misbehaves right before he gets on the bus in the morning, you may need to
wait until he gets home from school before you can give him a consequence.

When it's not possible to make the consequence immediate, give it to your child as soon as
possible. Just make it clear why he's getting in trouble now by reminding him which rule he
violated.

d) Use Consequences as a Teaching Tool

There’s a difference between consequences and punishments. Consequences should be used as a

teaching tool and shouldn’t shame or embarrass kids. In fact, those type of punishments
make behavior problems worse, not better. Logical consequences are a great way to ensure that
the consequence fits with the misbehavior. So if your child refuses to turn off his video games,
take away his video games. Or, if he rides his bike outside the boundaries, take away his bike.

e) Give Consequences Sparingly

Consequences become less effective when they are used too much. Kids who lose all of their
privileges for an extended period of time begin to lose motivation to earn it back. Time-out also

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 becomes less effective when it is used multiple times throughout the day. If your child requires
frequent consequences, try switching things up. Use other discipline tools, such as reward
systems, praise, and active ignoring.

Positive discipline techniques can be instrumental in helping kids turn things around. It motivates
them to improve their behavior and can also help improve relationship along the way.

4. MODELLING CAN STRENGTHEN OR WEAKEN BEHAVIOR

MODELLING

Modeling which is also called observational learning or imitation , is a behaviorally based

procedure that involves the use of live or symbolic models to demonstrate a particular
behavior , thought , or attitude that a client may want to acquire or change. Modeling is
sometimes client need not actually perform the behavior in order to learn it.

Modeling therapy is based on social learning theory. Modeling has be effectively to treat
individuals with anxiety disorder.

Purpose

Modeling therapy is based on social learning theory. This theory emphasizes the importance of
learning from observing and imitating role models, and learning about rewards and punishments
that follow behavior. The technique has been used to eliminate unwanted behaviors, reduce
excessive fears, facilitate learning of social behaviors, and many more. Modeling may be used
either to strengthen or to weaken previously learned behaviors.

Modeling has been used effectively to treat individuals with anxiety disorders, post-traumatic
stress disorder , specific phobias , obsessive-compulsive disorder , eating
disorders, attention-deficit/hyperactivity disorder , and conduct disorder . It has also been
used successfully in helping individuals acquire such social skills as public speaking
or assertiveness.

 The effectiveness of modeling has led to its use in behavioral treatment of persons with
substance abuse disorders, who frequently lack important behavioral skills. These persons may

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 lack assertiveness, including the ability to say "no"; in addition, they may have thought patterns
that make them more susceptible to substance abuse.
 Modeling when used alone has been shown to be effective for short-term learning. It is,
however, insufficient for long-lasting behavior change if the target behavior does not produce
rewards that sustain it. Modeling works well when it is combined with role-play
and reinforcement . These three components are used in a sequence of modeling, role-play,
and reinforcement.
 Role-play is defined as practice or behavioral rehearsal of a skill to be used later in real-
life situations. Reinforcement is defined as rewarding the model's performance or the client's
performance of the newly acquired skill in practice or in real-life situations.

Several factors increase the effectiveness of modeling therapy in changing behaviors.

Modeling effects have been shown to be more powerful when:

 The model is highly skilled in enacting the behavior; is likable or admirable; is friendly; is
the same sex and age; and is rewarded immediately for the performance of the particular
behavior.
 The target behavior is clearly demonstrated with very few unnecessary details; is presented
from the least to the most difficult level of behavior; and several different models are used to
perform the same behavior(s).

FACTOR INFLUENCING BEHAVIOURAL PEDIATRICS

 ETHICAL ISSUES
Children with developmental or behavioral disorders may have unique needs or face end of life
issues more frequently than do other children, but the fundamental approach to resolving ethical
issues is and should be the same as for any other child.
 LACK OF EXPERTS

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III. COMMON BEHAVIOURAL PROBLEMS OR DISORDERS OF PEDIATRICS

Emotional and behavioral problems are seen commonly during the period of growing up and are
due to the stress of development and adaptation of family expectation. Infancy and childhood are
of paramount importance in determining and patterning the future behavior and character of the
children. Childhood is the period of dependency. Gradually, children learn to adjust in the
environment. But there is any complexity around them they cannot adjust with that circumstance.
Then they become unable to behave in the socially acceptable way and behavioral problems
develop with them.

Normal children are healthy, happy and well-adjusted. This adjustment is developed by
providing basic emotional needs along with physical and physiological needs for their well-
being. The emotional needs are considered emotional food for healthy behavior. The children
are dependent on their parents, so parents are responsible for fulfillment of the emotional needs.

Around 12% children attending pediatric outpatient clinics meet the diagnosis of behavioral and
emotional disorder.

STATISTICS

 The World Health Organization (WHO) estimates that globally, 7.4 percent of DALYs are
caused by disorders in the mental and behavioral disorders category.
 The WHO data below show the breakdown of disorders within that category, and the
percentage that each individual disorder contributes to DALYs caused by the mental and
behavioral disorders category.
a) Major depressive disorder accounts for 34.12 percent of DALYs in the mental and
behavioral disorders category.
 ADHD, behavior problems, anxiety, and depression are the most commonly
diagnosed mental disorders in children
 9.4% of children aged 2-17 years (approximately 6.1 million) have received an ADHD
diagnosis.

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 7.4% of children aged 3-17 years (approximately 4.5 million) have a diagnosed behavior
problem
 7.1% of children aged 3-17 years (approximately 4.4 million) have diagnosed anxiety.
 3.2% of children aged 3-17 years (approximately 1.9 million) have diagnosed depression.
Some of these conditions commonly occur together. For example:
 Having another disorder is most common in children with depression: about 3 in 4 children
aged 3-17 years with depression also have anxiety (73.8%) and almost 1 in 2 have behavior
problems (47.2%).
 For children aged 3-17 years with anxiety, more than 1 in 3 also have behavior problems
(37.9%) and about 1 in 3 also have depression (32.3%).
 For children aged 3-17 years with behavior problems, more than 1 in 3 also have anxiety
(36.6%) and about 1 in 5 also have depression (20.3%).

Depression and anxiety have increased over time

 “Ever having been diagnosed with either anxiety or depression” among children aged 6–17
years increased from 5.4% in 2003 to 8% in 2007 and to 8.4% in 2011–2012.
 “Ever having been diagnosed with anxiety” increased from 5.5% in 2007 to 6.4% in 2011–
2012.4
 “Ever having been diagnosed with depression” did not change between 2007 (4.7%) and
2011-2012 (4.9%).

Treatment rates vary among different mental disorders

 Nearly 8 in 10 children (78.1%) aged 3-17 years with depression received treatment.
 6 in 10 of children (59.3%) aged 3-17 years with anxiety received treatment.
 More than 5 in 10 children (53.5%) aged 3-17 years with behavior disorders received
treatment.

Mental, behavioral, and developmental disorders begin in early childhood

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 1 in 6 U.S. children aged 2–8 years (17.4%) had a diagnosed mental, behavioral, or
developmental disorder.

Rates of mental disorders change with age

 Diagnoses of depression and anxiety are more common with increased age.
 Behavior problems are more common among children aged 6–11 years than children
younger or older.
b) CAUSES OF BEHAVIORAL DISORDERS

Behavioral disorders are caused by multiple factors. No single event is responsible for this
condition. The Important contributing factors are -:

a) Faulty Parental Attitude

Overprotection, dominance, unrealistic expectation, over criticism, unhealthy comparison,

under-discipline or over-discipline, parental rejection, disturbed parent child interaction,
broken family ( death, divorce), etc. are responsible factors for development of behavioral
problems. The first child, the last child, the only child, the child of elderly parents, the only son
or only daughter, adopted child, chronically ill child and the child with birth-defects are likely to
be pampered and over-protected. An over protected child is never left alone and is not allowed
to play with other children for the fear that other children may beat him. These over protected
children are not allowed to play cricket or ride a bicycle or allowed to go for swimming for the
fear of injury. The mother helps such child in homework also. Hence he becomes dependent on
parents and turns out

 Over-emotional parents : Since early life, the children of emotional parents learn to go
into temper-tantrums, if their needs are not fulfilled. Later these children waste time, become a
nuisance and are not accepted by even their own age group.
 Alcoholic parents : The child witnesses the frightening and unpredictable changes in the
moods and behavior of his alcoholic parents. The child fails to have security at home. He either
becomes timid or takes to vices and becomes aggressive.

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 Divorced parents : Divorce is a shocking experience to the child, who is often used by
parents as a weapon of revenge against each other. The divorced parents can still continue to be
good parents and carry parental responsibility though no longer living as husband and wife.
b) Inadequate Family Environment

poor economical status, cultural pattern, family habits ,child rearing practices, superstition,
parent’s mood and job satisfaction, parental illiteracy, inappropriate relationship among family
members, etc. influence on child’s behavior and may cause behavioral disorders.

A dysfunctional family is a family in which conflict , misbehavior and often child neglect or
abuse on the part of individual parents occur continuously and regularly ,leading other members
to accommodate such action.

c) Mentally and Physically Sick or Handicapped Conditions

Children with sickness and disability may have behavioral problems. Chronic illness and
prolonged hospitalization can lead to this problem. Mental illness is a term that deacribes a
broad range of mental and emotionally

d) Influence of Social Relationship

Maladjustment at home and school, disturbed relationship with neighbors, school teachers,
schoolmates and playmates favoritism, punishment, etc. may predispose behavioral problems.

e) Influence of Mass Media

Television, radio, periodicals and high-tech communication systems affect the school children
and adolescence leading to conflict and tension which may cause behavioral disorder. All these
cause development of various risky behaviors.

f) Influence of Social Change

Social unrest, violence, unemployment, change in value orientation, group interaction and
hostility, frustration, economic insecurity, etc. affect older children along with their parents and
family members resulting abnormal behavior.

g) Gender

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 Gender difference in cognitive variables as an explanation for gender difference in
depression and behavior problem.
h) Life style

Life style whichkids also trying to imitate the bad behavior in their future. may affect ones
behavior pattern . the parents with alcoholic te

i) Rearing practices

Mental health is an essential component of health. Child rearing practices play an important role
in shaping one’s behavior and personality of the individual. Children’s mental health has serious
implications for mental health has serious implications for mental health of future adults.
Fostering social and emotional health in children as a part of healthy child development must
therefore be a national priority.

I. INFANCY AND TODDLER

A. REPETITIVE BEHAVIOR

BODY ROCKING

HEAD BANGING

B. BREATH HOLDING SPELLS

C. THUMB SUCKING

D. NAIL BITING

E. EVENING COLIC

F. STRANGER ANXIETY

G. TEMPER TANDRUM

II. PRESCHOOL

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 A. STUTTERING

B. PICA
C. TIC DISORDER
D. ENURESIS
E. ENCOPRESIS
F. MASTURBATION
III. SCHOOL AGE
A. ENURESIS
B. ENCOPRESIS
C. CONDUCT DISORDER
IV. ADOLESCENCE
A. EATING DISORDER

B. JUVENILE DELINQUENCY

C. CONDUCT DISORDER

I. INFANCY AND TODDLER

A. HEAD BANGING

This involves rhythmic hitting of the head against a solid

Surface often the crib mattress. This occurs in 5—6%of during infancy and toddler years. This
is common at bedtime before going to sleep or after a child wakes during night or in the
morning. It can cause callus form abrasions and contusions but no intracranial injury.

CAUSES

 Many theories have been put forward to explain head banging perhaps the rocking and
even the head banging provide a form of pleasure related to the movement. This joy in
movement is called our kinesthetic drive

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 All infants are rocked by their mothers when they are carried about in utero. Later on ,
they enjoy being held and rocked in parents arm. Movement activities continue as kids grow :
the pleasure of jump rope , swings, slides, amusement park rides and dancing. These activities
all engage the vestibular system of brain , the amount and type of movement that provides
pleasure varies from child to child

 Kids who under stimulated (those who are blind , deaf, bored, or lonely) head bang for
stimulation.

SIGNS AND SYMPTOMS

The child seems compelled to rhythmically move his head against a solid object such as a wall
or the side of a crib. Often he rocks his entire body.

For most children it occurs at sleepy times or when upset. This behavior can last for minutes at
a time or sometimes for hours.

It can even continue once the child has fallen asleep.

 Rolling side-to-side on the bed or crib, in such a fast way that the head impacts on the

mattress or the side of the crib, even leading to the development of a bald spot.
Rocking back and forth rhythmically when on their hands and knees and going low
enough to repeatedly hit their head on the floor.

DIAGNOSIS

Three hallmark behaviors are the key signs that distinguish kids with autism associated head
banging and those with normal head hanging.

 Lack of pointing:

By fourteen months of age most children will point at objects in order to get another person to
look.

 Lack of gaze-following:

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By fourteen month , infants will often turn to look in the same direction an adult is looking.

 Lack of pretend play:

By fourteen months , children will begin to play using object substitution ,e.g ; pretending to
comb the hair with a block.

TREATMENT

Assurance to the parents.

Reassure the patient that it can be corrected by proper caring and treatment and by providing
safe environment.

Padding of bed rails to prevent injury. If the head banging disrupting child’s sleep,

o Offer an alternative bedtime comfort object, such as a blanket or stuffed animal.

o Stick to fairy strict routines for bedtime and naps

o Make sure that child in a safe environment when she goes to sleep and can’t hurt herself
while banging her hand. The crib sturdy , so it won’t break or fall apart due to any aggressive
head banging or body rolling . Be certain the screws are all tightened as much as possible

II. BREATH HOLDING SPELLS

Breath holding spell is common in children under six years of age. Breath holding spells can
happen after the child has a fright, a minor accident, is frustrated or gets very upset . Breath
holding is often called a , spell or an attack and is most common in toddlers .

Breath holding spells or breath holding spasms is a benign involuntary phenomenon seen in
children between 6 months and 6 years of age. Either due to pain, fear or in anger frustration the
child cries and then holds the breath.

STATISTICS

They constitute 4-18% of all the psychosomatic disorders seen in the pediatric age group.

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 Among otherwise normal children, up to 27% may have BHS with a male to female ratio of 3:1.
However, a community survey in India among 0-3-year-old children reported HHS to be the
most common psychiatric disorder in this age but with a prevalence of only 5.9%, There was no
difference in prevalence among rural, urban and slum children. Among an Indian general
hospital psychiatry clinic, 11 % of the preschoolers BHS.

DEFINITION

A breath holding spell is an involuntary pause in breathing, sometimes accompanied by loss of

consciousness. It usually occurs in response to an upsetting or surprising situation. Breath
holding spells appear to be a response to pain, or a traumatic event. The sudden reaction can the
nervous system to temporarily slow the heart rate or breathing, causing breath holding and color
changes.

ETIOLOGY

 FAMILY HISTORY

A positive family history is present in 23-38% of children with spells suggesting some genetic
association. An analysis of family members of children with breath-holding spells showed a
50:50 of inheritance from an affected parent.

Voluntary breath-holding as a cause of BHS. However, cinefluoroscopy has shown conclusively

that these episodes occur during expiration, and are thus involuntary. Another factor considered
to have important etio-pathological role been the presence of behavioral problems in BHS.
Children BHS were described as neuropathic children of neuropathic parents almost a century
back. Some workers suggested correlation between behavioral problems and BHS, including
abnormal behavior like temper tantrums and hyperactivity in 30% of these children.

 Neurological problem

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A maturational delay in myelination of brainstem to have a role in the etiology of breath holding
spells in children, whereas others have reported altered selenium and antioxidant levels in
children with BHS.

TYPES

1. Blue spells (cyanotic breath, holding)are the most common. A fright or pain often triggers
a spell. The child cries out or screams, then turns red in the face before going blue, usually
around the lips. The child becomes and unconscious .

2. Pale spells (pallid breath holding) are less common. They can occur very early in life,
often after a minor injury or when the child is upset. The child opens their mouth as if to cry, but
no sound comes out, before the child faints, looking pale.

3. Some children can have both cyanotic and pallid spells.

4. On rare occasions a child can have a seizure as part of breath-holding spell, but these are
brief and not harmful.

PHASES OF BREATH HOLDING SPELLS

Provocation – consists of some strong physical or emotional stimulus: a fall, anger, frustration,
or pain. Breath holding spell typically starts with crying, lasting 15 sec or less .

Expiratory apnea and cyanosis-Consists of sustained, forced expiration, followed by

progressive cyanosis in major cases.

Opisthotonic rigidity (backward arching)- The patient becomes restless and then opisthotonic,
with strongly extended back, arms, and legs.

Stupor- The apneic stage of the attack ends with a gasp or the resumption of quiet breathing.
The normal color promptly returns, and the patient lies motionless. The patient typically remains
stuporous drowsy for minutes to hours after an attack.

CAUSES

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It is more common in 2 months old and up to 2 years old can start having breath holding spells.
Most children stop having breath holding spells by the times they are 6-8 years old. Some
Children have severe spells. They usually stop by the time the child is6-8 Years old.

Children can have breath holding spells when they are responding to:

fear , Pain ,Traumatic event ,Being startled or confronted.

Breath holding spells are more common in children with:

Genetic conditions, such as Riley syndrome or Retts syndrome .Iron deficiency anemia ,A
family history of breath holding spells (parents may have had similar spells when they were
kids)

SIGNS AND SYMPTOMS

Breath holding spells most often occur when a child becomes suddenly upset or surprised.

Child makes a short gasp, exhales and stops breathing.

The child’s-nervous system slows the heart rate or breathing for a short amount of time.

 Breath holding spells are not to be a willful act of defiance, even though they often occur
with temper tantrums.

 Blue or pale skin ,then no breathing ,fainting or loss of alertness (consciousness),Jerky

movements (short, seizure-like movements)

 Normal breathing starts again after a brief period of unconsciousness ,child’s color
improves with the first breath. This may occur several times per day or only on rare
occasion.

DIAGNOSIS

1. The diagnosis of BHS depends only on a good and detailed clinical history, describing the
entire episode as and when it occurred. It should also include presence of any precipitating event
like emotional stimuli or trauma .

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2. Other important clues from the history that could help in diagnosis include the presence or,
urinary incontinence, unrolling of eyeballs, and deviation of mouth, which are more commonly
seen with seizures, especially if not preceded by a cry.

3. If feasible, parents may be encouraged to make a video recording of a typical episode that
could further help in confirming the diagnosis.

4. A complete physical examination including growth and development is essential,

especially cardiovascular examination for any rhythm disturbances or murmers. No imaging or
specific laboratory test is needed to make the diagnosis.

