Presentation regarding common behavioral problems in Children

1. Definition
• When children cannot adjust to a complex
environment around them, they become
unable to behave in the socially
acceptable way resulting in exhibition of
peculiar behaviours and this is called as
behavioural problems.

2. • Faulty Parental Attitude
• Inadequate Family Environment
• Mentally And Physically Sick or Handicapped
Conditions
• Influence of Social Relationships
• Influence of Mass Media

3. CLASSIFICATION
OF BEHAVIOURAL
DISORDERS
AGE
Infancy
Childhood
Adolescent
NATURE
Movement, Habit
Toileting, Speech,
School, Sleep, Eating

4. Infancy
• Impaired appetite or Resistance to
feeding
• Abdominal Colic
• Stranger Anxiety

5. • Temper tantrums
• Breath holding spell
• Thumb sucking
• Nail biting
• Enuresis or Bed wetting
• Encopresis
• Pica or Geophagia
• Tics or Habit spasm
• School Phobia
• Attention Deficit Hyper
Activity Disorder
• Speech Problems
– Stuttering or stammering
– Cluttering
– Delayed Speech
• Sleep Disorders
– Sleep walking
– Sleep talking
– Bruxism

6. Adolescent
• Masturbation
• Juvenile Delinquency
• Substance Abuse
• Anorexia Nervosa

7. Infantile colic
• Abdominal colic in child less than or equal
to 12 months
• Colicky pain
• Endemic colic
• Evening colic
• Infantile colic

8. • A colicky baby is a healthy, well-fed baby
who cries more than three hours a day,
three days a week, for more than three
weeks.

9. • The crying usually occurs at about the same
time every day for no apparent reason and
may be intense, with the baby having
clenched fists and tensed abdominal
muscles. The baby may be inconsolable.
• There is no known cause for colic. It may last
from the first few weeks of birth through four
months of age.

10. BREATH HOLDING SPELLS

11. • It may occur in children between 6 months
to 5 years of age.
• It is observed in response to frustration or
anger during disciplinary conflict.
• The child is found with violent crying,
hyperventilation and sudden cessation of
breathing on expiration, cyanosis and
rigidity.
Breath Holding Spells

12. • Loss of consciousness, twitching and tonic-
clonic movements may also be found.
• The child may become limp and look pallor and
lifeless. Heart rates become slow.
• There may be spasm of laryngeal muscles.
• This attack lasts for 1 to 2 minutes, then glottis
relaxed and breathing resumed with no residual
effects.

13. 13 Mable_Maria
Clinical Features

14. Types of Breath Holding Spells
Blue spells (cyanotic breath holding)
• Most common.
• A fright or pain often triggers a spell.
• Child cries out or screams, then turns red in the
face before going blue, usually around the lips.
• Child becomes floppy and unconscious.

15. Types of Breath Holding Spells
Pale spells (pallid breath holding)
• less common.
• Can occur very early in life, often after a minor
injury or when the child is upset.
• Child opens their mouth as if to cry but no sound
comes out, before the child faints, looking pale.
Some children can have both cyanotic and pallid
spells.

16. First aid
• Lie child on their side and watch them keep their arms,
legs and head from hitting anything hard or sharp
• Do not shake child
• Do not put anything in mouth
• Do not splash your child with water.
• No need to help with breathing. Child will start to
breathe again on their own after the spell subsides (and
will sometimes cry or scream).
On rare occasions a child can have a seizure as part of a
breath-holding spell

17. • Identification and correction of precipitating factors
(emotional, environmental) are essential approach.
• Overprotecting nature of parents may increase
unreasonable demand of the child.
• Punishment is not appropriate and may cause another
episode.
• Repeated attacks of spells to be evaluated with careful
history, physical examination and necessary investigations
to exclude convulsive disorders and any other problems.
Management

18. THUMB SUCKING

19. • Thumb sucking is defined as the habit of
putting thumb into the mouth most of the
time.
• It usually involves placing the thumb into the
mouth and rhythmically repeating sucking
contact for a prolonged duration.
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Defination

20. • A gratifying action especially under
unpleasant and unsatisfying feeding
situation.
• Psychological
• Precipitants
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ETILOGY

21. • Parental counselling
• Behaviour Therapy
• Use of T-guards
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Management

22. PICA

23. Pica is a habit disorder of eating non edible
substances such as clay, paint, chalks,
pencil, plaster from wall etc.
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Pica

