COMMON BEHAVIORAL PROBLEMS IN CHILDREN
Dr. Sharmila B. Mukherjee*
Assistant Professor of Pediatrics, Lady Harding Medical College, New Delhi. Email: theshormi@yahoo.co.in *
In the process of growing up, most children will have emotional and behavioral problems that are transient in nature and are due to the stresses of development and adaptation to family and social expectations. It has been seen in epidemiological studies that annually around 20% children suffer from emotional and behavioral problems that are severe enough to interfere with day to day functioning. The goals of a pediatrician are not only to assist this group of children who have major mental problems but also to help the other 80% of children and their parents manage the stresses of normal growth and development. The pediatrician is usually the first professional to whom parents turn for advice. They can be managed at their level or referred for further evaluation. One of them should have the basic knowledge and awareness to be able to identify a problem and decide whether the most critical duty is convincing the parent that there is a problem and additional assistance is needed. If a pediatrician can reassure the parents and explain the basic components of behavioral assessment and management, this may effectively reduce the stigma associated with mental health services. The role of pediatrician in detecting and managing cases with less severe or less complex psychiatric disorders has increasingly come into focus. They are often trusted by families and are therefore in a position to provide them with information, support and advice. They may thus also be in a good position to implement preventive interventions.

It has been seen in epidemiological studies that annually around 20% children suffer from emotional and behavioral problems that are severe enough to interfere with day to day functioning.

Various theories have attempted to address the changes which occur during development. These include development as maturation, learning, resolution of conflict, cognitive change and cultural adaptation. The failure of any one theory to explain the complexity of development across ages and areas has led to general acceptance of a transactional and/or ecological perspective of development, which attempts to account for factors within the child, family and society that influence the child either directly or indirectly. Thus developmental change (both positive and negative) is the result of the transactional dialogue among each child with his or her unique biological/genetic makeup, the physical and social environment and the cultural milieu into which he or she is born.
Etiopathogenesis
Children are immature and developing individuals whose capacities and coping skills change markedly during childhood. Symptoms arise in times of stress (birth of sibling, starting school, marital breakup, life-threatening illness) when the demands on the child are excessive. The child may cope successfully with the stress, thereby enhancing self esteem and confidence. Alternatively the child may be overwhelmed, responding with the development of symptomatic behavior.

Symptoms arise in times of stress (birth of sibling, starting school, marital breakup, life threatening illness) when the demands on the child are excessive.


It is important to identify the function of the behavior or the reason why it occurs. These may be: 1) To gain attention 2) To avoid/escape an undesirable task/demand or unpleasant experience 3) To receive something tangible (object), or 4) For internal satisfaction (covert stimulation)

Behavior problems may be externalizing (non-compliance, aggression, inattention, hyperactivity) or internalizing (depression, anxiety). The behavioral repertoire through which the behavior may be expressed are:

i. Internal, cognitive, or verbal (e.g. learning difficulties, reading problems, intrusive thoughts)
ii. Overt, motor related problems (hyperactivity, tantrums, tics)
iii. Physiological/emotional in nature (e.g., anxiety, depression). The problem may be behavioral excesses or inappropriate behavior that is occurring too often (temper tantrums, hyperactivity, self injury) or it may be behavioral deficit or appropriate behavior that is occurring too infrequently (eye contact, self-control, academic skills).

Behavior problems may be externalizing (non-compliance, aggression, inattention, hyperactivity) or internalizing (depression, anxiety).
There are two aspects of behavior which needs to be considered and evaluated:
  1. Developmental aspect: is the behavior age appropriate?
  2. Psychopathological: is the behavior abnormal Knowledge of the developmental norms is clearly essential for the pediatrician to recognize which behaviors are excessive or deficient for children at a given developmental stage. The developmental tasks of children change with age and each stage of development presents unique challenges to children and parents.

