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The Difficult Child I. Manor, S. Tyano. What is a difficult child A child who is difficult to live with A child who is difficult to live with It is a.

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Presentation on theme: "The Difficult Child I. Manor, S. Tyano. What is a difficult child A child who is difficult to live with A child who is difficult to live with It is a."— Presentation transcript:

1 The Difficult Child I. Manor, S. Tyano

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

3 The disorders forming the syndrome Mostly additive Separate or Additive

4 The disorders forming the syndrome Attention Deficit and Hyperactivity-Impulsivity Disorder (ADHD/ADD) Attention Deficit and Hyperactivity-Impulsivity Disorder (ADHD/ADD) Conduct Disorder (CD) Conduct Disorder (CD) Oppositional defiant Disorder (ODD) Oppositional defiant Disorder (ODD) Post Traumatic stress Disorder (PTSD ) Post Traumatic stress Disorder (PTSD )

5 A frequent syndrome This syndrome presents quite a large percentage of all references to the ambulatory services in children and adolescents 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 CD: Up to 14%. 7-8% males, 3-4% females ODD: Up to 16%. 6% males, 11% females ODD: Up to 16%. 6% males, 11% females ADHD: 3-10%. (4-9:1 M:F ratio) ADHD: 3-10%. (4-9:1 M:F ratio) PTSD: There are only estimations, based on studies of at-risk children. Estimates fluctuate between 0-100% (Yule, 2001). PTSD: There are only estimations, based on studies of at-risk children. Estimates fluctuate between 0-100% (Yule, 2001).

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

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

8 The result is a lot of aggression …

9 Initial assessment Or How do we approach the difficult child

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

11 Assessment What is the difficulty What is the difficulty Where is the difficulty Where is the difficulty To whom is one difficult To whom is one difficult Does one feel the difficulty Does one feel the difficulty

12 Disruptive Disorders Affective Disorders Psychosis PTSD Neurological/ Medical Child and adolescent psychiatrist: D.D. and Comorbidity

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

14 Overdiagnosis and Underdiagnosis Underdiagnosis Overdiagnosis Quiet children Unacceptable behavior according to societal rules Deviant intelligence Severe Axis I Disorders (psychosis and affective disorders) Recoil from the more severe diagnoses GirlsBoys Social factors

15 Evaluation of the difficult child History of child Classification Criteria Psychiatric status Possible Diagnoses according to probabilities Specific Rating Scales Cognitive tests Continuous Performance Tests Specialized tests: MRI, SPECT.. Diagnosis and Comorbidity

16 Stage I: Clinical Examination History History Heredity Heredity Psychiatric status Psychiatric status Getting to the differential diagnosis Getting to the differential diagnosis

17 Stage II: specific measures Questionnaires Questionnaires Rating Scales Rating Scales Neurocognitive tests Neurocognitive tests Continuous Performance Tests (CPT) Continuous Performance Tests (CPT) Imaging Imaging

18 Final Diagnosis Single or in comorbidity Integration

19 The specific syndromes Etiology Clinical picture prognosis

20 ADHD

21 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

22 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

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

24 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.

25 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

26 ADHD in Childhood

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

28 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 The Pearl Model

29 Most Important Features Age Dependent High comorbidity Response to ritalin Sociability

30 Co-occurring Disorders in Children (n=579) Oppositional Defiant Disorder 40% Tics 11% Conduct Disorder 14% ADHD alone 31% Anxiety Disorder 34% Mood Disorders 4% MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1088–1096

31 ADHD in adolescence

32 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

33 ADHD in adolescence Apart from what is seen in children, there are two important comorbid states: Alcohol and substance abuse Delinquency

34 Oppositional Defiant Disorder/ Conduct Disorder

35 Conduct Disorder : Developmental progression (Lahey & Loeber 1994) EarlyConduct disorder disorder Severeconductdisorder Oppositional symptoms symptoms AGE

36 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) 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). 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).

