Concepts of Development and Behavior in Children
Developmental-behavioral pediatrics is a subdiscipline that has emerged in recent years from child healthcare. Developmental and behavioral issues are common during childhood, including conditions like attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), tic disorders, sleep disorders, and learning disabilities. During adolescence, psychological and emotional problems tend to become more prominent.
Common Developmental and Behavioral Problems in Childhood
Breath-Holding Spells
Breath-holding spells are a type of abnormal behavior associated with personality and are commonly seen in infants aged 6 to 18 months. These episodes usually resolve naturally by the age of 5 years. Breath-holding spells typically occur during intense emotional reactions such as anger, fear, pain, or excessive crying. They often involve hyperventilation, which leads to inhibition of the respiratory center. During crying episodes, breath-holding may result in cerebral vasodilation and hypoxia, causing fainting, loss of consciousness, cyanosis of the lips, rigidity in the trunk and limbs, and, in some cases, limb convulsions. Symptoms usually last 30 seconds to 1 minute, after which breathing resumes, symptoms subside, lips regain their color, the muscles relax, and the child wakes up. Episodes may occur several times a day. Such children often display temperamental traits like irritability, willfulness, and frequent outbursts. Strengthening family education practices can be helpful. Addressing conflicts with patience and reasoning, rather than using harsh reprimands or physical punishment, can reduce the likelihood of tantrums or crying episodes. When necessary, distinguishing breath-holding spells from epilepsy may be required.
Thumb-Sucking and Nail-Biting Habits
Infants around 3 to 4 months of age have a physiological need for sucking and often engage in thumb-sucking for self-soothing. This behavior typically occurs when the child is hungry or before sleep and usually diminishes with age. However, in some cases, lack of psychological fulfillment, tension, fear, parental neglect, or insufficient stimulation from toys, music, or visuals may lead children to engage in thumb-sucking for comfort, eventually forming a habit that persists into later childhood. Chronic thumb-sucking can affect dental, gum, and jaw development, leading to malocclusion, forward protrusion of the jaw, and interference with chewing.
Nail-biting habits develop in a similar way to thumb-sucking, often arising from emotional tension or unmet emotional needs and are common in preschool and school-aged children. Providing love and care to reduce feelings of loneliness or depression can help address these habits. Redirecting attention to other activities when thumb-sucking or nail-biting occurs and encouraging the development of confidence to break the habit can be effective strategies. It is important to avoid scolding or sarcasm, as these approaches may lead to feelings of inferiority. Applying bitter medications to the fingers often proves ineffective.
Enuresis
Normally, children gain control over urination between the ages of 2 and 3 years. Enuresis refers to involuntary urination, typically occurring after the age of 5 years. Most cases involve bedwetting during deep sleep, known as nocturnal enuresis. Enuresis can be categorized into two types:
Primary Enuresis
This is more common and often familial, with higher prevalence in boys than girls (2:1 to 3:1). It is typically not associated with organic abnormalities and is often due to delayed development of bladder control.
Secondary Enuresis
This may result from systemic or urinary tract diseases such as diabetes mellitus or diabetes insipidus. Other contributing factors may include intellectual disability, neuropsychiatric trauma, urinary tract abnormalities, infections (particularly cystitis or urethritis), or inflammation of the perineum. Symptoms of secondary enuresis usually resolve after treatment of the underlying condition.
Primary enuresis tends to occur at night but may occasionally happen during daytime naps. Frequency can range from 1–2 times per week to nightly or even multiple times per night. Factors such as poor health, fatigue, overexcitement, tension, or emotional fluctuations can exacerbate symptoms. Symptoms may spontaneously improve or resolve but can also recur. About 50% of affected children experience a gradual decrease in frequency over 3–4 years, leading to self-resolution, though some continue to have enuresis into adolescence, causing significant psychological distress and affecting daily life and academic performance.
When managing children with enuresis, underlying systemic or local disorders that may lead to secondary enuresis must first be ruled out.
