Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.


Behavioral Disorders

Donna Hallas


A. Various instruments are available for assessment of children with behavioral and emotional disorders in primary care settings. Based on the results of these assessments, referral to a psychiatrist, psychologist, or social worker for completion of additional assessment tools may be indicated. Data from these evaluations will assist in understanding dynamics of family functioning and behavioral management plan (Boxes 34-134-234-3).

Box 34-1 Behavioral Assessment Rating Scales

Achenbach Child Behavior Checklist System (CBCL)

• Parent Form (CBCL)

• Teacher Report Form (TRF)

Attention Deficit Disorders Evaluation Scales (ADDES)

• Home Version

• School Version

Behavior Assessment System for Children (BASC)

• Parent Rating Scale (PRS)

• Teacher Rating Scale (TRS)

Connor's Parent/Teacher Rating Scale

Personality Inventory for Children-Revised (PIC–R)

Social Skills Rating Scale (SSRS)

Walker Problem Behavior Identification Checklist (WPBIC)

Box 34-2 Behavioral Assessment: Self-Report Rating Scales

Achenbach Child Behavior Checklist System (CBCL)

Youth Self-Report

Behavior Assessment System for Children (BASC)

Self-Report of Personality

Child Anxiety Scale

Children's Personality Questionnaire (CPQ)

Early School Personality Questionnaire (ESPQ)

High School Personality Questionnaire (HSPQ)

Revised Children's Manifest Anxiety Scale (RCMAS)

Social Skills Rating System (SSRS)-Student Form

Box 34-3 Behavioral Assessment: Protective Measures

Draw a Person: Screening Procedure for Emotional Disturbance (DAP: SPED) Minnesota Multiphasic Personality Inventory–A (MMPI-A) Tell Me a Story (TEMAS)


Arithmetical disorder, 315.1

Emotional disorder, V40.9

Attention deficit/hyperactivity disorder, 314.01

Impulsivity, 314.01

Behavioral disorders, 312.9

Inattentive behavior, 314

Combined hyperactive/inattentive, 314.01

Language disorder, 315.31

Dyspraxia, 315.4

Learning disability, 315.2

ADHD-not otherwise specified, 314.9

Reading disorder, 315

A. ADHD is one of the most common chronic conditions of childhood and the most common neurobehavioral disorder in child health. ADHD is characterized by the children presenting with three core behavioral symptoms: hyperactivity, impulsive behaviors, and inattentive behaviors outside the normal parameters of the psychosocial development for child's age. Symptoms are displayed by the child before 7 years of age even though diagnosis may not be established until child enters the school setting. Three subtypes of ADHD are now recognized: (1) hyperactive/impulsive (ADHD-HI), (2) inattentive (ADHD-IA), and (3) combined (ADHD-CT).

B. ADHD-not otherwise specified: for children who present with symptoms predominantly of inattentive type but do not meet the full criteria.

C. The American Academy of Pediatrics (AAP) evidence-based guidelines for diagnosis and management of ADHD are limited to children 6 to 12 years of age with any coexisting conditions.

D. Etiology.

1. Specific etiology unknown. Believed that abnormal dopamine transport and uptake at nerve synapse may account for symptoms displayed.

E. Occurrence.

1. The prevalence of ADHD is 5%.

2. Two-thirds of children with ADHD continue to have symptoms in adolescence.

3. More prevalent in males than females–approximate ratio of 4:1.

4. Prevalence of comorbid conditions ranges from 9-50% depending on specific comorbid condition. Refer to Table 34-1.

F. Clinical manifestations.

1. Child displays and/or parents and teachers report inappropriate degrees of:

a. Hyperactivity.

b. Impulsivity.

c. Inattentive behaviors.

2. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnostic criteria delineate clinical manifestations of ADHD and clarify criteria utilized to make definitive diagnosis (Box 34-4).