5. An electroencephalogram (EEG) is usually not indicated unless history is incomplete or

unclear, convulsive activity is too prolonged or seizure cannot be ruled out on the basis of
history.

MANAGEMENT

No treatment is usually needed

 During the episode ,lie than on their side and watch them , do not put anything In their
mouth or splash with water.

 Parents and family members become very anxious with the attack. Attempt to prevent the
spells is usually not successful. Parents need assurance about the harmless fleets of the attack
and should be tolerant, calm and kind. Identification and correction of precipitating factors
(emotional, environmental) are essential approach. Overprotective nature of parents may
increase unreasonable demand of the child. The child can use secondary gain as advantages,
Punishment is not appropriate and may cause another episode. Repeated attacks of the spells
need to be evaluated with careful history, physical examination and necessary investigations to
exclude convulsive disorders or any other problems.

 If the child has been diagnosed with breath holding spells take the following steps.

Place a cold cloth on the child’s forehead during a spell to help shorten the episodes.

After the spell ,try to be calm.

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Avoiding giving too much attention to the child as this can reinforce the behaviors that of spells.

Avoid situations that cause a child’s temper tandrum. This can help to reduce the number of
spells.

B. THUMB SUCKING

DEFENITION

Thumb sucking can be defined as placement of thumb in to the mouth for various depths.
Thumb sucking and finger sucking can more generally be termed as digit sucking.

During the first year of life , thumb sucking is considered as normal and usually does not lead to
long term effect. It usually disappears by 3-4 years of age . When this habit persist beyond
preschool it is considered as abnormal.

ETIOLOGY

PSYCHOLOGICAL REASONS:

Due to deep rooted emotional factor like insecurities , neglect and loneliness experienced by the
child

HABITUAL:

The child sucks the thumb as a habit.

 SOCIO-ECONOMIC STATUS

In high socio-economic status the mother is in a better position to feed the baby and in a short
time the baby’s hunger is satisfied. Whereas in the low socio-economic group mother is unable
to provide sufficient breast milk to infants, hence in the process he infants suckles intensively
for a long time thereby exhausting the sucking urge.

 WORKING MOTHER
The sucking habits is commonly observed to be present in children with working parents
because such children are brought up in hands of caretaker and develop feeling of insecurity.
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 NUMBER OF SIBLING
The development of habit can be related to the number of siblings because more the number
increases the attention meted out by the parents to the child gets divided. A child who feels
neglected by the parents may attempt to compensate his feelings of insecurity by means of
this habit
 FEEDING HABITS
Thumb sucking is seen to be more frequent in among breast –fed children. Yet abrupt
weaning from the bottle or breast has been hypothesized to contribute to acquiring an oral
habit. A negative relation is also seen between breastfeeding and the devlopent of dummy or
finger sucking.

TYPES OF THUMB SUCKING

1) Type A:

Where whole digit is placed inside the mouth with the pad of the thumb pressing over the palate
while at the same time maxillary and mandibular anteriors contact is present . This is the most
common type and seen in almost 50% cases.

2) Type B:

In this type is placed in to the oral cavity without touching the vault of the palate while at the
same time maxillary and mandibular contact is maintained. It is seen in almost one third of
children.

3) Type C:

Where thumb is placed in to the mouth just beyond the first joint and contact the hard palate and
only the maxillary incisors but there is no contact with the mandibular incisors. This is also
common as Type B.

4) Type D:

Very little portion of the thumb is placed in to the mouth. It is seen in 6% of children.

DIAGNOSIS

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 Diagnosis is mainly based on the history

 Detailed history regarding the frequency, intensity and duration of the habitat is to be
taken

 Enquire about the feeding patterns , parental care of the child and also about other habits.

 Clinical examination will reveal signs of chronic inflammation on the thumb.

TREATMENT

Treatment of thumb sucking should be considered after 4-6 years of age an when it causes dental
problem, digital malformation ,or distress to the child . if child is willing partner, the treatment
is more effective.

Psychotherapy is an important part of the treatment which also includes motivation of the child
to stop the behavior , by positive reinforcement . Reminder therapy includes various methods
which remind the child to stop thump sucking . It is of different types.

Extra oral approach: using bitter flavored preparation like pepper , quinine or asafetida on the
on the fingure.

Intra oral approach : orthodontic appliances , which can be removable type ( like palatal crib or
palatal arc) or fixed type (upper lingual tongue screens ). In resistant cases, fixed intra oral anti
thumb – sucking appliances are used.

Preventive therapy

Firstly feed the child whenever he is hungry and let him let as much as he wants. Secondly feed
the child the natural way. Thirdly never let the habit to be started the practice must be
discontinued at its inception.

 Reminder therapy

a) Chemical therapy

Recommends the use of hot flavored, bitter and sour tasting or foul smelling
preparations, placed on the thumb or fingers that are sucked. The chemical therapy use

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 cayenne (red) pepper dissolved in a volatile liquid medium. Quinine and Asafetida ,
castor oil which have bitter taste and an offensive odor respectively, also may be used.
This should be done only when the patient has a positive attitude and wants treatment to
break the habit. A commercially available product FEMITE (denatonium benzoate) is
also used for prevention of digit sucking.

b) Mechanical therapy

Mechanical restraints applied to the hand and digit like splints, adhesives tapes. Thump
guard is the most extra oral appliance for control of the habit.

 Thermoplastic thumb post

 Ace bandage approach

 Nortan and Gellin

 Use of long sleeve Nightgown

 Thumb –home concept.

III. NAIL BITING

Nail baiting also known as onychophagy is an oral compulsive habit.

Habit is often a way to ease anxiety or to keep at least one part of the body occupied while the
mind lacks interest.

CAUSES

 Frustration and loneliness are additional emotional triggers that can lead to nail biting.
Research suggests genes may play a role.

 Fingernails can also be a symptom or a psychological such as obsessive compulsive

disorder (OCD). People who wash their hands several times in a row or check front door locks
compulsively may also bite their nails as part of the same spectrum of behaviors. Many children
who are nail biters also have other psychiatric disorders, such as attention deficit hyperactivity
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 disorder (ADHD), oppositional defiant disorder (ODD), separation anxiety disorder, or bed-
wetting. Regular nail biting that causes severe damage to the and surrounding skin can be
considered a form of self –mutilation, similar to cutting and related behaviors.

PREVENTIVE MEASURES

 Try to Tackle the Habit Early

Try to identify if the child is developing a nail biting habit at an early stage. Just like any other
habit once it becomes established it will be a lot harder to break.

 Identify Triggers

It could be boredom, or stress or a particular time of day. Ask the older child to write down in a
diary when they notice they are nail biting. Ask them to note down what they were at the time
and if anything springs to mind as to what triggered the biting.

 Increase Awareness

One of the biggest problems is that it is a subconscious habit. A lot of the time a child will not
even notice when they start to bite. Raise the consciousness __ of_ their nails. To do this could
try taking photos of their nails every day for a week or two. She can compare the photos and
look for any progress or otherwise. Anything that helps someone to think about their nails on a
more regular basis can help.

 Start to Protect a Nail Campaign

Select a nail and make it the one cannot be bitten. I would suggest you take a nail is already badly
damaged. Watch it grow! This should help Your child to feel they are making progress. Once
the nail becomes reestablished select another nail to become its protected partner.

 Make Them Taste Foul

There are many liquids you can buy that cover the nail with a foul tasting coating. You do need
to ensure that this is reapplied on a regular basis. This is one of the most popular methods used
to try to break the habit.

 Substitute Another Activity

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In case the problem is stress or boredom related try another activity that uses the hands. First
one that springs to mind is squeezing a rubber stress ball. You need to be careful if you select
substitute activities as many of these have the potential to develop into irritating habit
themselves.

 Increase Calcium Intake

In case calcium deficiency does play a role in your child· snail biting problem then increase
amount of calcium in their diet. High levels of calcium can be found in leafy green vegetables,
nuts and seeds, dairy products and dried fruit.

IV. EVENING COLIC

Colic is frequent, prolonged and intense crying or fussiness in a healthy infant. Colic can
be particularly frustrating for parents because the baby's distress occurs for no apparent
reason and no amount of consoling seems to bring any relief. These episodes often
occur in the evening, when parents themselves are often tired.

DEFENITION

It is spasmodic cramps, during first 3 months of life. Pain typically begins in the evening and
baby is inconsolable. Parents frequently complains of excessive cry which is at peak in eve and
night hours n settle down during morning hours.

CAUSES

 The cause of colic is generally unknown. Fewer than 5% of infants who cry excessively
turn out to have an underlying organic disease, such as constipation, gastro esophageal reflux
disease, lactose intolerance, anal fissures, subdural hematomas, or infantile migraine.

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 Babies fed cow's milk have been shown to develop antibody responses to the bovine
protein, causing colic. Studies performed showed conflicting evidence about the role of
cow's milk allergy.
 An immature digestive system. Digesting food is a big task for a baby's brand new
gastrointestinal system. As a result, food may pass through too quickly and not break down
completely, resulting in pain from gas in the intestines.

 Another theory holds that colic is related to hyper peristalsis of the digestive tube
(increased level of activity of contraction and relaxation). The evidence that the use of anti
cholinergic agents improve colic symptoms supports this hypothesis.

 Psychological and social factors have been proposed as a cause, but there is no evidence.
Studies performed don't support the theory that maternal (or paternal) personality or anxiety
causes colic, nor that it is a consequence of a difficult temperament of the baby, but families
with colicky children may eventually develop anxiety, fatigue and problems with family
functioning as a result.

 Tobacco exposure: There is some evidence that cigarette smoke may increase the risk. It
seems unrelated to breast or bottle feeding with rates similar in both groups. Reflux does not
appear to be related to colic.
 Food allergies or sensitivity. Some experts believe that colic is the result of an allergy to
milk protein (or lactose intolerance) in formula-fed babies. More rarely, colic may be a reaction
to specific foods in Mom’s diet in breastfed babies. Either way, these allergies or sensitivity can
cause tummy pain that may set off colicky behavior.

SIGNS AND SYMPTOMS

 Intense crying: The infant cries intensely and furiously, and there is not much the parents
can do to comfort them. The baby's face will become red and flushed. Crying episodes tend
to occur at the same time every day - generally during the late afternoon or evening.
Episodes may last from a few minutes to much longer periods. Crying usually starts

25
 suddenly and for no apparent reasonCrying occurs at the same time every day (usually in the
late afternoon or early evening, but it can vary).Crying seems to occur for no reason (not
because baby has a dirty diaper or is hungry or tired).
 Baby may pull up his legs, clench his fists and generally move his legs and arms more.
 He also often will close his eyes or open them very wide, furrow his brow, even hold his
breath briefly.
 Bowel activity may increase, and he may pass gas or spit up.
 Eating and sleeping are disrupted by the crying — baby frantically seeks a nipple only to
reject it once sucking has begun, or dozes for a few moments only to wake up screaming.

MANAGEMENT

 Respond. Crying is a baby's only way of communicating her needs. But it's also her only way
of wielding any control at all over a vast and bewildering new environment: She cries, you come
running to her side — powerful stuff when you're otherwise completely powerless. In fact, studies
show that responding promptly to your baby's cries will reduce her crying in the long run.
 Excise excitement. Limit visitors and exposing your baby to new experiences in stimulating
environments, particularly in the late afternoon and early evening. Watch how your baby responds
to certain stimuli — and steer clear of any that seem to offend.
 Create calm. Trying to make her environment peaceful might help her relax. Dim the lights,
speak or sing in soothing tones (or don't speak at all) and keep other noise and distractions to a
minimum.

Suspect gastrointestinal issues:

 Apply pressure to baby’s tummy. Some colicky babies find relief when pressure is placed on the
abdomen — and the power of touch alone can be very soothing for both mother and child. So place
your infant face-down on your lap or upright with his tummy against your shoulder, or try the “colic
carry,” where your little one lies face-down with his belly resting on your arm. Then gently rub or
pat his back as you hold him.

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 Try burping your baby. If your baby's inconsolable fussiness is due to gas, sometimes burping

him will help relieve the pain. Check to make sure you're burping your baby effectively by
following some basic tips.
 Ask about antigas drops:Studies show that reducing gas may reduce the discomfort (and crying).

So ask your pediatrician about trying gas drops made with simethicone, which works by breaking
up gas bubbles and can relieve your baby's symptoms. Though research hasn’t yet shown that this
treatment definitively helps with colic, your doctor may think it's worth a try.
 Consider probiotics: Probiotic drops may curb the crying in some colicky babies, probably
because they ease tummy troubles (probiotic bacteria grow naturally in the digestive tract and help
promote intestinal health). Again, research has yet to back this up, but check with your pediatrician
to see if you should give it a go.
 Watch what you eat. If you’re breastfeeding, talk to your doctor about whether you should try

temporarily eliminating any foods from your diet that can cause tummy troubles, such as gas-
causing cruciferous veggies (cabbage, cauliflower), acidic citrus fruits ,or allergenic foods (dairy,
soy, wheat, eggs, peanuts, tree nuts, fish).
 Ask about switching formulas. For some formula-fed infants, swapping a standard variety for

one designed for sensitive tummies or one that doesn't contain cow's milk can make a difference.
Studies have found that giving colicky babies hypoallergenic whey-hydrolyzed formula decreases
colic symptoms in some babies. Just be sure to get your doctor’s approval before making the switch.
Also, steer clear of casein-hydrolyzed formula or partially hydrolyzed formulas as therapies for
colic — there simply isn't enough evidence that they work.
 Remember, Should never give your baby any medication, herbal or otherwise, without talking
to your pediatrician first. And always talk to doctor before making major changes in diet or baby’s.

Other calming remedies for colicky babies:

 Get close. Not only does cuddling, wearing or carrying your baby give her the pleasure of
security and physical closeness to you (and after 9 months of constant closeness, that may be just
what baby's crying for), but it may help you tune in better to her needs.

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 Swaddle. Toss a blanket in the dryer and while it's still warm, wrap it snugly around your
baby. The combination of warmth and the feeling of security may help dry baby’s tears.
 Make white noise. The hum of the vacuum cleaner or dryer can be comforting to babies (it
reminds them of the womb). You may even want to invest in a white-noise machine.
 Play soothing music. A crying baby might also respond to the quiet singing of a lullaby or a
softly playing classical music CD. Other infants enjoy the sounds of nature or the whir of a fan.
Repeating "shh" or "ahh" to your little one can also help. Experiment to find something your baby
seems to like.
 Offer a pacifier. Some colicky babies seem to want to eat all the time — and that might be
because sucking is soothing, not because they’re hungry. So if your child seems ravenous all the
time and adequate feedings don't seem to satisfy him, a pacifier might help. Check in with your
doctor if you're not sure whether baby is getting enough to eat at mealtimes, though.

 Get out of the house. Sometimes, just a change to an outdoor location will magically change
a baby's mood. Movement can help, too. Take your baby for a walk in the stroller or in a sling or
carrier, or strap her into the car seat for a drive (but turn around and head home if the crying
continues in the car — otherwise it could distract you from the road).

TREATMENT

Management of colic is generally conservative and involves the reassurance of parents. Calming

measures may be used and include soothing motions, limiting stimulation, pacifier use, and
carrying the baby around in a carrier. Although it is not entirely clear if these actions have any
effect beyond placebo. Swaddling does not appear to help.

MEDICATION

No medications have been found to be both safe and effective.

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Simethicone drops: Simethicone is an anti-foaming agent that reduces the amount of trapped
wind. It brings together small bubbles of gas that are trapped in the stomach contents when an
infant swallows air.As the bubbles group together and become larger, they are easier to expel by
burping or passing wind. Simeticone works locally in the gut and does not get into the
bloodstream. It is said to relieve abdominal pain.Typically, an infant will be given a 2.5 milliliter
(ml) spoonful after each feed. It can be added to the infant's bottle or given directly into the
mouth, either with a spoon or an oral syringe.

Lactase drops: Lactase is an enzyme that breaks down milk sugar lactose into glucose and
galactose. People with lactase deficiency in the gut can develop abdominal cramping
and diarrhea after consuming milk products. Lactase helps to prevent this.Sometimes lactase
drops help infants with colic

Dicycloverine, or dicyclomine: This is a medication used for stomach cramps. It used to be

commonly used as a colic treatment. However, it has been found to cause breathing difficulties,
seizures, weakening of the muscles, loss of consciousness, and coma in infants.

DIET

Dietary changes by infants are generally not needed.

 In mothers who are breastfeeding, a hypoallergenic diet by the mother—not eating milk and
dairy products, eggs, wheat, and nuts—may improve matters, while elimination of only cow's
milk does not seem to produce any improvement. In formula-fed infants, switching to a soy-
based or hydrolyzed protein formula may help. Evidence of benefit is greater for hydrolyzed
protein formula with the benefit from soy based formula being disputed. Both these formulas

29
 have greater cost and are not as palatable. Supplementation with fiber has not been shown to have
any benefit.

V. STRANGER ANXIETY

Stranger anxiety is a form of distress that children experience when exposed

to strangers. Stranger anxiety and stranger fear are two interchangeable terms. Stranger
anxiety is a typical part of the developmental sequence that most children experience. It
can occur even if the child is with a caregiver or another person they trust. [1] It peaks
from six to 12 months[2] [3] but may recur afterwards until the age of 24 months. [4] As a
child gets older, stranger anxiety can be a problem as they begin to socialize. Children
may become hesitant to play with unfamiliar children. This stranger anxiety is a
normal part of a child's cognitive development . It usually begins at around
eight or nine months and generally lasts into the child's second year.
Normal separation anxiety develops during this same period. Both of these
responses arise because the baby has reached a stage of mental
development where she can differentiate her caretakers from other people,
and she has a strong preference for familiar faces. Rather than indicating
emotional difficulties, the emergence of a fear of strangers in the second half
of the first year is an indicator of mental development.

Read more: http://www.healthofchildren.com/S/Stranger-
Anxiety.html#ixzz5lJ0Stpys

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 DEFINITION

Stranger anxiety is fear or wariness of people with whom a child is not familiar. Stranger
anxiety is a typical part of the developmental sequence that most children experience. It can
occur even if the child is with a caregiver or another person they trust. It peaks from six to 12
months but may recur afterwards until the age of 24 months.

