The Difficult Child

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The Difficult Child

• I. Manor, S. Tyano

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What is a difficult child

• A child who is difficult to live with
• It is a judgmental term
• It refers to a large spectrum of disorders, all
  with behavioral features

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The disorders forming the syndrome
Separate or Additive
Mostly additive
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The disorders forming the syndrome

• Attention Deficit and Hyperactivity-Impulsivity
  Disorder (ADHD/ADD)
• Conduct Disorder (CD)
• Oppositional defiant Disorder (ODD)
• Post Traumatic stress Disorder (PTSD)

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A frequent syndrome

• This syndrome presents quite a large percentage
  of all references to the ambulatory services in
  children and adolescents
• CD Up to 14. 7-8 males, 3-4 females
• ODD Up to 16. 6 males, 11 females
• ADHD 3-10. (4-91 MF ratio)
• PTSD There are only estimations, based on
  studies of at-risk children. Estimates fluctuate
  between 0-100 (Yule, 2001).

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The child in his own eyes

• A difficult child experiences oneself as
  difficult
• It is a behavioral reaction to his own
  helplessness and lack of control
• It becomes a part of his personality structure

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The child in others eyes

• The child evokes uneasiness in others due to
  their helplessness
• An interaction and a vicious circle of cause and
  effect

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The result is a lot of aggression
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Initial assessment

• Or
• How do we approach the difficult child

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Referrals
Paramedical staff
teacher
Councilor
pediatrician
parents
Child and adolescent psychiatrist
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Assessment

• What is the difficulty
• Where is the difficulty
• To whom is one difficult
• Does one feel the difficulty

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Child and adolescent psychiatrist D.D. and
Comorbidity
Disruptive Disorders
PTSD
Affective Disorders
Psychosis
Neurological/Medical
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Differential Diagnosis/Comorbidity

• Unipolar/ Bipolar Disorder (Affective Disorder)
• Anxiety Disorder
• Learning Disorders
• Right Hemisphere syndrome
• Tic Disorder/ Tourette Disorder
• Sleep Disorders
• Drug and alcohol abuse
• Very high or very low intelligence
• Organic Syndromes

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Overdiagnosis and Underdiagnosis
Underdiagnosis Overdiagnosis
Quiet children Unacceptable behavior according to societal rules
Deviant intelligence Deviant intelligence
Severe Axis I Disorders (psychosis and affective disorders) Recoil from the more severe diagnoses
Girls Boys
Social factors Social factors
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Evaluation of the difficult child
History of child Classification
Criteria Psychiatric status
Possible Diagnoses according to probabilities
Cognitive tests Continuous Performance Tests
Specialized tests MRI, SPECT..
Specific Rating Scales
Diagnosis and Comorbidity
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Stage I Clinical Examination

• History
• Heredity
• Psychiatric status
• Getting to the differential diagnosis

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Stage II specific measures

• Questionnaires
• Rating Scales
• Neurocognitive tests
• Continuous Performance Tests (CPT)
• Imaging

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Final Diagnosis

• Single or in comorbidity
• Integration

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The specific syndromes

• Etiology
• Clinical picture
• prognosis

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ADHD
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Early Age ADHD
The first symptoms include 1. Unregulated sleep
and appetite 2. Early motor development 3.
Tendency to inattention, a need of parents
attention and holding
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Early Age ADHD

• The most prominent feature the hyperactivity
  impulsivity
• Attention is sometimes very difficult to measure
• Young children with ADHD exhibit more problem
  behavior and are less socially skilled than
  normal counterparts

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Differential Diagnosis

• Difficult temperament
• Children who have been given no clear limits.
• Behavioral disorder or ODD
• Deviations in IQ (talented / retarded).
• Spasms of Petit Mal type.
• Chronic inflammation of the middle ear,
  antihistaminic medications.
• Undiagnosed sight and hearing problems.
• Other physical and/or chronic conditions, such as
  impaired sight, impaired hearing, hyperthyroid,
  hypothyroid and severe anemia.

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Early Age ADHD Comorbidity

• Preschool children with ADHD are likely to
  exhibit ODD, anxiety, or mood disorders
• Many children with ADHD also show developmental
  disorders such as fine motor skills disorder,
  language disorder, etc.

