1. The Difficult Child
I. Manor, S. Tyano

2. 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
המונח ילד קשה הוא בפני עצמו מונח מורכב.
ילד קשה הוא ילד שלא נוח לחיות עמו.
הוא מהווה את ההיפוך של ילד קל, כלומר יוצר קושי לסביבה בתוכה הוא נמצא, ולכן הוא מטריד, ומעורר תשומת לב.
בניגוד לתחומים אחרים, לא מדובר כאן במונח רפואי מקצועי, אלא במונח משפת היומיום, ויותר מכך, מדובר כאן במונח שיפוטי.
קשה פירושו לא נוח, בעייתי, הכולל מגוון של תחושות ומחשבות שיפוטיות, המתעוררות במי שדן ב"ילד הקשה".
מכלל ההפניות למרפאות החוץ של בריאות הנפש בילדים, האחוז הגבוה ביותר של הפניות הוא של ילדים אשר התסמינים שלהם מוגדרים כקשים, ובשאלות ספציפיות יותר מתוארים כמציגים בעיות התנהגות שונות.
קשה מאד להעריך את אחוז הילדים המוגדרים כקשים מכלל הקהילה, היות ומדובר בהערכות מצטברות של מספר הפרעות שונות.

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

4. 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)

5. 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%. (4-9:1 M:F ratio)
PTSD: There are only estimations, based on studies of at-risk children. Estimates fluctuate between 0-100% (Yule, 2001).
According to various studies, which will be presented below in all their complexity, the prevalence of CD and ODD is relatively high, and according to some studies reaches 16% for CD and 14% for ODD. A rough average would show a prevalence of CD of 7-8% of all boys and 3-4% of all girls. Regarding ODD, a rough average would be 6% for boys and 11% for girls, based on the findings of Loeber et al. (2002). Other researchers report an even higher prevalence, fluctuating between 5-25% (Malmquist, 1991). In addition, Remshmidt and Walter’s (1989) study, which examined its relative prevalence as compared to other adolescent disorders, demonstrated that it is the most commonly diagnosed at this age, and reaches approximately 20%.
There are no extant studies to date estimating prevalence in children, and estimates that were done based on studies of at-risk children fluctuate between 0-100% (Yule, 2001). Estimates for children are complicated and depend both on the children’s age, the amount of time that has passed since the trauma, assessment methods and the edition of DSM that was used by the researchers

6. 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
באותה מידה ילד קשה הוא ילד החווה את עצמו כקשה. ילדים רבים חווים עצמם כנטל, כמעמסה, ביקורתיים מאד כלפי התנהגותם ותפקודם.
רבים מילדים אלו מפתחים "נבואה שמגשימה את עצמה" היות ועם הזמן הם אכן הופכים קשים להתמודדות, עקב הדיכאון והפרעות ההתנהגות שהם מפתחים.
כלומר, הילד הקשה הוא ילד המעורר בסביבתו חווית אי נוחות , המבוססת בעיקרה על תחושת חוסר אונים. ההורים, ובעקבותיהם הסביבה כולה, אינם מצליחים להסתדר עם הילד, ומרגישים שאינם יודעים מה לעשות וכיצד להתמודד.
ברמה הרגשית ילד כזה מעורר תסכול וחוויה של עלבון ושל כעס, כאשר הוא מעמיד את המבוגר המתמודד איתו במצב של חוסר ידיעה , חוסר שליטה, ושל ספק.
כך, הילד הקשה מעורר את האינטראקציה, היוצרת בסופו של דבר את המעגל הסגור של סיבה ותוצאה, תוך הנצחה של הקושי והמצוקה.

