Behavioral Problems in Children and Adolescents

Scott E. Moser and John F. Bober

Chapter contents

Sleep Problems

443

Oppositional Defiant Disorder

450

Sleep Refusal

444

Assessment

450

Night Waking

444

Management

450

Management

444

Conduct Disorder

450

Obstructive Sleep Apnea Syndrome

445

Assessment

451

Sleep Deprivation and Delayed Sleep-Phase Syndrome

445

Management

451

Narcolepsy

445

Eating Disorders

452

Autism

445

Feeding and Eating Disorders of Infancy and Early Childhood

452

Assessment

446

Anorexia Nervosa and Bulimia Nervosa

452

Management

446

Encopresis and Enuresis

446

Attention-Deficit/Hyperactivity Disorder

446

Assessment

447

Management

447

Behavioral problems are common reasons for parents to bring their child to see the family physician. In addition, addressing behavioral issues is an important component of the well-child visit. Childhood behavioral problems are a complex assortment of individual mental disorders, genetic and medical disorders, family interaction difficulties, social and school problems, and combinations of these. The rates of many psychosocial problems in children and adolescents, including depression, suicide, conduct disorders, and drug and alcohol abuse, have been rising in recent years throughout Western culture (Fombonne, 1998). This increase is only partly explained by changes in diagnostic criteria and reporting. The trend is particularly troubling when economic conditions and physical health of the population have been improving. The implication for office physicians is that psychosocial problems will encompass a growing proportion of patient care both as presenting problems and as cofactors in other medical conditions.

This chapter is arranged in problem-focused fashion along a developmental continuum from infancy through adolescence based on when various problems are most frequently encountered in practice. For conditions encountered at different developmental stages, discussions include similarities and differences in recognition and treatment at different ages. Management focuses on early, brief interventions the physician can make with the patient and family as well as suggestions about referral.

Regardless of the behavioral concern or the child's age, general principles for evaluation and management include the following:

1. Obtain specific examples of the problem behaviors rather than general conclusions. For example, "Child is out of his seat, walking around the classroom every few minutes," rather than, "Disruptive in class"; and "Screams inconsolably at 2 am," rather than, "Doesn't sleep well."

2. Obtain as complete information from as many observers as possible. Unusual seizure disorders and other neurologic problems are included in the differential diagnosis of many behavioral disorders. Keys to their diagnosis are found in a careful history.

3. For the same reason just stated, include a careful neurologic and age-appropriate mental status examination.

4. Emotional stressors and abuse, whether physical, verbal, or sexual, can be important precipitators or exacerbators of behavioral problems. Therefore, explore these, including an interview of the child apart from their parents once the child is verbal.

5. Consider multiple diagnoses simultaneously. Multi-factorial etiologies are common for many behavioral complaints, and many psychiatric diagnoses carry a high risk of comorbid conditions. Therefore, avoid a linear approach of working up one potential diagnosis at a time.

6. Use a multidimensional treatment approach. Many behavioral problems respond best to combinations of psychotherapy, medication, parent and teacher education, and other therapies, rather than only one of these at a time.

7. Familiarize yourself with the mental health regulations for the various insurance plans in which you participate. Many plans have "carve-outs" (separately contracted providers) for mental health services. If you are the initial contact regarding a concern, you may either assist or hinder your patient obtaining the appropriate assistance based on your knowledge of available service channels. This is particularly important in crisis situations; know the services in your area, including specific providers available on various insurance plans, and how to access them during evenings and weekends.

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We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.

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