24. • Parental neglect, poor attention of the
caregiver, inadequate love and affection,
mental health conditions like mental
retardation and OCD etc.
• Nutritional deficiencies.
• Children of poor socio economic status
family, malnourished and mentally
subnormal children.
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Causes

25. • Anaemia
• Perverted appetite
• Intestinal parasitosis
• lead poisoning
• Vitamins and mineral deficiency,
• Trichotillomania, trichobezoar etc.
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Clinical features

26. • Blood investigations
• According to the DSM classification, a person is
said to have pica, only if:
• Persistent eating of non nutritive substances for a
period of at least one month
• Does not meet the criteria for either having autism,
schizophrenia, or Kleine-Levin syndrome.
• The eating behaviour is not culturally sanctioned.
• If the eating behaviour occurs exclusively during the
course of another mental disorder
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Diagnosis

27. • Treatment of the deficiencies.
• Parental counselling
• Education and guidance
• Behaviour modification
• Psychotherapy
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Treatment

28. dr. vinit warthe
Associate professor in pediatrics ,gmc akola

29. • When our children have issues and crises, these issues and
crises affect us just as much, if not more, than it affects them.
Writer Elizabeth Stone once said "Making the decision to have
a child is momentous. It is to decide forever to have your heart
go walking around outside your body.“
• When it seems like something is not quite right with your
children - perhaps they seem more afraid than other kids, or
they seem to get a lot angrier than their playmates do over
certain things - this odd or "off" behaviour can be experienced
as terrifying.
• You might not know what to do to help your child, or where to
go for help.

30. Types of Child and Adolescent Mental Health Problems
• Disorders of Social Interaction
– Autism
• Internalizing Disorders
– Anxiety Disorders
– Depression
– Trauma Responses
• Externalizing Disorders
– Attention Deficit Hyperactivity Disorder
– Conduct Disorder

31. • Behavioral disorders- NE, BHS, Temper tantrums
• Appetite Disorders
– Eating Disorder
– Substance Abuse
– Self-Harming Behavior
• Mental Retardation
– Learning Disability
• Early onset major mental illness
– Schizophrenia
– Bipolar Disorder
Types of Child and Adolescent Mental Health Problems

32. Differences of Child psychiatry from adult psychiatry:
• The child’s existence and emotional development depends on the
family or care givers - cooperation with family members; sometimes
written consent
• The developmental stages are very important assessment of the
diagnosis
• Use of psychopharmaco therapy is less common in comparison to
adult psychiatry
• Children are less able to express themselves in words
• The child who suffers by psychiatric problems in childhood can be an
emotionally stable person in adulthood, but some of the psychic
disturbances can change a whole life of the child and his family

33. ATTENTION-DEFICIT
HYPERACTIVITY DISORDER

34. • Hyperkinetic disorders occur mostly in first five years of life,
and they are several times more frequent in boys than in girls
• The main marks of the syndrome are:
– inattention
– impulsivity
– hyperactivity
• Prevalence is from 3% to 10% of elementary-school children

35. Attention-Deficit Hyperactivity Disorder
ADHD
Impulsivity
HyperactivityInattention

36. Inattention
• Inattention refers to a behavioural pattern in which
the individual has difficulty initiating, remaining
engaged in and completing a task.
• Inattentive children struggle to organize tasks and
activities, to listen , plan or execute actions.
• Inattention also includes distractibility, forgetfulness,
frequent loss or difficulty keeping track of objects.

37. Hyperactivity
Hyperactivity is characterized by:
• Excessive physical activity
• Constant feelings of restlessness, incapable of
remaining still even in situations in which that is expected
• Non-goal-directed motor activity; i.e. activity is
purposeless & affects the environment in a –ve way
• Frequent fidgeting or squirming in their seat
• Inability to play quietly
• Talking too much, running around /climbing when it is
inappropriate.

38. Impulsivity
• Impulsivity refers to difficulty in delaying an action or
response even when it is known that this action will have
negative consequences.
• Impulsiveness is associated with the need for immediate
over delayed gratification, even when postponement
would lead to better results.
• Difficulty in waiting one’s turn to speak, in games and
play activities or crossing the street.
• Tendency to act without thinking.

