Behavior Patterns

Understanding your child

Understanding your child

Understanding Your Child: It is necessary for us to understand some of the problems of our children that we come across during their growing age; because of our failure to understand the basic causes we fail to manage them properly. Here I would like to share my experiences of some common problems faced by infants and young children.

Temper Tantrums: Temper tantrums, one of most common problems, are normal in toddlers but may become a problem if they are severe and persistent. This is likely to happen if they are reinforced by attention and gratification. This may occur in unstable families where other aspects of child care are unsatisfactory. They are thus often part of a more widespread disturbance.

Since temper tantrums are an expression of rage at being frustrated, their escalation or cure depends upon how situations that are frustrating for the child are handled by the parents and other care-givers. Firm but kind limit-setting in an emotionally warm and accepting context will usually bring about a rapid improvement. Inconsistent or hostile attitudes, and especially the intermittent reinforcement of the tantrums by giving into them, will tend to cause them to worsen.

Failure to Sleep: Failure to sleep as and when expected by the parents may simply be due to unrealistic expectations by the parents, or a lack of knowledge of the amount of sleep needed by a child of the age in question. Moreover, the amount of sleep needed by different children seems to vary considerably. Failure to conform to a regular pattern of sleeping behaviors may occur in chaotic and disorganized homes where there is no regular bedtime and a bedtime routine is not adhered to, so the child does not have the opportunity to learn a set pattern of sleeping and waking behavior. Failure to sleep, with crying, is common in babies, but normally settles after a few months if feeding and the general care of the intent are satisfactory. Persistence of the trouble into toddler years is quite common.

In many instances of sleep problems, however, where the child is in other ways mentally and physically healthy, the trouble is transient and clears up after some weeks or months.

Night Terrors: Night terrors can be alarming for parents who have not seen them before, but are common in perfectly healthy toddlers. These children wake up in a frightened, even terrified, condition. They are inaccessible and do not respond when spoken to, nor do they appear to see their surroundings. Instead they may appear auditory or visually hallucinated, talking to and looking at people and things not actually there. They may be difficult to comfort at first, and the period of disturbed behavior and altered consciousness may last up to fifteen minutes, occasionally even longer. Eventually the disturbance subsides with or without comfort from a parent, and the child goes back to sleep. There is usually no memory of the incident when the child wakes up in the morning.

Nightmares: Nightmares are unpleasant or frightening dreams. The child does not wake up, nor necessarily becomes overtly disturbed while having a nightmare. If waken up the child reacts normally and there is no period of altered consciousness or inaccessibility such as occurs in night terrors. Nightmares occur in REM sleep (‘rapid eye movement’ or light sleep).

Sleep-walking: Sleep-walking, or somnambulism, may accompany either nightmares or night terrors. Apparently the content of the dream or terror is acted out in a state of sleep or altered consciousness. Nightmares and restless sleep are common in acute febrile illnesses.

Feeding Problems: Feeding problems are common in young children, in whom they sometimes occur in the absence of other significant problems. Children may eat, or be thought by their parents to eat, too little or too much; they may be excessively particular over what they eat or may eat items not normally regarded as edible.

Pica is the eating of items not usually regarded as edible, for example paper, soil, paints, wood and cloth. Many other materials may be involved. The symptom has many causes, including adverse environmental factors and emotional distress; it is often associated with distorted developmental patterns, but is sometimes seen in children of normal intelligence. The children often have relationship difficulties.

Breath-holding Spells: Breath-holding spells occur commonly in pre-school children. They usually start before age the age of two, but seldom before 6 months. The spells usually die out by age 5 or 6.

Breath-holding spells are usually precipitated by some minor upsetting incident or frustration. This is followed by crying which increases in intensity until the child reaches a state of rage. Breathing then stops, usually in expiration, and cyanosis becomes manifest in blueness of the face, especially around the lips.

The spells seem to be used by some children to alarm their parents, who may reinforce them by a show of concern and indulgence. They are better treated calmly and with as little fuss as possible. The outcome is usually good.

Thumb-sucking and nail-biting: Thumb-sucking and nail-biting, both these behaviors are common in young children, and in one population biting also occurs frequently in older children. In a survey, it was found to reach a peak at 9 years in boys and 11 years in girls. Thumb- and finger-sucking are normal in babies and gradually lessen during the second and subsequent year. Persistent thumb-sucking usually has little significance on its own but may be one feature in a pattern of regressive behavior in a child who is anxious or under stress. It often requires no treatment, but if necessary can usually be stopped by simple reminders, rewards or even sanctions. Occasionally, it becomes a severe, compulsive behavior and more active treatment is required. Severe thumb-sucking can cause dental malocclusion in older children and may merit treatment for this reason.

