Common behavioral issues Flashcards
§ Most teens have ____ -hr sleep phase delay due to changes in hormonal regulation of the circadian system
~1-3
T/F Sleeping is not inborn; a behavior
that develops over time
T
Two physiologic states of sleep
- Non-rapid eye movement (NREM) sleep
- Rapid eye movement (REM) sleep
Rapid eye movement (REM) sleep
■ Brain activity ↑
■ Physiological activity ↑
■ Similar to wakefulness
Non-rapid eye movement
(NREM) sleep
■ Sleep stages 1 – 4
■ Most physiologic functions
are markedly REDUCED
compared with wakefulness
■ Pulse ↓
■ Respirations ↓
■ Blood pressure ↓
■ NO penile erection
■ Relatively peaceful state
Nightmares/terrors in NREM sleep:
■ Stages 3 & 4
■ Disoriented & disorganized thinking & brief
arousals during these stages associated with
amnesia*
■ Enuresis
■ Somnambulism (sleepwalking)
■ Stage 4 night terrors
Newborns sleep ____ hrs/day
10-19
§ 2–5-hour blocks
Nightmares/terros in REM sleep
■ Pulse ↑
■ Respiration ↑
■ Blood Pressure ↑
■ > NREM sleep & often higher than during waking
■ Men → partial or full penile erection
■ Near-total paralysis of skeletal muscles
■ Most distinctive feature is dreaming
■ abstract & surreal
Nightmares features (Peak ~3-5 yo)
OCCUR DURING REM SLEEP
§ Self limited, no tx needed
■ Usually associated with:
■ Stress
■ Trauma
■ Anxiety
■ Sleep deprivation causes
rebound REM sleep
Guidance to give child who is having nightmares
§ Reassure child, discuss the
bad dream (next day)
§ Leave bedroom door open
§ Nightlight
§ Avoid stimuli
§ ie scary shows
§ Others?
§ “Monster Spray” J
Night Terrors (~3-6yo)
OCCUR DURING NREM SLEEP
§ Glazed look in eyes, incoherent, &
unresponsive to comforting
§ Child will exhibit rapid breathing,
tachycardia, & sweating
§ Occur ~2 hours after sleep onset
§ Last up to 30 min
§ Parents should let it run its course
§ Child amnestic to the event
Guidance parents can give child with night terros
§ If wake ups are predictable
§ Wake child 15 min prior
to the anticipated
arousal
§ Allow child to go back
to sleep 5 min later
§ D/C intervention once
the terrors stop
How to avoid a situation where a child refuses to go to sleep unless rocked/fed
■ this is a Learned behavior
■ 1st weeks of life the
result of the parents behavior
§ Put the child to bed
while drowsy, but still
awake
§ Create a quiet, secure
bedtime environment
§ Be Consistent
Proper parental response to child awakening during the night
Do not reinforce the behavior
§ Comfort quietly
§ Minimal stimulus
§ Establish normal bedtime routines (Be consistent)
“Cry it out”
§ Progressively responding
later to cries, until child
tires or learns self soothing
Early solids (before 5 months) = ___ night waking, ____ sleeping
↓; ↑
Toilet Training prerequisites
- CHILDREN MUST BE READY
(avg. age 22 – 30 mo) - Physiologic sphincter control
- (~18-24 months old)
Nighttime bladder control is NOT expected until ___ yo
5-7
T/F Early initiation of toilet training (<27 mo) correlates with a shorter training
F - it is longer the earlier you start
3 factors associated with toilet training completion at a later age
- Initiation of training at an older age
- Presence of stool toileting refusal
- Presence of frequent constipation
Developmental readiness signs for toilet training
ü Ambulates to the toilet
ü Stable, sitting on the toilet
ü Remains dry for 2-3 hr
ü Able to pull clothes ↑ & ↓
ü Follows 2-step commands
ü Able to communicate the
need to use the toilet
Behavioral readiness signs for toilet training
ü Imitates behaviors
ü Able to put things away
ü Interested in toilet training
ü Desires to please
ü Independent & controlling
ü Able to resist & say “No,”
BUT ↓ oppositional
behaviors & power struggles
Guidance for beginning toilet training
- Place the “potty” in the child’s bathroom
- Encourage child to sit on the potty for 2-3 min/day
* Initially clothed & after ~1 week without - Child goes with parent to empty soiled diapers into the little potty…
… & then to the big potty
Encopresis & Enuresis
These are diagnoses
* Does not achieve urine & bowel continence by 5–6 years of age
* No underlying pathology for the incontinence
* Child does not respond to a full bladder or rectum
* Child is constipated &/or is withholding stools
T/F Constipation & enuresis often co-occur
T
Enuresis guidelines
- Education & avoid judging/shaming the child
- Behavioral strategies (Be consistent)
- Limit liquids before sleep & wake the child at night to void
- Bedwetting alarms
- Child should rise & void very time the alarm goes off
- Cures 2/3 of children
- Failure?