39. Incidence

40. Etiology
• Etiology: genetic predisposition, maternal deprivation,
environmental toxins or intrauterine or postnatal brain
damage
• About 50% of children with hyperkinetic syndrome have
so called “soft signs” and minor abnormalities in EEG
• IQ: from subnormal to high intelligence
• Specific learning disabilities often coexist with
hyperkinetic syndrome

41. • Genes (DAT1, DRD4,DRD5, 5HTT, HTR1B, SNAP25)
• ADHD is a familial disorder with a strong genetic
component. Its heritability has been estimated as 76%
(Faraone et al, 2005)
• Prematurity
• Intra-uterus exposure to tobacco
• Low birth weight
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Risk factors

42. • Families commonly misinterpret symptoms as “part
of their personality” or their “way of being.”
• Parents are unlikely to seek medical attention unless
the behavior is associated with impaired
functioning noticed by others, like academic failure.
Treatment rates among children with ADHD ranged
from none to 7% (Polanczyk et al, 2008)

43. • Complete medical evaluation.
• A psychiatric evaluation.
• Detailed prenatal history & early developmental
history.
• Direct observation, teacher’s school report,
parent’s report.
43
Diagnosis

44. The diagnosis of ADHD is
exclusively made on clinical
grounds and can follow
either Diagnostic and
Statistical Manual of Mental
Disorders, 4th edition (DSM-
IV) (American Psychiatric
Association, 1994) or ICD-10
(World Health Organization,
1993) criteria.

45. • Symptoms present for 6 months to a degree
that is maladaptive and inconsistent with
the developmental level of the child
• Clear evidence of clinically significant
impairment present in two or more settings
• Onset of impairment must be before age 7,
even if it was not diagnosed until later

46. Inattention Symptoms
(6 of 9):
• Careless mistakes
• Attention difficulty
• Listening problem
• Loses things
• Fails to finish things
• Organizational skills
lacking
• Reluctance in tasks
requiring sustained
mental effort
• Forgetful in Routine
activities
• Easily Distracted

47. • Hyperactive-
Impulsive Sx (6 of 9):
• Runs about or is
restless
• Unable to wait
his/her turn
• Not able to play
quietly
• On the go
• Fidgets with hands
or feet
• Blurts out answers
• Staying seated is
difficult
• Talks excessively
• Tends to interrupt

48. • Note exclusion criteria: ADHD is not diagnosed
if the symptoms occur in the course of a
pervasive developmental disorder, psychotic
disorder, or if the symptoms are likely due to
another psychiatric disorder (e.g., mood
disorder, anxiety disorder, dissociative
disorder, obsessive-compulsive disorder)

49. • Symptoms listed in the two classification systems
are equivalent.
• For ICD-10 criteria, symptoms must be present in
all three dimensions (attention, hyperactivity and
impulsivity)
• DSM-IV includes hyperactivity and impulsivity
symptoms in the same dimension and states that
individuals may present symptoms in only one
(out of two) dimension.

50. • Education of parents-Ensure that patients and their
family understand what ADHD is
• Psycho-educational Interventions, such as
cognitive-behavioral therapy, to improve impulse
control, and parent management training
• Classroom strategies and modifications
• Pharmacotherapy
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Treatment

51. Stimulants, first line:
-Methylphenidates
-Amphetamines
Amphetamines preferred in seizure disordered
patients
Common side effects include appetite loss,
sleep disturbance, and changes in pulse and
blood pressure. More serious -Dysphoria,
irritability, and precipitation or exacerbation of
tics
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Treatment

53. Non stimulants
• Atomoxetine (Strattera)
Dose: 0.5-1.2 mg/kg/day; max dose 1.4 mg/kg/day or 100
mg. (whichever is less)
– Advantage: 24 hour effect
– CYP2D6 substrate, so caution with medications such
as paroxetine, fluoxetine
– Common side effects: nausea, headache, anorexia,
insomnia
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Treatment

54. • Bupropion (Wellbutrin)
3-6 mg/kg/day; dose every morning
dose up to 150 mg/day; above that, divide
the daily dose bid
Side effects: weight change, dry mouth,
headache, GI effects, insomnia;
contraindicated in seizure disorders, eating
disorders/
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Treatment

55. • Venlafaxine (Effexor XR)
Dose: 37.5-150 mg every morning
Common side effects: Nausea, dizziness,
somnolence, constipation
• TRICYCLIC ANTIDEPRESSANTS
Imipramine /Tofranil- not more than 2.5mg/kg/day
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Treatment

56. α2 adrenergic agonis
• Clonidine (Catapress)
Dose: 3-10 mcg/kg/day, divided tid
Side effects: dry mouth, dizziness, drowsiness, fatigue,
constipation, arrhythmias
• May use patch and change every 5 days
• Guanfacine (Intuniv)
Dose: 1-4 mg/day
56
Treatment

