CONDUCT DISORDERS

Children are expected to behave within socially acceptable limits, determined by their age, social norms, training/moral standards and parent-child relationship. Negativism, i.e.

Conduct disorders (disruptive behavioral disorders) denote an anti-social behavior, usually due to parent­child conflict, child's urge for autonomy and expression of underlying anger, defiance or frustration. Emotional neglect and over-disciplined rearing are two important determinants of early disruptive behavior, apart from biological temperament, role models and social circumstances.

While many disruptive behaviors are seen in children, common ones are breath-holding spells and temper tantrums in under-five children and lying, stealing, truancy, etc. in older children. Serious disruptive behavior disorders, e.g. juvenile delinquency, substance abuse, teen pregnancy, etc. are more common in adolescents, discussed in Ch 13.3.

4.6.1 BREATH-HOLDING SPELLS_____________________

Breath-holding spells are commonest but benign manifestations of disruptive behavior in infants and toddlers, characterized by ‘sudden holding of breath in expiration (apnea), leading to cyanosis or pallor with/without loss of consciousness, hypotonia and seizures'. Frequency of these spells may vary from occasional attacks to gt;10-15 spells a day.

Incidence: Breath-holding spells are most common between 6 months to 2 years of age (up to 6 years), during which ~4-5% children experience at least one of these spells. Other high-risk factors include male sex, similar family history and labile temperament.

Etiology: Breath-holding spells are means of expression in a baby for internal frustration, anger and aggression.

Clinically: There are two major types of breath-holding spells; the more common cyanotic spells and the less common pallid spells.

• Cyanotic breath-holding spells are usually provoked by anger or frustration (akin to temper tantrum in older children), with a typical sequence of events - a loud shrill cry gt; forced expiration gt; breath-holding, i.e. apnea gt; cyanosis and unresponsiveness. Usually, each spell does not lasts for gt;10-15 seconds and terminates with a deep gasp gt; restarted breathing and gt; gradual disappearance of cyanosis. Baby may remain drowsy for a few minutes after the spell, before complete recovery. However, occasional attack may progress to develop generalized seizures, opisthotonus and bradycardia. Interictal EEG is normal.

• Pallid breath-holding spells, are less common and differ from cyanotic spells in following features: (a) usually provoked by sudden painful stimulus, e.g. fall, blunt injury or loud noise, (b) pallor and limpness instead of cyanosis, and (c) usually abnormal interictal EEG. Pallid spells may be induced by supraorbital pressure to stimulate oculocardiac reflex, though such maneuvers are risky and should be avoided.

Diagnosis depends on typical sequence of events, though should be differentiated from epilepsy, hypercyanotic (Tet) spells in cyanotic heart diseases and cardiac arrhythmias, e.g. long-QT syndrome (d/d pallid spells). Prognosis: Except a rare prolonged spell with significant hypoxia, breath-holding spells are essentially benign and disappear by 5-6 years of age. However, these children tend to have higher incidence of behavior problems in later life, e.g. temper-tantrums or syncopal attacks.

Management aims towards behavioral modification of the child and for early abortion of the attack, and includes:

a. Management during the attack: These spells can be easily aborted by physical stimulation, e.g.

b. Parental counseling: Parents need to be reassured about benign nature of these spells and the underlying behavioral basis. It is important to emphasize the need for certain discipline and consistency in childcare. The baby's demand, which has provoked the spell, should not be fulfilled immediately on recovery (purposeful neglect). Parents should also try to divert the attention of child from a potential precipitating event.

c. Pharmacologic therapy: Iron supplementation may be effective in some cases to reduce the frequency of attacks, even in absence of significant anemia. In children with pallid spells, recurrence of these attacks during a painful procedure may be prevented by previous atropinization.

4.6.2 TEMPER TANTRUMS___________________________

Temper tantrum are characterized by physical aggression, e.g. crying, howling, kicking, head banging, throwing objects, etc. in relatively older children above 2 years of age. Most of them learn to control their behavior by 5 years with gradual reduction in frequency of temper tantrums.

Incidence: Temper tantrums are common in children toddlers and pre-school children (~10%), with risk factors including over-indulgent child-rearing, e.g. in single child or working parents.

Etiologically, Negativism or defiant behavior is a normal phase of behavioral development in pre-school children, aimed to ascertain their autonomy. Temper tantrums are manifestations of excessive defiance and expression of internal anger and frustration. Parental anger and frustration may reinforce this defiance. Fatigue and hunger tend to trigger these attacks.

Management includes parental counseling regarding: (a) prevention of injury during the attack, (b) firm and consistent attitude towards the child, but with good communication,

(c) purposeful neglect during attack, i.e. ignoring the child's demand till the behavior is controlled, (d) positive reinforcement, i.e. praising or awarding him for periods of controlled anger. Parent should remain calm and firm during these episodes and must try to distract the child from a potential precipitating event.

4.7