Table 34-1 Prevalence of Comorbid Conditions in Children with ADH

Comorbid condition

Prevalence rate (%)


Conduct disorder, 312.81



Oppositional defiant disorder, 313.81



Depressive disorder, not otherwise specified, 311



Anxiety disorder, 300



Learning disorder, 315.2



Source: Adapted from Agency for Healthcare Policy and Research, U.S. Department of Health & Human Services.

Box 34-4 DSM-IV Diagnostic Criteria for ADHD

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3. Identifying at-risk child.

a. Nurse practitioner plays integral role in identifying children at risk for ADHD by evaluating comprehensive medical history.

b. Positive family history of one or more of hyperactivity disorder, conduct disorder, learning disorder, substance abuse, psychiatric disorder.

c. Intrauterine exposure to smoking and drug/alcohol use, especially during first trimester.

d. Parent, schoolteacher report that child displays impulsive and inattentive behaviors.

• School-age children tend to steal, tell lies, deliberately destroy property.

• Adolescents display behaviors associated with anger and mood lability: alcohol/substance abuse, smoking, sexually transmitted infections, early pregnancy, low self-esteem, involvement in motor vehicle accidents.

4. Comprehensive medical history–include questions that elicit details concerning each of following parameters:

a. Parental concerns.

• Onset and duration of symptoms.

• Parental approaches to displayed symptoms.

b. Behavioral history.

• Hyperactivity as described by parents, caregivers, teachers.

• Behaviors that display impulsivity, inattentiveness to details.

• Ability to focus on interactive video games.

• Sleep patterns.

• General behavior at home and in school settings.

• Previous results of Denver Developmental Screening Tests and any formal psychological testing.

• School performance.

• Identification of any learning disabilities.

• Behaviors displayed while playing with other children.

• Parenting styles: what works, what does not work with the child.

c. Significant past medical history.

• Prenatal, birth, neonatal history.

• Evaluation of growth charts.

• Evaluation of previous diagnostic testing including complete blood count (CBC) results, lead levels, visual and hearing test results.

• Seizures/seizure-like behaviors including staring episodes, tics, head trauma.

• Medication history (prescribed, OTC, illicit).

d. Developmental history.

• Achievement of developmental milestones.

• Speech and language development.

• Gross motor and fine motor development.

• Coordination.

e. Educational history.

• Type of educational program.

• Early intervention.

• Special education program.

• Participation in mainstream programs.

• One-on-one programs.

• Success/failure in each educational program.

• Mathematical ability.

f. Behaviors at school.

• Reports from teachers, counselors.

• Relationships with children at home and school.

• Relationships with teacher, school nurse, counselor.

g. Family history.

• Parents or siblings diagnosed with ADHD.

• Substance abuse.

• Mental illness.

• Learning disabilities.

h. Psychosocial history.

• Family structure, function.

• Head of family.

• Parents' occupation, employment, level of education.

• Substance abuse by parents/child.

• Evaluate family-child interactions.

• Family stress level due to child's behavior.

i. Manifestations consistent with comorbid conditions:

• Lack of motor control; clumsiness (developmental coordination disorder [dyspraxia]).

• Preschooler with speech, language delay (learning disability).

• Writes number in reverse order after age 7 (learning disability).

• Poor school performance: unable to learn to read, write, or do mathematics (learning disability).

• Insomnia.

• Enuresis, encopresis.

• Negative, hostile, defiant behaviors lasting at least 6 months (oppositional defiant disorder [ODD]).

• Violation of home/school rules (conduct disorder).

• Symptoms of depression.

• Inappropriate levels of anxiety.

• Low self-esteem.

• Autism spectrum disorders.

• Tic disorders.

G. Physical findings.

1. For diagnosis without comorbid conditions, physical examination is usually unremarkable.

2. Behavior during physical examination is often inappropriate for age: refuses to cooperate; refuses to respond to questions.

3. Dysmorphic features may be consistent with comorbid conditions.

4. Neurocutaneous lesions may be consistent with comorbid conditions.

H. Diagnostic tests.

1. No specific diagnostic tests for definitive diagnosis.

2. Diagnostics such as blood tests, brain scans, EEG, and psychological tests are not routinely necessary for children with AHDH without evidence of comorbid conditions.