57. Although evidence of the short-term efficacy of
stimulants is very robust, there are very few data
on the longer-term effectiveness of these
medications.
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Treatment

58. AUTISM SPECTRUM DISORDERS

59. ASD
• Very complex, often baffling developmental
disability
• First described by Leo Kanner in 1943 as early
infantile autism
• “Auto” children are “locked within themselves.”
• For next 30 years, considered to be an
emotional disturbance

60. • ICD-10 (World Health Organization, 1990) classifies
autism under the pervasive developmental disorders, a
group of conditions characterized by qualitative
abnormalities in reciprocal social interaction,
idiosyncratic patterns of communication and by a
restricted, stereotyped, repetitive repertoire of interests
and activities.
• These qualitative abnormalities are a feature of the
sufferer’s functioning in all situations.

61. Autism Spectrum Disorders
Core clinical characteristics of ASD include
impairments in two areas of
• functioning -social communication and
social interaction.
as well as restricted,
• repetitive patterns of behaviour, interests or
activities.

62. Autism
• Prevalence is 2-6/1000 individuals
• Typically appears during the first 3 years of life
• The CDC website also offers data from numerous
studies in Asia, Europe and North America showing an
average prevalence of ASD of about 1%.
• 4 times more prevalent in boys
• No known racial, ethnic, or social boundaries
• No relation to family income, lifestyle

63. • The AAP recommends screening for ASD all 18 and 24
month old children using a staged procedure .
• However, there are practical and ethical difficulties in
doing so and it is questionable if screening should be
routinely implemented worldwide.
• The mechanisms used to detect ASD are likely to be
different for each country and region, depending on
culture and child rearing practices, but will mainly
depend on the availability of developmental
surveillance.

64. Etiology
• Although the heritability of autism has been estimated
to be as high as 90% (Freitag, 2007), genetic factors are
heterogeneous, complex and for the most part poorly
understood.
• Neuroanatomic and neuroimaging findings, though not
diagnostic, have consistently revealed increased
cerebral volume that affects both grey and white
matter, as well as enlarged ventricles.
• Abnormalities in brain chemistry, serotonin synthesis, and
brain electrophysiology

65. • Environmental factors- mercury, cadmium,
nickel, trichloroethylene, and vinyl chloride
(Kinney et al, 2010).

66. ASD
Level 1:
Requires Support
• Mild Deficits
• Minimal Social
Supports
Level 2: Requires
Substantial Support
• Moderate Deficits
• Receiving Social
Supports
Level 3: Requires
Very Substantial
Support
• Severe Deficits
• Receiving Social
Supports

71. • May exhibit repeated body movements
(hand flapping, rocking).
• Unusual responses to people
• Attachment to objects
• Resistance to change in routine

72. Diagnosis
• No definitive medical test
• NICE (National Institute for Health and Care Excellence)
Guidelines can be used
• Team uses interviews, observation, & specific checklists
developed for this purpose.
• Team might include neurologist, psychologist,
developmental pediatrician, speech/language
therapist, learning consultant, etc.
• Must rule out MR, hearing impairment, behavior
disorders, or eccentric habits

73. Treatment
Recommended Treatment
Weakly
supported
by
evidence
Social skills programs
Augmentative / alternative communications systems
TEACCH (Treatment and Education of Autistic and Related
Communication-Handicapped Children) program
Cognitive behavioral therapy
Selective serotonin reuptake inhibitors in adults with ASDs (if
comorbid with obsessive compulsive disorder)
Stimulants in persons with ASD and comorbid ADHD
Supported
by
evidence
Behavioral interventions
Risperidone (for comorbid severe irritability or challenging
behaviors)

74. Art Therapy
Art therapy is a beneficial and enjoyable treatment because of its
inherent ability to Surpass Language barriers and achieve therapeutic
gains in a safe zone. Helps participants gain self-esteem, learn social
cues and norms, identify non-literal and nonverbal language, and
advance comfortable interpersonal relationships.

75. DYSLEXIA

76. DYSLEXIA
• Dyslexia is a language-based learning disability.
Dyslexia refers to a cluster of symptoms, which result
in people having difficulties with specific language
skills, particularly reading.
• Students with dyslexia usually experience difficulties
with other language skills such as spelling, writing, and
pronouncing words.

77. CAUSES of DYSLEXIA
• The exact causes of dyslexia are still not completely
clear, but anatomical and brain imagery studies show
differences in the way the brain of a dyslexic person
develops and functions.
• Have problems with identifying the separate speech
sounds within a word and/or learning how letters
represent those sounds, a key factor in their reading
difficulties.
• Dyslexia is not due to either lack of intelligence or
desire to learn; with appropriate teaching methods,
dyslexics can learn successfully.

