Behavioral Problems, Pediatric

Description

Behavior that disrupts at least one area of psychosocial functioning. Commonly reported behavioral problems are as follows:

• Noncompliance: active or passive refusal to do as requested by parent or other authority figure
• Temper tantrums: loss of internal control provoked by overtiredness, physical discomfort, or fear that leads to crying, whining, breath holding, or in extreme cases, aggressive behavior
• Sleep problems: sleep patterns that are distressing to caregivers or child; difficulty going to sleep or staying asleep at night, nightmares, and night terrors
• Nocturnal enuresis: enuresis that occurs only at night in children >5 years of age with no medical problems
  • Primary: children who have never been dry at night
  • Secondary: children dry at night for at least 6 months
• Functional encopresis: repeated involuntary fecal soiling that is not caused by organic defect or illness
• Problem eating: “picky eating,” difficult mealtime behaviors
• Normative sexual behaviors: developmentally appropriate behaviors in children in the absence of abuse
• Thumb-sucking: an innate reflex that is self-soothing; may be protective against sudden infant death. If persists, past eruption of primary teeth can affect teeth alignment and mouth shape.

Epidemiology

• Noncompliance issues: may manifest as children develop autonomy; males have a modestly greater likelihood of being noncompliant; decreases with age
• Temper tantrums: 87% of 18- to 24-month-old children; 91% of 30- to 36-month-old children; 59% of 3.5- to 4-year-old children; in children with severe tantrums, 52% have other behavioral/emotional problems (1).
• Sleep problems
  • Night waking in 25–50% of infants 6 to 12 months; bedtime refusal in 10–30% of toddlers
  • Nightmares in 10–50% of preschoolers; peaks between ages 6 and 10 years
  • Night terrors in 1–6.5% early childhood; peaks between ages 4 and 12 years
  • Sleepwalking frequently in 3–5%; peaks between ages 4 and 8 years (2)
• Nocturnal enuresis
  • At least 20% of children in the 1st grade wet the bed occasionally; 4% wet ≥2 times per week.
  • At 10 years of age, 7% in boys, 3% in girls (3)
• Functional encopresis
  • Rare before age 3 years, most common in 5- to 10-year-olds; more common in boys (4)
• Problem eating
  • Prevalence peaks at 50% at 24 months of age; no relation to sex/ethnicity/income (5)
• Normative sexual behaviors
  • Rare in infancy, except hand to genital contact
  • Increased in 3- to 5-year-olds; less observed in >5-year-olds because more covert
• Thumb-sucking: decreases with age; most children spontaneously stop between 2 and 4 years.

Commonly Associated Conditions

• Noncompliance: If exceeds what seems normative, rule out depression, compulsive patterns, adjustment disorder, inappropriate discipline.
• Temper tantrums: difficult child temperament, stress
• Sleep problems: often with inconsistent bedtime routine or sleep schedule, stimulating bedtime environment; can be associated with hyperactive behavior, poor impulse control, and poor attention in young children (2). Acute or chronic anxiety is associated with insomnia. Long-acting stimulant medications disturb sleep quality.
• Enuresis: secondary often with medical problems, especially constipation, and frequent behavior problems, especially ADHD and autism
• Functional encopresis: enuresis, UTIs, ADHD
• Normative sexual behaviors: family stressors such as separation or divorce