For primary enuresis, collaboration between the family and the child is key. Physicians play a role in guiding families to establish appropriate daily routines and maintain consistent toilet training. Scolding, ridicule, or punishment for wetting incidents should be avoided, as these actions can exacerbate psychological burdens. Training should include gradual extension of the intervals between urination and encouraging complete bladder emptying during each visit to the toilet. Limiting fluid intake after dinner, voiding before bedtime, and awakening the child before their usual enuresis time to urinate can be helpful techniques. Alarm devices may also assist with training when needed.
Pharmacological treatments achieve success in approximately 80% of cases. Commonly used medications include the antidiuretic drug desmopressin, which reduces urine output. The dosage is typically 0.1–0.2 μg taken orally before bedtime, with a treatment duration of 3–6 months. Tricyclic antidepressants, such as imipramine, can also be used in certain cases.
Habitual Leg Rubbing
Habitual leg rubbing refers to repetitive behaviors in children involving the friction of the perineum (external genital area). This behavior is not uncommon in childhood and is observed more frequently in girls and young children. Affected children typically have normal intelligence and remain conscious during episodes, which often occur before falling asleep, upon waking, or during play. The behavior can usually be interrupted by distracting the child. During episodes, girls may prefer to sit on hard objects, pressing their legs or lower abdomen together tightly, clenching their fists, or holding onto objects. Boys may rub themselves against the bed while lying face down or exhibit similar behavior to girls. After episodes, symptoms in girls may include vulvar congestion, increased secretions, or darkened pigmentation of the labia; boys may experience penile erection, slight congestion at the urethral opening, or mild swelling. Psychological and behavioral interventions, such as reducing psychological stress, promoting a cheerful and relaxed environment, and encouraging participation in various games and activities, are commonly recognized as effective measures. During episodes, drawing attention to engaging activities or ensuring the child goes to bed tired may help reduce occurrences. Prompt rising upon waking and maintaining cleanliness of the perineal area are also recommended. Habitual leg rubbing in children often diminishes naturally with age.
Attention-Deficit/Hyperactivity Disorder (ADHD)
The prevalence of ADHD among school-aged children is approximately 3–5%, making it one of the most common behavioral disorders in this age group. It is characterized by inattention, hyperactivity, and impulsive behavior, often accompanied by learning difficulties, while intelligence levels remain normal or near-normal. Boys are significantly more affected than girls. ADHD lacks specific etiological or pathological features, and there are no definitive physical signs or laboratory tests to assist in diagnosis. Diagnosis is primarily based on the child's medical history and observations, descriptions, and follow-up evaluations of specific behavioral symptoms. Commonly used behavioral assessment tools include the Conners Parent Rating Scale, Conners Teacher Rating Scale, Achenbach Child Behavior Checklist, and Teacher Report Form.
Diagnostic criteria often follow the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association. The 11th edition of the International Classification of Diseases (ICD-11) by the World Health Organization is also widely used.
The principles of ADHD treatment and management include medication and psychological or behavioral therapy. Common medications include central nervous system stimulants (methylphenidate hydrochloride) and norepinephrine reuptake inhibitors (atomoxetine hydrochloride). Psychological and behavioral therapies often involve reinforcement, shaping, extinction, and, in some cases, punishment. Consistent efforts to foster the child’s self-regulation abilities are also emphasized.
Autism Spectrum Disorder (ASD)
ASD refers to a group of heterogeneous disorders, with autism being a representative condition. Typical autism is clinically characterized by varying degrees of social interaction deficits, communication difficulties, restricted interests, and repetitive behaviors. The prevalence of ASD in the United States is approximately 1%. Over the past half-century, the understanding of ASD in terms of concepts, diagnosis, and classification has undergone significant changes, especially in the past decade. Advances have also been made in understanding its etiology, treatment, and prognosis. However, the exact cause remains unclear, and there is no specific curative medication. Early screening and early intervention have proven to be effective, primarily relying on comprehensive education and behavioral training to achieve varying degrees of symptom improvement.