ETIOLOGY OF STRANGER ANXIETY

Biological factors
The brain has special chemicals, called neurotransmitters, that send messages back and forth to
control the way a person feels. Serotonin and dopamine are two important neurotransmitters
that, when “out of whack,” can cause feelings of anxiety.
Family factors
Just as a child can inherit a parent’s hair color, a child can also inherit that parent’s anxiety. In
addition, anxiety may be learned from family members and others who are noticeably stressed
or anxious around a child. Parents can also contribute to their child’s anxiety without realizing it
by the way they respond to their child. For example, allowing a child to miss school when they
are anxious about going, likely causes the child to feel more anxious the next school day.
Environmental factors
A traumatic experience (such as a divorce, illness, or death in the family) may also trigger the
onset of separation anxiety disorder.

TYPES OF STRANGER ANXIETY

1. Body-Focused Repetitive Behaviors (BFRBs) are related to self-grooming, anxiety

management, or sensory stimulation. The most common BFRBs are trichotillomania (hair

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 pulling), dermatillomania (skin picking), onychophagia (nail biting), dermatophagia (skin
biting), rhinotillexomania (nose picking), as well as cheek biting and joint cracking.

2. Obsessive-compulsive disorder (OCD) causes children to experience pervasive, unwanted

obsessions or worries. Sometimes, they work to relieve this anxiety through repetitive physical
or mental behaviors called compulsions.]

Among kids and teens with OCD, common obsessions include:

 fear of dirt, germs or contamination

 a need for symmetry, order, and precision
 religious obsessions, lucky and unlucky numbers, sexual or aggressive thoughts, fear of
illness or harm coming to oneself or family, intrusive sounds or words

These compulsions are also common among kids and teens with OCD:

 grooming rituals, including hand washing, showering, and teeth brushing

 repeating rituals, including going in and out of doorways, needing to move through spaces
in a special way, or rereading, erasing, and rewriting
 checking rituals to make sure that an appliance is off or a door is locked, and repeatedly
checking homework
 ordering or arranging objects and cleaning rituals around the house
 counting rituals, hoarding and collecting things of no apparent value

3. Panic Disorder is characterized by the sudden onset of intense fear, called a panic attack,
followed by weeks of worry about having another similar attack. Symptoms include: difficulty
breathing, racing heart, sweating, needing to escape, sense of danger or doom, and chest pain,
among others.

4. Post Traumatic Stress Disorder is an anxiety disorder that can develop after involvement in
or exposure to a frightening, traumatic event. Symptoms include ongoing upsetting memories,

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 nightmares, flashbacks, feeling overly jumpy or irritable, and avoiding reminders of the
incident.

5. Social Anxiety Disorder causes children and teens to fear social and/or performance situations
because they worry about doing something embarrassing or being negatively judged by others.
The extreme manifestation of this is the rare condition Selective Mutism.

6. Separation Anxiety Disorder causes children to worry excessively about being separated

from primary caregivers or from the home.

7. Specific Phobias involve persistent, over-the-top fears of an object or situation that is beyond

the child’s control and significantly impacts life. Common phobias include insects, heights,
dogs, and loud noises.

Common Symptoms of Generalized Anxiety Disorder for Children at Home

Signs of stranger anxiety
1. In the presence of a stranger, some infants can abruptly go quiet and look at the stranger
with fear. Certain emotions will increase in other children while in the presence of a
stranger such as loud crying and fussiness.
2. And others will have the tendency to bury themselves in their caregiver’s arms or even
place themselves away from the stranger by placing the caregiver between themselves and
the stranger.

If you notice the following warning signs, schedule an appointment with your child’s doctor:

 Trouble falling asleep

 Fear of being alone
 Picking at skin, Nail biting, Strong startle response , Being overly self-critical
 OCD-like behaviors (e.g. checking and rechecking the door to make sure it is locked or
arranging objects “just so”) , Suddenly avoiding social contact
 Frequent urination

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Common Symptoms of Generalized Anxiety Disorder for Children at School

According to Child Mind Institute, your child’s anxiety may manifest at school in several ways.
Keep an eye out for these signs:

 Refusing to go to school or having a hard time at school drop-offs, Not turning in homework
 Difficulty participating in class and interacting with peers, Excessive worry about everyday
things, Trouble answering questions when called on by the teacher, Disruptive behavior,
Squirming

 Frequent trips to the nurse (with complaints of headaches, nausea, stomachaches, or even
vomiting),Avoiding socializing or group work,

If notice several of the above, ask child’s doctor to perform an in-depth screening of his mental
and physical health to rule out a mood disorder, ADHD, or a specific phobia, all of which can
look like GAD. Certain physical conditions, like thyroid disorders or heart conditions, can also
mimic anxiety-like symptoms. Your doctor can rule out most of these with simple blood and
urine tests -though some more complicated conditions may require x-rays or physical stress
tests.

MANAGEMENT OF STRANGER ANXIETY

a) Non pharmacology management

These tips may help you control or lessen symptoms:

 Cut down on foods and drinks that have caffeine, such as coffee, tea, cola, energy drinks,
and chocolate. Caffeine is a mood-altering drug, and it may make symptoms of anxiety
disorders worse.
 Eat right, exercise, and get better sleep. Brisk aerobic exercises like jogging and biking help
release brain chemicals that cut stress and improve your mood.

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  Sleep problems and anxiety disorder often go hand in hand. Make getting good rest a priority.
Follow a relaxing bedtime routine. Ask your doctor or pharmacist before taking any over-the-
counter meds or herbal remedies. Many contain chemicals that can make anxiety symptoms worse.

b) Medication:

Many antidepressants can work for anxiety disorders. They include escitalopram (Lexapro) and

fluoxetine (Prozac). Certain anticonvulsant medicines (typically taken for epilepsy) and low-dose
antipsychotic drugs can be added to help make other treatments work better. Anxiolytics are also
drugs that help lower anxiety. Examples are alprazolam (Xanax) and clonazepam (Klonopin).
They’re prescribed for social or generalized anxiety disorder as well as for panic attacks.

c) Psychotherapy:

This is a type of counseling that addresses the emotional response to mental illness. A mental health
specialist helps by talking about how to understand and deal with your anxiety disorder.

d) Cognitive behavioral therapy:
This is a certain type of psychotherapy that teaches you how to recognize and change thought
patterns and behaviors that trigger deep anxiety or panic.

VI. TEMPER TANTRUMS

Introduction

Temper tantrums are often defined as out of control behavior including screaming, hitting, head-
banging and falling down and other violent display of frustration, usually occurring in children
of 18 months to 4 years of age.

These are emotional outbursts in response to unmet needs or desires in younger children or
children with communication difficulty. In extreme case, they may be expressed by vomiting or
biting. When the behavior occurs many times a day, lasting 30 min at a time, and is associated

35
 with aggression at school and home; it usually requires intervention. Thus, it is important to
find out the frequency, intensity and duration of the behavior.

STATISTIC

Temper tantrums have been reported to be present in 22%of normally developing children. In
75.3%, these are present at the age of 3-5 years and, in 20.8% at 6-8 years of age, being least
common at 9-12 years (3.9%). They are more common in boys.

ETIOLOGY

 Temper tantrums are natural during early childhood.

It is a way communication during the period of developing autonomy separation from caregivers,
and is usually present in children between 1 year and 3 years of age who do not have enough
vocabulary to express their feelings.

 Tantrums gradually decrease by 4-5 years , after which they are uncommon, and need
intervention . Being tired, hungry, or sick, can make tantrums or more frequent.

 Underlying neurological disorders like autism spectrum disorder and intellectual disability
also make the child more prone may include frustration, attention-seeking behavior, or
unfulfilled demands.

 Parental factors like excessive disciplining, inconsistent parental attitudes and failure to set
limits may also be responsible.

 Temper tantrums which last for more than 15 min, or occur underlying medical, social or
emotional problem.

DIAGNOSIS

 Detailed history and examination is mandatory to find out if these problems are associated
with hunger, fatigue and overstimulation.

 Exposure to abuse or stress at home may be the reason of persistence of this behavior,
which otherwise would have subsided.

36
 Thorough physical examination to exclude physical abuse along with neurological and
behavioral assessment is important.

 Laboratory investigations include screening for iron-deficiency anemia and exposure to

lead. Other investigations should be done : there are any clues found on examination.

MANAGEMENT

 If the child engages in undesired behavior, parent can ignore the undesired behavior.

 Undesired behavior is often being reinforced because it results in parental attention.

Ignoring the undesired behavior reduces the frequency of that behavior over a period of time, as
undesired behavior is no longer reinforced by to inform parents that with this process, the
problem may worsen initially before it improves.

 Punishment usually used is verbal reprimand or privilege withdrawal. One of the

commonly used punishment strategies for sit in a chair, stand in the corner or go to the room for
brief period usually 1-5 min. Time out facing a comer means that the child has not be used,
though some behavioral techniques may be helpful.

 Encourage the child to use words .

 Praise good behavior .

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 PRE-SCHOOL

STUTTERING

Stuttering is not uncommon in children between the ages of 2 and 5. For many children, it's
simply part of learning to use language and putting words together to form sentences. It may come
and go, and it may last for a few weeks or for a couple of years. Most children outgrow stuttering
on their own without professional intervention. But for some, stuttering can become a life-long
condition that causes problems in school and in functioning as an adult.

DEFINITION OF STUTTERING

Stuttering is a speech disorder characterized by repetition of sounds, syllables, or words;

prolongation of sounds; and interruptions in speech known as blocks. An individual who stutters
exactly knows what he or she would like to say but has trouble producing a normal flow of
speech. These speech disruptions may be accompanied by struggle behaviors, such as rapid eye
blinks or tremors of the lips.

STATISTICS

 Roughly 3 million Americans stutter. Stuttering affects people of all ages. It occurs most
often in children between the ages of 2 and 6 as they are developing their language skills.

 Approximately 5 to 10 percent of all children will stutter for some period in their life,
lasting from a few weeks to several years.

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 Boys are 2 to 3 times as likely to stutter as girls and as they get older this gender difference
increases; the number of boys who continue to stutter is three to four times larger than the
number of girls. Most children outgrow stuttering.

 Approximately 75 percent of children recover from stuttering. For the remaining 25

percent who continue to stutter, stuttering can persist as a lifelong communication disorder.

The precise mechanisms that cause stuttering are not understood.

CAUSES

A family history of stuttering. There is disagreement as to whether stuttering is genetic, because

specific genes have not been identified. But close to 60% of all stutterers have someone in the family
who also stutters or stuttered.

Neurophysiology. In some children who stutter, language is processed in different parts of

the brain than it is for children who don't stutter. This may also interfere with the interaction between
the brain and the muscles that control speech.

Family dynamics. Some children's stuttering has been attributed to high family expectations and a
fast-paced lifestyle.

It was commonly believed that stuttering was often the result of either physical or emotional trauma.
Although there are some instances of stuttering following such traumas, they are rare and usually
connected with physical trauma or illness later in life. There is little evidence to support the idea that
children stutter as a result of emotional upheaval.

SYMPTOMS OF STUTTERING

Symptoms of stuttering can vary significantly throughout a person’s day. In general, speaking
before a group or talking on the telephone may make a person’s stuttering more severe, while
singing, reading, or speaking in unison may temporarily reduce stuttering.

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  Stuttering is sometimes referred to as stammering and by a broader term, disfluent
speech.

TYPES OF STUTTERING

Stuttering is commonly grouped into two types termed developmental and neurogenic.

 Developmental stuttering
Developmental stuttering occurs in young children while they are still learning speech and
language skills. It is the most common form of stuttering.

Some scientists and clinicians believe that developmental stuttering occurs when children’s
speech and language abilities are unable to meet the child’s verbal demands compared to
nonstuttering peers. Developmental stuttering may also run in families and research has shown
that genetic factors contribute to this type of stuttering. Starting in 2010, researchers at the
National Institute on Deafness and Other Communication Disorders (NIDCD) have identified
four different genes in which mutations are associated with stuttering. More information on the
genetics of stuttering can be found in the research section of this fact sheet.

 Neurogenic stuttering
Neurogenic stuttering may occur after a stroke, head trauma, or other type of brain injury. With
neurogenic stuttering, the brain has difficulty coordinating the different brain regions involved
in speaking, resulting in problems in production of clear, fluent speech.

 Psychogenic. This type originates in the part of the brain that governs thinking and
reasoning.

DIAGNOSIS
 Stuttering is usually diagnosed by a speech-language pathologist, a health professional
who is trained to test and treat individuals with voice, speech, and language disorders.

40
 The speech-language pathologist will consider a variety of factors, including the child’s
case history (such as when the stuttering was first noticed and under what circumstances), an
analysis of the child’s stuttering behaviors, and an evaluation of the child’s speech and language
abilities and the impact of stuttering on his or her life.
 When evaluating a young child for stuttering, a speech-language pathologist will try to
determine if the child is likely to continue his or her stuttering behavior or outgrow it. To
determine this difference, the speech-language pathologist will consider such factors as the
family’s history of stuttering, whether the child’s stuttering has lasted 6 months or longer, and
whether the child exhibits other speech or language problems.

TREATMENT FOR STUTTERING

Early treatment for stuttering is very important, as it is more likely to be eliminated when a child
is young (before entering elementary school). There are two main treatment approaches for
stuttering:

 Indirect treatment is when the speech-language pathologist helps the child's parents on
how to modify their own communication styles. Indirect approaches are effective at
reducing or even eliminating stuttering in many young children.
 Direct treatment involves the speech-language pathologist working with the children
themselves either one-on-one or in small groups, giving them specific speech strategies for
easing into words and reducing tension during stuttering events. In addition, direct
treatment may involve helping the child to differentiate between smooth (fluent) and
bumpy (stuttered) speech.  

After age 7, it becomes unlikely that stuttering will go away completely. Still, after age 7,
treatment can be very effective at helping a child effectively manage stuttering—helping develop
skills necessary to handle difficult situations (e.g., teasing and bullying) and participate fully in
school and activities. For older children, speech treatment is still beneficial, encouraged, and
effective in helping to reduce the severity and impact of stuttering

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MANAGEMENT
Although there is currently no cure for stuttering, there are a variety of treatments available. The
nature of the treatment will differ, based upon a person’s age, communication goals, and other
factors. It is important to work with a speech-language pathologist to determine the best
treatment options.

Therapy for children

 For very young children, early treatment may prevent developmental stuttering from
becoming a lifelong problem. Certain strategies can help children learn to improve their speech
fluency while developing positive attitudes toward communication.
 Health professionals generally recommend that a child be evaluated if he or she has
stuttered for 3 to 6 months, exhibits struggle behaviors associated with stuttering, or has a
family history of stuttering or related communication disorders.
 Some researchers recommend that a child be evaluated every 3 months to determine if the
stuttering is increasing or decreasing. Treatment often involves teaching parents about ways to
support their child’s production of fluent speech.
 Parenting education

Parents may be encouraged to:

 Provide a relaxed home environment that allows many opportunities for the child to speak.
This includes setting aside time to talk to one another, especially when the child is excited and
has a lot to say.

 Listen attentively when the child speaks and focus on the content of the message, rather
than responding to how it is said or interruptng the child.

42
 Speak in a slightly slowed and relaxed manner. This can help reduce time pressures the
child may be experiencing.

 Listen attentively when the child speaks and wait for him or her to say the intended word.
Don't try to complete the child’s sentences. Also, help the child learn that a person can
communicate successfully even when stuttering occurs.

 Talk openly and honestly to the child about stuttering if he or she brings up the subject. Let
the child know that it is okay for some disruptions to occur.

 Reduce communication stress. There are different techniques to put less pressure on a child
in a speaking situation. Rephrasing questions as comments (using "You played outside today at
school. It must have been fun!" instead of "What did you do at school?") is one effective
approach. Parents can also do their best to reduce situations that trigger their child's stuttering.

 Talk about it. When children are aware of their stuttering, it is best to be open and talk about
it in a positive way. Let them know it is okay to have "bumpy speech." If a child does not seem
to be aware of the problem, there is no need to bring it up until you are seeing a speech-
language pathologist.
 Practice patience. Give children time to finish what they are saying. Don't rush or interrupt
them. Don't tell them to "slow down" or "think about what you want to say." Phrases such as
those are generally not helpful to children who stutter.
 Model good speech habits. While telling a child how to talk is generally not helpful,
parents can model speech habits that help with stuttering, such as slowing down their own
speed when they talk, putting in more pauses between sentences, and speaking in a relaxed
manner.
 Seek a professional. There are many ways to find a speech-language pathologist. A child's
pediatrician can provide a recommendation. Children younger than 3 can receive a free
evaluation through their local Early Intervention Program. If a child is older than 3, parents can
contact their local public school for a free evaluation. Parents also have the option to seek out a
private speech-language pathologist with a child at any age.

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 Stuttering therapy
Many of the current therapies for teens and adults who stutter focus on helping them learn ways
to minimize stuttering when they speak, such as by speaking more slowly, regulating their
breathing, or gradually progressing from single-syllable responses to longer words and more
complex sentences. Most of these therapies also help address the anxiety a person who stutters
may feel in certain speaking situations.

 Drug therapy
The U.S. Food and Drug Administration has not approved any drug for the treatment of
stuttering. However, some drugs that are approved to treat other health problems—such as
epilepsy, anxiety, or depression—have been used to treat stuttering. These drugs often have side
effects that make them difficult to use over a long period of time.

 Electronic devices
Some people who stutter use electronic devices to help control fluency.For example, one type of
device fits into the ear canal, much like a hearing aid, and digitally replays a slightly altered
version of the wearer’s voice into the ear so that it sounds as if he or she is speaking in unison
with another person. In some people, electronic devices may help improve fluency in a
relatively short period of time.

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PICA

People with the disorder pica compulsively eat items that have no nutritional value. An affected
person might eat relatively harmless items , such as ice or they might eat potentially dangerous
items, likes flakes of dried paint or pieces of metal. In the latter case, the disorder can lead to
serious consequences, such as lead poisoning.

Definition

Pica involves the persistent eating of nonnutritive substances (e.g., plaster , charcoal, clay ,
wool, ashes, paint, earth,). The eating behavior is inappropriate to the developmental level(e.g.,
the normal mouthing and tasting of objects in infants and toddlers) and not part of a sanctioned
practice.

EPIDEMIOLOGY

Pica appears to be more common in children with mental retardation , pervasive developmental
disorder, obsessive compulsive disorder, and other neuropsychiatric disorder.

It is usually remits in childhood but can continue in to adolescence and adulthood.

Geophagia (eating earth)is associated with pregnancy and is not seen as abnormal in some
culture.

Children with pica are at increased risk for lead poisoning, iron deficiency anemia, obstruction ,
dental injury and parasitic infections.