Nail biting is also usually a tension-reducing habit and tends to occur in anxious and tense children. Direct treatment is not usually needed, but the underlying condition may need treatment in its own right. Nail-biting often disappears at puberty if it has not done so previously.

Conclusion: Behavioral approaches have also been used and mothers have been trained to act as therapists for their infants. Indirect treatments include counseling of parents and other caretakers by mental health professionals and pediatricians.

The writer is a consultant pediatrician at a Karachi Hospital

Courtesy Dawn.

Behavioral Problems

Behavioral Problems:

Nocturnal Enuresis It is repeated involuntary voiding of urine at night into bed or clothes after an age at which continence is expected. Bed-wetting three times a week for a period of a month indicates the child has a problem.

Most children are dry at age two or three years and by night at three or four years. Wetting after age 5 years is abnormal.

At teacher may suspect a child has problems with bed-wetting if the child persistently smells of urine.

Child Urine Control? A child is born without control over the bladder. During the first year of life, partial control of the sphincters (the muscles that keep the bladder closed) during the day gradually starts. It helps if the mother continuously encourages her baby to use the proper place for passing urine, with rewards for bladder control until the proper place is reached. During the second year children start to control the bladder completely.

The more the brain develops, the faster the child controls the bladder sphincters. This occurs between the third and fifth years gradually till complete control is seen by the age of five years.

Ninety percent of its causes are psychological. It is almost associated with home or school problems, such as:

Family discard. Arrival of a new sibling taking away the attention of the parents, leading to regression in the child and development of enuresis. Abusive parents (mainly physical abuse). Hospitalization of the child. Using threatening stories to discipline the child. Emotional distress in school due to learning problems or humiliation by teacher.

Conduct Disorder Conduct disorder is a persistent pattern of conduct in which the basic rights of others, and major age-appropriate social norms or rules are violated.

Behavior of the child with conduct disorder:

Stealing and confrontation with the victim Running away from home, overnight at least twice Frequent lies Deliberate fire setting Frequent truancy from school Deliberate destruction of others property Physical cruelty to other people or animal Initiation of aggression If this disruptive behavior has lasted at least six months with some of the above presentations, it is called conduct disorder. Th e age of onset is usually before puberty and most apparent amo ng adolescents (12 to 15 years) What is the Course of this Disorder? The mild form shows improvement over time. Early onset is associated with greater risk of continuation in the adult life as antisocial behavior.

Ways to Prevent Conduct Disorders Strengthening of lies of affection between parents and children Firm moral demands made by parents on their children Using a technique of punishment that is psychological rather than physica l (methods that signify or threaten withdrawal of love and approval thus provoking anxiety or guilt rather than anger). Intensive use of reasoning and explanation. As the school is the second home for the child use of appropriate technique in schools not involving aggression in order to provide good model for the children (e.g. the teacher should not insult the pupils or hit them to discipline them). Remember The same technique used for attention deficit with hyperactivity disorder can be applied to conduct disorder.

Example: Afzal is a 15years old boy who has a long history of trouble with authorities both in and out of school. He is frequently truant and has been caught lying and stealing at the school. He is barely passing his subjects although he is intelligent. Recently he has begun spending a great deal of time with a group of “bad boys”. Afzal’s parents are very defensive at school meetings with the teacher and deny or blame the school for his problems. One of his parents has a history of substance abuse. Afzal’s problem needs help from the school authorities, mental health professionals, family and community.

Drug Abuse Drug abuse is the consumption of drugs not in the course of medical treatment.

What are the Most Commonly Abused Drugs? They range from the widely and legally available substances such as caffeine and tobacco, to substances such as cannabis, barbiturates, amphetamine, and opiates like heroin.

Tobacco Tobacco is possibly the most dangerous drug legally available and so gets own section. We do not usually associate the world ‘drug abuse’ with tobacco smoking but it is an addictive habit that can lead to serious disease and death. In western culture smoking has started to be unacceptable behavior as its dangers to the smokers and those who have to breathe the second-hand smoke become widely known – smoking is banned in many public places. Smoking, however, is still socially acceptable in the countries of the developing world, and adolescents are eager to start smoking because it can be:

A sign of manliness or adulthood An imitation of an elder person such as father, a teacher or a movie star A sing of affluence; being able to afford to by tobacco To try something new, a sort of exploration. What are the Dangers of Smoking? Burning tobacco contain nicotine, a highly addictive drug, carbon monoxide, which interfere with the respiratory system, and tars and other noxious substances.