Sleep Disorders (SD)
Sleep disorders can generally be categorized into sleep dysregulation, parasomnia, and pathological sleep. In children, sleep disorders result from a combination of genetic factors, illnesses, perinatal factors, temperament, family environment, and parenting styles. Research from other countries highlights the significant impact of sleep disorders on children’s neuropsychological and cognitive functioning, including attention deficits, hyperactivity, memory decline, behavioral issues, and emotional problems. The prevalence of sleep disorders in children is approximately 20%.
The systematic evaluation of pediatric sleep disorders includes a comprehensive medical history, detailed social history, psychological/developmental screenings, and physical examinations. For diagnosing certain specific sleep disorders, additional psychological testing, neurological evaluations, laboratory screenings, or sleep studies conducted in a sleep laboratory may be necessary.
Like other disorders, understanding the characteristics and mechanisms behind sleep disorders allows for appropriate interventions, which can significantly alleviate or even resolve symptoms. Therapeutic interventions include health education, psychological and behavioral therapies, chronotherapy, light therapy, pharmacological treatments, physical therapy, and surgical interventions. Treatment typically begins with health education, as it is the least invasive and most convenient approach.
Learning Disabilities
Learning disabilities, classified as specific developmental disorders, refer to significant difficulties in acquiring and utilizing specific skills such as listening, speaking, reading, writing, calculation, or reasoning. These challenges often manifest alongside a range of associated syndromes. Learning disabilities are more prevalent among school-aged children, particularly in second and third grade, with boys being more affected than girls. Such disabilities may involve discrepancies in learning abilities, such as disparities between verbal and performance skills; coordination motor impairments, such as poor eye-hand coordination affecting fine motor tasks like drawing; and phonemic confusion, which disrupts listening, speaking, and comprehension. Other manifestations may include imbalances between comprehension and verbal expression, difficulties with reading and decoding, articulation disorders, or difficulties in communication. Perceptual conversion impairments may also occur, such as difficulties associating the word "dog" with its image or writing its representation. Visual and spatial perception challenges may lead to difficulty distinguishing numbers such as 6 and 9, or letters such as b and d, thereby impacting reading and comprehension abilities.
Children with learning disabilities do not necessarily exhibit intellectual impairment, but their cognitive characteristics result in difficulties adapting to schoolwork and daily life. A significant proportion of children refusing to attend school have been found to have learning disabilities. Careful assessment to identify causes and the implementation of tailored educational interventions are necessary for this population.
Psychological and Behavioral Problems Common During Adolescence
During adolescence, the body undergoes rapid growth and development, particularly in the reproductive system, which reaches sexual maturity during this period. However, psychological and social adaptation capabilities often develop more slowly, making adolescents vulnerable to psychological disturbances and fluctuations. This developmental disparity gives rise to complex mental health issues specific to adolescence.
Most adolescents experience emotional or behavioral challenges at some stage or in some aspect of their development during this period, a condition referred to as disturbed psychosocial development. Examples include anxiety, depression, or harmful habits. In the majority of cases, these challenges are temporary and can be resolved with appropriate guidance and support. If left unaddressed, however, they may persist for a longer duration, becoming increasingly complex and severe, potentially leading to psychological deficits that could affect health, education, work, and behavior throughout life. In severe cases, these issues may also pose risks to the well-being of families and society.
Adolescent Syndrome
Adolescent syndrome refers to a set of physiological imbalances and psychological disorders specific to adolescents. This syndrome arises when physical development and psychological development are not synchronized, with the latter lagging behind. Overuse of mental faculties and poor habits are also key contributing factors. The main manifestations of adolescent syndrome include the following:
Imbalance in Brain Neurological Function
This includes symptoms such as decreased memory, difficulty concentrating, inattentiveness during class, slowed thinking, mental confusion, and academic decline. Adolescents may experience lethargy and mental fog during the day, often dozing off in class, while at night they may feel overly stimulated, with racing thoughts, difficulty falling asleep, vivid dreams, and waking with extreme mental fatigue and a lack of vigor.