ETILOGY

1. Nutritional deficiencies
45
 In some cases, a deficiency in iron, zinc, or another nutrient may be associated with pica. For
eg, anemia or iron deficiency may be the underlying cause of pica.

2. People with certain mental health conditions such as schizophrenia and obsessive –
compulsive disorder may develop pica as a copying mechanism.
3. Low socio economic factors( e g, lead paint)

4. Child abuse and neglect, family disorganization(eg poor supervision)

5. Gastrointestinal distress: Children with GI distress find it soothing to eat non-food items,

especially earth.
6. Obsessive-compulsive spectrum disorders: The anxiety arising out of these disorders might
make the individual eat non-food items to get some relief. Any attempts to forcefully stop
them from eating can increase their anxiety and distress.
7. Malnutrition: Deficiency in the intake of nutritious food triggers cravings for soil or clay.
Though soil/ clay does not have the nutrients to meet the deficiencies, it binds iron in the
gastrointestinal tract, thus soothing the cravings.
8. Oral fixations: Some children have an oral fixation, an obsessive urge to put things into their
mouth. This is common in very young kids.
9. Mental and developmental growth delays: Children, especially those with autism or other
developmental conditions, often tend to eat unhygienic or non-food materials like dirt or
paper due to their ability to differentiate (5).
10. Lack of proper appetite stimulation: If your kid is a picky eater and does not eat properly,
he/she may feel hungry and eat non-food objects to feel full.
11. Poor parental attention: Parental neglect is a major cause seen mostly in people living in
poverty where they fail to supervise their kid’s diet.
If your child is eating non-food items, then observe the symptoms of pica.

DIAGNOSIS OF PICA

There are no laboratory tests for diagnosing pica. Hence, a pediatrician resorts to the below
methods :

46
 The primary investigation should be into possible causes like anemia, nutrient
deficiency or any poisoning such as lead poisoning.
 The doctor will ask you about your child’s medical history, psychological development,
and behavioral issues.
 The presence of GI problems such as constipation, diarrhea, abdominal pain, and
vomiting.
 They will ask about the child’s general feeding and dietary habits.
 The doctor may specifically want to know about the child’s food habits and the
ambiance at home and school, to understand if that is a possible triggering factor.
 Doctors may perform a developmental assessment on the child.
 The doctor may conduct a stool test to check for parasitic infections.
 Sometimes, imaging or an X-ray may be required to identify what was consumed or to
closely observe conditions such as obstructions in the intestines or bowels.
These steps will enable the doctor to diagnose pica and the cause behind it.

TREATMENT OF PICA
There is no one-way or direct treatment approach for pica as it all depends on the underlying
causes.

 In most cases, addressing the mineral or nutrient deficiencies through supplements and

dietary changes will resolve the pica problem in the child.
 Medicines may be given to reduce abnormal eating patterns if your child’s pica is
associated with developmental or intellectual disability.
 If pica is associated with behavioral issues then the doctor may ask you to consult
a psychologist.
 You are trained in providing a safe environment at home, caregiving methods, dietary
factors, physical activities, etc.

47
 The doctor will educate you on useful approaches such as keeping non-food items out of
children’s access, having child safety locks, hiding the household chemicals or medicines
from the child.
 Pica usually disappears as children get older. But in some cases, it may continue to bother
during early adolescence and adulthood too, especially in people with developmental issues.
Hence, be observant and maintain a safe home environment, besides continuing with the
medical treatment. A combined medical and psychosocial approach is generally indicated for
pica. The seuelae related to the ingested item can require specific treatment ( eg.., lead
toxicity , iron deficiency anemia, parasitic infestation).

COMPLICATIONS

 Certain items, such as paint chips, may contain lead or other toxic substances and eating them
can lead to poisoning, increasing the child's risk of complications including learning
disabilities and brain damage. This is the most concerning and potentially lethal side effect of
pica
 Eating non-food objects can interfere with eating healthy food, which can lead to nutritional
deficiencies.
 Eating objects that cannot be digested, such as stones, can cause constipation or blockages in the
digestive tract, including the intestines and bowels. Also, hard or sharp objects (such as
paperclips or metal scraps) can cause tears in the lining of the esophagus or intestines.
 Bacteria or parasites from dirt or other objects can cause serious infections. Some infections
can damage the kidneys or liver.
 Co-existing developmental disabilities can make treatment difficult.

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A. TIC DISORDER

DEFINITION

A tic is a nonvoluntary body movement or vocal sound that is made repeatedly, rapidly, and
suddenly. It has a stereotyped but nonrhythmic character. The child or adolescent with a tic
experiences it as irresistible but can suppress the movement or noise for a period of time. Tics
are categorized as motor or vocal, and as simple or complex.

CAUSES

1. Emotional factors were once viewed as the cause of tics, but this explanation has been
largely discounted. The search for causes now focuses on biological, chemical and
environmental factors. As of 2002, however, no definitive cause of tics has been discovered.
2. Neurotransmitter: Both functional and structural abnormalities in the brains of people
with tic disorders. Neurochemical cause is unknown, it is believed that
abnormal neurotransmitters (chemical messengers within the brain ) contribute to the
disorders. The affected neurotransmitters are dopamine, serotonin, and cyclic AMP. Researchers
have also found changes within the brain itself, specifically in the basal ganglia (an area of the
brain concerned with movement) and the anterior cingulate cortex. Functional imaging

49
 using positron emission tomography (PET) and single photon emission computerized
tomography (SPECT) has highlighted abnormal patterns of blood flow and metabolism in the
basal ganglia, thalamus, and frontal and temporal cortical areas of the brain. [The reader may
wish to consult the "Brain" entry for a diagram of the brain's structures.]
3. Genetic: or transmitted within families. Genetic factors are present in 75% of cases,
although no single gene has been found to cause tic disorders
4. DRUGS :In some cases, tic disorders appear to be caused or worsened by recreational
drugs or prescription medications. The drugs most commonly involved are such psychomotor
stimulants as methylphenidate (Ritalin); pemoline (Cylert); amphetamines ; and cocaine. It is
not clear whether tics would have developed anyway if stimulants had not been used. In a
smaller percentage of cases, antihistamines, tricyclic antidepressants, antiseizure medications,
and opioids have been shown to worsen tics.
5. ENVIRONMENT: Some forms of tic may be triggered by the environment. A cough that
began during an upper respiratory infection may continue as an involuntary vocal tic. New tics
may also begin as imitations of normally occurring events, such as mimicking a dog barking.
How these particular triggers come to form enduring symptoms is a matter for further study.
6. Neuropsychiatric disorders :, such as tic disorders and obsessive-compulsive disorder ,
have been shown to develop after streptococcal infection. No precise mechanism for this
connection has been determined, although it appears to be related to the autoimmune system.
There are other illness-related causes of tics, though they appear to be rare. These include the
development of tics after head trauma, viral encephalitis or stroke .

SYMPTOMS

1. Tics increase in frequency when a person is under any form of mental or physical stress,
even if it is of a positive nature (excitement about an upcoming holiday, for example). Some
people's tics are most obvious when the person is in a relaxed situation, such as quietly watching
television.
2. Tics tend to diminish when the person is placed in a new or highly structured situation,
such as a doctor's office- a factor that can complicate diagnosis . When the symptoms of a tic

50
 are present over long time periods, they do not remain constant but will wax and wane in their
severity.
3. In transient tic disorder, there may be single or multiple motor and/or vocal tics that occur
many times a day nearly every day for at least four weeks, but not for longer than one year. If
the criteria have been met at one time for Tourette's disorder or for chronic motor or vocal tic
disorder, transient tic disorder may not be diagnosed.
4. Chronic motor or vocal tic disorder is characterized by either motor tics or vocal tics, but
not both. The tics occur many times a day nearly every day, or intermittently for a period of
more than one year. During that time, the patient is never without symptoms for more than three
consecutive months. The severity of the symptoms and functional impairment is usually much
less than for patients with Tourette's disorder.
5. Children and adolescents with Tourette's disorder frequently experience additional
problems including aggressiveness, self-harming behaviors, emotional immaturity, social
withdrawal, physical complaints, conduct disorders, affective disorders, anxiety, panic
attacks, stuttering , sleep disorders , migraine headaches, and inappropriate sexual behaviors.

B. ENURESlS (BEDWETTING)

DEFENITION OF ENURESIS

Voluntary or involuntary repeated discharge of urine into clothes or bed, after a developmental
age when bladder control should be established (usually 5 years), is labeled as enuresis.

STATISTIC

Approximately 10% of the children with nocturnal enuresis will diurnal enuresis whereas 50%
of children with diurnal enuresis have nocturnal enuresis. Approximately 10% of the5-year old,
5% of the 10-year-old and I% of the 18-year-old children will have nocturnal enuresis.

Classification

Enuresis may be primary or secondary.

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1. Primary enuresis is defined as repeated ( at least twice a week for at least 3 consecutive
months) passage of urine into clothes/bed during night in a child of age times more common in
boys.

2. Secondary or late-onset enuresis, the child has been dry for at least 6 months before
bedwetting iegins again during sleep. In most of these children an underlying organic pathology
is detected whereas primary enuresis is mostly diopathic or behavioral in origin.

Monosymptomatic (uncomplicated) nocturnal enuresis involves voiding in the bed at night in

the absence of other genitourinary or gastrointestinal symptoms, or daytime symptoms. It
accounts for 30-85% of cases of nocturnal enuresis. Another 5-10% of the cases associated
daytime symptoms, such as urgency, frequency, incontinence, constipation, or encopresis. These
children labeled as having polysymptomatic (complicated) nocturnal enuresis.

ETIOLOGY

1. Primary enuresis, though multifactorial, could be related to sleep disorder. There is poor
arousability in response to acoustic stimuli.

2. Children are not able to appreciate when the bladder is full during sleep. Small functional
bladder capacity and detrusor overactivity play an important role in pathophysiology of
nocturnal enuresis.

3. Genetic factors include a positive family history in most cases.

4. Psychological causes may be related to stressors at home or school.

5. There might be a delay in neurological maturation to control bladder sphincter which is

more pronounced in children With mental retardation or spinal cord abnormalities.

6. Following factors have also been implicated in the pathology of nocturnal enuresis:
hyposecretion of arginine vasopressin (AVP), decreased responsiveness to low urine osmolality,
loss circadian rhythm of antidiuretic hormone (ADH) secretion.

52
7. Children who undergo training late ( after 24 months) are Prone to develop late nocturnal
bladder control; recommended age to begin toilet training is around 24 months, an age at which
developmentally normal children will be ready to be toilet trained.

8. Secondary enuresis

Too enthusiastic and immature toilet training result in secondary enuresis. Other causes include
emotional stress, parent child maladjustment, urinary tract infections, diabetes mellitus, or
diabetes insipidus. Secondary enuresis is [uently associated with stressful or traumatic events at
home or school or anything related to the daily life of the child.

9. Diurnal enuresis This is more common in preschool girls, is 1sually due to micturition
deferral (waiting till the last moment to pass urine and then being unable to hold any longer),
and ually settles by age of 9 years. It is mostly caused by the impaired transition from reflex
micturition control of infants to volitionally controlled micturition reflex in adults. Stress
incontinence, urinary tract infection, bladder outlet obstruction, ectopic ureter and Iiabetes are
the other causes of diurnal enuresis. Vaginal reflux of Young girls. Psychological causes include
constant anxiety, loss of parent, parental discord and abusive home environment. Some children
fail to appreciate the sense of bladder fullness or ignore it while playing. When both diurnal
enuresis and nocturnal enuresis present, abnormalities of the urinary tract or voiding disorders.

10. Chronic constipation is an important isolated risk factor for enuresis.

DIAGNOSIS

1. History and examination should be able to rule out the possibility any underlying
neurological disorder, voiding dysfunction, polyuric conditions ( diabetes mellitus, diabetes
insipidus, chronic renal failure) and bacterial cystitis.

2. Questions should be asked regarding daytime incontinence, urgency, frequency,

posturing, consumption and bowel habits should also be obtained.

3. A frequency void chart often helps to differentiate primary nocturnal enuresis from
voiding dysfunction.

53
4. Ideally an input-output chart should be maintained. The normal frequency of daytime void
in or at duration of less than 2 hours is considered abnormal.

5. Look for any deformity of spine or foot; or abnormality of gait. Physical signs of occult
spinal deformities such as dimples, tuft of hair, skin discoloration, lipoma and asymmetrical
buttocks may be useful.

6. Anal sphincter tone and perineal Sensation and reflexes should be assessed. Genital
examination is a must for all children. In boys abnormal meatus or abnormal urinary stream
should be evaluated. In girls, look for labial adhesions and ectopic ureteral ipenings.

7. Investigations for primary nocturnal enuresis involve routine urine examination including
osmolality, microscopy, reducing substance and culture.

8. A good ultrasonogram (USG) on full bladder can also give a rough estimate of bladder
capacity. Postvoid residual urine volume should be assessed during USG guide regarding
presence of voiding-dysfunction.

9. Urodynamic study is needed to assess bladder capacity and detrusor pressures in a child
who has an abnormal frequency void chart.

MANAGEMENT

 The timing of initiation of treatment for monosymptomatic

 Nocturnal enuresis varies from child to child. The major determinants are whether the
child and caregivers view the enuresis a problem and how strongly motivated they are to
participate in a treatment program. Any serious attempts to treat the condition should begin only
beyond 7-8 years of age as enuresis interferes socialization and behavior in older children.
Management should be aimed at completely stopping the enuresis.

 Establishing the diagnosis of primary nocturnal enuresis a treatment plan should be

discussed with the parent. Cooperation child in the management plan is essential.

 NONPHARMACOLOGICAL MEASURES

54
These are effective in 30% cases and consist of behavior nodification, alarm systems and bladder
strengthening exercises.

Behavioral treatment is the first mode of therapy for a child with enuresis without any disorder
of the genitourinary tract.

Counseling and reassurance to the family is the most essential step. They need to be assured of
the benign nature of the condition and high spontaneous resolution rate.

Ask the parents to maintain a diary record of dry nights; reward the child for such nights.

Parents should provide emotional support to the child, not to criticize and changing the
bedsheets without childs notice.

Avoid punitive measures. Positive reinforcement has been shown to have a success rate of more
than 85%. Parents should understand that enuresis is not under volitional control so punishment
is counterproductive.

Children should have an early dinner and appropriate fluids dinner. It is recommended to avoid
any form of fluid at least 2-3 hours prior to sleep. Ask the child to void before going to sleep.
Ample consumption of fluid in the morning and afternoon reduces the need for significant
intake later in the day. Isolated night-time fluid restriction, without compensatory increase in
daytime fluid consumption, may prevent the child from meeting his or her daily fluid
requirement and is usually unsuccessful .

Encourage regular daytime voiding schedule, emptying the bladder before going to sleep and
getting adequate sleep should also be encouraged .

Clinicians should also be aware of any comorbid condition constipation, encopresis, and any
psychiatric disturbance. Treating the comorbidity often rectifies the incontinence .

Repeated waking to void is not helpful, though using an alarm clock to wake the child once, 2-3
hours after falling asleep is indicated. Child should be fully aroused and walk unaided to the
toilet to urinate. Advantage of an alarm is that the child toilet to urinate. Advantage of an alarm
is that the child becomes aware of a sense of bladder fullness during sleep also.

55
Behavior conditioning or alarm system

Behavior conditioning with use of alarms is extremely effective. Enuresis alarms are a first line
treatment for children whose bedwetting has not responded to advice about fluid intake,
toileting, or an appropriate reward system. Enuresis alarms work best for well-motivated
families and children with frequent enuresis (more than twice per week). The is either a sound
or a vibratory device that may be clipped to underwear or kept at the bedside and rings as soon
as voiding starts. The child must get out of bed and finish the act of urination or must hold the
act until later. It is the most helpful way in training the child to improve bladder capacity and
avoid enuresis. It requires long-term use and approximately 70% improve with 5-12 of this
therapy. Relapse rates are lower ( 15-30% in 6 months aftertreannent) than that with
pharmacotherapy.

Bladder training exercises

Daytime bladder exercises are useful, especially in those with low functional bladder capacity.

The following bladder exercises have been found to be helpful;

(1) Hold urine as long as possible during the day to increase the functional bladder capacity;

(2) Practice repeated starting and stopping the stream at the toilet bowl;

(3) Practice getting up from bed and going to the bathroom at bedtime before sleep.

Kegels exercise, that is volitional contraction of pelvic floor muscles increases the detrusor
contractions.

Caffeine reduction Some soft drinks, cocoa and chocolates have significant amount of caffeine
which is known to have a diuretic action. Excessive consumption of these items can result in
enuresis and should be avoided.

PHARMACOLOGICAL MEASURES

Medications are indicated only in children older than 6 years who fail behavioral treatment.

Drugs used are ( 1) imipramine; (2) desmopressin (DDA VP}; and (3) Oxybutynin.

56
Tablet imipramine (25 mg and 50 mg tablets) 6-8 year (25 mg), 9-12 years (50 mg), greater than
12 years (75 mg) once a day at bedtime. It is a tricyclic antidepressant which alters the arousal-
sleep mechanism. It combines the anticholinergic effect to increase the bladder capacity with a
noradrenergic effect to decrease detrusor contractions. Success rate is 30- 60%, whereas relapse
rate may be up to 90%. The relapse rate can be decreased if treated for 3-4 months followed by
tapering over 3-4 weeks. Common side effects are drowsiness, lethargy, over 3-4 weeks.
Common side effects are drowsiness ,lethargy,sleep disturbances and cardiotoxic side effects.

Desmopressin acetate (DDAVP) orally or intranasally (nasal spray, 10 µg per

spray) at bedtime. It acts by reducing the urine output to a volume less than the functional
bladder capacity. Start with 10 µg given at bedtime daily and increase gradually by l O µg/week
to a maximum of 40 µg/ day. If effective, it should be used for 3-6 months. Success rate is 40-
60%, whereas relapse rate may be up to 90%. It is a costly drug, and has a fast onset of action. It
may be used intermittently to allow enuretic children to participate in sleepovers and night
camps.

Oxybutynin is an anticholinergic agent that can be used in above 6 years of age. It reduces
uninhibited bladder contractions and is useful in children manifesting with urgency urge
incontinence during day.

57
C. ENCOPRESIS

DEFENIION

Encopresis is defined as the involuntary or voluntary passage of formed feces, at inappropriate

places ( usually into the underwear) in the absence of any physical pathology, after 4 years of
age.

ETIOLOGY

1. The etiology of encopresis is multifactorial and includes psychological, anatomical,

genetic, physiological and dietary elements.

