Common Behavioural Problems in Children

These can be usefully classified into psychosocial disorders, habit disorders, anxiety disorders, disruptive behaviour and sleeping problems.

Psychosocial disorders

These may manifest as disturbance in:

• Emotions e.g. anxiety or depression
• Behaviour e.g. aggression
• Physical function e.g. psychogenic disorders
• Mental performance e.g. problems at school

This range of disorders may be caused by a number of factors such as parenting style which is inconsistent or contradictory, family or marital problems, child abuse or neglect, overindulgence, injury or chronic illness, separation or bereavement.¹

The child's problems are often multi-factorial and the way in which they are expressed may be influenced by a range of factors including developmental stage, temperament , coping and adaptive abilities of family, the nature and the duration of stress. In general, chronic stressors are more difficult to deal with than isolated stressful events.

Children do not always display their reactions to events immediately although they may emerge later. Anticipatory guidance can be helpful to parents and children in that parents can attempt to prepare children, in advance, of any potentially traumatic events e.g. elective surgery or separation. Children should be allowed to express their true fears and anxieties about impending events.

Young children will tend to react to stressful situations with impaired physiological functions such as feeding and sleeping disturbances. Older children may exhibit relationship disturbances with friends and family, poor school performance, behavioural regression to an earlier developmental stage, development of specific psychological disorders such as phobia or psychosomatic illness.

It can be difficult to assess whether the behaviour of such children is normal or sufficiently problematical to require intervention. Judgement will need to take into account the frequency, range and intensity of symptoms and the extent to which they cause impairment.

Habit disorders These include a range of phenomena that may be described as tension reducing.

Tension reducing habit disorders
Thumb sucking	Repetitive vocalisations	Tics
Nail biting	Hair pulling	Breath holding
Air swallowing	Head banging	Manipulating parts of the body
Body rocking	Hitting or biting themselves

All children will at some developmental stage display repetitive behaviours but whether they may be considered as disorders depends on their frequency and persistence and the effect they have on physical, emotional and social functioning. These habit behaviours may arise originally from intentional movements which become repeated and then become incorporated into the child's customary behaviour. Some habits arise in imitation of adult behaviour. Other habits such as hair pulling or head banging develop as a means of providing a form of sensory input and comfort when the child is alone.

• Thumb sucking - this is quite normal in early infancy. If it continues it may interfere with the alignment of developing teeth. It is a comfort behaviour and parents should try to ignore it while providing encouragement and reassurance about other aspects of the child's activities.
• Tics - these are repetitive movements of muscle groups that reduce tension arising from physical and emotional states, involving the head, the neck and hands most frequently. It is difficult for the child with a tic to inhibit it for more than a short period. Parental pressure may exacerbate it while ignoring the tic can reduce it. Tics can be differentiated from dystonias and dyskinetic movements by their absence during sleep.
• Stuttering - this is not a tension reducing habit. It arises in 5% of children as they learn to speak. About 20% of these retain the stuttering into adulthood. It is more prevalent in boys than girls. Initially it is better to ignore the problem since most cases will resolve spontaneously. If the dysfluent speech persists and is causing concern refer to a speech therapist.

Anxiety disordersAnxiety and fearfulness are part of normal development, however, when they persist and become generalised they can develop into socially disabling conditions and require intervention. Approximately 6-7% of children may develop anxiety disorders and of these 1/3 may be over-anxious while 1/3 may have some phobia. Generalised anxiety disorder, childhood onset social phobia, separation anxiety disorder, obsessive compulsive disorder and phobia are demonstrated by a diffuse or specific anxiety predictably caused by certain situations.

School phobia occurs in 1-2% of children of which an estimated 75% may be suffering some degree of depression and anxiety. Management is by treating underlying psychiatric condition, family therapy, parental training and liaison with school to investigate possible reasons for refusal and negotiate re-entry.

Disruptive behaviour 

 Many behaviours, which are probably undesirable but a normal occurrence at an early stage of development, can be considered pathological when they present at a later age. In the young child many behaviours such as breath-holding or temper tantrums are probably the result of anger and frustration at their inability to control their own environment. For some of these situations it is wise for parents to avoid a punitive response and if possible to remove themselves from the room. It is quite likely that the child will be frightened by the intensity of their own behaviour and will need comfort and reassurance. While some isolated incidents of stealing or lying are normal occurrences of early development they may warrant intervention if they persist. Truancy, arson, antisocial behaviour and aggression should not be considered as normal developmental features.

Attention deficit hyperactivity disorder This is characterised by poor ability to attend to tasks, (e.g. makes careless mistakes, avoids sustained mental effort) motor overactivity (e.g. fidgets, has difficulty playing quietly) and impulsiveness (e.g. blurts out answer, interrupts others). For the diagnosis to be made, the condition must be evident before age 7 years, present for >6 months, seen both at home and school and impeding the child's functioning. The condition is diagnosed in 3-7% of school-age children.

Methylphenidate (initiated by specialists only) is a stimulant medication that provides reduction of symptoms, at least in the short term. Management usually includes family therapy (a programme of behavioural modification for the child and the parents), although further research confirming its benefits is needed.  Essential fatty acids may alleviate some symptoms.

Sleeping problemsSleep disorders can be defined as too much or too little sleep than is appropriate for the age of the child. By the age of 1-3 months the longest daily sleep should be between midnight and morning. Sleeping through the night is a developmental milestone but at the age of 1 year 30% of children may still be waking in the night. Stable sleep patterns may not be present until age 5 years but parental or environmental factors can encourage the development of circadian rhythm.

Sleep disturbance can have a deleterious affect on the cognitive development of children, as well as the functioning of the parents. One study of 2-3 year olds found a significant link between sleep disturbance and emotional and behavioural disorders. Other links include memory loss and obesity.

Regular bedtimes, quieter activities and the creation of marked differences between the sounds, activities and light levels associated with night time sleeping and daytime activities may help to encourage better sleep patterns. A solid evidence base now supports the use of behavioural treatments in infants and pre-school children (under 5). All of these are based on the objective of the parents gaining control of the bedtime routine. They include unmodified extinction (ignoring the child's cries but monitoring for illness or injury), modified extinction (ignoring the child for a specified period of time) and positive routines (doing some quiet pre-sleep activity and ensuring that falling asleep is associated with a positive parental-child interaction)One study found that parental interventions that encourage independence and self-soothing were associated with extended and more consolidated sleep compared to more active interactions that were associated with shorter and more fragmented sleep.

Hypnotherapy has been found to be of benefit in school-age children.

The BNF for Children states that the use of hypnotics, except for occasional short-term treatment of night terrors and sleep-walking, is never justified. However, it is recognised that the treatment of paediatric insomnia is an area that needs further research.

Melatonin is sometimes of benefit in sleep disorder associated with visual impairment, cerebral palsy, attention deficit hyperactivity disorder and autism. It is unlicensed for this indication and specialist supervision is recommended for initiation and monitoring.