Description

Behavior that disrupts ≥1 area of psychosocial functioning; common problems:

• Noncompliance: active or passive refusal to do as requested by parent/authority figure
• Temper tantrums: loss of internal control that causes crying, whining, breath holding, aggressive behavior
• Sleep problems: difficulty going to sleep or staying asleep, nightmares, night terrors
• Nocturnal enuresis: bed-wetting in children >5 years of age for ≥3 months with no medical problems
  • Primary: never dry for a minimum of 6 months (1)
  • Secondary: return of enuresis dry period of ≥6 months (1)
  • Monosymptomatic enuresis: bed-wetting only
  • Nonmonosymptomatic enuresis: bed-wetting plus daytime incontinence, urgency, voiding difficulties or voiding <4 or >7 times per day
• Functional encopresis: repeated involuntary fecal soiling; can be retentive in 80% (functional constipation) or nonretentive (20%)
• Problem eating: “picky eating,” difficult mealtime behaviors
• Thumb-sucking: problematic if persists after primary teeth eruption

Epidemiology

• Noncompliance: more common in males; decreases with age
• Temper tantrums (2):
  • ≥12 months, up to 2 to 3 years old
  • 20% of 2-year-olds; 18% of 3-year-olds; 10% of 4-year-olds
• Sleep problems (3):
  • 10–30% of children, varies by age group
  • Bedtime resistance in 10–15% of toddlers
  • Nightmares in 10–50% of preschoolers; peak age 6 to 10 years
  • Night terrors in 1–6.5% early childhood; peak age 4 to 12 years
  • Sleepwalking in 3–5%; peak age 4 to 8 years
  • Nocturnal enuresis: 5–10% of 7-year-olds; 3% of teenagers wet the bed.
    • Monosymptomatic nocturnal enuresis is 2 × boys > girls.
    • Resolves spontaneously at a rate of approximately 15% per year
• Functional encopresis: rare in children aged <3 years, approximately 1–4% of 4-year-olds and 1–2% of children ≥7 years; more common in boys
• Problem eating: Prevalence peaks at 50% at 24 months; no relation to sex/ethnicity/income (4)
• Thumb-sucking: decreases with age; most children spontaneously stop between 2 and 4 years of age (4).

Etiology and Pathophysiology

Risk Factors

Adverse childhood experiences (ACEs) associated with behavioral problems in middle childhood (5)

Commonly Associated Conditions

• Noncompliance: Rule out depression, compulsive behaviors, adjustment disorder, inappropriate discipline.
• Temper tantrums: stress, normal development
• Sleep problems: inconsistent bedtime routine/schedule, stimulating bedtime environment; associated with hyperactive behavior, poor impulse control, poor attention in young children; acute/chronic anxiety is associated with insomnia. Long-acting stimulant medications may disturb sleep quality.
• Enuresis: associated with constipation, obstructive sleep apnea (OSA), neurodevelopmental conditions (ASD, ADHD)
• Functional encopresis: enuresis, ADHD, emotional stressors