2. Abnormal gastrointestinal motility and developmental delay also play a part. In most
cases, encopresis is thought to develop as a consequence of chronic constipation with re sulting
overflow incontinence ( retentive encopresis).

3. Psychological factors are especially important for secondary incontinence. In many cases
encopresis occurs when there is a stressful family situation, such as divorce, birth of a sibling, or
a transition such as starting school. When a child actually smears feces, there is a strong
indication that there may be a problem in family relationships. The child who is reluctant to
openly express anger may express it by soiling. Soiling may also occur in a child who has had a
traumatic or frightening experience, such as sexual or physical molestation.

58
4. Coercive toilet training can also result in encopresis. Other problems to be considered in
the diagnosis include the following ( especially in cases of primary incontinence): spina bifida,
meningomyelocele, spinal-cord injury with dysfunction of the anal sphincter, tethered spinal
cord, ultrashort-segment Hirschsprung disease and imperforate anus with fistula.

CLASSIFICATION

1. Encopresis can be primary ( children who were never continent since infancy).

2. Secondary ( children with a typical history of clean periods, followed by a relapse of

symptoms).

3. Encopresis is also classified as retentive and nonretentive based on retention of feces a

prolonged time. Approximately two-thirds cases are retentive and associated with chronic
constipation. Nonretentive encopresis is a behavioral or psychological problem.

CLINICAL FEATURES

1. Constipation

Which is often a result of overzealous toilet training by parents, resulting reactionary fecal
retention ( often out of anger or retaliation). Chilldren with non retentive incontinence are often
the products disturbed homes and with a poor parent-child relationship that a regular pattern of
toilet training was never achieved.

2. STRESS

Secondary encopresis is often a result of stress at home or at and whereas primary is associated
with developmental enuresis. This picture is further complicated by behavior psychological
abnormalities in such children. Punitive measures by parents always do more harm than good.
Encopresis has adverse implication on school performance and attendance child is often looked
down upon his peers for the foul smell emanating from him.

DIAGNOSIS

History

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1. The main aim of the history should be to differentiate between retentive and nonretentive
incontinence. It is important determine whether it is primary or secondary encopress . The onset
of incontinence, also frequency of symptoms , stool mass and consistency, any alteration in
bowel habits, the time of day it happens and any other related behavioral issues should be noted.
Parent-child relation, marital discord or any other family issue should be looked up.

2. Enquiry should be made if the child has sense of fullness, the urge to defecate and the
ability to differentiate between the passage of feces and flatus.

3. Urinary abnormality and lower limb weakness should also be assessed when suspecting
cord involvement.

4. Details about toilet training should also elicited as coercive toilet training can lead to fecal
retention late.

5. The skin over the spine should be examined for any midline defects. Sphincter tone should
be assessed.

6. Clinical and Laboratory tests These are undertaken for primary dysfunction is suspected.
These include proctoscopy and fiberoptic Studies of the lower bowel to rule out any structural
abnormality.

7. Barium enema and defecography study may be required to monitor the act of defecation in
cases where anatomical abnormality is suspected.

8. Specific studies may sometimes include anal sphincter electromyography (in children with
suspicion of anal sphincter abnormality), manometric studies, CT of puborectal muscles and
external sphincter ( for associated anomalies). Sacral ratio dividing distance from the lowest
point of the sacrum to the line joining the two posterior iliac spines by the distance from that
latter line .

MANAGEMENT

60
The approach to treating a child mainly aims at establishing the normal bowel habit and
improving the child to parent relation ship. It includes both pharmacological and
nonphannacological measures.

There are three main areas of intervention:

1. Immediate relief from constipation;

Immediate relief of fecal retention in children is achieved by a glycerin suppository or sodium

phosphate enema (6 mL/kg). For a slower relief of symptoms over 5-7 days, the available
options include oral administration of polyethylene glycol { 1.5 g/kg/ day x 3 days), lactulose
(2-3mL/kg/day q 12 hours x 7 days), or mineral oil (3 mL/kg/day q 12 hours x 7 days). The dose
should be sufficient to produce I -2 soft stools daily.

(2) Long-term relief from constipation through diet and drugs and

 Long-term laxative use is to be avoided. After removal of impacted stool, plan long-term
management constipation, primarily through dietary modification. A few children may also
require long-term maintenance therapy for relief constipation.

 Dietary changes are an important management element. Dietary counseling of both parent
and child is required promote the inclusion of fiber in diet. Excessive flatus and soiling may be
avoided by preventing certain food types.

 Dietary recommendations for few children with retentive encopresis are

Reduce the intake of dairy products and bananas (constipating foods)

Increase intake of high-fiber foods such as bran, whole wheat products, fruit and vegetables

Increase intake of water and other liquids. Avoid sweetened and high calorie drinks Limit
drinks with caffeine, such as cola drinks and tea

Eat well-balanced meals and snacks, and limit fast foods/junk foods that are high in fats and
sugars .Limit whole milk to about 250-300 ml a day for child over 2 years of age.

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 In few cases tricyclic antidepressants have tried but they should be used with caution in young
children because of their narrow therapeutic index and potential risk of arrhythmia. They should
be avoided in children with retentive incontinence as they may exacerbate constipation.

Concomitant behavioral management is required which lays stress on regular postprandial toilet
( sitting on potty seat for 10-15 min after the meal) and adoption of high-fiber diet. Often it may
be months before regular bowel habits are acquired. Punitive measures are a strict number,
Parents need counseling to be supportive and patient with the child.

( 3) Behavioral therapy and biofeedback training

Compliance may wane with time so reinforcement of behavior therapy along with continued use
of high-fiber diet is indicated. Biofeedback training, behavior modification and muscle training
coupled with appropriate medication is mostly beneficial. Failure of medical management
occasionally requires surgical correction. Long-term studies indicate that encopresis improves
irrespective of the method used.

Individuals with impaired bowel and bladder control often have low self-esteem with lower
perceived quality of life on several domains so an integrated approach involving both the parent
and child along with the treating physician has the most promising outcome.

D. MASTURBATION

DEFINITION

Masturbation refers to nonpenetrative sexual stimulation of a person’s genitals often to the point
of orgasm. The stimulation can be performed manually, by other types of bodily contact ( short
of sexual contact), by use of objects or tools or by some combination .

STATISTICS

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Masturbation or self-stimulation of genitalia is a common human behavior and is believed to
occur in 90-94% of males and 50-60% of females at some point during their life time. A study
Gujarat in 1995 in adolescent girls revealed 30% of sample indulged in masturbation.

CAUSES

1. It is most common at the age of 4 years and during adolescence. For preschoolers, it is a
part of sexual curiosity and exploration.
2. For preschoolers, it is a part of sexual curiosity and exploration.
3. Masturbation can be an expression of anxiety, boredom, or stress. In the case of
excessive masturbation, it may be associated with emotional or behavioral problems and
physical or sexual abuse
MANAGEMENT
 Parent education and reassurance
1. Encourage the parent to have positive sexual attitude. The parent should not show negative
gestures or emotions when children touch their genitals during bath or changing diapers. Parents
can use the opportunity to teach child the body parts.
2. As the child matures into adolescent, parents and doctor should introduce topics like
masturbation, night emissions high-risk behavior
3. Ensure adolescent privacy in their rooms.
4. Adolescents should be encouraged to have outdoor activities.
5. Redirection of the child to other activities, and discussion with the child regarding
appropriate boundary

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 SCHOOL AGE

A. ENURESIS
Definition
Bed-wetting also called nighttime incontinence or nocturnal enuresis is involuntary urination
while asleep after the age at which staying dry at night can be reasonably expected.

Causes

 A small bladder. Your child's bladder may not be developed enough to hold urine
produced during the night.

 Inability to recognize a full bladder. If the nerves that control the bladder are slow to
mature, a full bladder may not wake your child — especially if your child is a deep sleeper.

 A hormone imbalance. During childhood, some kids don't produce enough anti-diuretic

hormone (ADH) to slow nighttime urine production.

 Urinary tract infection. This infection can make it difficult for your child to control
urination. Signs and symptoms may include bed-wetting, daytime accidents, frequent urination,
red or pink urine, and pain during urination.

 Sleep apnea. Sometimes bed-wetting is a sign of obstructive sleep apnea, a condition in

which the child's breathing is interrupted during sleep — often due to inflamed or enlarged
tonsils or adenoids. Other signs and symptoms may include snoring and daytime drowsiness.

 Diabetes. For a child who's usually dry at night, bed-wetting may be the first sign of
diabetes. Other signs and symptoms may include passing large amounts of urine at once,
increased thirst, fatigue and weight loss in spite of a good appetite.

 Chronic constipation. The same muscles are used to control urine and stool elimination.
When constipation is long term, these muscles can become dysfunctional and contribute to bed-
wetting at night.

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  A structural problem in the urinary tract or nervous system. Rarely, bed-wetting is
related to a defect in the child's neurological system or urinary system.

RISK FACTORS

Bed-wetting can affect anyone, but it's twice as common in boys as in girls. Several factors have
been associated with an increased risk of bed-wetting, including:

 Stress and anxiety. Stressful events — such as becoming a big brother or sister, starting a
new school, or sleeping away from home — may trigger bed-wetting.

 Family history. If one or both of a child's parents wet the bed as children, their child has a
significant chance of wetting the bed, too.

 Attention-deficit/hyperactivity disorder (ADHD). Bed-wetting is more common in

children who have ADHD.

COMPLICATIONS

Although frustrating, bed-wetting without a physical cause doesn't pose any health risks.
However, bed-wetting can create some issues for your child, including:

 Guilt and embarrassment, which can lead to low self-esteem

 Loss of opportunities for social activities, such as sleepovers and camp

 Rashes on the child's bottom and genital area — especially if your child sleeps in wet
underwear

Types of Enuresis

TYPE CHARACTERISTICS

Primary enuresis (80 Enuresis in a child who

percent of cases) has never established
urinary continence for

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TYPE CHARACTERISTICS

more than six months

Secondary enuresis (20 Resumption of enuresis

percent of cases) after at least six months
of urinary continence

Nocturnal enuresis Enuresis that occurs

during sleep

Daytime wetting Urinary incontinence

that occurs while the
child is awake

Monosymptomatic Enuresis without lower

(uncomplicated) urinary tract symptoms
enuresis other than nocturia and
no history of bladder
dysfunction

Nonmonosymptomatic Enuresis with lower

enuresis urinary tract symptoms
(e.g., increase or
decrease in voiding
frequency, daytime
wetting, urgency,
hesitancy, straining,
weak or intermittent

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TYPE CHARACTERISTICS

stream, posturination
dribbling, holding
maneuvers,* sensation
of incomplete
emptying, lower
abdominal or genital
discomfort)

DIAGNOSIS

Many children may have enuresis from time to time. It can take some children longer than others
to learn to control their bladder. Girls often have bladder control before

boys. Because of this, enuresis is diagnosed in girls earlier than in boys. Girls may be diagnosed
as young as age 5. Boys are not diagnosed until at least age 6.

 History collection

 The physical examination should include evaluation of the ears, nose, throat, abdomen,
spine, genitalia, and rectum and a focused neurologic examination. In children with secondary
or persistent enuresis, the possibility of sexual abuse must be considered. Signs suggestive of
sexual abuse include bruising in areas that are typically protected (e.g., buttocks, back, trunk,
inner thighs, cheeks, neck); multiple bruises; and patterned bruises (e.g., handprints, belt buckle,
bite marks).18

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 Urinalysis and urine culture help detect infection. Select laboratory tests are useful in
diagnosing causes of secondary enuresis (e.g., elevated serum glucose level from diabetes,
elevated blood urea nitrogen and creatinine levels from chronic renal failure, low serum thyroid-
stimulating hormone level from hyperthyroidism). Imaging and urodynamic studies are reserved
for children with significant daytime symptoms, history or diagnosis of urinary tract infections,
features suggesting structural renal abnormalities, or refractory cases.

MANAGEMENT

 Motivational therapy: includes reassurance, emotional support, eliminating guilt, and

encouraging the child to take responsibility for the enuresis (i.e., although the child did not
cause the condition, he or she has a role in treating it).
 simple behavioral interventions include awakening the child to void at times usually
associated with bed-wetting; positive reinforcement for desired behavior (e.g., star or sticker
charts for rewarding periods of continence); bladder training; and minimizing fluid and caffeine
intake before bedtime. These methods are associated with significantly fewer wet nights, higher
cure rates, and lower relapse rates compared with control groups.
 However, behavioral interventions have higher nonadherence rates and require significant
parental involvement.Taking the child to the bathroom during the night is labor intensive and
can frustrate parents. If reward systems are used, failure to achieve dry nights may worsen the
child's self-esteem.

 Enuresis alarms (bells or buzzers) triggered by a moisture sensor in the bed pad or pajamas
have long-term effectiveness. Alarms condition children to awaken or contract their pelvic
muscles. Most children require six to 16 weeks of treatment. Enuresis resolves in nearly two
thirds of children during alarm use, and nearly one half of children who continue its use remain
dry.

PHARMACOLOGIC MANAGEMENT
 Pharmacologic therapies are not curative, but they decrease the frequency of enuresis or
temporarily resolve symptoms over time until spontaneous resolution occurs.
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 Options include anticholinergic agents (oxybutynin [Ditropan], hyoscyamine [Levsin]);
tricyclic antidepressants (imipramine [Tofranil], desipramine [Norpramin]); and desmopressin
(DDAVP). Of these therapies, only imipramine and oral desmopressin have been approved by
the U.S. Food and Drug Administration for the treatment of enuresis in children.
 Tricyclic antidepressants reduce bed-wetting by one wet night per week during treatment.
Imipramine doses range from 25 mg for children older than six years (weighing 20 to 25 kg [44
lb, 1 oz to 55 lb, 2 oz]) to 50 to 75 mg for children older than 11 years. Some recommendations
advise limiting the treatment period to three months (including gradual
withdrawal).19 Imipramine, 25 mg, should be taken orally one hour before bedtime. If the
response is not satisfactory after one or two weeks, the dose is increased to 50 mg in children
seven to 12 years of age and up to 75 mg in older children. Most children relapse after
discontinuing imipramine treatment.

B. ENCOPRESIS

DEFINITION

Encopresis (en-ko-PREE-sis), sometimes called fecal incontinence or soiling, is the repeated

passing of stool (usually involuntarily) into clothing. Typically it happens when impacted stool
collects in the colon and rectum: the colon becomes too full and liquid stool leaks around the
retained stool, staining underwear. Eventually, stool retention can cause swelling (distention) of
the bowels and loss of control over bowel movements.

Types

Two of the most commonly used subtypes in the literature are primary versus secondary, and
non-retentive versus retentive encopresis.

 Non-retentive encopresis is defined as the child voluntarily passing a normal stool in the
clothing inappropriately (Sprague-McRae et al, 1993).
 Retentive encopresis is characterised by involuntary leakage of faecal material as a
consequence of chronic constipation and stool impaction (Levine, 1975).

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 SYMPTOMS

Signs and symptoms of encopresis may include:

 Leakage of stool or liquid stool on underwear, which can be mistaken for diarrhea

 Constipation with dry, hard stool

 Passage of large stool that clogs or almost clogs the toilet

 Avoidance of bowel movements

 Long periods of time between bowel movements

 Lack of appetite

 Abdominal pain

 Problems with daytime wetting or bedwetting (enuresis)

 Repeated bladder infections, typically in girls.

ETIOLOGY

There are several causes of encopresis, including constipation and emotional issues.

1. Constipation

 Most cases of encopresis are the result of chronic constipation. In constipation, the child's
stool is hard, dry and may be painful to pass. As a result, the child avoids going to the toilet —
making the problem worse.
 The longer the stool remains in the colon, the more difficult it is for the child to push stool
out. The colon stretches, ultimately affecting the nerves that signal when it's time to go to the
toilet. When the colon becomes too full, soft or liquid stool may leak out around the retained
stool or loss of control over bowel movements may occur.

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Some causes of constipation include:

 Withholding stool due to fear of using the toilet (especially when away from home) or
because stools are painful

 Not wanting to interrupt play or other activities

 Eating too little fiber

 Not drinking enough fluids

 Drinking too much cow's milk or, rarely, an intolerance to cow's milk — though research
results conflict on these issues

2. Emotional issues

Emotional stress may trigger encopresis. A child may experience stress from:

 Premature, difficult or conflict-filled toilet training

 Changes in the child's life, such as dietary changes, toilet training, starting school or
schedule changes

 Emotional stressors, for example, the divorce of a parent or the birth of a sibling

DIAGNOSIS

To diagnose encopresis:

 Conduct a physical exam and discuss symptoms, bowel movements and eating habits to
rule out physical causes for constipation or soiling

 Do a digital rectal exam to check for impacted stool by inserting a lubricated, gloved
finger into your child's rectum while pressing on his or her abdomen with the other hand

 Recommend an abdominal X-ray to confirm the presence of impacted stool

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 Suggest that a psychological evaluation be done if emotional issues are contributing to
your child's symptoms

TREATMENT

Generally, the earlier that treatment begins for encopresis, the better. The first step involves
clearing the colon of retained, impacted stool. After that, treatment focuses on encouraging
healthy bowel movements. In some cases, psychotherapy may be a helpful addition to treatment.

1. Clearing the colon of impacted stool

There are several methods for clearing the colon and relieving constipation. Your child's doctor
will likely recommend one or more of the following:

 Certain laxatives
 Rectal suppositories
 Enemas

Recommend close follow-up to check the progress of the colon clearing.

2. Encouraging healthy bowel movements

Once the colon is cleared, it's important to encourage your child to have regular bowel
movements. Your child's doctor may recommend:

 Dietary changes that include more fiber and drinking adequate fluids
 Laxatives, gradually discontinuing them once the bowel returns to normal function
 Training your child to go to the toilet as soon as possible when the urge to have a bowel
movement occurs
 A short trial of going off cow's milk or checking for cow's milk intolerance, if indicated

3. Behavior modification

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 Teaching child to have regular bowel movements. This is sometimes called behavior
modification or bowel retraining.
 Recommend psychotherapy with a mental health professional if the encopresis may be
related to emotional issues. Psychotherapy may also be helpful if your child feels shame, guilt,
depression or low self-esteem related to encopresis.

4. Lifestyle and home remedies

 Avoid using enemas or laxatives — including herbal or homeopathic products — without

first talking to your child's doctor.

 Encourage regular bowel movements.

