Behavioural problems are common in children. Studies have shown that one in five children (20 per cent) show significant behaviour problems at some point of time throughout childhood. Clinically, they have a varied presentation and disorders manifest in different ways at different ages. Some of the observed behaviours may be normal childhood variations and often disappear with age.
However, some behaviour may be due to an underlying developmental or psychiatric disorder, which if not recognised and addressed, could have serious long-term consequences. These disorders may not occur in isolation. They are often overlapping and multiple problems may coexist.
Globally, mental health during childhood is increasingly being recognised as a foundation of mental health in adulthood. Hence, addressing and treating these problems early also has a preventive role as far as adult psychiatric illnesses are concerned.
Abnormal childhood behaviour can be classified into three groups:
- Normal behavioural pattern: This behaviour is transient, developmentally appropriate and does not disrupt functioning.
- Behavioural problem: When functioning is affected but severity is not enough to call it a disorder.
- Behavioural disorder: Severe behavioural problems, which disrupt normal functioning and cause disharmony in family relationships, are usually due to an underlying disorder. These disorders may be genetic or due to an underlying brain pathology. Specific treatment is required.
Common behavioural problems seen in children
Temper tantrums: A temper tantrum is an emotional outburst that is typically characterised by stubbornness, crying, screaming, yelling, shrieking, defiance, angry ranting, resistance to attempts at pacification, and in some cases, violence. Temper tantrums to some degree are seen in almost all children between the ages of 1.5 to four years. They actually signify development of assertiveness and independence in the child. If tackled properly, they automatically decrease with age. Sometimes they are severe and need evaluation.
Sleep problems: Children need at least nine hours of sleep every night. The requirement is higher in younger children. Young children may commonly have difficulty in initiating or maintaining sleep. Adolescents in particular are prone to sleep deprivation as they watch television or work on computer till late night. Lack of sleep leads to secondary problems like irritability, aggression, poor concentration and memory, and can have negative effects on school performance and social relationships.
Separation anxiety: Many healthy and secure babies start showing separation anxiety on being separated from parents/ familiar surroundings at around 11 to 12 months of age. The problem generally settles by three to four years. If severe or prolonged, it needs evaluation, because it may be a manifestation of underlying separation anxiety disorder (SAD). SAD is a psychological condition in which the child experiences excessive anxiety upon separation from home or from people with whom the child has a strong emotional attachment (e.g. parents, grandparents, siblings). It is characterised by significant and recurrent bouts of worry upon separation or even on anticipation of such an event. The severity of the symptoms ranges from uneasiness to full-blown symptoms of anxiety about separation.
Hyperactivity: Physical hyperactivity is common and normal in children less than five years of age. However, when it is severe and prolonged, it may signify an underlying attention deficit hyperactivity disorder (ADHD). In these cases, early intervention and measures to control hyperactivity should be instituted.
Aggression and agitation: Aggression is a common behavioural problem across all ages. It is found to have a genetic and a heritable basis and remains stable over time. Children may not grow out of this behaviour, and therefore intervention is indicated for persistent aggression. It is more common in boys and children with a difficult temperament. Exposure to aggressive models on television and in play has been shown to increase aggressive behaviour.
Older children: In older children, behavioural disorders are usually manifested as poor school performance, low self-esteem, aggression, frequent outbursts, and truancy/running away.
Underlying developmental or psychiatric illnesses
All the above-mentioned problems may be purely behavioural (largely determined by individual temperament, parenting styles and environmental factors) or may have an underlying developmental or psychiatric disorder. In such cases, a developmental paediatrician or a child psychiatrist must evaluate them. The following list gives an idea of symptoms of common psychiatric disorders associated with behavioural problems.
- Autism: Manifests as language delay and behavioural problems in small children (two to four years).
- ADHD: It is a common disorder of school age children characterised by poor concentration, easy distractibility, poor organisational skills and physical hyperactivity.
- Slow learners: The IQ of some children may fall in below normal range. The child may have poor school performance for which he/she is often blamed.
- Dyslexia: It refers to a specific difficulty in reading and writing despite having normal intelligence and verbal comprehension. This condition is also a common cause of poor school performance.
- Anxiety disorder: It is characterised by unexplained and excessive anxiety and worry, irritability and poor concentration.
- Oppositional defiant disorder : These children have a negativistic, hostile and defiant behaviour. They actively defy rules, deliberately annoy others and are often vindictive.
- Conduct disorder: This is marked by repetitive and persistent behaviour involving aggression to others (bullying, causing physical injury to others, using weapons), destroying property and forcing sexual activity.
Most behavioural problems have a reason. Since early treatment has been found to be important for long-term mental health of the child, it is important to diagnose these problems in time. ‘Wait and watch’ is no longer recommended. Please voice your concerns to your paediatrician who can refer you to the appropriate specialist for evaluation. Diagnosis is mostly clinical through questionnaires and child observation sessions. Investigations may be needed if some specific disorders are suspected.
A team of specialists comprising of a developmental behavioural paediatrician, child psychologist, and if required, a child psychiatrist, is involved. Others, like occupational therapists and special educators, may be required for certain problems.
Psychotherapy and medications
The cornerstone of treatment is cognitive behavioural therapy. The problem behaviour is identified and then targeted and modified. Parents are counselled about healthy parenting styles, and behavioural modification techniques are applied. If identified, an underlying disorder should be treated. Medications have a supportive role and should be started when indicated. They have a role in problems like ADHD, depression, anxiety disorders, and sleep disorders. Medications must always be given in consultation with a specialist and regular monitoring should be done.