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BEHAVIORAL PEDIATRICS AND PEDIATRIC NURSING

INTRODUCTION:
Children are born innocent. But the social institutions such as family, school, religious
institutions and their physical conditions determine how they grow, develop and behave. The
‘emotional food’ that he receives plays a great role in his behavioral development. Many children
are born and brought up in broken families tend to develop behavioral and social problems, where
as children, who receive adequate love, affection and protection from the parents or other family
members, becomes mentally healthy, who can adjust well with the society they live. Behavioral
disorders that represent significant deviation from the normal behavior. These disorders are
relatively stable, internalized and difficult to treat than the adjustment reactions, but less so than
neurosis and psychosis. The hyperkinetic reactions, runaway reactions and group delinquency are
examples of behavioral disorders. The root of problem usually is traceable to the home and or the
school environment. They always need special attention.

CAUSES OF BEHAVIORAL DISORDERS:

The etiology of behavior disorders is multifactorial including maladjustment at home and

/ or school, and factors operating before pregnancy, during pregnancy, during delivery and in the
neonatal period. The important contributing factors are:

1. HOME/ SCHOOL:
 Overprotection
 Dominance
 Unrealistic expectation
 Over criticism
 Unhealthy comparison
 Over discipline
 Parental rejection
 Disturber parent child interaction
 Broken family( death, divorce etc.)
2. INAPPROPRIATE RELATIONSHIP AMONG FAMILY MEMBERS:
Inappropriate relationship among family members, influence on child’s behavior and may
cause behavior disorders.
3. Parental illiteracy
4. Parent’s mood and job satisfaction
5. Child rearing practices
6. Family habits
7. Maladjustment at home and school
 8. Disturbed relationship with neighbors, school teachers, schoolmates, playmates.
9. Favoritism
10. Punishment, etc, may predispose behavioral problems

ECONOMICAL AND CULTURAL INFLUENCES:

 Poor – Economic Status:

- Cultural patterns
- Superstitions
- Economic insecurity, etc. affect older children along with their parents and family
Members resulting in abnormal behavior
 Sickness and disability:
Children with sickness and disability may have behavioral problems. Chronic
illness and prolonged hospitalization can lead to this problem
- Hostility
- Frustration
 Influence on mass media
- Television
- Radio
- Computer with internet connections

PRECONCEPTION FACTORS:

 Age of the parents

 Intensity of their desire for a child
 Duration of married life
 Forceful marriage
 Illegitimate child

PRENATAL FACTORS:

 Maternal disease
 Psychological stress,
 Preterm delivery

POSTNATAL FACTORS:

 Bond between parent and child

 Parents love for the child
 Overprotective parents
 Favoritism / rejection
  Parental habits
 Disturbed family
 Attitude of significant persons, e.g. teachers, friends and siblings

ASSESSMENT METHODS:

In order to treat the child with behavioral disorders , first he/she must be assessed of what
his/her problem is. This is done by direct and indirect methods.

1. DIRECT ASSESSMENT METHODS:

Direct assessment procedures typically allow for the assessment of clinically
relevant behaviors at actual time and place of occurrence. The behavior of a child
can be assessed in different ways. The various methods as follows:

a. NATURALISTIC OBSERVATIONS:

It is a systemic monitoring of representative sample of a child’s behavior in the

environment where the behavior has been identified as being problematic.
For example, observation in the classroom, observing interactions with peers on a
playground
b. ANALOG OBSERVATIONS:
This involves the observation of a child’s behavior in settings, which are
designed to increase the chance of occurrence of a specific behavior.
For example, parent child interaction in a structured setting in which specific
interactions is given ( having a parent request the child to clean up the playroom).
c. PARTICIPANT OBSERVATION:
This involves the observation by person who is normally a part of the child’s
everyday environment such as a parent, teacher or even another child( sibling), who
observes and even records selected behaviors of a child
d. SELF OBSERVATION:
A child is requested to observe his/her own behavior and then recorded its
occurrence. This obviously requires a motivational subject who has the ability to
discriminate between the presence or absence of specific target behavior.

2. INDIRECT ASSESSMENT METHODS:

Indirect assessment procedures collect information about relevant behaviors that
are obtained at a time and place different than where the actual problematic
behaviors occur. E.g.
- Clinical interview
 - Use of rating scale
- Checklists
- Self-report instruments

COMMON BEHAVIOR PROBLEMS IN CHILDREN:

1. PROBLEMS OF EATING:
- Resistance to feeding or impaired appetite
- Abdominal colic
- Pica
- Obesity
- Anorexia nervosa
- Rumination disorder
2. SPEECH PROBLEMS:
- Stuttering and Stammering
- Cluttering
- Delayed speech
- Dyslexia
- Developmental receptive disorder
3. SLEEP DISORDER
- Night terrors
- Nightmares
- Sleepwalking ( Somnambulism)
4. HABIT PROBLEMS
- Thumb Sucking
- Nail biting
- Enuresis
- Encopresis
- Tics or habit spasm
- Breath holding spells
- Rocking and head banging
- Teeth grinding
5. SCHOLOSTIC PROBLEMS:
- School phobia
- Attention deficit hyperactivity disorder (ADHD)
6. SEXUAL PROBLEMS:
- Masturbation
7. PERSONALITY PROBLEMS
 - Shyness
- Timidity
- Fears
- Anger
- Jealousy
8. ANTISOCIAL PROBLEMS:
- Juvenile delinquency
- Substance abuse
9. ADJUSTMENT PROBLEMS:
- Temper tantrum

FACTORS CONTRIBUTINY TO THE DEVELOPMENT OF BEHAVIORAL

DISORDERS ARE:

 Mental and physical illness:

SIX PRINCIPLES OF BEHAVIOR MANAGEMENT

1: Negative consequences sometimes change behavior, but they do not change attitude.

