TABLE 6-10 Emotional Disturbances in Children

Stage Disturbance Assessment: Symptoms or Characteristics Analysis: Behavior Related To: Plan/Implementation:

Anal (1-3years)
Elimination disorders (disturbances related to toilet training)
Constipation
  1. Diet.
  2. Child withholding due to history of one or two painful, hard bowel movements.
  3. Psychological causation: child withholds from parents to express anger, opposition, or passage through a very independent development stage.
  • Evaluate diet and consistency of stools. Fecal softener may be prescribed if necessary.
  • In all cases, help parent avoid making an issue of constipation with the child.
  • Enemas are contraindicated. If child is withholding, work with parents around not forcing rigid toilet training on child.
  • Most children are more cooperative about toilet training at 18-24 months.

Encopresis (soiling).
  • Child’s expression of anger or hostility. It is usually directed toward the parent with whom the child is experiencing conflict and is rarely physiological.
  • Medical evaluation, then assessment and intervention in the child-parent relationship.
  • Therapy for child and parent may be indicated.

Excessive rebelliousness
Frequent temper tantrums, fighting, destruction of toys and other objects, consistent oppositional behavior.
  1. Fear caused by inconsistency in handling the child, the setting of rigid limits, or the parents’ refusal or inability to set limits, which can all create insecurity and fear in the child.
  2. Excessive rebelliousness, usually indicating a frightened child; should not be confused with expression of negativism normal at around age 2, which is a necessary (though trying) developmental stage.
  • The nurse should offer parent counseling if necessary.
  • When working with the child, the nurse needs to be receptive and sympathetic while establishing and maintaining firm limits.

Excessive conformity
Lack of spontaneity, anxious desire always to please all adult authority figures, timidity, refusal to assert own needs, passivity.
  1. Very rigid control established in an attempt to handle fears.
  2. Harsh toilet training, resulting in an overcompliant child. These children need help as much as overrebellious children, but they get it less frequently because their behavior is not a “problem”—that is, it is not difficult for parents to tolerate.

  • Excessive conformity can lead to compulsive, ritualistic, or obsessive behavior later. The nurse needs to be able to identify such a child, then work with the child and parents to encourage self-expression in the child.
  • Referral for psychotherapy may be necessary to help the child deal with repressed anger.

Enuresis. Ordinarily refers to wetting while asleep (nocturnal enuresis), though some enuretic children wet themselves during the day also. Enuresis is a symptom, not a diagnosis or disease entity.
  1. Faulty toilet training (especially if child wets during the day also) or.
  2. Psychological stress.
  3. Physiological etiology, such as genitourinary (GU) tract infections or CNS disease, is rare. The child under 4 years old is usually not considered enuretic but is included in this section because bladder training is part of toilet training. Etiology is uncertain.

  • Many approaches have been tried with varying degrees of success. These include fluid restriction, behavioral intervention (in which a buzzer wakes the child when the child starts to wet), and psychotherapy.
  • Educating parents in bladder training techniques and attitudes can help solve the problem on a primary level.
  • It is important when working with enuretic children or their parents to suggest ways to help the child overcome feelings of shame and guilt. These feelings are often exacerbated by well-meaning but misguided parents.