Focus on fiber. Feed your child a balanced diet that includes plenty of fruits, vegetables, whole
grains and other foods high in fiber, which can help form soft stools.
Encourage your child to drink water. Drinking enough water helps keep stool from
hardening. Other fluids may help, but watch the calories.
Limit cow's milk if that's what the doctor recommends. In some cases, cow's milk may
contribute to constipation, but dairy products also contain important nutrients, so ask the doctor
how much dairy your child needs each day.
Arrange toilet time. Have your child sit on the toilet for five to 10 minutes at regular times
every day. This is best done after meals because the bowel becomes more active after eating.
Praise your child for sitting on the toilet as requested and trying.
Put a footstool near the toilet. This may make your child more comfortable, and changing the
position of his or her legs can put more pressure on the abdomen, making a bowel movement
easier.
Stick with the program. It may take months to resume normal bowel sensation and function
and develop new habits. Sticking with the program can also reduce relapses.

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 Be encouraging and positive. As you help your child overcome encopresis, be patient and use
positive reinforcement. Don't blame, criticize or punish your child if he or she has an accident.
Instead, offer your unconditional love and support.

Juvenile delinquency

a) DEFINITION

Juvenile delinquency is participation in illegal behavior by minors (juveniles). A juvenile

delinquent is a person who is typically under the age of 18 and commits an act that otherwise
would have been charged as a crime if they were an adult. They include truancy, curfew
violation running away from home and the use of alcohol.

Juvenile delinquency can be divided into three categories·.

 Delinquency, crimes committed by minors, which are with by the juvenile courts and
justice system;
 Criminal behavior, crimes dealt with by the criminal justice system;
 Status offenses, offenses which are only classified as such because one is a minor, such as
truancy, also dealt with by the juvenile courts.

b) Causes

i. Social disorganization

Current positivist approaches generally focuses on the culture.

ii. Family

Almost all research works have accepted that families of delinquents are characterized by
discords , desertions and divorces such families have been pointed out as one of the main
causes of delinquency.

iii. Peer group

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 To those in sore need of a substitute for family love and group –belongingness, the peer group or
the gang present itself as a kind of close unit that will solve the purpose

iv. Neighbourhood

The immediate environment of a child also affect the trend be will adopt in connection with his
personality. It has been seen that more delinquents come from slums and thickly populated
areas.

v. Educational curriculum

Although school and educational institutes are playing an increasingly important role in the
training and upbringing of future citizens , they are also contributing towards many cases on
juvenile delinquency. Delinquents are typically non bookish and non academic individuals who
take studies like a burden. When they fail family , then tend in indulge themselves in delinquent
acts.

vi. Poverty and democracy

Poverty and democracy are also the major contributing factors towards juvenile delinquency.
People indulge themselves in delinquent acts in order to meet and satisfy the primary wants of
their democratic orders also increase delinquency.

vii. Activities done in juvenile delinquency

Lying , theft, bulglary , truancy from school , run away from home, habitual disobedience ,
mixing with anti-social gang, cruelty to animals, destructive attitude , muder, sexual assault.

c) Dimensions of Delinquency: Characteristics

 Socialized-subcultural –

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Delinquents who scored high on the socialized-subcultural dimensions were defined by such
traits as having strong allegiance to selected peers, being accepted by delinquent subgroup,
having bad companions, staying out late at night, and having low ratings on shyness and
seclusiveness.

 Unsocialized-psychopathic – The delinquents, in contrast, were described as solitary

rather than grouporiented delinquents who were rated high on such traits as inability to profit
from praise or punishment, defiance of authority, quarrelsomeness, irritability, verbal
aggression, impudence, and assaultiveness.
 Disturbed-neurotic – These delinquents were described as unhappy, shy, timid and
withdrawn, and prone to anxiety, worry, and guilt over their behavior.
 Inadequate – Immature – This fourth group of :Youngsters are characterized as being
relatively inadequate in their functioning and often unable to cope with environmental demands
because of a poorly developed behavioral repertoire.

d) Treatment

 Institution-based treatments: Skill based treatments to provide skills that promote a pro-
social lifestyle decreasing the likelihood of future delinquency.
 Community-based treatments: Home like setting with to seven or eight other residents and
two house , parents who are trained in behavior management skills.
 Positive reinforcement.
 Group treatment approaches.

e) Delinquency prevention

Delinquency prevention is the broad term for all efforts aimed at preventing youth from
becoming involved in criminal ,or other social activity. increasingly , governments are
recognizing the importance of allocating resources for the prevention of delinquency.

Prevention of juvenile delinquency is possible by eliminating of contributing factors:

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1. The problem is delinquent behaviors is now increasing must be emphasized by healthy
family and social environment.

2. Healthy parent- child relationship, tender loving care of the family, fulfillment of basic
needs, educational opportunities, facilities for sports, exercise and recreation, healthy teacher
taught relationship etc.
3. Delinquent child needs sympathetic attitude with necessary guidance and counseling for
modification of behavior.

The child should be reffered to child gudence clinic for necessary help. A team approach is
necessary in management of this condition including social workers, psychologist, psychiatrist,
pediatricians, community health nurse , school teachers, family members and parents.

4. Modification of social environment and rehabilitation of the delinquent child should be

promoted.

Conduct disorder

Introduction

Aggression, oppositionality and impulsivity are some of the most frequent behavioral problems
seen at children and adolescents clinic. CD is characterized by a persistent pattern of aggressive
and nonaggressive rule breaking antisocial behaviors leading to considerable burden for the
patients, their functioning in multiple domains in adult life. Both of these disorders are
important clinical conditions because they repeatedly cause physical harm and property loss of
others and also patients themselves are at risk for depressive symptoms, suicidal tendency and
substanceuse.

ETIOLOGY

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 No single or combination of etiologies can be described as definitive. Both genetics and
environmental factors can contribute. Neurotransmitter system abnormalities, noradrenergic and
dopaminergic activities, and serotonin may play a role. It is perhaps more useful and accurate to
view CD etiology in terms of risk factors
 Temperamental Factors/Child Factors

Male gender, difficult temperament, early behavioral problems, low IQ and school failure,
impulsivity, emotional dysregulation, and hyperactivity.

 Familial Factors

Poor family functioning, marital discord, child abuse and neglect, poor parenting (harsh,
inconsistent, lack of supervision), parental rejection, large family size, frequent changes in
caretakers and psychiatric diagnosis in parents.

 Environmental Factors

Poor quality of schooling, socioeconomic disadvantage, peer rejection, association with

delinquent peer groups, exposure to violence.

DIAGNOSIS

Diagnostic and Statistical Manual Fourth edition (DSM-IV) lists 15 criteria or symptoms
grouped into 4 major categories:

(1) Aggression to people or animals,

(2) Destruction property,

(3) Deceitfulness or treachery

( 4) Serious violations of rules.

(1) Aggression to people or animals,

Aggression to people or animals includes bullying, threatening and often indulging in physical
fights with others; using any blunt or sharp object as a weapon that can cause serious physical

78
 harm to others; being physically cruel to people or animals; stealing with actual confrontation of
victim and forced sexual activity ( eight symptoms).

(2) Destruction property,

Destruction of property comprises deliberate fire setting with intention of causing serious damage
to others and deliberate destruction of someone’s property, other than fire setting ( two
symptoms).

(3) Deceitfulness or treachery,

Deceitfulness or treachery involves breaking into a house, building or car; lying to obtain goods
or favors and stealing nontrivial value items without breaking or shoplifting (three symptoms).

( 4) Serious violations of rules.

Serious violations of rules symptom list consist of staying out at night (running away overnight is
defined as running away at least two times from home while living in parental or surrogate
parental home or only once, but for a lengthy amount of time) and skipping school despite
parental prohibitions and it should begin before age 13 (two symptoms).

Three (or more) of the criteria or symptoms should have been present for the last 12 months, with
at least one criterion or symptom must be present in the past 6 months for diagnosis of CD.
Conduct disorder is classified as mild, moderate and severe according to severity of symptoms.

MANAGEMENT

Assessment

 Active probing for each of the DSM 5 or ICD IO symptoms of CD is required, when
interviewing the patient and other informants.
 Assessment should further address important issues regarding presence of comorbid
disorders including ADHD, anxiety and mood disorders, learning difficulties and substance use
disorders in adolescence. All structured psychiatric interview schedule.

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Treatment

General Approach

 To be effective, treatment must be multimodal, involve a family based and social systems-
based approach, to address multiple locus and to continue for substantial periods of time.
 Treatment should start with informing the patient and his parents/ caretakers about the
disorder and its potential complications and long-term sequelae.
 Treatment strategies should be targeted to identify comorbid disorders, such as AD HD.
 Pharmacological management usually not the first choice, but should be considered in. those
patients who have previously failed to respond to other interventions and show escalating levels
of dangerous aggression and violent behavior.
 Additionally, phramacotherapy is more effective when administered in combination with
psychosocial/ behavioral treatments.

Psychological Interventions

Behavioral or contingency management programs has four basic mechanism:

(1) To define a clear behavioral target that figure a child behavior in specific area of concern;

(2) To monitor the child progress toward achieving these target;

(3) To strengthen suitable steps toward achieving these target; and

( 4) To identify and to grant consequences for inapt behavior. These programs have been found to
be effective for altering inappropriate behaviors in · different settings ( e.g. home, school).

Parent management training (PMT) Parent management training teaches consistent parenting,
positive and less harsh discipline practices, monitoring of the child and positive feedback for
the child. Parent management training programs focus on structured contingency management

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 programs at home, improving the quality of parent-child interactions and to use more effective
discipline strategies, to increase positive prosocial behaviors, to strengthen parents supervising.
Among all psychological intervention for children with conduct disorder, the efficacy of parent
training has been the most consistently reported.

Cognitive-behavioral skills building approach: social-cognitive and social problem-solving

deficits in children and adolescents with conduct problem are targeted by this intervention. In
these deficits, children with CPs tend to think their violent behavior will lead to positive results
and this cognitive error makes them more likely to select belligerent choices when solving peer
conflict. Programs inhibit impulsivity or recklessness, by training them to internalize a sequence
of problem-solving steps and to adapt alternative responses and overcome deficits in the way
they process social information.

Multisystemic Therapy

Multisystemic therapy, functional family therapy and multidimensional treatment foster care are
programs developed the treatment of aggression in older children and adolescents with juvenile
justice involvement. These programs have shown effectiveness in the treatment of aggressive
and violent adolescents, resulting in decreased arrest rates. In juvenile justice system,
replacement home may be indicated.

Medical Interventions

Psychostimulants such as methylphenidate, atomoxetine, amphetamine are used to treat

aggression/ oppositional defiant symptom in the context of CD and ODD as a comorbid
condition with ADHD. Apart from psychostimulants, risperidone amongst The second
generation antipsychotics is the most widely studied medication for the treatment of aggression
and conduct symptoms children and adolescents.

Prevention

School-based programs are also effective to identify antisocial behavior or delinquent peer groups
at school and provide adequate support. Family physicians have also greater role in identifying

81
 early cases of ODD when parents report an excessively quarrelsome, disobedient, aggressive
and hostile child. Other programs named intensive home visiting support services child centered
preschool stimulation program are effective in preventing early emerging conduct problems.

EATING DISORDER

INTRODUCTION

Eating disorders were previously often considered as a Western disorder of the affluent, driven by
the social and cultural pressure thinness and perception of beauty, and were labeled as a form
culture-bound syndrome. Over the last few decades, multiple reports of ED have been
documented from eastern countries, most notable from Japan, Hong Kong and China reflecting
the undeniable march of globalization and changing value systems in Asia. In India too, these
disorders are being reported with increasing regularity from metropolitan cities, in tune with the
changing definition of Indian beauty from buxom to petite.

ANOREXIA NERVOSA

DEFINITION

Anorexia nervosa is an ED where sufferers drastically reduce their total food intake or partake in
severe physical exercise and other purging behaviors in their inexorable quest for progressive
thinness.

ETIOLOGY

 Dysfunction in the neurotransmitters involved in regulating eating behavior; namely:

serotonin, dopamine and norepinephrine are commonly reported in studies.
 Endogenous opioids may play a role in denial of hunger by anorexic patients and opiate
antagonists like naltrexone have been shown to cause dramatic weight gains in some AN
patients.
 Starvation induced biochemical changes, such as hypercortisolemla, hypothyroidism, and
positive dexamethasone suppression test are also seen, although they reverse on alimentation.

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 Psychological factors implicated in etiology of AN include having a lifetime of
generalized anxiety and obsessive-compulsive traits, a lack of the sense of autonomy and
selfhood, poor self. Esteem and low optimism.
Clinical Features
 Anorexia nervosa patients eat significantly less, although they harbor a normal appetite
and indeed are often excessively preoccupied with food.
 Inability to maintain the anorexic control results in binging, characterized by sudden bouts
of excessive eating, which is then followed by purging, commonly by self-induced vomiting.
 In severe cases, features of starvation like abnormal reproductive hormone functioning,
amenorrhea, hypothermia, bradycardia, orthostasis, dependent edema, hypotension and lanugo
hair appear.
 Adolescents with AN might suffer from delayed puberty, and adults generally also show
aversion to sex while anorexic.
 Patients of AN often report additional obsessive-compulsive behavior, depression or
anxiety symptoms.

Management

 These patients are generally brought to clinical attention unwillingly by their family
members, often resist treatment, or openly hostile to treating team. Therefore, involving family
members into the treatment plan is necessary for success.
 Hospitalization, at least at the beginning of the therapy, may be needed for severe cases
and in patients where compliance to outpatient treatment fails.
 The primary consideration during hospitalization is to correct patients· dehydration,
electrolyte imbalances and nutritional state; as these can seriously compromise health or lead to
death.
 Constipation often occurs in AN due to the minimal food intake and is usually relieved
when patients begin to eat normally, Stool softeners may occasionally be given, but never
laxatives. Realimentation should be started slowly because of the rare complication of stomach

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 dilation and possibility of circulatory overload when patients immediately consuming large
calories.
 Multiple small feeds (about six) throughout the day or liquid food supplement may be
better accepted by patients.
 Psychotherapy is preferred over pharmacorherapy
 Family therapy, stressing on family relationships may also help pharmacotherapy,
selective serotonin reuptake inhibitors (SSRIs) have had some success in causing weight gain
and in reducing symptoms anxiety or depression, and fluoxetine at dosage at or 20 mg/ day has
shown some promise in preventing relapse.
BULIMIA NERVOSA
DEFINITION
BN can be considered as a failed attempt at AN, where despite their body weight concern,
patients lack the superego strength to prevent their eating binges.
Etiology
 The neurotransmitters related to satiety, serotonin and norepinephrine, are also associated
with BN.
 Additionally, raised plasma endorphin levels in BN patients who vomit may explain the
feeling of well-being which these patients experience after vomiting.
 Genetic predisposition is lesser than AN.
CLINICAL FEATURES
Bulimia nervosa is essentially characterized by three cardinal features: (1) binges, (2) purges and
(3) body image disturbances.
1. Binges refer to periods of rapid consumption of food, accompanied by a sense of loss of
control overeating. Food that is sweet, soft, high on calories and otherwise avoided; like cakes
and pastries, are preferred. Stress, negative mood states, adverse comments about body shape
and lapse in dieting regimes often the night, in bathroom or when otherwise alone. Food is
gulped rapidly and often not even chewed and some patients will onsume any food without
consideration for taste.

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 2. Purging follows the binge to counter guilt, anguish and physical discomfort. The
commonest purging method involves self- induced vomiting by inserting finger into the throat,
although some patients vomit on will. At all other times, BN patients invariably follow a strict
dieting pattern, where the type, quantity and time of eating are strictly predetermined.
3. Body image disturbance Bulimia patients suffer from a morbid fear of fatness, worry about
their body image and harbor concern about their sexual attractiveness. These weight-related
concerns are seen almost all EDs are therefore considered as core symptoms.
Diagnosis
 Only when body weight is maintained, diagnosis of BN is made. Of other psychiatric
disorders, while depression closely resembles AN, atypical depression mimics BN.
Management
 In contrast to patients of AN, most patients of BN can be managed on outpatient
department ( OPD) basis and hospitalizations are rarely necessary, except for management of
electrolyte imbalance or gastric/ esophageal tears. BN patients are also less secretive as many
consider the binges to be ego-dystonic ( distressing) thereby actively partaking in therapy for
decreasing binges.
 Pharmacotherapy includes tricyclic antidepressants and SSRis. Fluoxetine can reduce
binge-purge episodes by 50%. A higher dose ( 60 mg) has been found better than 20 mg.
Sertraline and fluvoxamine are alternative drugs.
 Cognitive behavioral therapy ( CBT) has shown robust evidence of effectiveness and many
national guidelines .CBT has more patient retention as compared to pharmacotherapy alone and
the benefits of CBT are maintained even 12 months post-therapy. CBT aims to modify patient’s
cognitive distortions about food, weight and body image; while behavior alteration focuses on
interrupting the cycle of binging dieting. Other psychotherapies which have shown promise in
BN include interpersonal therapy and dynamic therapy.

VII. PARENT CHILD RELATIONSHIP

DEFINITION

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The parent-child relationship consists of a combination of behaviors, feelings, and expectations
that are unique to a particular parent and a particular child. The relationship involves the full
extent of a child's development.

FACTORS INFLUENCING PARENTCHILD RELATIONSHIP

Of the many different relationships people form over the course of the life span, the relationship
between parent and child is among the most important. The quality of the parent-child
relationship is affected by the parent's age, experience, and self-confidence; the stability of the
parents' marriage; and the unique characteristics of the child compared with those of the parent.

Characteristics of the parent

Parental self-confidence is an important indicator of parental competence. Mothers who believe

that they are effective parents are more competent than mothers who feel incompetent. Also,
mothers who see themselves as effective also tend to believe their infants as less difficult to
handle. Parental age and previous experience are also important. Older mothers tend to be more
responsive to their infants than younger mothers. In addition, parents who have had previous
experience with children, whether through younger siblings, career paths, or previous children,
are often times better able to cope with parenthood.

Characteristics of the child

Characteristics that may affect the parent-child relationship in a family include the child's
physical appearance, sex, and temperament . At birth, the infant's physical appearance may not
meet the parent's expectations, or the infant may resemble a disliked relative. As a result, the
parent may subconsciously reject the child. If the parents wanted a baby of a particular sex, they
may be disappointed if the baby is the opposite sex. If parents do not have the opportunity to
talk about this disappointment, they may reject the infant.