- Turning off the alarm & go back to sleep
Medical Management of enuresis
- Desmopressin acetate (DDAVP)
- Imipramine (Tofranil®)
- Imipramine should be used only as a last resort
Primary vs. Secondary encorpresis
Primary: Stool continence has never been achieved
Secondary: Stool incontinence occurs after a
period of successful toilet training
Encopresis guidance
Assuming no GI abnormalities…
* Start with treatment of constipation
* Behavioral strategies
* Child sits on the toilet after meals (gastrocolic reflex)
* Read a book
* Establish a bowel regimen;
* Avoid punishing or inducing guilt or shame
* Helping the child to cleanup > criticism & reproach
Encopresis medical management
- Oral medication or enema for a
“bowel cleanse” - Consider abdominal Xray
- Oral medications
- Fiber, laxatives, or
mineral oil - Never to use mineral oil in any
child who is at risk of aspiration,
can cause chemical pneumonitis
Stranger/Separation Anxiety
Usually appears at about 6-9
months & can last until 24
months of age
Discipline vs. Punishment
Discipline = (Latin) discipulus → instruction, knowledge
Punishment = (French) punir → inflict penalty, take vengeance
Guidance for Aggression/ Frustration
(~3 years)
“Time Out” (~1 min/year of age)
■ Calm, few words, NOT a monologue
■ NOT punishment
■ Time to cool down
■ Non-stimulating location
■ No eye contact or interaction
Guidance for Temper Tantrums (12 mo to 4 yrs)
§ Do not to become angry
§ Help child communicate
§ Present options within the
child’s capabilities
§ Positively reinforce when child
is gaining control
§ If a child’s demand led to the
tantrum, do not grant demand
Breath-Holding Spells (6mo – 6yo)
■ Reflexive, NOT voluntary,
usually occurs in response to
anger or injury
■ Child holds breath*
■ Becomes pale or cyanotic
■ Usually resolves
spontaneously
■ May lose consciousness
■ Severe cases; tetanic spasms,
body jerks, urinary incontinence
Guidance for Breath-Holding Spells
(6mo – 6yo)
§ Terrifying for the parents
§ Not harmful & will not cause brain damage
§ Do NOT to become permissive
§ Treat with iron supplementation?
Guidance for whining
■ Establish regular routines
■ Easier to meet expectations
■ Explain to the child Whining ≠ Attention
■ Respond positively when
tone of voice improves
Guidance for Need for Attention
§ Younger children
§ Brief attention immediately (use echoing)
§ Younger & older children
§ Special time (Time reserved solely for than child)
Guidance for Head-Banging
■ Harmless unless severe
■ Usually seen in children with
intellectual disabilities
■ Most children stop by age 3
■ Can occur with sensory
deprivation (neglect)
■ Increase rhythmic activities,
reduce stress
Guidance for Thumb-sucking
■ Intervene by 36 months
■ Child must be motivated before s/he will consider stopping
■ Thumb guard at night for habitual sucking
■ Topical products may aid
■ Praise child when not sucking
thumb
Guidance for refusing food
■ Gorging or refusing food
■ Put out a tray with a variety of nutritious foods for the child to have access to for the entire day & then bring the child to regular meal-times
■ If not hungry, they can be excused from the table
■ Disruptive behavior at table?
■ Remove food & excuse from the table & then allow to eat later
■ Do not become involved in a power struggle