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Early Age ADHD Treatment

• Preschool children with ADHD respond to
  psychostimulants but need close monitoring
  because of frequent side effects compared to
  older children.
• Psychostimulants are not a necessary component of
  effective treatment for many children with
  preschool ADHD
• Constructive training in parenting strategies is
  an important element

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ADHD in Childhood
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Childhood ADHD

• The time factor begins to be critical (before
  adolescence)
• There is high frequency of comorbidity, which
  increases with age.

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The Pearl Model
The pearl is created around the grain of sand,
which penetrates the oyster. It is an organic
nucleus around which layers of stimuli are
developing. It is a mono-nucleus disorder
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Most Important Features

• Age Dependent

High comorbidity
Sociability
Response to ritalin
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Co-occurring Disorders in Children (n579)
Oppositional Defiant Disorder 40
ADHD alone 31
Tics 11
Conduct Disorder 14
Anxiety Disorder 34
MTA Cooperative Group. Arch Gen Psychiatry
1999 5610881096
Mood Disorders 4
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ADHD in adolescence
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ADHD in adolescence

• The clinical features of adolescent ADHD are
  comprised from the clinical features of ADHD as
  well as those of adolescence
• Which means that these adolescents tend to be
  oppositional, defiant, and have a need to be
  exactly like their peers.
• They are also highly interested in their body and
  its perfection
• Hence, they reject being diagnosed and being
  treated, especially by medications

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ADHD in adolescence

• Apart from what is seen in children, there are
  two important comorbid states
• Alcohol and substance abuse
• Delinquency

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Oppositional Defiant Disorder/Conduct Disorder
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Conduct Disorder Developmental progression
(Lahey Loeber 1994)

Early Conduct disorder
Oppositional symptoms
Severe conduct disorder
AGE 3 4 5 6 7 8 9 10 11
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The development of ODD into CD

• ODD is considered a comparatively benign disorder
  with a good prognosis, but it increases the risk
  for CD (Burke et al, 2000)
• When the children mature, they exhibit a change
  in their behavior, where the most disturbed
  children in one age group become the most
  disturbed ones in the second age group
  (Farrington, 1997).

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The development of ODD into CD in girls

• The rate of development of ODD to CD in girls is
  not clear, since girls tend to develop the
  special form of CD without a history of ODD, and
  apparently girls develop CD in other ways.
• It is also not clear if the less serious
  characteristics of CD in girls, such as lying,
  develop into more serious ones, such as theft

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Models of continuous development of disruptive
behavior disorders

• Overt progression
• aggressiveness physical conflict
  violence (Loeber et al, 2000)
• Covert progression
• Slight covert behaviors property damage
  delinquency (up to age 15)
• Authority conflict
• stubbornness rebellion against
  authority wandering, running away, etc. (up to
  age 12)

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Developmental ODD/CD

• Prognosis is stable over time
• For the younger age group, symptoms such as
  biting and defiance will appear at kindergarten
  age, aggressiveness towards peers at elementary
  school age, internalizing symptoms such as fraud,
  shoplifting or drug abuse in pre-adolescence,
  attacks on property or human beings, even
  including murder, in adolescence or young
  adulthood.

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Developmental ODD/CD (cont)

• A development progression of symptoms such as
  this is called heterotypic continuity (Moffit,
  1993).
• High-risk factors can lead to an earlier
  appearance of symptom development (Patterson,
  Reid Dishion, 1993).

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Child Vs Adolescent CD

• These two disorders differ in regard to symptoms,
  development of the disorder, relative severity,
  gender ratio and prognosis.
• Those in which the disorder appears earlier are
  generally boys whose failures of achievement are
  greater, who have more neuropsychological defects
  and stability over longer periods.

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PTSD
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Risk factors for developing PTSD
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Role of parents

• Children of holocaust survivors were examined who
  were suffering from PTSD (Yehud, 2001).
• It was found that the parents childhood trauma
  constitutes first and foremost a high risk for
  the development of PTSD in children after trauma.

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Davis et al, 2000

• Prior psychopathology, frequent distress
  situations in parents and a high percentage of
  prior sexual abuse differentiated between them
  and those suffering from the partial syndrome or
  not suffering at all.