78. • The impact that dyslexia has is different for each person
and depends on the severity of the condition
• The core difficulty is with word recognition and reading
fluency, spelling, and writing.
• Some dyslexics manage to learn early reading and
spelling tasks, especially with excellent instruction, but
later experience their most debilitating problems when
more complex language skills are required, such as
grammar, understanding textbook material, and writing
essays.
EFFECTS OF DYSLEXIA

79. • Dyslexia can also affect a person's self-image. Students
with dyslexia often end up feeling "dumb" and less
capable than they actually are.
• After experiencing a great deal of stress due to academic
problems, a student may become discouraged about
continuing in school.
EFFECTS OF DYSLEXIA

80. • The problems displayed by individuals with dyslexia
involve difficulties in acquiring and using written
language.
• It is a myth that dyslexic individuals "read backwards,"
although spelling can look quite jumbled at times
because students have trouble remembering letter
symbols for sounds and forming memories for words.
SIGNS OF DYSLEXIA

81. Other problems
• Learning to speak
• Learning letters and their sounds
• Organizing written and spoken language
• Memorizing number facts
• Reading quickly enough to comprehend
• Persisting with and comprehending longer reading assignments
• Spelling
• Learning a foreign language
• Correctly doing maths operations
Not all students who have difficulties with these skills are
dyslexic. Formal testing is the only way to confirm a diagnosis of
suspected dyslexia.

82. Treatment
• Dyslexia is a life-long condition.
• Early identification and treatment is the key to helping dyslexics
achieve in school and in life.
• Most people with dyslexia need help from a teacher, tutor, or
therapist specially trained in using a multisensory, structured
language approach.
• It is important for these individuals to be taught by a systematic
and explicit method that involves several senses (hearing, seeing,
touching) at the same time.
• Many individuals with dyslexia need one-on-one help so that they
can move forward at their own pace.

83. School modifications include:
– Giving a student more time
on a test
– Listening to tapes to help
them sound out letters and
words
– Using a computer software
where they can type rather
than write
• Accommodations can be made
with dyslexia students inside
and outside the classrooms.
– A one-on-one tutor to help
with reading and writing
skills
– Sensory and motor skill
therapy
– Reading test aloud to them
as they answer questions
MODIFICATIONS & ACCOMMODATIONS IN CLASSROOM

84. Upside side of dyslexia
• Over 50% of NASA Scientist are Dyslexic
deliberately employed for superb problem
solving skills and 3D orientation

85. Picasso is a world famous artist.
People say that he was such a
brilliant artist because he was
dyslexic…

87. NOCTURNAL ENURESIS

88. • Enuresis is defined by both ICD-10 (World Health Organisation,
2008) and DSM-IV-TR (American Psychiatric Association, 2000) as
involuntary (or even intentional) wetting in children 5 years of age
or older after organic causes have been ruled out.
• The wetting must have persisted for at least three months to be
considered a disorder.
88
Definition
ICD-10 if wetting occurs two times a month in children under 7 years of
age and once a month in children 7 years and older.
DSM-IV if wetting at least twice per week or else must cause clinically
significant distress or impairment in social, academic
(occupational) or other important areas of functioning.

89. • Primary NE
- never been dry for a period of at least 6 months
• Secondary NE
- previously consistently dry for at least 6 months
Distinction is important because children with secondary enuresis have
experienced stressful life-events (such as separation of parents, birth of
siblings, etc.) more often and have higher rates of comorbid psychiatric
disorders
• Daytime wetting is termed urinary incontinence, which
can be organic (structural, neurogenic or due to other
physical causes) or functional.
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Definition

90. -Monosymptomatic enuresis. Patient without other lower
urinary tract symptoms and without a history of bladder
dysfunction.
-Non-monosymptomatic enuresis is the presence of
increased or decreased voiding frequency, day-time
incontinence, urgency, hesitancy, straining, weak stream,
intermittency, holding manoeuvres, feeling of incomplete
emptying, post micturition dribble and genital or lower
urinary tract pain.
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91. Definition
Definitions according to the Children’s Continence Society
Symptom Disorder
Intermittent wetting during sleep
• Age 5 or more
Enuresis or nocturnal enuresis
Daytime wetting
• Age 5 or more
Urinary incontinence or daytime
urinary incontinence (not “diurnal
enuresis”).
In most cases functional.