Smoking is often associated with drug dependency and can lead to taking illegal drugs such as cannabis.

Smoking can lead to serious illnesses such as: cancers of the mouth, throat, lung and bladder, and most lethal, cancer of the pancreas. It is also associated with respiratory and heart disease.

Smoking among school children has been closely associated with coughing, sputum and shortness of breath on exertion.

What is the Role of the Teacher in School to Control Smoking? The teacher should set a good example by not smoking. Health education material in school textbook should be imaginatively prepared and should form an essential part of primary and secondary school curricula. Students should be en-courage to analyze the real nature of smoking through debates, essay competitions and sports. Life skill-approaches to smoking prevention are more effective than traditional information based approaches. Remember Drug abuse prevention is more important than treatment. It can be in the form of:

Knowledge regarding the types of drug abusers and their complications Providing skills to protect adolescents from drugs by being able to say NO. Provision of healthy school activities like sports and art Promotion of quality of life and healthy life style. Opium and Heroin Opium is a highly addictive natural product made from a plant. Heroin, derived from opium, is strongly and highly addictive. Heroin abusers can inject the drug and often share needles: this can expose them to infection with the HIV and hepatitis viruses.

Prescription Drugs The most commonly abused prescription drugs are the sedatives: sleeping pills, painkillers and some cough syrups. Used temporarily and under medical supervision sedatives can relieve anxiety and promote sleep. When abused, however they can habit forming. At high doses they may lead to unconsciousness or even death.

What Causes some Young People to Become Drug Abusers? In majority of cases, teenagers first try drugs for fun or as a sign of independence from the family or for the thrill of unknown. Often, social pressure is a factor, to keep up with peers, where young people try to coop with anxiety and social situation by taking drugs.

Most adolescents never even experiment with drugs. Others try it, dislike it and soon give up. Some adolescent however, become social users, willing to smoke cigarettes, or in rare cases try other substances either by themselves or in a gathering.

Remember It is true, young people slip easily in a substance abuse, but with the right treatment, guidance and support, they can also climb back out of it. The crucial factors are; getting them to treatment in the first place, and making sure that they participate in a strong, long term follow up program. To make their rehabilitation a success, they often need to connect with an entirely new circle of friends-youngsters of their own age, who do not drink or take drugs a good treatment program will ensure that they make the important connections.

Which Teenagers are Most likely to Become Substance Abusers? There are personal familial, environmental and social factors, which can make the teenagers a high risk:

Those who have a parent, sibling or other blood relative who is drug addict. Those who seem to ‘fall in live’ with drugs on their very first try. Those who grow up surrounded by drug abuser role models. Generally speaking those young people who start to smoke appear to have lower self-image and lower self-esteem than their non-smoking peers.

How do You Tell if a Particular Person is Abusing Drug? In the early stages, it is hard to tell. Drug abuse often begins socially, as a form of recreation, and dependency may develop insidiously if you suspect that you care about may be abusing drugs watch for evidence such as possession of drug, also, stay alert for other warning signs, such as:

Significant, unexplained weight loss or weight gain Agitation Over suspiciousness Chronic lying Withdrawal from family and friends School problems Financial difficulties What to Do if You Think that an Adolescent Might have a Substance Abuse Problem? Help the adolescent’s family to arrange a professional evaluation. This would include complete physical examination, blood and urine tests and psychological assessment. Treatment for drug-abuse consists of two phases, detoxification and rehabilitation. Detoxification is the treatment used to remove the toxic effect of some drugs or chemical substances and help the body to return to normal (this may take several days). Rehabilitation is much longer phase, consisting of a daily schedule of different type of therapy.

Example: Kamal is a young 17 years old boy who experienced a recent drop in his school performance, his teacher noticed that he had widely varying moods and had recently changed friends. Kamal’s father is known as an addict in the small community where they live. Kamal’s teacher arranged a meeting with his father and family to resolve his problem, including necessary professional help and a special effort was made to increase his involvement in after school social community activities. Kamal’s grades have improved, his moodiness has decreased, and he has found new friends in the after school groups who do not abuse substance.

Eating Disorders Faulty eating habits are a frequent complaint presented to the physicians. In dealing with such problems, several important considerations must be kept in mind:

Age of the child Mental capacity Attitudes and expectations of the parents Opportunities the child has had to master the skills involved in feeding him Feeding one self is a skill which requires time and patience to learn. All children should be encouraged to feed themselves when they show willingness or readiness.