Knowledge of the developmental norms is clearly essential for the pediatrician to recognize which behaviors are excessive or deficient for children at a given developmental stage.
Infant Development (birth to 1 year)
During this period the quality of primary caregiver - infant attachment and the child's temperamental characteristics can potentially influence the child's future functioning. Temperament is the behavioral style of a child's interaction with the environment. A cluster of traits have been used to categorize the child into three functional temperamental groups (Table 1). Different combinations of temperamental traits may be manifest by individual children. However, not all difficult children develop behavioral problems and some easy children may exhibit maladaptive behavior. This has been accounted for by a concept termed as 'the goodness of fit'. This results when the properties of the environment and its expectations and demands are in accord with the organisms own capacities, motivations and styles of behavior. Poorness of fit involves discrepancies between environmental opportunities and demands and the capacities and characteristics of the organism so that distorted development and maladaptive functioning occur. Difficult infants with highly stressed, unresponsive caregivers are considered at higher risk for behavior problems than difficult infants with calm, responsive and sensitive caregivers. Similarly, easy infants born into dysfunctional, highly stressed families may develop problems later.
Toddler development (1-2 years)
The hallmark of this period is the child's striving for autonomy and independence at the same time that he or she wants to be close to the primary attachment figure. A certain amount of defiance and non-compliance is normally expected during this period. For the first time, behavior management becomes an important issue for parents. Inappropriate parental responses to this can exacerbate the problem. It is important to determine whether the defiance represents self-assertion necessary to achieve independence or a reflection of anger and disturbance. Parents often misinterpret this as a threat to their authority resulting in excessive punishment; conversely they may have problems setting appropriate limits for fear of stifling their children's initiative.

It is important to determine whether the defiance represents self-assertion necessary to achieve independence or a reflection of anger and disturbance.
Pre-school development (2-4 years)
This period is very important as the foundation for the further development of many areas is laid down during this time. Two important developmental aspects is the development of language and of self-regulation. Emotional regulation is the process of initiating, maintaining and modulating the occurrence, intensity or duration of internal feeling states and emotional related physiological processes. Behavioral regulation refers to the ability to control emotionally driven behavior. Children face many challenges in learning to regulate their emotions and behaviors. The inability to regulate one's emotions is associated with behavior problems.
School - Age development (5-12 years)
The developmental tasks for school age children involve the consolidation and refinement of skills necessary to meet the expectations of society. Socially and emotionally they confront the challenges of dealing with increased numbers of adults and children in both structured and unstructured settings. The hallmarks of development are increased cognitive skills, a more consistent and internalized sense of self with the development of self concept (one's view of oneself) and self-esteem (one's self evaluation), and the development of social relationships outside the home.
Classification
The pre-existing systems of classification of mental disorders are the International Classification of Disease (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) of the American Psychiatric Association (DSM-IV) classifications. However these fail to address those problems which are less serious, but nevertheless commonly prevalent behavioral problems. In 1996, the AAP and partner organizations published the Diagnostic and Statistical Manual for Primary Care, Child and Adolescent Version. This gives guidelines for psychological behaviors that are within the range expected for the age of the child, problems that may disrupt functioning but are not sufficiently severe to warrant the diagnosis of a mental disorder, and disorders that do meet the criteria outlined in the DSM-IV. According to this system, behavior problems have been divided into the following categories.
  1. Developmental variations: These are concerns which are normal and expected during the course of development of a child, but causes concern and distress to their parents. Reassurance and appropriate, individualized counseling regarding management strategies empower the parents to be able to tackle these problems. This includes (i) Negative Emotional Behavior Variation (ii) Aggressive/Oppositional behavior variation.
  2. Problems: These behaviors disrupt one or more areas of psychosocial functioning (academic, social, emotional or family), but are not serious enough to warrant an official DSM IV or ICD diagnosis. These problems require early identification, and may require management and referral to mental health care professionals. These also include a more severe variety of (i) Negative Emotional Behavior Problem, (ii) Aggressive/Oppositional Problem.
  3. Disorders: These problems are severe enough in intensity and frequency to warrant an official DSM IV diagnosis. These disorders require multi-disciplinary interventions of the mental health personnel and psychologist for appropriate management. These include: (i) Conduct Disorder (childhood onset) and Conduct Disorder (adolescent onset)/Adjustment disorder with disturbance of conduct/Disruptive Behavior Disorder, not otherwise specified. The behaviors harm others and break societal rules including stealing, fighting, destroying property, lying, truancy, and running away from home. (ii) Oppositional Defiant Disorder refers to hostile, defiant behavior towards others of at least 6 months duration that is developmentally inappropriate.