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PTSD in Early childhood
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• Infants and toddlers perceive and remember
  traumatic events (mostly implicit memory, which
  does not require conscious awareness or recall of
  a retrieved memory) and do develop PTSD, with
  many symptoms similar to those of older children
  and adults.
• The impact of developmental skills on the extent
  to which events become traumatic for an infant
  and on the phenomenology of traumatic reactions
  is huge

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Diagnostic issues four main criteria (Tyano
Keren)

• Re-experiencing Repetitive post-traumatic play,
  distress with reminders, dissociation episodes.
• Numbing of responsiveness, or interference with
  developmental momentum Social withdrawal,
  restricted affect, loss of skills
• Increased arousal sleep disorder, short
  attention span, hyper-vigilance, startle
  response.
• New fears and aggression aggressive behavior,
  clinging behavior, fear of toileting and/or
  others.

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PTSD in Childhood
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PTSD in Children Six groups of symptoms

• A communicative style of avoidance difficulties
  in forming ties with people
• Depressive symptoms
• A high degree of anxiety (stress syndrome).
• A high degree of aggressiveness
• Suicidal tendencies.
• A more widespread use of primitive defense
  mechanisms denial, projection, interviction
  (identification with the attacker), regression
  and also repression.
• The fourth characteristic is the chief one which
  includes these children in the category of
  difficult children.

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Salmon Bryant (2002) 3 groups of symptoms

• PTSD children exhibit 3 groups of symptoms
• A recurrent experience of the trauma
• Avoidance characteristics
• Arousal symptoms such as insomnia, irritability,
  lack of concentration and heightened startle
  response
• This third group is what makes these children
  difficult.

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Treatment

• Integration and specific disorders

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This is NOT the recommended treatment
Although it might be tempting.
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Treatment of the Difficult Child
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Major principles of treatment

• Basic assumptions
• Multi-systematic
• Multi-layers
• Multi-diagnoses
• Time itself a therapeutic factor
• Variable therapies (integration of therapies) as
  a therapeutic factor
• Flexibility of treatment and changeability

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Treatment Algorythm
What is the major problem (Why doesnt the child
function)?
Therapy
Pharmaco-
Socio-
Psycho-
Improvement
No improvement
Partial improvement
How to create more improvement
What other diagnoses are discovered or can Be
treated now?
Reconsider the diagnosis
Therapy
????? ????
Pharmaco-
Socio-
Psycho-
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Childhood ADHD Treatment

• The Triangle principle

Pharmacotherapy
Parents Education and BT
School Instruction
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Comorbidity Algorythm
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ADHD treatment according to age
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Disruptive Behaviour DisordersTreatment
Approaches
Psychological Interventions
Dynamic therapy Cognitive behaviour
therapy Family therapy Other non-drug
interventions Preparing the teacher
Pharmacological Interventions
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ODD/CD Therapeutic Principles
Psychotherapy
Pharmacotherapy
CBT
Dynamic Psychotherapy
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PTSD treatment
Psychotherapy
Supportive pharmacotherapy
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An Integrative-dynamic model
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Introduction

• Understanding the phenomenon called the
  difficult child is based on our perception of
  three major components
• Integration of personality components
• Interaction between the child and the environment
• The dynamic of these processes

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The Development of a Difficult Child

• The Pearl Model
• The pearl is created around a grain of sand,
  which penetrates the oyster.
• It is an organic nucleus around which layers of
  stimuli are developing.
• There might be several nuclei, but around each
  one of them, layers would be built

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Development

• Hence, the development of the difficult child is
  based on an organic nucleus that is in constant
  interaction with other characteristics of the
  person carrying it.
• Therefore, there is an integration of the ever
  evolving personality, and the interrelations
  which been developed while the difficult child is
  formed.

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Development

• In addition, there is the interaction that
  develops between the child and his environment,
  starting with his parents and ending with large
  social systems.

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Development

• These interactions equally shape the development
  of the difficult childs characteristics, and in
  fact significantly influence the diagnostic
  process, whether it is ADHD, ODD/CD or PTSD.

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• It is reasonable to assume that such a child has
  multiple diagnoses.
• Since it is frequently the case that there is a
  common etiological source to the disorders, the
  same child is likely to be diagnosed differently
  at different stages in his development,
  exhibiting different metamorphoses of that same
  common source.

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• Here dynamics, the third component of the model,
  enters the picture, which until now was dealt
  with only indirectly.