Eating disorder is characterized by gross disturbances in eating behavior:

Lack of appetite Ravenous appetite Reverted appetite The child may refuse to eat practically all food, may eat well one day and refuse the next, may eat only small amount, may like food one day and dislike it next day. All these are related to:

Lack of parental understanding Parental over concern Parental tension Parental attitude toward food Usually, these problems begin at the end of first year. Many parents become upset when a child’s appetite falls off. This can lead to confrontation, which tends to:

Increase the child’s resistance Teach the child to use feeding as an attention grabber. Management Helping the parents to understand the nutritional needs of their child. Encouragement of regular meals. Parents should be taught that no serious harm will come to the child if she misses a meal or two. Threats, urging, or use of unusual devices to encourage eating are to be avoided. Lack of Appetite What are the essential features?

Refusal to maintain body weight over a minimal normal weight for age and height. Intense fear of gaining weight or becoming fat, even though underweight. A distorted view about how one’s body looks (body image). Irregularity or stopping of menstruation in females (amenorrhea). Age of Onset : Usually early to late adolescence, although it can range from puberty to, rarely, the early thirties.

Sex Ratio: Much more common among girls

Impairment: The severe weight loss often necessitates hospitalization to prevent severe consequences including death by starvation.

Excessive Appetite What are the essential features?

Recurrent episodes of binge eating(rapid consumption of a large amount of food in a discrete period of time) A feeling of lack of control over eating behavior during the eating binges Self induced vomiting Use of laxatives or diuretics (because of over concern with body shape and weight) A binge is usually terminated by abdominal discomfort, sleep, social interruption, or induced vomiting.

Age of Onset: usually begins in adolescence or early adult life.

Perverted Eating Disorder: Perverted eating disorder is persistent eating of a non-nutritive substance (Such as paper or clay) for at least one month after the age of two years.

Predisposing Factors:

Mental Retardation Neglect Poor Supervision Example: Naila is a 16 years old girl who has been noted by her teacher to be quite moody. She is very interested in the approval of others. Naila was slightly overweight at the beginning of the school year, then lost a great deal of weight, and now is slightly underweight. One of the Naila’s friends told the teacher that Naila makes herself throw up after meals. Naila’s teacher discussed this information with Naila’s mother and with community mental health team. A referral for counseling was arranged. The school staff encouraged and facilitated Naila to participate in school activities where she is able to express her feelings.

Sleeping Problems People used to think of sleep as a period of quite and inactivity. But during sleep, a lot of complex activity occurs both in the brain and in the body.

What Really Happened in Sleep? Sleep is not a continuous, unified condition. From the beginning of sleep till they wake up in the morning people pass alternately through two different stages of sleep roughly corresponding to periods of dreaming and non-dreaming.

What about Sleep Pattern According to Age? It was once thought that a person needs more sleep as he gets older. Now it is known that once a person reaches adulthood, he requires about the same amount to sleep at all ages. Newborn infants sleep an average of 16 � hours daily and by six months usually average about fourteen hours. At age two, the average sleep time is 12 � hours (1 � hours of nap-time and 11 hours at night). By age 6 most children need naps, and sleep time is reduced to about 11 hours. Sleep time of the 10 years old averages 10 hours and by ages 15-19 it averages around 7 � to 8 � hours. In adulthood it declines to about 6 � hours.

What are the Rules for Better Sleep Hygiene? A regular wake-up time in the morning strengthen the circadian cycle and finally lead to regular times of sleep onset. A steady daily amount of exercise probably deepens sleep. Occasional loud noises disturb sleep even in people who are not awakened by noises and cannot remember them in the morning. Hunger may disturb sleep. Caffeine in the evening disturbs sleep, even in those who feel it does not. Chronic use of tobacco disturbs sleep. People who feel angry and frustrated because they cannot sleep should not try harder and harder to fall asleep but should get up and do something different. Sleep Disorders: Insomnia Refers to the difficulty in falling asleep or the difficulty in staying asleep.

Insomnia can be:

1. Secondary to another disorder, such as:

Insomnia related to another mental disorder (depression and anxiety) Insomnia related to a known organic factor (such as physical disorder like arthritis, use of a psychoactive substance like amphetamines, or use of a medication such as prolonge d decongestants) 2. Primary insomnia, characterized by excessive worry during the day about not being able to fall and stay asleep.

