Behavioral Disorders


Attention-deficit/hyperactivity disorder(ADHD)


- Psychosocial and behavioral treatment

- stimulant Medications:

  • Short-acting , intermediate-acting , and long- acting methylphenidate and long – acting dextroamphetamine are widely used
  • Non stimulant medications , including tricyclic antidepressants , may be helpful for children who have not responded to stimulant medication .

Control of elimination

- Enuresis

- Definition: urinary incontinence in a child who is considered adequately mature to have achieved continence

- Classification

- Diurnal(day time): dryness is expected in the U.S. by age 4 years

- Nocturnal(night time): dryness is expected by age 6 years

another classification

- Primary: incontinence in a child who has never achieved dryness

- Secondary: incontinence in child who has been dry for at least 6 months.




- Multiple possible etiologic factor

  • Primary enuresis often is associated with a family history delayed acquisition of bladder control
  • Genetic etiology and familial groups with autosomal dominant phenotypic pattern of nocturnal enuresis have been identified
  • Although most children with enuresis do not have a psychiatric disorders , stressful life events can trigger loss of bladder control
  • Sleep physiology may play a roll in the etiology of nocturnal enuresis with a high arousal threshold commonly noted.
  • In a subgroup enuretic children , nocturnal polyuria relates to a lack of a nocturnal Vasopressin peak.
  • Malformation of the detrusor muscle: involuntary contractions even when the bladder contains small amounts of urine
  • Chronic constipation with a large dilated distal colon which impinges on the bladder

Clinical manifestation:


  • How often does wetting occur?
  • Does it occur during the day , night or both?
  • Are there any associated conditions with wetting episodes(bad dreams , caffeinated drinks or exhausting day)?
  • Has the child hade a period of dryness in the past?
  • Stressful event (family move , birth , or death of a family member)?
  • A review of systems should include a developmental history and detailed information about the neurologic , urinary and gastrointestinal systems(including patterns of defecation)
  • A history of sleep patterns also is important
  • A family history often reveals that one of both parents had enuresis as children


Physical examination:

  • Child developmental patterns
  • Special attention is paid to the abdominal , neurologic and genital examination.
  • A rectal examination is recommended if the child has chronic constipation
  • The lumbosacral spine should be examined for signs of spinal dysraphism
  • For most children the only laboratory test is a clean catch urinalysis to look for chronic urinary tract infection , renal disease and diabetes mellitus.



-Treatment of organic causes like: UTIs , diabetes mellitus , sleep disorder , urologic abnormalities and chronic constipation

- Conditioning therapy:

- Enuresis alarm (an alarm that rings when the child wets)success rate 70%

- Pharmacotherapy

- Is 2nd – line treatment(desmopressin acetate , imipramine)



  • Is the passage of feces into inappropriate places after a chronological age of 4 years
  • Encopresis with constipation
  • Encopresis without constipation
  • May persist from infancy(primary) , or may appear after successful toilet training(secondary)


Clinical manifestation

  • The first consideration in managing encopresis is assessment of fecal retention
  • A positive finding on rectal examination is sufficient to document fecal retention(chronic constipation)
  • A negative finding requires X-ray of abdomen
  • Sometimes there is an abnormal anal sphincter function which needs an electromyography
  • Secondary encopresis is associated with high levels of psychosocial and conduct disorders



  • The standard treatment begins with clearance of impacted fecal material and short – term use of mineral oil or laxative to prevent further constipation
  • Behavioral treatment with regular post prandial toilet sitting and adaption of a high – fiber diet

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