3. Laboratory tests that may assist in ruling out or verifying comorbid conditions.

a. CBC with differential.

b. Lead level (children 7 years and younger).

c. Basic metabolic panel.

d. Liver function panel.

e. Thyroid studies including thyroid-stimulating hormone (TSH).

f. ECG: to evaluate heart rate and QT interval (positive family history).

g. EEG: recommended for all children who may be placed on medication therapy and have a past medical history of seizures and/or a family history of a seizure disorder.

4. Diagnosis of ADHD.

a. For definitive diagnosis, must use DSM-IV diagnostic criteria for ADHD (Box 34-4).

b. AAP published evidenced-based guidelines for primary care diagnosis and clinical evaluation of children suspected of having ADHD. AAP guidelines require that a child meet the DSM-IV criteria.

c. AAP guidelines require evidence directly obtained from the classroom teacher regarding the core symptoms of ADHD, the duration of symptoms, the degree of functional impairment, and coexisting conditions.

I. Differential diagnosis.

1. Because diagnosis has several significant comorbid conditions, comprehensive history and physical examination essential to establish definitive diagnosis and formulate treatment plan.

2. Differential diagnosis included in Table 34-2.

J. Treatment (Box 34-5).

1. Both medication and behavior therapy.

2. Evidence suggests that discontinuing treatment leads to reemergence of symptoms.

3. Aimed at alleviating major symptoms child displays and improving child's ability to function within family unit, social and educational environments.

4. In addition, if child also displays symptoms of one or more comorbid conditions, treatment is highly recommended to reduce or alleviate these symptoms.

Table 34-2 Differential Diagnosis of ADHD

Differential Diagnosis

Characteristic Symptoms or Presentation


Learning disability, 315.2

Language delay especially in preschool years


Persistent reversal of numbers after 7 years of age


Unsuccessful in achieving reading, writing, math skills


Difficulty understanding concept of left and right


Sleep disorders, 780.5

Insomnia leading to attention deficit in school activities


Sleeping during class


Extended daytime naps at home or in school (preschool or kindergarten)


Frequent episodes of night terrors or nightmares


Mild mental retardation, 317

Children who present with learning diffi culties in


elementary grades


Tourette syndrome, 307.23

Usually symptoms are evident after 7 years of age


Reports by parents/caregivers that child has had 2+ motor tics and 1 vocal tic during 1-year interval


Oppositional defiant disorder, 313.81




Defi ant behaviors


Uncontrolled temper




Refuses to comply with social rules at home, school


Behaviors are associated with poor school performance


Conduct disorder, 312.9

Violates rights of others


Violates societal norms


Violates rules at home, school


Participates in at-risk behaviors: smoking, substance abuse


Often suspended from school


Anxiety disorder, 300

Feels threatened without apparent reason, cannot identify source of threat


Feelings of uneasiness




History of breathlessness, palpitations, restlessness, chest tightness, trembling


Depression, 311

Low self-esteem, low self-image


Reports feeling depressed


Poor social relationships, does not participate in school activities


Bipolar disorder, 296.7

Mood lability, irritability


Evidence of depression


Pervasive developmental

Language delay


disorders, 299.8; autism, Asperger's syndrome, 299.8;

Abnormal social behaviors


childhood disintegrative

Ritualistic movements


disorder, 299.1; Rett syndrome, 330.8

Impaired intellectual functioning


Box 34-5 Role of Nurse Practitioner in Managing Children with ADHD

1. Office assessment identifying parental concerns and child's behavior patterns.

2. Establish rapport with psychiatrist or psychologist to identify treatment plan.

3. Include parents, child, and school personnel in the treatment plan.

4. Monitor effects of stimulant medication to ensure desired treatment plan outcomes.

5. Follow up should include biannual physical examinations and appropriate laboratory studies including hemoglobin, because anemia is a side effect.