How to Overcome Primary Insomnia? Go to bed only when sleepy Use the bed only for sleeping If unable to sleep, get up and move to another room Repeat step 3 as often as necessary throughout the night Set the alarm and get up at the same time every morning regardless of how much you slept during the night Do not nap during the day Concentrate on your breathing, follow each breath as it enters and leaves your body If previous suggestions fail, consult a physician for use of anxiolitic drugs. Hypersomnia Hypersomnia can be:

Related to another mental disorder, such as Depression, somatoform disorders, Schizophrenia or among adolescents and young adults, to a wish to escape from some distress. Related to a known organic factor, such as physical disorder (such as sleep apnea), a psychoactive substance-use disorder (such as cannabis dependence) or medication (such as prolonged use of sedatives and anti-hypertensive) Attention Problems Youngsters who are excessively impulsive, have serious trouble in paying attention, and find it difficult to focus on a task, may be suffering from what is known as Attention Deficit Hyperactivity Disorder (ADHD). It is a state characterized by inattention, impulsiveness and hyperactivity. They are easily distracted and often cannot organize work cooperative in sports.

Even though the child with ADHD wants to be good student, impulsive behavior and inability to pay proper in the class interferes. Teachers, parents and friends know that the child is “misbehaving” of “different”, but they may not be able to tell exactly what is wrong.

The onset of the disorder is before age four. Frequently the disorder is not recognized until the child enters school. It is 6 to 9 times more common in boys than girls.

What are the Manifestations of Attention Deficit with Hyper Activity Disorder? These can appear in any situation, including at home, in school and in social situation, but to varying degrees.

A Child in the Classroom Does not stick with tasks to the end, indicating inattention and impulsiveness Often performs work messily, carelessly and impulsively Make comments out of turn Fails to wait his or her turn in a group task Fails to heed directions fully before responding to assignments Interrupts the teacher during a lesson Goes on talking to other children during a quite work period Has difficulty remaining seated, excessively jumps about, runs in the class room, fidgets, twists and wiggles in the seat; all indicating hyperactivity. A Child at Home Fails to follow other’s requests and instructions Frequently shifts from one incomplete activity to another Interrupts or intrudes on other family members Shows accident-prone behavior Can’t remain seated when expected to do so Is excessively noisy A Child with fears Fails to follow the rules of structured games or listen to other children Does not await his or her turn in a game, indicating impulsiveness Engages in potentially dangerous activities without considering a possible consequences Talks excessively Can’t play quietly or regulate his activity to conform to the demands of a game Remember Hyperactivity among children younger than 9 years can be an early warning sign of Depression.

How to Manage Children with Behavioral Problems Psychological Management The most important issue is to reduce the impulsiveness and aggression and try to let the child focus on his task. This can be done through cooperation between the school and the parent to fulfill the following:

Finding an effective positive reinforce, such as discovering from the child things he/she wants or observing the type of free-time activities in which the child behaves in an acceptable and controlled way. Help the child to control his behavior by training him on thinking properly through the following stop-think-start. Role of Teacher in the Class The aim is to improve the social adjustment of the hyperactive child in the school especially if his intelligence is normal.

You should do the following:

Observe the degree of aggression and distractibility of the child in the classroom. Try to ignore some of child’s behavior and praise good behavior. Encourage good behavior in the class rather than using punishment, because punishment always worsens this condition. Reinforce positive behavior by giving the child something he/she likes to eat. Divide into parts the task given to the child and give rewards if the finishes the task on time. Cooperative with the parents to follow the progress of the child’s behavior. Help the child to be in a small, quite classroom with few distractions and a consistent teaching approach if this is available. What is the Role of Punishment? For instance, if a child misbehaves in the classroom, the teacher can remind him of his misbehavior in front of the class telling him that if this misbehavior continues, he will be sent out of the room.

If in spite of this warning the improper behavior continues, and teacher has to dismiss the child from the class (for not more than ten minutes), the child should come back to the class and promise not to repeat this behavior.

Remember Frequent physical punishment can make the hyperactive child more aggressive

Drug Treatment Usually drug treatment is started when

The child’s behavior is unmanageable The child’s family is not sufficiently intelligent to help the child There is need to combine drug therapy with psychological management to let the child focus on schoolwork. Example: ‘Akbar” is a 7year old boy who was noted by his teacher to have trouble paying attention, controlling his impulses and sitting still. Due to his impulsive, active nature, he has poor relationships and his inability to pay attention interferes with his academic performance. On teachers and community mental health team’s referral, Akbar’s parents consulted a mental health specialist who designed a program at school and at home, which decreased the distractions in Akbar’s environment, when he is trying to learn, provides praise for desired behavior when it occurs, and avoids emphasizing negative aspects of his behaviors.