Behavioral Problems, Pediatric

BASICS

Behavior that disrupts ≥1 area of psychosocial functioning; common problems:

Noncompliance: active or passive refusal to do as requested by parent/authority figure
Temper tantrums: loss of internal control that causes crying, whining, breath holding, or aggressive behavior
Sleep problems: difficulty going to sleep or staying asleep, nightmares, night terrors
Nocturnal enuresis: bed-wetting in children >5 years of age for ≥3 months with no medical problems
- Primary: never dry for a minimum of 6 months (1)
- Secondary: return of enuresis dry period of ≥6 months (1)
- Monosymptomatic enuresis: bed-wetting only
- Nonmonosymptomatic enuresis: bed-wetting plus daytime incontinence, urgency, voiding difficulties or voiding <4 or >7 times per day
Functional encopresis: repeated involuntary fecal soiling; can be retentive (associated with functional constipation 80%) or nonretentive (20%)
Problem eating: “picky eating,” difficult mealtime behaviors
Thumb-sucking: problematic if it persists after primary teeth eruption

Noncompliance: more common in males; decreases with age
Temper tantrums (2):
- ≥12 months, up to 2 to 3 years old
- 20% of 2-year-olds; 18% of 3-year-olds; 10% of 4-year-olds
Sleep problems:
- 10–30% of children, varies by age group
- Bedtime resistance in 10–15% of toddlers
- Nightmares in 10–50% of preschoolers; peak age 6 to 10 years
- Night terrors in 1–6.5% early childhood; peak age 4 to 12 years
- Sleepwalking in 3–5%; peak age 4 to 8 years (3)
- Nocturnal enuresis: 5–10% of 7-year-olds, 3% of teenagers wet the bed (4)
  - Monosymptomatic nocturnal enuresis is twice as common among boys than girls.
  - Resolves spontaneously at a rate of approximately 15% per year.
Functional encopresis: rare in children aged <3 years, approximately 1–4% of 4-year-olds and 1–2% of children aged ≥7 years; more common in boys (4)
Problem eating: Prevalence peaks at 50% at 24 months; no relation to gender/ethnicity/income (5)
Thumb-sucking: decreases with age; most children spontaneously stop between 2 and 4 years of age (5).

Sleep problems in 25–50% of children aged ≥6 months; 20% in preschool/early school-ages; 20–40% in middle childhood, with girls > boys (6)
Adolescents 16 to 18 years old, 12% seen in males compared to 23% in females
Higher prevalence seen with ADHD, autism, and neurodevelopmental disorders (6).

Nocturnal enuresis: 45% risk if one parent has history, 75% if both parents have history after 5 years of age

Adverse childhood experiences (ACEs) associated with behavioral problems in middle childhood (6)

Noncompliance: Rule out depression, compulsive behaviors, adjustment disorder, and inappropriate discipline.
Temper tantrums: stress, normal development
Sleep problems: inconsistent bedtime routine/schedule, stimulating bedtime environment; associated with hyperactive behavior, poor impulse control, poor attention in young children; acute or chronic anxiety is associated with insomnia. Long-acting stimulant medications may disturb sleep quality.
Enuresis: associated with constipation, obstructive sleep apnea (OSA), neurodevelopmental conditions (autism spectrum disorder, ADHD)
Functional encopresis: enuresis, ADHD, emotional stressors

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