6. Emotional support measures for child and parents.

5. Mental health referrals for all children suspected of having comorbid psychiatric conditions.

6. Characteristics of treatment plan.

a. Parent education.

• Provide education about ADHD and appropriate comorbid condition.

• Identify available resources and support groups for parents (Table 34-3).

b. School-based strategies.

• Structured classroom setting.

• Consistent instruction and application of rules of conduct.

Table 34-3 Evidence-Based Treatment Guidelines for the School-Age Child

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• Meets educational needs of child as identified through in-school testing.

c. Behavior modification.

• Strategies are consistent and followed at home and at school.

• Inform child of rules of acceptable behavior.

• Rewards for demonstrating positive behaviors (positive reinforcement).

• Consequences for failure to meet the goals (punishment).

• Repetitive application of the rewards and consequences shapes behavioral changes.

d. Medication therapy.

• Basic principles.

i. Begin with lowest dosage and increase dosage every 5-7 days based on parent and teacher assessment of child's response (changes in behavior) to medication.

ii. Once positive response to medication therapy is reported, increase dose at least one more time.

iii. Medication administered every 12 hours has been shown to be most effective in controlling symptoms of ADHD.

• Drugs of choice.

i. May use immediate-release tablets: methylphenidate (Ritalin), dextroamphetamine levoamphetamine (Adderall), dextroamphetamine (Dexedrine), atomoxetime (Strattera)–a nonstimulant medication.

ii. May use sustained-release tablets: methylphenidate (Ritalin SR; Concerta; Metadate ER; Metadate CD), dextroamphetamine levoamphetamine (Adderall XR), dextroamphetamine (Dexedrine Spansule).

• Potential side effects:

i. Decreased appetite, weight loss.

ii. Insomnia.

iii. Tachycardia.

iv. Increased blood pressure.

v. Nervousness.

vi. Headache.

vii. Dizziness.

viii. Irritability.

ix. Rebound moodiness.

x. Leukopenia/anemia.

xi. Skin rash.

xii. Abnormal liver function tests.

xiii. Exacerbations of tics and Tourette syndrome.

• Management of side effects:

i.  Administer dose after meals to improve appetite; frequent high-calorie snacks.

ii. Avoid caffeine intake.

iii. Modify time of administration if sleep problems.

K. Follow up.

1. Monitor height, weight, heart rate, blood pressure every 3 months in children younger than 12 years of age. School nurse can play integral role in monitoring these measurements in child every 3 months and report these findings to primary care provider.

2. In children older than 12 years of age, monitor height, weight, heart rate, blood pressure every 6 months.

3. Monitor CBC or hemoglobin every 6 months. Children are at increased risk for leukopenia/anemia while on psychostimulant drug therapy.

4. Perform interval history, physical assessment every 6 months to evaluate child's response to treatment program.

5. Consult with teacher and school psychologist prior to each 6-month healthcare evaluation for continuity of care.

6. Follow up with psychiatric referrals, as appropriate.

L. Complications.

High blood pressure, 401.9

Tourette syndrome, 307.23

Increased heart rate, 785

Weight loss, 783.21

Tic disorder, not otherwise specified 307.2


1. Complications from medication therapy include weight loss, increased heart rate and blood pressure, growth suppression, exacerbations of tics and Tourette syndrome.

2. Once medication is discontinued, symptoms related to complications of medication therapy resolve; however, evidence shows that ADHD symptoms return even with continuous behavior-modification therapy.

M. Education.

1. Parent education is key to successful management.

a. Parents should receive initial and updated education related to behavior modification strategies for successful treatment as child reaches each new developmental stage.

b. Parents need to understand medication management.

c. Know possible side effects of medication therapy.

d. Support groups.

e. Group and family therapy.

f. Internet resources.