7. 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

8. The result is a lot of aggression…

9. Or How do we approach the difficult child
Initial assessment Or
How do we approach the difficult child

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

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

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

13. 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

14. Overdiagnosis and Underdiagnosis
Quiet children
Unacceptable behavior according to societal rules
Deviant intelligence
Severe Axis I Disorders (psychosis and affective disorders)
Recoil from the more severe diagnoses
Girls
Boys
Social factors
לאחר שסקרנו את האבחנות המבדלות – ותחלואה נלווית אפשרית ניתן לראות כי אבחון היתר של הפרעה אחת מהווה בעצם את האבחון חסר של הפרעה אחרת, גם כאשר מדובר בהפרעות המתקיימות בו זמנית. אבחון היתר ואבחון החסר הם בעיה מרכזית של אנשי מקצוע המנסים להתמודד עם הילד הקשה. יש לציין כי ה"יתר" או ה"חסר" משתנים ומופיעים באופן שונה לגבי צורות שונות של הילד הקשה, כאשר צורות מסוימות מעודדות אבחון יתר ואחרות אבחון חסר. הסיבות העיקריות לשני מצבים אלו הן המגוון הגדול מאוד של אפשרויות האבחון בילדים אלה בשילוב עם מרכיב ה"עמדה" (לתת דוג'?! ע"מ 71). כלומר, באבחון יתר ואבחון חסר משחקים תפקיד גורמים פסיכולוגיים כמו ידע מחד וגורמים דינמיים כמו העברה נגדית. גם גורמים חברתיים כמו "אופנת אבחון", מקובלות חברתיות וכדומה נכנסים למקום זה. גורם נוסף הוא העמדה כלפי מחלת הנפש. ההתייחסות בקרב הציבור היא אמביוולנטית. הדחייה קטנה ככל שהשכלתו של המשיב גדלה וככל שהתנהגותו של החולה פחות תוקפנית אך העמדה השלילית מתחזקת ככל שעמדת הקרבה המצופה אליו גדלה. באבחון ילדים יש רתיעה נוספת מפני מתן "גזר דין" קשה מידי על כל המשמעויות שיש לו בגיל צעיר כל כך.
לסיכום, אבחון היתר ואבחון החסר אינם מוציאים את הילד מכלל ההגדרה השיפוטית של "הילד הקשה". כלומר,הילד הקשה נקרא קשה בכל מקרה. הם פועלים יותר בתנועת גומלין זה כלפי זה כאשר אבחון החסר של הפרעה אחת (למשל מחלה) גורם לאבחון יתר של אחרת ( למשל ADHD).

15. 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

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

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

18. Single or in comorbidity Integration
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
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.
1) A deviation from the norm: difficult temperament. As was stated above, one temperament type is the difficult one, which involves difficulty in regulation, much crying, difficulty in calming down, hyperactivity etc.
2) Children who have been given no clear limits.
3) Behavioral disorder or rebellious opposition disorder. Rarer at these ages, although it exists.
4) Deviations in IQ (talented / retarded).
5) Spasms of Petit Mal type. This disease causes staring into space and dissociation, behaviors that are not obvious to others. It appears mostly at ages 5-6 years, but might appear even earlier. The disease is relatively easy to diagnose, since a characteristic pattern can be detected on an EEG (a lug and a wave at a rate of three per second). In addition, anti-spasm medications, such as Phenobarbital, might themselves cause attention deficits.
6) Chronic inflammation of the middle ear, antihistaminic medications. The disease itself, which causes hearing loss and introversion, is an important distinguishing diagnosis. In addition, medications taken for it may cause attention deficit (blurred perception and drowsiness).
7) Undiagnosed sight and hearing problems.
8) Other physical and/or chronic conditions, such as impaired sight, impaired hearing, hyperthyroid, hypothyroid and severe anemia.
9) Genetic syndromes: Fragile X syndrome, William’s Syndrome, Neuro-Developmental Pervasive Disorder.
10) PDD – Pervasive Developmental Disorders: disturbances in reality perception and judgment, widespread developmental disorders.
11) Psychosis.
12) Infancy affective disorders, including anxiety disorder, infantile depression and Mixed Disorder of Emotional Expressiveness. In these children, the inappropriateness of affect stands out more than attention difficulties, although these certainly exist.
13) Child-Parent Attachment Disorder, of the type Attachment Disorder with Self-Endangerment, which is described by Zeanah (2000). In this case, the tendency for self-endangerment, aggressiveness and impulsiveness displayed by the small child are aimed at capturing the attention of an unavailable or incapable parent, and for this reason they will appear mainly when the child is interacting with the parent. In severe and prolonged cases, these behaviors will appear in the presence of any adult whom the child sees as a potential psychological parent.
14) Regulatory Disorders, Motorically Disorganized/Impulsive Type: although the concept of regulatory disorders in affect, attention and processing sensory information is well known to clinicians (Greenspan & Weidwer, 1993), much work is still needed in order to determine the validity of these diagnoses (Barton & Robins, 2000). Degangi (1993) reported on a subgroup of children that as babies showed signs of regulatory disorders, and as four-year-old children showed symptoms of ADHD. Ermer & Dunn (1998) demonstrated that children who suffer from ADHD in early childhood show a marked tendency to seek stimulation and distraction. However, reliable and valid tools for the diagnosis of regulatory disorders are lacking, both in the sensory process and in the regulation of affect.
15) Post Traumatic Stress Disorder (PTSD) of Infancy. Irritability and attention difficulties are very common in young children who have experienced trauma, yet the origins of the disorders are entirely different, so in most cases it is easy to distinguish between the two. At the same time, in complex cases where the young child is chronically exposed to difficult experiences, diagnosis is harder (Thomas, 1995).