Imbalance in Sexual Neurological Function
This includes frequent sexual impulses, the development of unhealthy sexual habits, and excessive masturbation that becomes difficult to overcome with willpower. Due to excessive masturbation or poor hygiene, symptoms such as redness, swelling, itching, and odor may develop, sometimes leading to inflammation or underdevelopment of reproductive organs.
Imbalance in Psychological Function: The above physiological disturbances may lead to psychological distress. Signs include poor mental well-being, feelings of inferiority, self-blame, anxiety and depression, irritability, negativity, sensitivity, lack of interest in studies, aloofness, sadness, fear, self-abandonment, school refusal, truancy, running away from home, and, in extreme cases, self-harm or suicidal ideation.
Although adolescent syndrome is not classified as a severe psychological abnormality, it can have a detrimental impact on adolescents’ psychological development and personality formation. Failing to address these challenges promptly could result in more serious psychological disorders. Adequate attention is needed to support adolescents in overcoming this phase. Educational efforts to help adolescents evaluate themselves accurately, understand human physiology and hygiene, and deal constructively with issues related to sexuality are crucial. Cultivating rational thinking and building strong willpower to overcome harmful behaviors can help adolescents transition through this period in a healthy and balanced manner.
Adolescent Anxiety Disorder
Adolescent anxiety disorder is a form of anxiety neurosis characterized by emotional syndromes dominated by anxiety, accompanied by significant dysfunction of the autonomic nervous system. Adolescence is a high-risk period for anxiety disorders due to the rapid developmental changes and physical and psychological transitions taking place. The emergence of secondary sexual characteristics and the accompanying physical, physiological, and psychological changes can evoke feelings of mystery and confusion in adolescents, leaving them uncertain about how to cope.
For instance, girls may feel self-conscious about their developing breasts, leading to slouched posture, or they may experience anxiety and discomfort with the onset of menstruation. Boys may struggle with guilt and self-reproach following sexual impulses, nocturnal emissions, or masturbation. These experiences can significantly impact adolescents' mental health, emotions, and behavior. Adolescents often exhibit signs of curiosity, fear, unease, shyness, loneliness, self-doubt, and frustration. Physical symptoms may also manifest, including dizziness, headaches, insomnia, vivid dreams, vertigo, fatigue, dry mouth, poor appetite, palpitations, shortness of breath, nervousness, emotional instability, weight loss, and general anxiety.
Adolescents with these symptoms may frequently seek consultation in internal medicine and neurology departments, often undergoing repeated examinations that fail to identify any organic abnormalities. In mental health settings, these conditions are commonly diagnosed as adolescent anxiety disorder. This condition poses a serious threat to adolescents’ physical and psychological health and requires timely and appropriate treatment. Treatment typically involves psychological therapy as the primary intervention, often supplemented by medication.
Adolescent Depression
Emotional changes during adolescence represent an adaptation to physical changes, shifts in social roles, and evolving relationships. These changes are characterized by high-intensity reactions, variability, and complex emotional shifts. Adolescents may easily experience intense joy or anger, as well as profound sadness or fear. Emotional instability, such as frustration, anxiety, and depression, frequently arises from unfavorable external factors, including neglect, suppression, or perceived unfairness by parents or teachers, academic pressure, and confusion regarding sexual development. The onset of sexual maturity, combined with the academic demands, intensifies the stress on the nervous system, making it more prone to dysfunction, particularly in the face of setbacks or distress. Excessive emotional intensity or persistent low mood can lead to sustained states of tension, anxiety, depression, guilt, or panic, culminating in depression.
Depression is characterized by a low mood, slowed thinking, decreased activity and speech, accompanied by anxiety, physical discomfort, and sleep disturbances. Persistent depression is commonly defined as low mood that occurs at least three times a week, with each episode lasting three hours or more. The prevalence of adolescent depression is reported to range from 0.4% to 8.3%, with females being two to three times more likely to develop it than males.
