Review – Kaplan Pediatrics: Behavioral/Psychological Disorders
Pica
- After year 2, needs investigation
- Increased risk for lead poisoning, iron deficiency, and parasitic infections
Enuresis
bladder control should be present mostly by age of 5 years
Primary Enuresis:
- No significant dry period; most common and usually nocturnal
- hyposecretion of ADH and/or receptor dysfunction
- Management:
- begin with behavioral treatment
- void before going to sleep; alarm to wake once 2–3 hours after falling asleep; no punishment or humiliation
- Psychotherapy for traumatized children or behavioral therapy failed
- Imipramine for failed behavioral therapy in nocturnal enuresis
Secondary Enuresis:
- After a period of dryness > = 6 months
- Secondary to psychological, urinary tract infection, constipation, diabetes
- More common in girls
Children with both diurnal and nocturnal enuresis:
- Ultrasonography or flow studies are indicated
Encopresis
- Definition—after a chronologic age of 4 years, or equivalent developmental level
- May be primary or secondary
- Secondary to psychological (toilet phobia), early toilet training, aggressive management of constipation, painful defecation, fissures
- Retentive encopresis most common
- Hard stool on rectal examination is sufficient to document, but a negative exam requires a plain abdominal x-ray
- Presence of fecal retention is evidence of chronic constipation, and thus treatment will require active constipation management
- May have abnormal anal sphincter function
- Management:
- First—clear impacted feces and short-term use of mineral oil or laxatives. No long-term laxative use
- Regular postprandial toilet-sitting
- High-fiber diet
- Familial support for behavior modification
Parasomnias
Episodic nocturnal behaviors that often involve cognitive disorientation and autonomic and skeletal muscle disturbance
| Sleepwalking and Sleep Terrors (Partial Arousal) | Nightmares |
| First third of night | Last third of night |
| During slow-wave sleep | REM sleep |
| No daytime sleepiness or recall | Daytime sleepiness (if prolonged waking) and vivid recall |
| High arousal threshold (agitated if awakened) | Low arousal threshold (easily awakened) |
| Common family history | No family history |
| Displaced from bed | May be displaced from bed |
| Sleepwalking relatively common; night terrors rare | Very common |
| Treatment: parental education, reassurance, avoid exacerbating factors, i.e., sleep deprivation, safety precautions | Do not usually require treatment unless persistent/frequent, in which case investigate possible abuse or anxiety disorder. |