• American Academy of Child and Adolescent Psychiatry:

• American Academy of Pediatrics:

• National Association of Pediatric Nurse Practitioners:

• Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD):

• National Resource Center on ADHD:


Asperger's syndrome, 299.8

Echolalia, 784.69


Autistic disorder, 299

Language disorder, 315.31


Autistic spectrum disorder, 299

Rett syndrome, 330.8


Childhood disintegrative disorder, 299.1

Social disorder, 313.22


A. ASD is a biologically based, neurobiological disorder that includes autistic spectrum disorder, Asperger's syndrome, childhood disintegrative disorder, pervasive developmental disorder, not otherwise specified, Rett syndrome (which will be removed in the DMS-V). Characterized by impairment in verbal and nonverbal communication, impaired cognitive abilities, and impaired social interactions.

B. Etiology.

1. Genetic susceptibility: children with a diagnosis of tuberous sclerosis; fragile X; Rett syndrome (identified gene mutation).

2. Genetic susceptibility and environmental factors: no single environmental factor identified, however, may be linked to prenatal exposure to thalidomides, valproic acid, and mesoprostol.

3. There is no evidence that links the measles-mumps-rubella (MMR) vaccine or any immunizations to the autistic spectrum disorders.

C. Occurrence.

1. Male-to-female ratio 3:1.

2. In the United States: 1% of the population is affected.

3. In the United States 1 child is affected for every 100 live births.

4. Recurrence rate in siblings of affected children is 2-8%.

5. Present in all racial, ethnic, and socioeconomic groups.

D. Clinical manifestations.

1. Red flags.

a. Significant impairment in social communication and interaction.

b. Repetitive, restricted, and stereotyped patterns of behavior.

2. Symptoms develop before 30 months of age.

a. Lack of (or poorly developed) verbal and nonverbal communication skills.

• Abnormal speech patterns; echolalia, nonsense rhyming.

• Bruxism.

b. Abnormal social play, solitary play, no friendships.

• No eye contact.

• No social smile.

• Regression in language or social skills.

• Repetitive body movements.

• Ritualistic behaviors; need for sameness.

• Preoccupation with an object.

• Tantrums when ritual is disrupted.

• Rocking behaviors.

c. Impaired intellectual functioning.

• Mental retardation (I.Q. < 70 in 40-62% of the children).

• Occasionally child has particular talent (e.g., art, music).

E. Physical findings.

1. Physical examination is most often normal.

2. May have dysmorphic features.

a. Long face and large eyes.

b. Large head size not observed in infancy but observed in preschool years.

c. May have microcephaly.

3. Lack of communication skills and psychosocial skills in interactions in the home and during the office exam.

F. Diagnostic tests.

1. No specific tests.

2. Lead screening (children under 7 years old) and genetic testing may be indicated for identification of comorbid conditions.

3. Refer to psychologist for cognitive and psychological testing.

4. Refer to neurologist for full neurologic diagnostic workup including blood work, MRI with contrast, CT scan, EEG.

5. Refer for early intervention services.

6. Autistic measures (Box 34-6).

G. Differential diagnosis.

Asperger's syndrome, 299.8

Mental retardation, 319


Childhood disintegrative disorder, 299.1

Obsessive-compulsive disorder, 300.3


Conduct disorder, 312.9

Pervasive disorder, 299.8


Fragile X syndrome, 759.83

Rett syndrome, 330.8


Hearing disorder, 389.9

Schizophrenia, 299.9


Lead poisoning, 984.9

Tourette syndrome, 307.23


1. Obsessive-compulsive disorder, Tourette syndrome.

2. Conduct disorder, mental retardation, hearing disorder.

3. Schizophrenia of childhood.

4. Lead poisoning.

5. Fragile X syndrome.

6. Additional pervasive disorders.

7. Asperger's syndrome.

a. Impairment is primarily in social interactions, which includes repetitive and obsessive behaviors.

b. Children usually do not have language impairments characteristic of autism.

c. Rare disorder characterized by normal development until 2-4 years old, at which time there is severe mental and social deterioration.