92. Incidence
• There is a rapid decline in the
incidence of nocturnal
enuresis until the age of 5–6
years. 15% of children aged
5–6 years wet the bed and
beyond this age there is an
annual spontaneous decline
of approximately 15%.
Approximately 0.5–1% of the
population in their late teens
or early adulthood remain
enuretic.

93. Prevalence in children
Aged 5-7 Years
Author Country Girls (%) Boys (%)
Gamil Waly et al
1998:2004
Egypt 3.5 7.5
Järvelin et al. 1998 Finland 3.9 8.6
Hellström et al. 1990 Sweden 3.0 5.0
Bower et al. 1995 Australia 4.0 6.0

94. • Genetic-The recurrence risk for a child to be
affected by enuresis is 40 % if one parent and 70 % if
both parents had been enuretic (Bakwin 1973)
• Psychological-parental separation or divorce
• The time of initiation and intensity of toilet training,
has no effect on the development of enuresis
(Largo et al, 1978; 1996)
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Etiology

95. Pathophysiology
• Bladder function
• Sleep
• Urine production
• Genetics
• Psychopathology

96. Bladder function

97. Sleep

98. Sleep/ Arousal Disorder
Enuretics have a polysomnographically normal
sleep (still they may have an arousal defect)

99. Balance between bladder
Capacity and Nocturnal urine volume

100. Urine production
Diurnal Variation in Plasma Vasopressin
Normal Patients

101. Urine production
Urine production rate Urine osmolality
Normal
Patients
Patients
Normal

102. • History
• 48-hour frequency/ volume chart
• Questionnaires
• Pediatric physical examination
• Urinalysis
• Child psychiatric-screening or assessment
• Sonography
• Only if indicated-Urine bacteriology Uroflowmetry & pelvic-floor EMG
• Other diagnostic procedures: Radiological examinations, invasive
urodynamics, cystoscopy, etc.
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Investigations

103. Treatment
• In West Africa, children who wet the bed
were “treated” by attaching a large frog to
their waist, and this apparently frightened
them into being dry.
• Among the Navaho tribe, one preferred
treatment was a ritual that required enuretic
children to stand naked over a burning
bird's nest, and this was believed to
produce a cure of bedwetting because
birds did not soil their nests (Houts, 2000)

104. Treatment
• General measures
- restrict fluid 3-4 hours before bedtime
- empty bladder before retiring to bed
- encourage child to make bedtime resolution
- keep a chart of wet and dry nights
- reward for dry nights
-Avoid punishment/criticism

105. Principles of Toilet training
All approaches emphasize importance of:
• No undue pressure, calm, matter of fact approach
• Minimal attention and no negativity about mistakes
• Positive attention for success (praise, maybe
stickers)

106. Non Pharma logical T/t
Reassurance and counseling
- Bladder training program
- Enuresis alarm

107. • PARENTAL COUNSELLING
• Remove psychological factors leading to this problem
such as separation from parents, parental neglect
marital disharmony, excessive punishments, criticism in
front of others etc.
• The toilet training should be given properly.
• It should not be too lax nor be too strict.
• Toilet training can be delayed to 5 years in case of
mentally retarded children.

108. Alarm treatment
Mower and mower devised an apparatus in 1938 consisting of an alarm buzzer
which could be set off by the discharge of urine onto a detector circuit and child
wakes up from the sleep to pass the urine at right place.
A simple addition to the alarm is the so called “arousal training” by van Londen et al
(1993). In arousal training the alarm is set up before sleep, the alarm is triggered,
children are instructed to turn off the alarm within three minutes, go to the toilet and
reset the alarm. Child is rewarded for dry nights.

109. Pharmacological T/t
Imipramine : rarely used now in children
Used in children over 6 yrs .
T/t for 3-6 mo
effective in 10-50% .
60%relapse.
Side effects : toxicity, sleep and appetite dry mouth .
Oxybutynine : Anticholinergics in patients proven to have
detrusor instability .

110. Pharmacological T/t
Desmopressin – DDAVP
Synthetic analog of antidiuretic hormone vasopressin
Dose-1 spray in each nostril- up to 2 each(tabs also)
Rapid response 1-2 weeks
50%- 90% relapse after discontinuation
Desmopressin is taken in tablet form in the evenings only.
The oral dosage is 0.2mg to 0.4mg.
Compared with the alarm, desmopressin has a distinctly
lower curative effect in the long run.

111. GOOD BOY

112. THANKYOU