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Vectorial Dynamic Model
Time Axis

• Here dynamics, the third component of the model,
  enters the picture, which until now we have dealt
  with only indirectly

Biological Axis
Psychological Axis
Social Axis
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The Time Component

• Alongside the integration of the three axes,
  there is an additional important component the
  time line
• The subject of timing is often raised in matters
  such as the time when the symptoms appeared and
  the developmental process of the disorder
• Continuity is also frequently referred to.
• Continuity is crucial for understanding the
  integrative nature of the disorder and its having
  a primary organic source, but it also sheds
  additional light on the process.

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Resilience

• The same disorders are likely to look totally
  different at various points in time (i.e. ages).
  In turn, the interactions between the disorders
  and the child at varied points in time create new
  situations and transactions.
• The interactions between the child, his
  environment and the situations that evolve, all
  together create a mechanism of transactional
  duality.
• The concept of risk factors and protective
  factors, or alternatively the currently more
  acceptable concept of resilience is included in
  the continuity process

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Interaction of Factors

• This phenomenon is much broader than each of the
  factors themselves, but stems from the continuous
  interaction amongst them, which is dynamic and
  has an existence of its own.
• Therapy constitutes an additional factor, which
  creates different interactions, biological, as
  well as psychological and social.

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Integrative Dynamic model (the chaos model)
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The Non-phenomenological difficult child

• Phenomenologically speaking, the separate
  syndromes joined to the difficult child syndrome
  are described one next to the other.
• In a clinically based perspective, which has
  nothing to do with rating scales or standard
  classification, these syndromes are actually
  combined in a very different formulation.
• This formulation is the integrative dynamic
  combination of these phenomenological entities
  and it is quite un-phenomenological.

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Synthesis and Chaos

• This clinical formulation is the synthesis of all
  the separate syndromes, i.e., it is a new
  syndrome, quite different from its components.
• This model of the difficult child is ruled by the
  laws of the Chaos model, since it is
  unpredictable, ever-changing, and multi-factorial
  dependent.

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• Hence, the difficult child is a multi-vectorial,
  multi-factorial syndrome, changing from one point
  of time to its next.
• That is also why each final product of the
  difficult child is different from the others.

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• In the same way that it is impossible to bathe
  twice in the same river, it is impossible to
  diagnose the same child twice.
• The change that occurs is ongoing, continuous and
  inevitable.
• Both the integration and the interaction that
  make up the personality model are in constant
  motion, while factors are added to the equation
  and subtracted from it at all times

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• In a situation in which the equilibrium is
  disturbed, symptoms appear, so this is the time
  when it is possible to make a diagnosis and begin
  treatment.
• On the other hand, at this stage the symptoms are
  likely to begin developing at a rapid rate, so
  that early preventive treatment must be
  immediate.

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• The model being dynamic provides an advantage and
  protection. The equilibrium may be disturbed but
  it can also be righted when there is a continual
  process of change.
• Diagnosis, the beginning of treatment or other
  changes are all likely to facilitate a return of
  equilibrium.
• This is an additional reason for the importance
  of early diagnosis and treatment when
  equilibrium is righted, the phenomenon of the
  difficult child will recede.

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Conclusion

• The difficult child phenomenon is time-dependent,
  and is very likely to be temporary.
• However, if goes untreated, the sharp changes in
  the childs functioning levels along the time
  axis, might lead to the development of many
  psychiatric disorders and to the need of
  multi-diagnosis.
• Assessment and treatment alike refer to the child
  in a certain moment and in a certain dynamics.

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Conclusion

• hence, we are forces to define the child
  according to the multi-vectorial model
• Being a difficult child is an unstable and a
  multi-faceted syndrome, changing rapidly through
  time.
• Dealing with these children might be as unnerving
  and dizzying as the roller coaster ride to which
  it is so similar

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Conclusions (3)

• The therapeutic attitude will be different from
  child to child according to the intensity and the
  severity of the dominant factor in
  psychopathological picture
• Hence, no systematization of the model of therapy
  can be done since there are no straight lines
  from diagnosis to treatment but a whole spectrum
  of therapies.

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Conclusions

• We, as clinicians, must choose from this spectrum
  the techniques specific to the individual child.
• Thus, we create a specific and individual mosaic
  plan every single time

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Thats all fellas