Pediatric Neurology

The emotional and behavioral disorders can be primary psychiatric anomalies or may occur as a sequel of neurological issues. It’s imperative to identify them and treat accordingly.

The different types of behavior disorders are:

• Oppositional Defiant Disorder
• Conduct Disorder
• Attention Deficit Hyperactivity Disorder (ADHD)
• Intermittent Explosive Disorder
• Kleptomania
• Pyromania

Oppositional Defiant Disorder:

It is more common in boys than in girls. This disorder is found in every one in ten children under the age of 12 years of age. About five to fifteen percent school children have this disorder.

The behavioral symptoms of these children include frequent temper tantrums, child easily gets angered or frustrated. He/she gets easily into arguments with adults specially their parents.

They refuse to obey rules and usually have a low self-esteem and self- worth.

Attention Deficit Hyperactivity Disorder (ADHD):

About two to five per cent of children have this disorder. Boys outnumber girls by three to one.

The characteristic features of ADHD are: inattentiveness, impulsive and over activity.

The child has difficulty in concentrating on his/her daily work. They are easily distracted, forget instructions and move from one task to another without completing anything.

The child has a habit of talking over the top of others, has a short fuse and there is a tendency to be accident prone. The child is constantly fidgeting and restless.

Conduct Disorder :

About five percent of children in the age group 8 to 10 years have conduct disorder, with boys outnumbering girls by four to one.

They tend to have delinquent behavior and refuse to obey authority figures like their parents, teachers etc.

They have a tendency to use drugs from an early age. They show aggressiveness towards other people and animals and pick up fights easily. They show criminal tendencies such as stealing, breaking into houses and vandalism.

Treatment:

The treatment of the child depends on the type of disorder and factors contributing to it.

The basic therapies involved are:

Education of the parents– The parents are taught communication and problem solving skills which can help them in handling their child.

Cognitive behavior therapy– The child is taught to control his/her thoughts and actions.

Social training– The child is taught social skills; he learns to interact with his peers and elders and to cooperate with others. The child is encouraged to participate in extracurricular activities to build his self-esteem.

Relaxation techniques – The child is taught how to cope with situations which could lead to him/her getting frustrated or angered. Stress management is also taught.

Medication – Can be given to control impulsive behavior.

Headaches are common in children. The type of primary headaches in children includes: Migraine, Tension Type Headache, Chronic Daily Headache.

Migraine affects boys and girls equally in the pediatric age group.

Migraine is the most common recurrent headache in children accompanied with nausea/vomiting, phonophobia, photophobia, abdominal pain and relieved with sleep. The headache may last for an hour or two.Children with migraines have a much greater probability of irregular behavioral scores than children without headaches, primarily in social, anxiety-depressive, internalizing, and attention areas.

Childhood migraine syndromes

• Benign paroxysmal vertigo
• Cyclical vomiting (abdominal migraine)
• Basilar artery migraine
• Acute confusional migraine

Cyclical Vomiting in children (2 – 8 yrs) may have episodic abdominal pain as well child maybe pale with increase sensitivity to light and noise. Headaches appear when the child is older.

Benign Paroxysmal Vertigo of children is characterized by brief episodes of vertigo, imbalance and nausea. Usually occurs in young children (2 – 6yrs). There is no accompanying ear disease. These children develop headaches (migraine) as they grow up.

Tension-type headaches can last from 30 minutes to several days. The symptoms include mild to moderate, non – pulsating pain on both sides of the head. Younger children may withdraw from regular play and want to sleep more.

Chronic Daily Headache may be caused by migraine, tension type headache, infection, minor head injury, or taking pain medications too often.

Headaches that worsen over time and occur along with other neurological symptoms such as loss of vision, speech problems, or muscle weakness, can be the sign of a more serious problem, such as: meningitis, encephalitis, hemorrhage, tumor or head trauma

What are the red flags, when to seek prompt medical care:

• When the headaches worsen and become frequent
• Associated with persistent vomiting/visual problems.
• Change in behavior and personality
• Awakening at night because of headaches
• Fever and neck pain accompanying the headache.
• Children often have difficulty in expressing their symptoms that can be inferred from their behavior.

