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Behavioral Problems, Pediatric

Basics

  • Behavioral problems disrupt psychosocial functioning, including:
  • Noncompliance (active/passive refusal)
  • Temper tantrums (crying, aggression, breath holding)
  • Sleep problems (difficulty falling/staying asleep, nightmares, night terrors)
  • Nocturnal enuresis (bedwetting >5 years old, ≥3 months)
    • Primary: never dry at night
    • Secondary: dry >6 months previously
    • Monosymptomatic vs. nonmonosymptomatic (with daytime symptoms)
  • Functional encopresis (fecal soiling without organic cause)
  • Problem eating ("picky eating")
  • Thumb-sucking (concern if persists after eruption of primary teeth)

Epidemiology

  • Noncompliance more common in males; decreases with age
  • Temper tantrums common in toddlers; 20% of 2-year-olds have daily tantrums
  • Sleep problems prevalent in infants/toddlers; nightmares peak age 6-10
  • Nocturnal enuresis common: 5-10% of 7-year-olds; boys twice as affected
  • Functional encopresis affects 1-4% of 4-year-olds; more common in boys
  • Problem eating peaks at 24 months; no sex or ethnicity predilection
  • Thumb-sucking usually resolves spontaneously by 2-4 years

Etiology and Pathophysiology

  • Genetics: Nocturnal enuresis has familial risk (45% if one parent, 75% if both)
  • Behavioral problems can be linked to temperament, stress, or underlying conditions (ADHD, anxiety)

Commonly Associated Conditions

  • Noncompliance: depression, OCD, adjustment disorder
  • Temper tantrums: difficult temperament, stress
  • Sleep problems: anxiety, hyperactivity, stimulant medication effects
  • Enuresis: constipation, obstructive sleep apnea, neurodevelopmental disorders
  • Encopresis: ADHD, emotional stressors

Diagnosis

History

  • Noncompliance: duration ≥6 months, impact on structured activities, relationships, academics
  • Temper tantrums: typical behaviors, frequency, triggers (hunger, fatigue)
  • Sleep: bedtime routine, awakenings, daytime sleepiness (BEARS screen)
  • Enuresis: onset, prior dryness, daytime symptoms, family history, voiding diary
  • Encopresis: stooling patterns, pain, trauma history
  • Problem eating: diet review, growth curves
  • Thumb-sucking: duration, impact on dentition

Physical Exam

  • Enuresis: growth, tonsils, constipation signs, spinal dysraphism features
  • Encopresis: abdominal and rectal exam, spine exam for dimples or hair tufts

Differential Diagnosis

  • Temper tantrums: autism, language deficits, DMDD
  • Enuresis: UTI, bladder dysfunction, diabetes insipidus, OSA, spinal defects
  • Encopresis: Hirschsprung disease, neurologic disorders

Diagnostic Tests & Interpretation

  • Enuresis: urinalysis for infection and glucose
  • Encopresis: TSH, celiac screening if poor growth, urinalysis, culture
  • Imaging for spinal anomalies or Hirschsprung disease as indicated
  • Sleep studies if apnea suspected

Treatment

General Measures

  • Educate caregivers about behavioral problem specifics
  • Parent management training programs effective for many issues
  • Temper tantrums: normal development; manage triggers, time-outs, firm consistent responses
  • Sleep: consistent bedtime routine; graduated extinction or fading methods
  • Enuresis: positive reinforcement, enuresis alarms, treat constipation in nonmonosymptomatic
  • Encopresis: disimpaction, maintenance laxatives, behavior modification (toileting routine, rewards)
  • Problem eating: avoid punishment; offer healthy variety; limit milk and juice intake
  • Thumb-sucking: praise cessation, alternatives, negative reinforcement if needed

Medication

  • Sleep disorders: CBT and sleep hygiene first-line; melatonin trial after behavioral methods
  • Enuresis:
  • First line: Desmopressin (0.2-0.4 mg before bedtime)
  • Second line: tricyclic antidepressants (imipramine)
  • Third line: anticholinergics (oxybutynin)
  • Encopresis: laxatives, enemas as needed

Issues for Referral

  • Severe tantrums beyond age 5, self-injury, aggression → psychologist/psychiatrist
  • Chronic insomnia or anxiety → mental health referral
  • Enuresis with OSA symptoms → sleep study and possible surgical referral
  • Sexual behavior concerns or suspected abuse → child protective services and psychology
  • Encopresis refractory to medical treatment → gastroenterology or surgery
  • Thumb-sucking resistant to behavior therapy → pediatric dentist

Ongoing Care

  • Nutrition: balanced diet, avoid excess sugar and caffeine to reduce behavioral issues
  • Monitor behavioral progress, family dynamics, and adjust interventions

Patient Education

  • Parent training programs available (CDC resource)
  • Encourage consistent routines, positive reinforcement, and supportive environments

Clinical Pearls

  • Well-child visits are opportunities for screening behavioral problems
  • Extreme disobedience may warrant screening for ADHD, OCD, ODD, or conduct disorder
  • Temper tantrums are common in toddlers; typically at least one daily episode