The manifestations of adolescent depression are varied and include the following:
- Self-Devaluation: Adolescents may show self-blame and self-pity, perceiving themselves as clumsy, foolish, unattractive, or lacking worth.
- Hyperactivity: This pattern is more common in males, who may appear indifferent outwardly but feel deeply lonely and empty internally. Some adolescents channel their emotional distress into behaviors such as excessive activity, provocation, fighting, truancy, or vandalism.
- Apathy: Persistent low spirits, dissatisfaction, or gloom is common. Adolescents in this category often feel as though everything around them is bleak or lifeless.
The severity of depression can vary significantly. Mild forms of adolescent depression are most common, but severe cases can have a profound impact on physical and mental well-being. Adolescents in severe depressive states may lose interest in academics, struggle to concentrate, and experience sharp declines in academic performance. Pessimism toward the future, suicidal thoughts, poor interpersonal relationships, and an inability to recognize their condition or seek help are also common. Without effective intervention, severe depression often leads to serious consequences. Preventing and addressing adolescent depression is, therefore, a critical component of adolescent health care.
Other Issues
Internet Addiction
Internet addiction refers to excessive or prolonged immersion in online activities, leading to a state of dependency that is difficult to escape from both behaviorally and psychologically. Four main criteria are used to assess internet addiction:
- A sense of psychological and behavioral dependence on the internet.
- A significant loss of self-regulation and control over internet use.
- Disruption of normal work, life routines, or social functioning.
- Significant harm to physical and mental health.
Adolescents with internet addiction often lose track of time while online and may experience irritability, restlessness, or a sense of emptiness when unable to access the internet. Many report feeling happier or more fulfilled online compared to real-life interactions. A growing number of adolescents are becoming engrossed in online gaming or internet use, leading to difficulty disengaging. Extended internet use can give rise to emotional instability, difficulty concentrating, low mood, slowed thinking, loneliness, anxiety, autonomic dysfunction, and sleep disturbances. These behaviors can severely damage physical and mental health. In some cases, internet addiction has led adolescents to engage in risky or illegal activities, such as drug use, theft, or other criminal behavior, often facilitated by meeting strangers online.
While the internet’s rapid development has revolutionized daily life and productivity, understanding and utilizing internet technology effectively is essential for entering the information age. For adolescents, attention must be paid to their unique physiological and psychological stages of development. Purely prohibitory measures alone are not sufficient to address internet addiction. Collaboration between teachers and parents is an indispensable aspect of helping adolescents overcome the problem. Open communication with adolescents and guidance on responsible internet use are key to enabling them to harness the abundant resources available online for their personal growth and development.
Substance Abuse
Substance abuse refers to the repeated and excessive use of harmful substances with no medical purpose, particularly substances with addictive potential. These include tobacco, alcohol, and certain drugs such as sedatives, painkillers, opioids, cannabis, cocaine, hallucinogens, and anabolic steroids. Due to the psychological characteristics of adolescence, the increasing complexity of modern society, and the widespread availability of various substances, more adolescents are engaging in substance abuse.
A community survey of adolescents and adults revealed a notable prevalence of substance dependence among individuals aged 15–24, with differing severity depending on the substance in question. Many cases of substance abuse in children and adolescents go undetected and untreated. The physical and mental damage caused by substance abuse has become a significant worldwide concern, particularly in the adolescent population.
The types of substances abused vary according to factors such as age, gender, region, race, and geography. Commonly abused substances among adolescents include alcohol, tobacco, hallucinogens, sedatives, stimulants, and opioids, each with its unique associated harms.
An effective method for preventing adolescent substance abuse involves strengthening awareness and education during adolescence regarding the risks of substance use. Psychological support and guidance are also critical in fostering resilience against substance abuse.
Successful long-term management of adolescents with substance use disorders typically involves physiological detoxification, followed by continued medical monitoring and the provision of appropriate psychosocial support.