Oppositional Defiant Disorder refers to hostile, defiant behavior towards others of at least 6 months duration that is developmentally inappropriate.
Assessment
Children suspected of having emotional-behavior disorders are referred for screening only after teachers are referred for screening only after teachers become concerned about these children's notable misbehaviors. Behavior assessments guide behavioral interventions, which are designed to modify variables that trigger, maintain or mediate problem behaviors. The underlying core assumption is that the maintaining conditions of the behavior exist in the current environment. The variables that are targeted in a behavioral assessment are guided by the assumption that antecedent and consequent factors are important sources of variance in behavior and behavior problems. The various techniques which are available are interviews, objective questionnaires, self-report inventories/rating scales and direct observation. Some of the widely-used screening tests are:
  1. Behar & Stringfield's Behaviour Rating Scale
  2. Pre-School Behavior Checklist
  3. Pediatric Symptom Checklist
  4. Achenbach Child Behavior Checklist
  5. Systematic Screening for Behavioral Disorders
  6. Behavior Rating Profile 2nd Edition

A functional assessment of the problem behavior attempts to (i) clearly define the target problem (ii) identify the events, times and situations that maintain the problem behavior (iii) identify the consequences that maintain the problem behavior (iv) develop hypotheses that describe the relationship between the predictors, behaviors, and consequences (v) collect direct observation data to support these hypotheses
Management
The focus must be on promoting positive behavior and preventing challenging behaviors.

Some of the common principles used in management are as follows:
  1. Positive reinforcement refers to the presentation of a stimulus immediately following the target behavior which results in an increase in the future likelihood of the behavior. This may be pleasant for acceptable behavior (i.e., praise for completion of a task) or a reprimand may also be a positive reinforcer, since it gets the parents attention.
  2. Negative reinforcement refers to the removal of an aversive stimulus immediately following the behavior which results in an increase in the future likelihood of the behavior. This can be in the form of 'escape' - termination of a negative stimulus depending on the child's response (i.e., removal of a demand, when the child throws a temper tantrum) or 'avoidance' - postponement or prevention of a negative stimulus depending on the child's response (i.e., not sending the child to school to give a test, when the child feigns a stomach ache). Contrary to popular belief, negative reinforcement does not refer to procedures that decrease behavior and is not equated with punishment.

    Contrary to popular belief, negative reinforcement does not refer to procedures that decrease behavior and is not equated with punishment.
  3. Punishment by contingent stimulation refers to the presentation of an aversive stimulus (spanking, criticism) immediately following the target behavior, that results in a decrease in the future likelihood of the behavior.
  4. Punishment by contingent withdrawal refers to the termination of a stimulus or condition (turning off the television when children are fighting over the control) immediately following the target behavior, that results in a decrease in the future likelihood of the behavior.

Punishment by contingent withdrawal refers to the termination of a stimulus or condition (turning off the television when children are fighting over the control) immediately following the target behavior, that results in a decrease in the future likelihood of the behavior.

Behavior management approaches comprise of behavior modification techniques, skill building (problem solving skills, social skills, and anger coping skills), cognitive-behavioral therapy, specific behavior management programs and parent training. Reinforcement behavior techniques may be intended to increase the frequency of appropriate behavior; these are based on positive reinforcement. To maximize effectiveness the appropriate reinforcers should be reinforced frequently, consistently and immediately. These include: (1) Social reinforcers, which consist of attention, labeled praise (the praise should be specific for the act), approval and acknowledgement of others, (2) Tangible reinforcement consists of tangible or material objects that have personal value to the child (stickers, candies, toys) or social rewards (reading with mom or dad, playing a game with either parent, etc. (3) Token economy is a reinforcement system in which children can earn tokens (stickers, points, stars) for specific target behaviors which can be exchanged for secondary reinforcers and activities.
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