Children who are loved thrive better than those who are not. Either parent or a nonparent
caregiver may serve as the primary caregiver or form the primary parent-child love relationship.
Loss of love from a primary caregiver can occur with the death of a parent or interruption of
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 parental contact through prolonged hospitalizations. Divorce can interfere with the child's need
to eat, improve, and advance. Cultural norms within the family also affect a child's likelihood to
achieve particular developmental milestones.

Cultural impact

In some countries, childrearing is considered protective nurturing. Children are not rushed into
new experiences like toilet training or being in school. In other countries, children are
commonly treated in a harsh, strict manner, using shame or corporal punishment for discipline. 
In Central American nations, toilet training may begin as early as when the child can sit upright.

Childhood in the United States stretches across many years. In other countries, children are
expected to enter the adult world of work when they are still quite young: girls assume domestic
responsibilities, and boys do outside farm work. In addition, in Asian cultures, parents
understand an infant's personality in part in terms of the child's year and time of birth.

Impact of birth order

The position of a child in the family, whether a firstborn, a middle child, the youngest, an only
child, or one within a large family, has some bearing on the child's growth and development. An
only child or the oldest child in a family excels in language development because
conversations are mainly with adults. Children learn by watching other children; however, a
firstborn or an only child, who has no example to watch, may not excel in other skills, such as
toilet training, at an early age.

Infancy

As babies are cared for by their parents, both parties develop understandings of the other.
Gradually, babies begin to expect that their parent will care for them when they cry. Gradually,
parents respond to and even anticipate their baby's needs. This exchange and familiarity create
the basis for a developing relationship.

PARENT-INFANT ATTACHMENT One of the most important aspects of infant psychosocial

development is the infant's attachment to parents. Attachment is a sense of belonging to or
connection with a particular other. This significant bond between infant and parent is critical to
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 the infant's survival and development. Started immediately after birth, attachment is
strengthened by mutually satisfying interaction between the parents and the infant throughout
the first months of life, called bonding. By the end of the first year, most infants have formed an
attachment relationship, usually with the primary caretaker.

If parents can adapt to their babies, meet their needs, and provide nurturance, the attachment is
secure. Psychosocial development can continue based on a strong foundation of attachment. On
the other hand, if a parent's personality and ability to cope with the infant's needs for care are
minimal, the relationship is at risk and so is the infant's development.

By six to seven months, strong feelings of attachment enable the infant to distinguish between
caregivers and strangers. The infant displays an obvious preference for parents over other
caregivers and other unfamiliar people.

Anxiety , demonstrated by crying, clinging, and turning away from the stranger, is revealed when
separation occurs. This behavior peaks between seven and nine months and again during
toddlerhood, when separation may be difficult. Although possibly stressful for the
parents, stranger anxiety is a normal sign of healthy child attachment and occurs because
of cognitive development . Most children develop a secure attachment when reunited with their
caregiver after a temporary absence. In contrast, some children with an insecure attachment
want to be held, but they are not comfortable; they kick or push away. Others seem indifferent
to the parent's return and ignore them when they return.

The quality of the infant's attachment predicts later development. Youngsters who emerge from
infancy with a secure attachment stand a better chance of developing happy and healthy
relationships with others. The attachment relationship not only forms the emotional basis for the
continued development of the parent-child relationship, but can serve as a foundation for future
social connections. Secure infants have parents who sensitively read their infant's cues and
respond properly to their needs.

Toddlerhood

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When children move from infancy into toddlerhood, the parent-child relationship begins to
change. During infancy, the primary role of the parent-child relationship is nurturing and
predictability, and much of the relationship revolves around the day-to-day demands
of caregiving: feeding, toileting, bathing, and going to bed.

As youngsters begin to talk and become more mobile during the second and third years of life,
however, parents usually try to shape their child's social behavior. In essence, parents become
teachers as well as nurturers, providers of guidance as well as affection. Socialization(preparing
the youngster to live as a member of a social group) implicit during most of the first two years
of life, becomes clear as the child moves toward his or her third birthday.

Socialization is an important part of the parent-child relationship. It includes various child-rearing

practices, for example weaning, toilet training, and discipline.

Dimensions of the parent-child relationship are linked to the child's psychological development,
specifically how responsive the parents are, and how demanding they are. Responsive parents
are warm and accepting toward their children, enjoying them and trying to see things from their
perspective. In contrast, nonresponsive parents are aloof, rejecting, or critical. They show little
pleasure in their children and are often insensitive to their emotional needs. Some parents are
demanding, while others are too tolerant. Children's healthy psychological development is
facilitated when the parents are both responsive and moderately demanding.

During toddlerhood, children often begin to assert their need for autonomy by challenging their
parents. Sometimes, the child's newfound assertiveness during the so-called terrible twos can
put a strain on the parent-child relationship. It is important that parents recognize that this
behavior is normal for the toddler, and the healthy development of independence is promoted by
a parent-child relationship that provides support for the child's developing sense of autonomy. In
many regards, the security of the first attachment between infant and parent provides the child
with the emotional base to begin exploring the world outside the parent-child relationship

Preschool

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Various parenting styles evolve during the preschool years. Preschoolers with authoritative
parents are curious about new experiences, focused and skilled at play , self-reliant, self-
controlled, and cheerful.

School age

During the elementary school years, the child becomes increasingly interested in peers, but this is
not be a sign of disinterest in the parent-child relationship. Rather, with the natural broadening
of psychosocial and cognitive abilities, the child's social world expands to include more people
and settings beyond the home environment. The parent-child relationship remains the most
important influence on the child's development. Children whose parents are both responsive and
demanding continue to thrive psychologically and socially during the middle childhood years.

During the school years, the parent-child relationship continues to be influenced by the child and
the parents. In most families, patterns of interaction between parent and child are well
established in the elementary school years.

Adolescence

As the child enters adolescence , biological, cognitive, and emotional changes transform the
parent-child relationship. The child's urges for independence may challenge parents' authority.
Many parents find early adolescence a difficult period. Adolescents fare best and their parents
are happiest when parents can be both encouraging and accepting of the child's needs for more
psychological independence.

Although the value of peer relations grows during adolescence, the parent-child relationship
remains crucial for the child's psychological development. Authoritative parenting that
combines warmth and firmness has the most positive impact on the youngster's development.
Adolescents who have been reared authoritatively continue to show more success in school,
better psychological development, and fewer behavior problems.

Adolescence may be a time of heightened bickering and diminished closeness in the parent-child
relationship, but most disagreements between parents and young teenagers are over less

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 important matters, and most teenagers and parents agree on the essentials. By late adolescence
most children report feeling as close to their parents as they did during elementary school.

PARENTING STYLES

Parenting has four main styles: authoritarian, authoritative, permissive (indulgent), and
detached. Although no parent is consistent in all situations, parents do follow some general
tendencies in their approach to childrearing, and it is possible to describe a parent-child
relationship by the prevailing style of parenting. These descriptions provide guidelines for both
professionals and parents interested in understanding how variations in the parent-child
relationship affect the child's development.

a) Parenting style is shaped by the parent's developmental history, education, and

personality; the child's behavior; and the immediate and broader context of the parent's life.
Also, the parent's behavior is influenced by the parent's work, the parents' marriage, family
finances, and other conditions likely to affect the parent's behavior and psychological well-
being. In addition, parents in different cultures, from different social classes, and from different
ethnic groups rear their children differently. In any event, children's behavior and psychological
development are linked to the parenting style with which they are raised.

b) Authoritarian parents

Authoritarian parents are rigid in their rules; they expect absolute obedience from the child
without any questioning. They also expect the child to accept the family beliefs and principles
without questions. Authoritarian parents are strict disciplinarians, often relying on physical
punishment and the withdrawal of affection to shape their child's behavior.

Children raised with this parenting style are often moody, unhappy, fearful, and irritable. They
tend to be shy, withdrawn, and lack self-confidence. If affection is withheld, the child
commonly is rebellious and antisocial.

c) Authoritative parents

Authoritative parents show respect for the opinions of each of their children by allowing them to
be different. Although there are rules in the household, the parents allow discussion if the
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 children do not understand or agree with the rules. These parents make it clear to the children
that although they (the parents) have final authority, some negotiation and compromise may take
place.

Authoritative parents are both responsive and demanding; they are firm, but they discipline with
love and affection, rather than power, and they are likely to explain rules and expectations to
their children instead of simply asserting them. This style of parenting often results in children
who have high self-esteem and are independent, inquisitive, happy, assertive, and interactive.

a. Permissive parents

Permissive (indulgent) parents have little or no control over the behavior of their children. If any
rules exist in the home, they are followed inconsistently. Underlying reasons for rules are given,
but the children decide whether they will follow the rule and to what extent. They learn that they
can get away with any behavior. Indulgent parents are responsive but not especially demanding.
They have few expectations of their children and impose little or inconsistent discipline. There
are empty threats of punishment without setting limits. Role reversal occurs; the children act
more like the parents, and the parents behave like the children.

Children of permissive parents may be disrespectful, disobedient, aggressive, irresponsible, and

defiant. They are insecure because they lack guidelines to direct their behavior. However, these
children are frequently creative and spontaneous. Although low in both social responsibility and
independence, they are usually more cheerful than the conflicted and irritable children of
authoritarian parents.

b. Disengaged parents

Finally, disengaged (detached) parents are neither responsive nor demanding. They may be
careless or unaware of the child's needs for affection and discipline. Children whose parents are
detached have higher numbers of psychological difficulties and behavior problems than other
youngsters.

Parental concerns

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Child's development is affected by family conditions such as divorce, remarriage, and parental
employment. The parent-child relationship has a more important influence on the child's
psychological development than changes in the composition of the household. Parenting that is
responsive and demanding is related to healthier child development regardless of the parent's
marital or employment status. If changes in the parent's marital status or work life disrupt the
parent-child relationship, short-term effects on the child's behavior may be noticeable. One goal
of professionals who work with families under stress is to help them reestablish healthy patterns
of parent-child interaction.

Discipline is also a concern of parents. Children's behavior offers challenges to even the most
experienced and effective parents. The manner in which parents respond to a child's behavior
has an effect on the child's self-esteem and future interactions with others. Children learn to
view themselves in the same way the parent views them. Thus, if the parent views the child as
wild, the child begins to view himself that way and soon his actions consistently reinforce his
self image. This way, the child does not disappoint the parent. This pattern is a self-fulfilling
prophecy. While discipline in necessary to teach a child how to live comfortably in society, it
should not be confused with punishment.

Pediatric concepts /disorders

MATERNAL DEPRIVATION

It is a condition characterized by developmental retardation that occurs as a result of

physical or emotional deprivation. It is seen primarily in infants. Typical symptoms
include lack of physical growth with weight below the third percentile for age and size ,
malnutrition ,pronounced withdrawal, silence, apathy, irritability and a characteristic
posture and body language, featuring unnatural stiffness and rigidity with a slow
response reaction to others.

CAUSES

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 Multiple and comple, involving such factors as parental indifference , emotional
instability or insecurity of the mother , lack of delayed development of the mother –child
attachment process

Management

Treatment often requires hospitalization especially in case of severe nutrition, especially

in case of severe nutrition.
Care includes assessment of the family situation, and treatment often involves
psychotherapy, counseling

FAILURE TO THRIVE

DEFINITION

Growth failure or thrive (FTT) is a sign of inadequate growth resulting from inability to
obtain or use calories requires for growth

Traditionally the three general categories of failure to thrive

1. Organic failure to thrive

Result of a physical cause congenital heart defect , neurologic lesions ,
microcephaly, chronic renal failure, gastro-oesophageal reflux malapsorption
syndrome, endocrine dysfuction ,cystic fibrosis or acquired immunodeficiency
syndrome (AIDS).
Non organic failure (NFTT)
A definable cause that is unrelated to disease. NFTT is most often the result of
psychosocial factors, such as inadequate nutritional information by the parent,
deficiency in maternal care or a disturbance in maternal-child attachment, or
disturbance in the child’s ability to separate from the parent , leading to food refusal
to maintain attention
Idiopathic failure to thrive

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 Unexplained by the usual organic and environmental etiologies but may also be
classified as NFTT.
Clinical manifestation of failure to thrive
1. Anthropometric measurement
2. Physical examination for evidence of organic causes, developmental assessment
and family assessment
3. A dietary intake history either a 24 hour food intake or a history of food consumed
over a 3- 5 day period is also essential and also child’s activity level , parental
height, perceived food allergies
4. Providing a positive feeding environment, teaching the parents successful feeding
strategies , and supporting the child and family are essential components of care
5. Nurses play a critical role in the diagnosis of FTT through their assessment of the
child , parents and family interactions.
6. Accurate assessment of a initial weight and height and daily weight, as well as
recording of all food intake is mandatory.
7. An excellent observation instrument is the nursing child assessment , satellite
training (NCAST) feeding scale , which is designed to assess the feeding
interaction of infants up to 12 month of age.
8. Some parents are at increased risk of attachment problems because of
 Isolation and social crisis
 Inadequate support system, such as teenage and single mothers
 Poor parenting role models as a child
Because part of the difficulty between parent and child should have a
primary care of nurses

Four primary goals in the nutritional management of FTT are to:

1. Correct nutritional deficiencies and achieve ideal weight for height.

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 2. Allow for catch up growth.
3. Restore optimum body composition.
4. Educate the parents or primary caregiver regarding the child’s nutritional
requirement and appropriate feeding methods.
The nurse teaches infant care techniques to the parents through example and
demonstration rather than by lecturing.

Therapeutic management

The primary management of FTT is aimed at reversing the cause of the growth
failure.

1. If malnutrition is severe , the initial treatment is directed at reversing the

malnutrition.
The goal is at provide sufficient calories ton support ‘cat-up’ growth greater tan the
expected rate for age. Any co-existing medical problems are treated.
2. In most cases of FTT a multidisciplinary team of physician , nurse, dietitian, child
life specialist , occupational therapist, pediatric feeding specialist, and social
worker or mental health professional is needed to deal with the multiple problems.
3. In some cases family therapy is needed. Temporary placement in a foster home
may relieve the family’s stress, protect the child and allow the child some stability
if insurmountable.
4. Behavior modification aimed at mealtime rituals and family social time may be
required.
5. Hospitalization admission is indicated for
 Evidence (anthropometric ) of severe malnutrition.
 Child abuse or neglect
 Significant dehydration
 Caretaker substance abuse or psychosis
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  Outpatient management that does not result in weight gain.

Nursing care management

Caring of the child with FTT presents many nursing challenges , whether treatment takes
place in the hospital , clinic or home effects on the child’s behavior may be noticeable.
One goal of professionals who work with families under stress is to help tem reestablish
healthy patterns of parent- child interaction.

Discipline is also a concern of parents. The manners in which parents respond to a child’s
behavior has an effect on the child’s self- esteem and future interactions with other.
Discipline in necessary to teach a child how to live comfortably in society , it should not
be confused with punishment.

CHILD ABUSE

One of the most common types of violence against children is child abuse. This type of
violence can have implication for both the physical and mental health of children , and
influence their health status long after the abuse has occurred.

TYPES

1. Physical abuse

It is the deliberate maltreatment of another individual that inflicts pain or injury and may
result in permanent or temporary disfigurement or even death. It includes burns a child,
hits, kick, or bites, holds the child under water, shakes or throws the child, throw objects at
the child, ties up the child

2. Physical neglect
It is te deliberate withholding of or failure to provide the necessary and available
resource to the child. Behaviours constituting physical neglect include failure to

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 provide for the following needs. Adequate nutrition and hydration and appropriate
heath care.
3. Emotional abuse
Usually involves shaming , riculing, embraising or insulting the child. It can also
include the destraction of a child’s personal property such as tearing up the child’s
favorite favorite family photographs or letter or harming , killing or giving away the
child’s pet.
4. Sexual abuse
An essential component to identifying sexual abuse is the interview. Child sexual
abuse is often perpetrated b someone known to the children, including family
members.

CLINICAL MANIFSTATION
CLINICAL THERAPY
1. Diagnosis of abuse is made on the basis of a careful history and thorough physical
examinations
2. X-ray studies may be order to identify signs of recurrent abuse such as healed
fractures
3. Neglect, which is more difficult to define and identify , frequently requires
hospitalizations with a comprehensive medical, social and psychiatric evaluation.
4. Five basic categories must be considered when attempting to diagnose neglect.
 Medical care neglect (lack of necessary medical care)
 Gross safety neglect(lack of appropriate supervision)
 Physical neglect( lack of food and shelter)
 Emotional neglect and educational neglect

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 Individual treatment with art therapy is often used initially because it
is least threatening method in the early stages of treatment method in
the early stages of treatment , it can easily be tailored to need the
child’s individual needs and its prepares the child for others forms of
treatment such as family and group therapy.

Family or group therapy may be of benefit in exploring the child’s concern and feelings.

 Anger is common , especially the children who are abused by a trusted adult
such as father or stepfather .

NURSING MANAGEMENT

Nursing assessment and diagnosis

 Nursing assessment in instances of separated child abuse or neglect requires a

comprehensive history and physical examination with documentation of findings ,
consultation with social agencies in the community is important if the family is
receiving services.
 Obtaining the history can be stressful for both the nurse and the parent . use of
therapeutic techniques and a quiet unhurried environment are helpful. Maintaining a
non-judgmental attitude at all times is essential
 Obtaining information about abusive and neglectful behaviors requires the nurse to
establish a trusting relationship with parents ,who are often afraid to trust any
professional
 The health history sequence should
 Parental concerns
 General family history
 Specified child history

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 This sequence begins with non threatening topic and allows the nurse to
demonstrate concerns before asking abuse –related questions.
It is desirable to interview with child and parent both separately and together
parent-child interaction during an intensive history taking session provides an
opportunity to observe the child’s behaviors and parents method of handling
and responding to the child.
 Documentation of finding s is important in all situations, but is essential incases of
suspected child abuse and neglect. Record physical findings as observed.
 Draw diagrams to document skin injuries. Document the location , nature, and
extent of injuries with photographs.
PREVENT FURTHER INJURY
Works with social services ad community agencies to assess the child’s home
environment individuals living in the home and actions surrounding the abuse.
Assist in removing the child from the home to temporary custody of the court of
foster care of another relatives if indicated.
 Counsel family members about abuse and refer for appropriate therapy
PROVIDE SUPPORTIVE CARE

 Protect and treat the child’s injuries includes parents in the child’s treatment plan and
keep them informed about the child’s progress, even if suspected of inflicting injuries
to the child , parent is still the primary care taker.
 Be supportive of any guilt expressed. Encourage the parent to assist with the child’s
care.
 Observe parent-child interactions and document supportive behaviors and child
response to the parents versus other care providers.