8. Childhood disintegrative disorder.

9. Rett syndrome.

a. Development normal until 1 year of age, at which time language and motor development regress.

b. Microcephaly is usually evident by 1 year of age.

H. Treatment.

1. No single best evidence-based treatment.

a. Treatment is individualized to the child.

• Management of challenging behaviors.

Box 34-6 Autistic Measures

Autistic Diagnostic Observation Schedule (ADOS) Childhood Autism Rating Scale (CARS)

• Sleep problems.

• Social skills training.

b. Medication.

• For aggressive behaviors and irritability for children and teens with autism: resperidone and aripiprazole.

• Stimulants for comorbid symptoms of ADHD.

• Other comorbid conditions treated as appropriate by psychiatric specialists.

c. Implement all early intervention services in home and school: speech therapy, occupational and physical therapy, behavior modification strategies.

2. Diagnosis.

a. Denver Developmental II screening test: valuable tool used to assist in early recognition.

b. Screening Tool for Autism in Toddlers and Young Children.

c. Autism Spectrum Screening Questionnaire for 6-17 years old.

d. Refer to developmental neurologist and Early Intervention services (under age 5) as soon as symptoms are suspected.

3. Comorbidity.

a. ADHD.

b. Intellectual disabilities.

c. Mood disorders.

d. Depression.

e. Anxiety.

f. Obsessive-compulsive behaviors.

g. Phobias.

I. Follow up.

1. Recognize early signs and symptoms of autism, Asperger's syndrome, childhood disintegrative disorder, Rett syndrome, and make appropriate referrals.

2. Support for parents, other primary caregivers is essential. Families may benefit from connecting with the Autism Society (

3. Encourage parents to find respite care for child.

J. Complications.

Autism, 299

1. Autism is a chronic disease with no cure.

K. Education.

1. Families need education about the disorder, what treatments have been proven to be successful; multidisciplinary interventions.

2. Families need to be careful when investigating treatment programs and determine proven benefits from these programs. Families must consider own safety and that of their child.

3. Internet resources.

a. Autism Society:

b. Centers for Disease Control and Prevention:

c. American Academy of Pediatrics:


Apnea, 786.03

Cyanosis, 782.5


Bradycardia, 427.89

Cyanotic spells, 782.5


Breath holding spells, 786.9

Loss of consciousness, 780.09


Breath holding, 312.81

Pallid spells, 782.61


Cerebral anoxia, 348.1

Tonic seizure activity, 345.1


Clonic jerks, 333.2


A. Characterized by episodes in which infant/young child holds breath, which leads to cerebral anoxia resulting in limp body and extremities, unresponsiveness. Two types: cyanotic spells and pallid spells.

B. Etiology.

1. Unknown.

C. Occurrence.

1. Usually begins after 6 months old.

2. Highest incidence is at 2 years old.

3. Usually resolves by 5 years old.

4. Usually occurs in response to an upsetting, unexpected, or traumatic event.

5. May occur with genetic conditions such as Rett syndrome.

6. Associated with iron-deficiency anemia.

D. Clinical manifestations.

1. Cyanotic spells.

a. Brief shrill cry followed by forced expiration and apnea.

b. Onset of cyanosis.

c. Loss of consciousness.

d. Generalized clonic jerks.

e. Bradycardia.

2. Pallid spells.

a. Usually follows fall in which child strikes head, causing pain.

b. Cessation of normal breathing pattern; prolonged apneic episode.

c. Loses consciousness.

d. Pallor.

e. Tonic seizure activity (occasional).