In children who consider consequence structures, negative consequences such as

time out, sentence writing, restriction of privileges, verbal correction, and physical
punishment, as well as others, will effect at least temporary behavior change. Unless used
in combination with equally powerful positive reinforcement strategies, they will, however,
worsen the negative attitudes that underlie the misbehavior and increase the likelihood of
subsequent misbehavior.

2: Only positive reinforcement strategies produce long-term attitudinal change.

As children grow older and into adulthood, positive behavior is not maintained
through the threat of negative consequences; it is maintained because the individual has an
internal attitude or value system, which discriminates between right and wrong behaviors.
In the long term, children behave properly because they want to, not because they are forced
to.

3: Negative consequences do not improve the behavior of impulsive children and frequently
increase the frequency and intensity of misbehavior.
 Impulsive children, by definition, do not consider the consequence structure prior to
initiation of the behavior. No matter how negative the consequence, it cannot influence
behavior unless it is considered prior to the behavior itself. In impulsive children, the
consideration of the consequences comes after the behavior, meaning that it has been outside
conscious cognitive control. When punished for behaviors that are outside their control, they
learn helplessness and respond emotionally with anger, resignation, and eventually
depression.

4: Cognitive control of behavior can be learned through the use of appropriate positive
reinforcement systems.

Even very impulsive and behaviorally difficult children can learn greater behavioral
control through cognitive strategies. Time out works very well if used for brief periods for
the purpose of establishing emotional control and behavioral calm, and if the time-out period
is followed by cognitive discussion of the reasons for misbehavior with appropriate positive
alternatives. Where possible, the alternative positive behaviors should be practiced and
positively reinforced, even if the behavior occurs only with the direct instigation of an adult.
Cognitive cueing strategies, which rely on nonverbal cues for self-control, are the most
effective long term strategy for controlling impulsive behavior, but their effective use
requires much consistency and patience on the part of the adults involved in the behavior
management system.

5: Positive reinforcement systems must be incremental in nature such that the child can directly
observe even small improvements in behavior.

Many children with significant behavioral problems are very discouraged regarding
the possibility that they can effect positive changes in their lives. Positive reinforcement
systems which have expectations set too high, such that it is difficult for the child to earn
rewards at the outset are a cause of further discouragement and have a negative effect on
esteem. Systems that have expectations too low however, where almost all children involved
in the program receive the same reward, devalue the accomplishments of the child who
makes very significant progress, and can be equally esteem defeating. Well-designed
positive reinforcement systems rely on incremental rewards where the range of
reinforcement varies from no reinforcement to mild reinforcement to moderate
reinforcement to intense reinforcement, so that the child can witness in a visible and tangible
way relative levels of progress.

6: You must always reinforce the final compliance with adult authority no matter how long it
takes to get there.
 Many children in management systems require numerous requests, or even
commands, before their behavior finally complies with adult expectation. The tendency is
to not provide positive reinforcement after many reminders, since adult patience is limited
and the adult expectation is that the child should do what he is told the first time.
Unfortunately, if no positive reinforcement is provided following the final compliance, all
that children learn is that there is no reason to comply. The imposition of negative
consequences following compliance only increases the likelihood that non-compliant
behavior will occur in the future.

IN THE CLASS ROOM SETTINGS:

Principle One: Behavior is largely a product of its immediate

environment.
The classroom environment teachers create through the expectations they set
will influence students more than outside factors do. This allows teachers to take
control and influence the students’ behavior in their classrooms. If a student is
acting out, the teacher should pay special attention to altering the classroom
(immediate environment). If the teacher changes the classroom, the behavior of
the students will change.
Principle Two: Behavior is strengthened or weakened by its
consequences.
When disruptive behavior becomes a pattern, it is important to take a look at
what is happening immediately after the behavior. Attention from a teacher is a
powerful motivator for most students. If you pay more attention to students who
are behaving appropriately than to students who are not, you will be
encouraging appropriate behavior.
Principle Three: Behavior ultimately responds better to positive than to
negative consequences.
People respond better to positive encouragement than to negative processes.
Think of the tasks you do every day; if someone thanks you or compliments you
on how well you did, you feel much more likely to continue the task. As a teacher,
you can help stop undesirable behavior and increase appropriate behavior by
genuinely reinforcing the latter.
Principle Four: Whether a behavior has been punished or reinforced is
known only by the course of that behavior in the future.
If an appropriate behavior is repeated, it has been reinforced. If an undesirable
behavior is repeated, it too has been reinforced. If an undesirable behavior has
discontinued, it has been properly disciplined.
The only way to tell if a response to a behavior is punishing or reinforcing is to
watch what happens to the behavior in the future. What is considered a
punishment to one person may reinforce and perpetuate a behavior in another.
Understanding these four principles of human behavior is a key to your success
in the classroom. As you work to fully apply and practice each one, you will feel
confident when approaching the classroom because you can make correct
decisions about managing behavior. The most important thing to remember
about each of these principles is that they are a call to action on your part—you
can manage student behavior properly only by first managing your own.