37 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. 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 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

38 Models of continuous development of disruptive behavior disorders Overt progression: Overt progression: aggressiveness physical conflict violence (Loeber et al, 2000) Covert progression: Covert progression: Slight covert behaviors property damage delinquency (up to age 15) Authority conflict: Authority conflict: stubbornness rebellion against authority wandering, running away, etc. (up to age 12)

39 Developmental ODD/CD Prognosis is stable over time 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. 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.

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

41 Child Vs Adolescent CD These two disorders differ in regard to symptoms, development of the disorder, relative severity, gender ratio and prognosis. 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. 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.

42 PTSD

43 Risk factors for developing PTSD

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

45 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. 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.

46 PTSD in Early childhood

47 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. 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 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

48 Diagnostic issues: four main criteria (Tyano & Keren) Re-experiencing: Repetitive post-traumatic play, distress with reminders, dissociation episodes. 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 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. 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. New fears and aggression: aggressive behavior, clinging behavior, fear of toileting and/or others.

49 PTSD in Childhood

50 PTSD in Children: Six groups of symptoms A communicative style of avoidance: difficulties in forming ties with people A communicative style of avoidance: difficulties in forming ties with people Depressive symptoms Depressive symptoms A high degree of anxiety (stress syndrome). A high degree of anxiety (stress syndrome). A high degree of aggressiveness A high degree of aggressiveness Suicidal tendencies. Suicidal tendencies. A more widespread use of primitive defense mechanisms: denial, projection, interviction (identification with the attacker), regression and also repression. 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.

51 Salmon & Bryant (2002): 3 groups of symptoms PTSD children exhibit 3 groups of symptoms A recurrent experience of the trauma A recurrent experience of the trauma Avoidance characteristics Avoidance characteristics Arousal symptoms such as insomnia, irritability, lack of concentration and heightened startle response Arousal symptoms such as insomnia, irritability, lack of concentration and heightened startle response This third group is what makes these children difficult.

52 Treatment Integration and specific disorders

53 This is NOT the recommended treatment … Although it might be tempting ….

54 Treatment of the Difficult Child

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

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

57 Childhood ADHD: Treatment The Triangle principle Pharmacotherapy Parents Education and BT School Instruction

58 Comorbidity Algorythm

59 ADHD treatment according to age

60 Disruptive Behaviour Disorders: Treatment Approaches Pharmacological Interventions Psychological Interventions Dynamic therapy Cognitive behaviour therapy Family therapy Other non-drug interventions Preparing the teacher

61 PsychotherapyPharmacotherapy CBT Dynamic Psychotherapy ODD/CD Therapeutic Principles

62 PTSD treatment Psychotherapy Supportive pharmacotherapy

63 An Integrative-dynamic model

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

65 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

66 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. 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. Therefore, there is an integration of the ever evolving personality, and the interrelations which been developed while the difficult child is formed.

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

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

69 It is reasonable to assume that such a child has multiple diagnoses. 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. 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.

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

71 Biological Axis Psychological Axis Social Axis Time Axis Vectorial Dynamic Model Here dynamics, the third component of the model, enters the picture, which until now we have dealt with only indirectly Here dynamics, the third component of the model, enters the picture, which until now we have dealt with only indirectly

72 The Time Component Alongside the integration of the three axes, there is an additional important component : the time line 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 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 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. 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.

73 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 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 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 The concept of risk factors and protective factors, or alternatively the currently more acceptable concept of resilience is included in the continuity process

74 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. 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. Therapy constitutes an additional factor, which creates different interactions, biological, as well as psychological and social.

75 Integrative Dynamic model (the chaos model)

76 The Non-phenomenological difficult child Phenomenologically speaking, the separate syndromes joined to the difficult child syndrome are described one next to the other. 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. 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. This formulation is the integrative dynamic combination of these phenomenological entities and it is quite un-phenomenological.

77 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 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. 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.

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

79 In the same way that it is impossible to bathe twice in the same river, it is impossible to diagnose the same child twice. 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. 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 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

80 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. 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. 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.

81 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. 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. 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. 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.

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

83 Conclusion hence, we are forces to define the child according to the multi- vectorial model 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. 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 Dealing with these children might be as unnerving and dizzying as the roller coaster ride to which it is so similar

84 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 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. 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.

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

86 That s all fellas


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