E. Physical findings.

1. Normal physical exam findings.

F. Diagnostic tests.

1. EEG. Referral to neurologist is recommended.

G. Differential diagnosis.

Seizure disorder, 780.39

1. Seizure disorder.

H. Treatment.

1. No treatment necessary.

2. Parental support and reassurance.

3. Avoid situations that provoke the breath-holding episodes.

4. Treat iron-deficiency anemia if present.

I. Follow up.

1. Call within a few days to assess how family is dealing and answer questions.

2. Parents' level of comfort with breath-holding spells determines further follow up.

J. Complications.

1. Head injury if child falls during episode.

K. Education.

1. Discussion of management plan that parents can follow consistently. Parents must feel comfortable with plan.

2. Provide safe environment for child during and at conclusion of episode.

3. Avoid reinforcement of these behaviors.

4. Most children outgrow breath-holding episodes by 4 to 8 years old.


Dilated pupil, 379.43

Nightmares, 307.47


Hyperventilation, 300.11

Tachycardia, 785


Night terrors, 307.46


A. Etiology.

1. Actual cause unknown.

2. Dysfunctional family relationships should be suspected.

B. Occurrence.

1. Occurs in 1–3% of children, mostly in boys between 5 and 7 years old.

C. Clinical manifestations.

1. Night terrors: sudden, unexpected screams during sleep; usually occurs within 2 hours of the time the child goes to sleep.

2. Nightmares: frightening dreams that awake the child and make the child afraid to return to sleep; usually occurs during the last third of the sleep cycle during REM sleep.

3. Appears frightened; pupils dilated.

4. Tachycardia, hyperventilation.

5. Thrashing of extremities.

6.  Inconsolable, not aware of parents' presence.

7. Panic.

8. Sleepwalking.

9. Returns to sleep.

10. No recall of night terror in morning.

D. Physical findings.

A. None.

E. Diagnostic tests.

A. None necessary.

F. Differential diagnosis.

Anxiety, 300

Emotional disorder, V40.9


Depression, 311

Seizure, 780.39


1. Rule out emotional disorder; anxiety; depression.

2. Seizures.

G. Treatment.

1. Child should be encouraged to lie down and be helped back to sleep (e.g., talking quietly, rubbing back).

2. Turn on light or use a nightlight in the bedroom.

3. Encourage family to wake child before episode for 1-2 weeks to attempt to break cycle.

4. Protect child from injury.

5. Prepare babysitter for possible episode.

6. Leave bedroom door open.

7. Provide comfort, reassurance to child.

8. Counseling may be necessary for children who have severe nighttime fears.

H. Follow up.

1. Refer to psychologist or psychiatrist if night terrors or nightmares persist.

2. Complete family evaluation may be necessary.

I. Complications.

Night terrors, 307.46

1. Injury.

2. Continued nighttime fears.

J. Education.

1. Often night terrors are self-limiting.

2. Family support may be necessary to reduce parental anxiety.


A. School-refusal behavior refers to any refusal to attend school or difficulty attending classes for an entire day by a child.

B. Occurrence.

1. 5-28% of youths.

2. Prevalence: fairly equivalent among gender, racial, and economic status.

C. Triggers for school refusal.

1. Dysfunctional family patterns.

2. Impending school changes.

3. Illness.

4. Traumatic experiences.

D. Clinical manifestations.

1. Range of behaviors.

2. Depression.

3. Social anxiety.

4. Fears.

5. Fatigue.

6. Somatic complaints.

7. Noncompliance.

8. Aggression.

9. Clinging.

10. Temper tantrums.

11. Run away from home.

E. Physical findings.

1. No physical exam findings.

2. Mental health assessment may reveal comorbid mental health problems.

F. Diagnostic tests and assessment tools.

1. Consider drug and alcohol screening based on presenting history.

2. Consider pregnancy testing and screening for sexually transmitted disease if history of runaway.

3. Anxiety Disorders Interview Schedule for DSM-IV (Parent and Child versions).

4. The School Refusal Assessment Scale-Revised (SRAS-R).

G. Treatment.

1. Determine who will conduct the interventions: refer to school psychologist, social worker.

2. Cognitive behavioral therapy.

3. Relaxation therapy.

4. Problem solving skills instruction.

5. Parent interventions.

6. Morning and evening routines.

H. Education.

1. Instructions for parents on effective parenting skills.

I. Follow up.

1. Monitor progress weekly and then monthly until problem resolves.


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