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/authority figure
• Temper tantrums: loss of internal control that leads to crying, whining, breath holding, or aggressive behavior
• Sleep problems: difficulty going to sleep or staying asleep, nightmares, night terrors
• Nocturnal enuresis: bed-wetting that occurs in children >5 years of age for ≥3 months with no medical problems
  • Primary: children who have never been dry at night
  • Secondary: children previously dry at night for at least 6 months
  • Monosymptomatic enuresis: only have bed-wetting
  • Nonmonosymptomatic enuresis: bed-wetting in addition to daytime incontinence, urgency, voiding difficulties or voiding <4 or >7 times per day
• Functional encopresis: repeated involuntary fecal soiling that is not caused by organic defect or illness; can be retentive (associated with functional constipation 80%) or nonretentive (20%)
• Problem eating: “picky eating,” difficult mealtime behaviors
• Thumb-sucking: can be problematic if persists past eruption of primary teeth (Teeth alignment may be impacted.)

Epidemiology

• Noncompliance issues: manifest as children develop autonomy; slightly more common in males; decreases with age
• Temper tantrums: 5–7% of children 1 to 3 years of age have tantrums lasting at least 15 minutes ≥3 times per week; 20% of 2-year-olds, 18% of 3-year-olds, and 10% of 4-year-olds have at least one tantrum every day (1).
• Sleep problems
  • Night waking in 25–50% of infants 6 to 12 months old
  • Bedtime refusal in 10–30% 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 frequently in 3–5%; peak age: 4 to 8 years (2)
• Nocturnal enuresis: Common, 5–10% of 7-year-olds and 3% of teenagers wet the bed (3).
  • Monosymptomatic nocturnal enuresis is twice as common among boys than girls.
  • Resolves spontaneously at a rate of approximately 15% per year
• Functional encopresis: rare before age 3 years, affects approximately 1–4% of 4-year-olds and 1–2% of children aged ≥7 years; more common in boys (3)
• Problem eating: Prevalence peaks at 50% at 24 months of age; no relation to sex/ethnicity/income (4)
• Thumb-sucking: decreases with age; most children spontaneously stop between 2 and 4 years of age (4).

Etiology and Pathophysiology

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

Commonly Associated Conditions

• Noncompliance: If excessive or aggressive, rule out depression, compulsive patterns, adjustment disorder, and inappropriate discipline.
• Temper tantrums: difficult child temperament, stress, normal development
• Sleep problems: inconsistent bedtime routine/sleep schedule, stimulating bedtime environment; can be associated with hyperactive behavior, poor impulse control, and 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 such as autism spectrum disorder and ADHD
• Functional encopresis: enuresis, ADHD, emotional stressors