Watch your child’s behavior when having a headache:

• If the child talks less
• Wants to lie in a quiet place to have a nap
• If the child is irritated
• Does not wish to play or watch T.V. (wishes to avoid light)
• Does not wish to eat his/her favorite food or complains of stomach ache (nausea)
• When the child resumes his/her normal activities

Treatment should be comprehensive pharmacological and non pharmacological after the type of headache is identified.

• Lead a disciplined life with regular meals, exercise and adequate sleep to avoid the triggers.
• The pain killers should not be used more than twice a week, unless under medical supervision.
• Factors that trigger the headaches should be avoided.

Therapies

• Relaxation techniques can be applied. These are deep breathing, yoga, meditation and progressive muscle relaxation.
•  Biofeedback therapy teaches a child to control certain body responses that help reduce pain. The child learns how to reduce muscle tension and slow his/her heart rate and breathing.
• Cognitive behavioral therapy can help the child to cope with severity of headaches. A counselor can help a child learn ways to cope with life events more positively.

Cerebral palsy is a neurological disorder caused by brain injury or any malformation that occurs while the child’s brain is developing. Cerebral palsy primarily affects body movement, muscle coordination and intelligence in the form of mental retardation.

Cerebral palsy is the most common childhood motor disability and approximately 2 to 3 children in 1,000 over the age of three have cerebral palsy. There are an estimated 25 lakh children and people in India with CP, making it the commonest cause of disability.

Causes of Cerebral Palsy:

Asphyxia during labour, infections during pregnancy, premature babies, blood diseases or severe jaundice in the neonatal period.

Most of the time in cerebral palsy the arms and legs are very stiff and feel weak. Thus all kinds of action and movement become very difficult. The stiffness and spasm can be very painful. These children tend to have a lot of behavioral issues.The quality of life of a child depends on severity and type of the cerebral palsy.

The earliest indicator that a child has cerebral palsy is a delay in achieving developmental milestones. The child may have trouble in crawling and walking, speech difficulties or some may have writhing movements of the hands and feet. Studies highlight that more than 40 percent of children with cerebral palsy suffer from an intellectual disability. Some children may have recurrent seizures.

Behavioral problems are common in children with cerebral palsy. They are easily frustrated, upset or angry. They may get anxious or moody quickly. They have difficulty in following daily routine. Their attention span maybe short and are easily distracted.

Treatment

• Physiotherapy is begun soon after diagnosis.
• Sometimes braces, splints or casts are used along with physiotherapy to improve function of the hands or legs.
• Drugs sometimes are recommended to ease spasticity and also control seizures.
• Occupational therapists work with the child on skills required for daily living and also for behavior modification.
• Speech therapy may help children with speech disabilities.
• Surgery may be recommended for children with spasticity in both legs.

One of the most common neurological disorders in children is epilepsy. It is more common in children than in adults. Paras Hospitals, Gurgaon has specialized clinical protocols to treat all types of epilepsy’s.

Epilepsy can be symptomatic or idiopathic:

Symptomatic is when the cause is known. This includes birth trauma, infection, poor development of the brain, a tumor or neurocysticercosis. Epilepsy is called ‘idiopathic’ when the cause is not known or due to a genetic defect. The quality of life of a child is affected due to epileptic seizures.

Drugs for control of seizures may also affect learning and bring down the scholastic performance in children.Tonic-clonic seizures can affect a child’s memory and the recovery time needed after the seizure may affect the child’s school life due to increased absenteeism.

Absence seizures can be brief and can be mistaken for day dreaming or lack of attention. They can occur many times in a day therefore affecting the child’s ability to learn.

Children with epilepsy commonly have behavioral and emotional problems like anxiety, depression, reduced independence, low self esteem and social isolation. There may be significant contribution by overprotective parents.

Treatment:

Anti-epileptic drugs: AEDs help in stopping seizures from happening, but do not cure epilepsy.

More than 2/3rd of children with epilepsy have a very good seizure control with anti epileptic drugs.

Ketogenic diet: This diet may help in reducing the number or severity of the seizures, especially in case of refractory epilepsy. The diet is a medical treatment which is given along with AEDs and is supervised by specialists.

Surgery: Involves removing a small area/lesion in the brain that is causing recurrent seizures in spite of taking multiple anti epileptic drugs. Removal of the cause provides better control of seizures