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PE5.1-4 | Behavioural Problems — Assignment

CLINICAL SCENARIO

You will assess a real or standardised paediatric case involving a child presenting with a behavioural problem (feeding difficulty, breath-holding spell, temper tantrums, pica, or enuresis). You will construct a structured clinical write-up covering history, diagnosis, evidence-based management, and parent counselling strategy. This exercise builds competency in recognising behavioural presentations in Indian paediatric practice, distinguishing normal developmental variants from pathological conditions, and communicating a management plan to caregivers.

Instructions

Select a case from your recent clinical exposure (OPD/ward) or use the standardised case provided by your faculty. The case must involve one of the following: feeding problem (PE5.1), breath-holding spell (PE5.2), temper tantrum or pica (PE5.3), or enuresis (PE5.4).
Obtain a detailed history using the structure in Section 1 below.
Perform a targeted physical examination relevant to the complaint (document findings in Section 2).
Develop a differential diagnosis and justify your working diagnosis in Section 3.
Outline your investigation plan and interpret any results in Section 4.
Devise a management plan that addresses both the organic and behavioural dimensions in Section 5.
Write out the key points you would communicate to the parents/caregivers in plain language in Section 6.
Reflect on how socioeconomic and cultural factors (e.g., Indian family feeding practices, joint-family dynamics, school pressures) influence presentation and management in Section 7.
Submit your write-up by the due date for peer review.

Length: 1200-1800 words (excluding growth charts and investigation reports)

What to Submit

Section 1: Clinical History

Guidance: Record: chief complaint in the parent's own words; detailed characterisation of the behavioural symptom (onset, duration, frequency, triggers, pattern, progression); birth history; developmental milestone chart (motor, language, social, adaptive — with ages achieved); feeding history from birth; family history of similar conditions; psychosocial history (family structure, recent stressors, school, sibling dynamics); immunisation status. For enuresis: distinguish primary vs secondary; daytime vs nighttime; voiding pattern; fluid intake; sleep history.

Section 2: Physical Examination Findings

Guidance: Document: growth parameters (weight, height, OFC) plotted on IAP/WHO growth chart with centile; general examination (pallor — for iron deficiency/anaemia in BHS/pica; oedema); CNS examination (tone, reflexes, developmental screening); abdominal examination (organomegaly); genitourinary examination if enuresis (meatal stenosis, labial adhesions, signs of spinal dysraphism — sacral dimple, hair tuft, naevus).

Section 3: Diagnosis and Differential Diagnosis

Guidance: State your working diagnosis with diagnostic criteria met. For breath-holding spells, specify cyanotic vs pallid and how the history distinguishes them from epilepsy (trigger, cry, colour change, LOC duration, post-ictal state). For enuresis, distinguish primary vs secondary and include organic differentials (UTI, posterior urethral valves, DM, DI, spinal dysraphism). For pica, list organic associations investigated (iron deficiency, lead, ASD, intellectual disability). For temper tantrums, address whether developmental red flags for ASD are present.

Section 4: Investigations

Guidance: Justify each investigation ordered. Must include: haemoglobin and peripheral smear (for anaemia in BHS/pica); serum ferritin and iron indices; blood lead level (mandatory if pica involves paint chips/soil/chalk); urine routine and culture (enuresis); renal ultrasound (if structural enuresis cause suspected). For BHS, state whether EEG is routinely required and justify your decision. Interpret all results in clinical context.

Section 5: Management Plan

Guidance: Structure the plan as: (a) Treat any identifiable organic cause (iron supplementation for iron deficiency; DMSA chelation threshold and dose if BLL ≥45 mcg/dL; UTI treatment if culture positive); (b) Behavioural and environmental strategies specific to the condition (responsive feeding; extinction for tantrums; star charts/alarm for enuresis; source removal for pica); (c) Pharmacological options with specific indications, dosing, and when they are second/third line (desmopressin for enuresis: oral tablet preferred; imipramine: third-line only); (d) Referral criteria (when to refer to developmental paediatrics, neurology, nephrology/urology, child psychiatry). State explicit follow-up plan with milestones.

Section 6: Parent Counselling Script (Plain Language)

Guidance: Write what you would actually say to the parent in 150-200 words of plain language (avoid jargon). Must address: what the diagnosis is and why it is or is not dangerous; what to do during an episode (relevant for BHS tantrums); what the expected natural course is; three practical things the parent can do at home; when to bring the child back urgently. Demonstrate empathy — acknowledge parental anxiety explicitly.

Section 7: Sociocultural and Contextual Reflection

Guidance: Reflect (200-300 words) on: How do Indian cultural norms around feeding (pressure to finish plate, specific textures/foods considered essential) contribute to feeding problems? How do joint-family dynamics and multiple caregivers affect management of tantrums and enuresis? How does stigma around bed-wetting in school-aged children affect help-seeking and management adherence? What health-system barriers exist for accessing an enuresis alarm in a low-income family in rural India, and what alternatives can you suggest?

Grading Rubric — Behavioural Problems Case Write-Up Rubric

Criterion	Points	Full-marks descriptor
History quality and symptom characterisation	20 pts	All key elements documented: triggers, pattern, duration, developmental milestones with ages, psychosocial context, and feeding/voiding/birth history as relevant. Primary vs secondary enuresis or cyanotic vs pallid BHS correctly distinguished with evidence from history.
Diagnostic reasoning and differential diagnosis	20 pts	Working diagnosis explicitly stated with criteria met. Differentials are clinically appropriate and distinguished by specific features in the history/examination (e.g., BHS vs epilepsy vs cardiac; enuresis vs structural/organic causes). Organic causes are systematically excluded.
Investigation plan and interpretation	15 pts	All indicated investigations ordered with explicit justification (e.g., EEG not routinely indicated in typical BHS — stated with reason; blood lead level mandatory in paint-chip pica; urine culture in enuresis). Results correctly interpreted and linked to management decisions.
Management plan (organic + behavioural + pharmacological)	25 pts	Three-component plan clearly articulated: (1) organic treatment (iron dose mg/kg, lead chelation with correct threshold ≥45 mcg/dL for DMSA, UTI treatment); (2) behavioural strategies specific to the condition (responsive feeding, extinction, star charts + alarm for enuresis); (3) pharmacological options with correct indications and drug-specific hierarchy (desmopressin oral = second-line; imipramine = third-line; DMSA for BLL ≥45). Follow-up milestones and referral criteria stated.
Parent counselling and sociocultural reflection	20 pts	Counselling is in plain language, explicitly acknowledges parental anxiety, covers natural course, home strategies, and return-to-clinic criteria. Reflection meaningfully addresses Indian cultural feeding norms, joint-family dynamics, stigma around enuresis, and at least one practical alternative for a resource-limited family (e.g., bell-and-pad vs alarm substitutes; community health worker support).

PEER REVIEW

Your peer reviewer will assess your write-up against the rubric above. As a reviewer: (1) Check that the working diagnosis is justified by the history; (2) Verify that the primary vs secondary enuresis / cyanotic vs pallid BHS distinction is correctly drawn if applicable; (3) Confirm the management hierarchy is correct — note if first-line pharmacological agents are used before behavioural strategies; (4) Assess whether blood lead level was mentioned if pica is the presenting complaint; (5) Comment on the parent counselling language — is it jargon-free and empathetic? Provide at least two specific strengths and two specific suggestions for improvement. Numerical scoring should reflect the rubric descriptors precisely.