Common behavioral issues

Question 1

§ Most teens have ____ -hr sleep phase delay due to changes in hormonal regulation of the circadian system

Answer 1

~1-3

Question 2

T/F Sleeping is not inborn; a behavior
that develops over time

Answer 2

T

Question 3

Two physiologic states of sleep

Answer 3

1. Non-rapid eye movement (NREM) sleep
2. Rapid eye movement (REM) sleep

Question 4

Rapid eye movement (REM) sleep

Answer 4

■ Brain activity ↑
■ Physiological activity ↑
■ Similar to wakefulness

Question 5

Non-rapid eye movement
(NREM) sleep

Answer 5

■ Sleep stages 1 – 4
■ Most physiologic functions
are markedly REDUCED
compared with wakefulness
■ Pulse ↓
■ Respirations ↓
■ Blood pressure ↓
■ NO penile erection
■ Relatively peaceful state

Question 6

Nightmares/terrors in NREM sleep:

Answer 6

■ Stages 3 & 4
■ Disoriented & disorganized thinking & brief
arousals during these stages associated with
amnesia*
■ Enuresis
■ Somnambulism (sleepwalking)
■ Stage 4 night terrors

Question 7

Newborns sleep ____ hrs/day

Answer 7

10-19
§ 2–5-hour blocks

Question 8

Nightmares/terros in REM sleep

Answer 8

■ 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

Question 9

Nightmares features (Peak ~3-5 yo)

Answer 9

OCCUR DURING REM SLEEP
§ Self limited, no tx needed
■ Usually associated with:
■ Stress
■ Trauma
■ Anxiety
■ Sleep deprivation causes
rebound REM sleep

Question 10

Guidance to give child who is having nightmares

Answer 10

§ Reassure child, discuss the
bad dream (next day)
§ Leave bedroom door open
§ Nightlight
§ Avoid stimuli
§ ie scary shows
§ Others?
§ “Monster Spray” J

Question 11

Night Terrors (~3-6yo)

Answer 11

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

Question 12

Guidance parents can give child with night terros

Answer 12

§ 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

Question 13

How to avoid a situation where a child refuses to go to sleep unless rocked/fed

Answer 13

■ 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

Question 14

Proper parental response to child awakening during the night

Answer 14

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

Question 15

Early solids (before 5 months) = ___ night waking, ____ sleeping

Answer 15

↓; ↑

Question 16

Toilet Training prerequisites

Answer 16

• CHILDREN MUST BE READY
  (avg. age 22 – 30 mo)
• Physiologic sphincter control
• (~18-24 months old)

Question 17

Nighttime bladder control is NOT expected until ___ yo

Answer 17

5-7

Question 18

T/F Early initiation of toilet training (<27 mo) correlates with a shorter training

Answer 18

F - it is longer the earlier you start

Question 19

3 factors associated with toilet training completion at a later age

Answer 19

1. Initiation of training at an older age
2. Presence of stool toileting refusal
3. Presence of frequent constipation

Question 20

Developmental readiness signs for toilet training

Answer 20

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

Question 21

Behavioral readiness signs for toilet training

Answer 21

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

Question 22

Guidance for beginning toilet training

Answer 22

1. Place the “potty” in the child’s bathroom
2. Encourage child to sit on the potty for 2-3 min/day
   * Initially clothed & after ~1 week without
3. Child goes with parent to empty soiled diapers into the little potty…
   … & then to the big potty

Question 23

Encopresis & Enuresis

Answer 23

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

Question 24

T/F Constipation & enuresis often co-occur

Answer 24

T

Question 25

Enuresis guidelines

Answer 25

* 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

Question 26

Medical Management of enuresis

Answer 26

* Desmopressin acetate (DDAVP) * Imipramine (Tofranil®) * Imipramine should be used only as a last resort

Question 27

Primary vs. Secondary encorpresis

Answer 27

Primary: Stool continence has never been achieved Secondary: Stool incontinence occurs after a period of successful toilet training

Question 28

Encopresis guidance

Answer 28

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

Question 29

Encopresis medical management

Answer 29

* 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

Question 30

Stranger/Separation Anxiety

Answer 30

Usually appears at about 6-9 months & can last until 24 months of age

Question 31

Discipline vs. Punishment

Answer 31

Discipline = (Latin) discipulus → instruction, knowledge Punishment = (French) punir → inflict penalty, take vengeance

Question 32

Guidance for Aggression/ Frustration (~3 years)

Answer 32

“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

Question 33

Guidance for Temper Tantrums (12 mo to 4 yrs)

Answer 33

§ 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

Question 34

Breath-Holding Spells (6mo – 6yo)

Answer 34

■ 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

Question 35

Guidance for Breath-Holding Spells (6mo – 6yo)

Answer 35

§ Terrifying for the parents § Not harmful & will not cause brain damage § Do NOT to become permissive § Treat with iron supplementation?

Question 36

Guidance for whining

Answer 36

■ Establish regular routines ■ Easier to meet expectations ■ Explain to the child Whining ≠ Attention ■ Respond positively when tone of voice improves

Question 37

Guidance for Need for Attention

Answer 37

§ Younger children § Brief attention immediately (use echoing) § Younger & older children § Special time (Time reserved solely for than child)

Question 38

Guidance for Head-Banging

Answer 38

■ 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

Question 39

Guidance for Thumb-sucking

Answer 39

■ 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

Question 40

Guidance for refusing food

Answer 40

■ 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