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  Use team meetings in develop strategies that enable you to work with the parent and
child.
HOME CARE TEACHING
If there is any question about the child returning to a potentially dangerous situations
support the child’s removal from the situation. The child may receive supervised
care in the home by court order.
Child care, social worker, visits may need to be arranged. Parents should be referred
to parent effectiveness classes, family therapy, and support groups as necessary.
 Encourage the family to confirm other care providers when the child’s abuse history
may affect a response to care.

BATTERED CHILD SYNDROME

Battered child syndrome: A disease in which children are physically abused. The battered child
syndrome is a form of child abuse. Not until the 19th century were children granted the same
legal status as domesticated animals in regard to protection against cruelty and/or neglect. In 1962
the term "battered child syndrome" entered medicine. By 1976 all states in the United States had
adopted laws mandating the reporting of suspected instances of child abuse.

STATISTICS

The total abuse rate of children is 25.2 per 1,000 children, with physical abuse accounting for 5.7
per 1,000, sexual abuse 2.5 per 1,000, emotional abuse 3.4 per 1,000, and neglect accounting for
15.9 per 1,000 children. These categories overlap, with sexual and physical abuse often occurring
together; physical abuse or neglect seldom occur without emotional abuse. These numbers may
be underestimates due to underreporting of the problem or failure of diagnosis by medical
personnel.

In 1996, more than 3 million victims of alleged abuse were reported to child protective services in
the United States; reports were substantiated in more than one million cases. Parents were abusers
in 77 percent of the confirmed cases; other relatives in 11 percent. More than 1,000 children died
from abuse in 1996.
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DEFINITION
The battered child syndrome refers to the non accidental injuries and other adult strike out their
help and harm infant when the child is suffering from physical injury, sexual abuse or
psychological harm , due to full negligence of the parents or other adults known as abused or
battered child syndrome.

Causes and symptoms

 Low socio-economy

Battered child syndrome (BCS) is found at every level of society, although the incidence
may be higher in lower-income households, where adult caregivers may suffer greater
stress and social difficulties and have a greater lack of control over stressful situations.

 Other risk factors include lack of education, single parenthood, and alcoholism or other
drug addictions. The child abuser most often injures a child in the heat of anger or during
moments of stress. Common trigger events that may occur before assaults include
incessant crying or whining of infants or children; perceived excessive "fussiness" of an
infant or child; a toddler's failed toilet training ; and exaggerated perceptions of acts of
"disobedience" by a child.
 Traditional culture

Sometimes cultural traditions may lead to abuse, including beliefs that a child is property,
that parents (especially males) have the right to control their children any way they wish,
and that children need to be toughened up to face the hardships of life. Child abusers were
often abused as children themselves and do not realize that abuse is not an appropriate
disciplinary technique. Abusers also often have poor impulse control and do not
understand the consequences of their actions.

Symptoms

 may include a delayed visit to the emergency room with an injured child; an implausible
explanation of the cause of a child's injury; bruises that match the shape of a hand, fist or

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 belt; cigarette burns; scald marks; bite marks; black eyes; unconsciousness; lash marks;
bruises or choke marks around the neck; circle marks around wrists or ankles (indicating
twisting); separated sutures; unexplained unconsciousness; and a bulging fontanel in
small infants.
 Emotional trauma may remain after physical injuries have healed. Early recognition and
treatment of these emotional "bruises" is important to minimize the long-term effects of
physical abuse.
 Abused children may exhibit: a poor self-image, sexual acting out, an inability to love
or trust others, aggressive, disruptive, or illegal behavior, anger, rage, anxiety , or fear,
self-destructive or self-abusive behavior, suicidal thoughts, passive or withdrawn
behavior, fear of entering into new relationships or activities, school problems or failure,
sadness or other symptoms of depression, flashbacks or nightmares, drug or alcohol
abuse
 Sometimes emotional damage of abused children does not appear until adolescence or
even later, when abused children become abusing parents who may have trouble with
physical closeness, intimacy, and trust. They are also at risk for anxiety, depression,
substance abuse, medical illnesses, and problems at school or work. Without proper
treatment, abused children can be adversely affected throughout their life.

DIAGNOSIS

 Battered child syndrome is most often diagnosed by an emergency room physician or

pediatrician, or by teachers or social workers.

 Physical examination will detect injuries such as bruises, burns,

swelling, retinal hemorrhages (bleeding in the back of the eye), internal damage such as
bleeding or rupture of an organ, fractures of long bones ore spiral-type fractures that result
from twisting, and fractured ribs or skull.

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 X rays , and other imaging techniques, such as MRI or scans, may confirm or reveal other
internal injuries. The presence of injuries at different stages of healing (i.e., having
occurred at different times) is nearly always indicative of BCS. Establishing the diagnosis
is often hindered by the excessive cautiousness of caregivers or by actual concealment of
the true origin of the child's injuries, as a result of fear, shame and avoidance or denial
mechanisms.

TREATMENT

 Medical treatment for battered child syndrome will vary according to the type of injury
incurred.

 Counseling and the implementation of an intervention plan for the child's parents or
guardians are necessary. The child abuser may be incarcerated, and/or the abused child
removed from the home to prevent further harm. Decisions regarding placement of the
child with an outside caregiver or returning the child to the home will be determined by an
appropriate government agency working within the court system, based on the severity of
the abuse and the likelihood of recurrence.

 Both physical and psychological therapy are often recommended as treatment for the
abused child. If the child has siblings, the authorities should determine where they have
also been abused, for about 20 percent of siblings of abused children are also shown to
exhibit signs of physical abuse

PREVENTION

 Recognizing the potential for child abuse and the seeking or offering of intervention,
counseling, and training in good parenting skills before battered child syndrome occurs is
the best way to prevent abuse.

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 The use of educational programs to teach caregivers good parenting skills and to be aware
of abusive behaviors so that they seek help for abusive tendencies is critical to stopping
abuse.

 Support from the extended family , friends, clergy, or other supportive persons or groups
may also be effective in preventing abuse. Signs that physical abuse may occur include
parental alcohol or substance abuse; high stress factors in the family life; previous abuse of
the child or the child's siblings; history of mental or emotional problems in parents; parents
abused as children; absence of visible parental love or concern for the child; and neglect of
the child's hygiene.

NURSING MANAGEMENT

 Complete history of family and relatives, physical examination of child.

 When the abused child is admitted to the hospital , the nurse must help to establish a
tone of treatment for the child and parent rather than a tone of punishment.

 Counseling the parents appropriately.

Long term goals an planning

After the abusing incident is reported service include:

Rapid and thorough investigation of each family and maintenance of a central

registry, since parents of abused children frequency take them to different
physicians or hospitals to avoid identification with previous attacks.

Special agencies

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Self help , non-profit groups should help them. These groups attempt to provide an
atmosphere in which abusive parents can discuss on a 24 hour telephone service or
in person , their descriptive tendencies and seek a means to stop them without fear
or secrimation

For those families , who requires more extensive therapy a child abuse team
composed of members of the helping professionals (physician, psychiatrist, lawyer,
nurse, and social worker) should be made available at the community level to deal
compassionately with both parents and child.

Our country has laws and make child abuse a criminal offense but , his legislations ,
however leaves much to be desired if children are to be protected from abuse. The
law should give full protection to the person reporting the abuse and it should also
provide sufficient protective social services to bear the burden of treating the family
and child.

CHILD GUIDANCE CLINIC

Child guidance clinic were started in 1922, as part of programme sponsored by a

private organization ‘common wealth funds’ programme for the prevention of
juvenile delinquency. The first CGC was started in India in 1939 at the TATA
institute Mumbai. The CGC in Delhi was started in 1955 at RAK CON ,
simultaneously with madras.

DEFINITION

Child guidance clinic are specialized clinics that deal with children of normal and
abnormal intelligence exhibiting a range of behaviors and psychological problems,
which are summed up as maladjustments.

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 CONCEPT

1. The concept involves the all round development of a child’s physical and
psychological functioning and the environment to which he is exposed at
home and school . All this is possible through interaction with and counseling
of the child and his family by a health care team.

PURPOSES OF CHILD GUIDANCE CLINIC

 The child guidance clinic provides diagnostic and counseling services to children,
ages three to eighteen , who are experiencing emotional and or behavioral
difficulties.

 Trauma focused counseling for children who have experienced trauma such as
sexual and physical abuse is a major service of child and family agency. Family
therapy is the context for much of the clinical work done at child and family.
Caregivers are routinely involved in their child’s treatment.

 Individual counseling with children and Adolescents include play therapy , crisis
intervention and other evidence based models.

 Diagnostic and evaluation services include a full range of psychiatric,

psychological services to children and their families.

 Coordination with schools , physicians and other agencies is a significant part of

the service.

OBJECTIVES

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 Providing help for children with behavioral problem like pica , bedwetting, sleep
waling, speech defects etc.

Some disorders are only characterized in small age such as bedwetting , speech
defect , encopresis and pica etc. giving psychological support to them is must
important rather than medical treatment.

 Providing care for children with learning difficulties.

 Providing counseling, guidance and information to parents to parents regarding

care and upbringing of children.

Guidance and counseling , small children are very much exposed for bad
behaviors such as abuse and alcohol due to stress or any social or familiar cause.
If right amount of guidance and counseling from right sources is essential to
avoid negative brain washing. and also promoting positive personality by giving
right care the person will develop good behavior and will ultimate lead to good
life.

PRINCIPLES O CHILD GUIDANCE CLINIC

 The treatment of the child is carried out not by one person by a team of workers.
The team of staff members is constituted of a psychiatrist, a pediatrician, a PHN,
and educational psychiatric social worker, and playroom workers.

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 The child is treated as a whole and the personality has many aspects , physical,
intellectual, educational, emotional, social and economic etc. each of these
aspects is studied by the respective staff members who has specialized in that
particular field.

TEAM MEMBERS

 Psychiatrist

 Clinical pathologists, educational psychologist

 Psychiatric social worker

 Public health nurses

 Pediatrician

 Psychologist

 Speech Therapist

 Social worker

 Nurses

 Teachers

 Occupational Therapist

 Neurologist

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  The psychiatrist is the central figure who does the correct diagnosis and
formulating the line of treatment.

SERVICES PROVIDED BY CHILD GUIDANCE CLINIC

1. PARENT EDUCATION SERVICES

 Child development specialists offer programs which focus on the prevention of

development and behavioral problems by providing assessment , education and
intervention services to parents and young children.

 Administer developmental screening and assessment to children. Provide

parent consultation with regard to their child’s growth, development and
behavior.

 Teach parent to enhance parenting skills and strengthen family interaction.

2. PSYCHO SOCIAL SERVICES

 Services to promote , maintain or restore mental health to children and families

in coordination with developmental and physical health services.

 Assess , diagnose and treat mental health problems and promote healthy
interactions in the prevention of mental disorders.

3. SPEECH , LANGUAGE , AND HEARING SERVICES

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 Speech language pathologists evaluate children’s speech and language
abilities. Following evaluation, parents are counseled regarding their child’s
developmental in the areas of language, articulation, fluency and voice.

 Hearing acuity is screened and additional tests may be administered to assess

the efficiency with which the child is able to understand and use what he
hears.

 If treatment of a problem area is indicated, a variety of methods may be used

to help the child improve his skills, including involvement of parents in a
home program. Parents are often included in the session to encourage positive
parent –child interaction and increase language stimulation.

4. SCREENING

A screening is not a complete evaluation. It is a method used to check for

possible problems in development, speech, language, hearing , social,
emotional and or behavioral skills. Not passing a screening does not
necessarily indicate a disorder, but rather is an indication for referral for more
in-depth testing. Due to the limited nature of a screening , certain problems
may not be entirely rules out even if a screening is passed.

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SUMMARY

As far we discussed about definition of nursing, definition of pediatric nursing, principles,

common behavioral disorders, role of pediatric nurse, pediatric nursing involves taking the
responsibility of care for children and families throughout the lifespan. This task includes health
promotion, illness care, health restoration, and rehabilitation of the child . Definition of
pediatrics that as the branch of medical science that deals with the care of the children from
conception to adolescence , in health and illness. It is concerned with preventive , curative and
rehabilitative care of children. Principles of behavioral pediatrics that understand the functions
of behavior, understanding comes from observation of ABCs, modeling can strength or weaken
behavior .Common behavioral problems like breath holding spells is breath holding spasm is a
benign involuntary phenomenon seen in children between 6 month and 6years of age. Thumb
sucking defined that as placement of thumb in to the mouth for various depths . Nail biting habit
is often a way to ease anxiety or to keep at least one part of the body occupies while the mind
lacks interest. Stranger anxiety is fear or wariness of people with whom a child is not familiar.
Temper tantrum which screaming, hitting , head banging and falling down and other violent
display of frustration, usually occurring in children of 18 months to 4 years of age.

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Pediatric nursing requires understanding the developmental aspects of children and physical
difference between children and adults. Pediatric nurses must also recognize the role that
families play in the child’s health and reflect family –centered care in practice

CONCLUSION

The developmental years in the children are very dynamic phases. A simple mood swing can turn
in to grave difficulty if not treated properly. Understanding toddler emotion is one of the hardest
jobs. Much progress has been made over the past century in understanding the special attributes
of children and the importance of their healthy development to the health of the population as a
whole. Nevertheless, in the United States, the current failure to adequately consider, define,
conceptualize, and measure the dynamic and multidimensional aspects of children’s health has
profound implications for the entire population, with potentially compromising effects on the
nation’s health. It is time—arguably overdue—to repurpose efforts at the federal, state, and local
levels to focus on the nation’s most valuable national resource—children. The reasons for and
the steps involved in this establishment of children and their health as a national priority have
been described in this report; in short, it is time to develop ways of looking at and assessing
children that will demand that the nation nurture and develop their inherent richness and
potential across the multitude of geographic, racial, cultural, socioeconomic, and developmental
spectrums. This effort requires a shared vision from local communities through the highest
levels of national government and should be treated as an urgent national priority.

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BIBLIOGRAPHY

1. Ball .w. Jane .(2005).Pediatric nursing. caring for children . 3rd edition . india. The health
science oublisher, 128-130
2. Gupta piyush . (2009). General pediatrics and neonatology.vol.1. India.the health science
publisher,758-790
3. Mockenberry.(2012). Wongs essentials of pediatric nursing. 8th edition. The health science
publisher , 396-400
4. Pai panchali .Text book of pediatric nursing 1 st edition . India. Paras medical
publisher,438-509
5. Pamaja.(2008).Text book of health nursing . 2nd edition. India .jaypee the health science
publisher ,645-662
6. Varghese Susamma .(2009). Text book of pediatric nursing. 2 nd edition. India . Jaypee the
health science publishers, 599-624
JOURNAL
1. Leem,pachter (2019)journal of development behavioural pediatrics . vol.40 .page no: 60-
80
2. Erin .R. Franzier. (2014)journal of creating a safe place for pediatric care . page no: 247-
250

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INTERNET
1. www.health of chilile|p|pac
2. www.prenatal.com
3. www.health of children . com

BEHAVIOUARAL PEDIATRICS AND PEDIATRIC NURSING

INTEX

Page no

Sl no content
1. Introduction
2. Definition
3. Principles of behavioual pediatrics
4. Common behavioural disorders
5. Role of pediatric nurse
6. Summary
7. Research abstract
8. Conclusion
9. Bibliography

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116
ROLE OF A PEDIATRIC NURSE

The role of the pediatric nurse may vary from one health institution to others, but the basic
responsibilities remain the same. It may vary depending upon the educational preparation of the
pediatric nurse and exposure to the specialized training. The characteristic social behavior of
pediatric nurse· as role model for the child care can be summarized as follows:

1. Primary caregiver: Pediatric nurse should provide preventive, promotive, curative and
rehabilitative care in all levels of health services, as therapeutic agent. She/he acts as case finder
and compassionate skilled caregiver needed by the today’s society. In hospital, care of the sick
children, i.e. comfort, feeding, bathing, safety, etc. are basic responsibilities of the pediatric
nurse. Health assessment, immunization, primary health care and referral are basic
responsibilities at the community level as quality care provider.

2. Health educator: Important role of the pediatric nurse is to deliver planned and incidental
health teaching information to the parents, significant others and children to create awareness
about healthy lifestyle and maintenance of health. Change in health behavior and attitude and to
develop healthful practice regarding child should be initiated by the pediatric nurse as change
agent, teacher and health educator.

3. Nurse-counselor: Problem-solving approach and necessary guidance in health hazards of

children to minimize or to solve the problem and to help the parents and family members for
independent decision-making in different situations are essential role of the pediatric nurse in
the present health care delivery system.

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4. Social worker: Pediatric nurse can do case work especially for children and try to alleviate
social problems related to child health. She/he can participate in available social services or
refer the child and family for necessary social support from the child welfare agencies.

5. Team coordinator and collaborator: Pediatric nurse should work together and in
combination with other team members towards better child health care. She/he should act as
liaison among the members and maintain good interpersonal relationship. The nurse interprets
the objectives of health care to the family and coordinates nursing services with other services
necessary for the child. Co-operations and good communication among team members should
be promoted by the nurse.

6. Manager: The pediatric nurse is the manager of pediatric care units in hospital, clinics and
community. She/he should organize the care orderly for successful outcome with better
prognosis and good health.

7. Care advocate: Child or family advocacy is basic to comprehensive family-centered care.

As an advocate, the pediatric nurse can assist the child to obtain best care possible from the
particular units. Advocacy can range from consulting dietary department for special to arrange
team meeting to discuss plan of care.

8. Nurse consultant: The pediatric nurse can act as consultant to guide the parents and
family members for maintenance and promotion of health and prevention of childhood illness.
The nurse can promote self-care within the family and prepare self-care agent for the children
who are unable to take care of their own health. The nurse help the older children to become
responsible for their own lives. The nurse assesses the children’s ability to do self –care
activities and assist them in developing the ways of self –care and self-responsibility.

9. Researcher: Nursing research is an integral part of professional nursing. Pediatric nurse

should participate or perform research projects related to child health. Clinical and applied
research provides the basis for changes in nursing practice and improvements in the health care
of children ,

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Beside the above roles, pediatric nurses have to respond to the social need with expanded roles.
The independent role of pediatric nurse reflects the expansion of the role as pediatric nurse
practitioner, pediatric clinical nurse specialist, etc. New and responsibility can be added to the
pediatric nurse in situations of child care in future.

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