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 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

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

30. Co-occurring Disorders in Children (n=579)
Oppositional
Defiant
Disorder
40%
ADHD
alone
31%
Tics
11%
Conduct
Disorder
14%
Given the high rate of comorbidity with ADHD, a differential diagnosis must exclude coexisting conditions that are symptomatically distinct (e.g. conduct disorder, learning disability, oppositional defiant disorder, Tourette’s disorder, and speech or language disability)1 and require distinct management.
1. Zametkin AJ, Ernst M. Problems in the management of attention-deficit hyperactivity disorder. N Engl J Med 1999; 340:
Anxiety
Disorder
34%
MTA Cooperative
Group. Arch
Gen Psychiatry 1999; 56:1088–1096
Mood Disorders 4%

31. ADHD in adolescence

32. 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

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)
Early
Conduct
disorder
Oppositional
symptoms
Severe
conduct
disorder
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)
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).
The development of ODD into CD
According to a survey conducted by Burke et al. (2000), ODD is considered on the one hand a comparatively benign disorder with a good prognosis, but on the other hand, it increases the risk for CD. In a certain research study, a four times greater likelihood of CD developing from ODD is discussed. 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).
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.
Models of continuous development of disruptive behavior disorders
There is a conception according to which slight symptoms develop into medium ones and into severe ones. Loeber et al. (1993) presented a model for boys according to which there are three forms of CD: modified, intermediate, advanced, in accordance with the developmental succession of onset and severity of symptoms. In addition, Loeber and associates (2000a) presented another model for boys based on three tracks:
An overt progression from slight aggressiveness to physical conflict and violence.
aggressiveness physical conflict violence
A covert progression before age 15 from covert behaviors to property damage and from there to more severe forms of delinquency
Slight covert behaviors property damage delinquency (up to age 15)
A progression of damage to authority before age 12, beginning with stubbornness and continuing to defiance and avoidance of accepting authority: running away, truancy, staying out late.
Authority conflict: stubbornness rebellion against authority wandering, running away, etc. (up to age 12)
This model actually builds up different forms of CD, better clarifying the development of the disorder in extremely problematic children.

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.
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
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.

38. 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)
Models of continuous development of disruptive behavior disorders
There is a conception according to which slight symptoms develop into medium ones and into severe ones. Loeber et al. (1993) presented a model for boys according to which there are three forms of CD: modified, intermediate, advanced, in accordance with the developmental succession of onset and severity of symptoms. In addition, Loeber and associates (2000a) presented another model for boys based on three tracks:
An overt progression from slight aggressiveness to physical conflict and violence.
aggressiveness physical conflict violence
A covert progression before age 15 from covert behaviors to property damage and from there to more severe forms of delinquency
Slight covert behaviors property damage delinquency (up to age 15)
A progression of damage to authority before age 12, beginning with stubbornness and continuing to defiance and avoidance of accepting authority: running away, truancy, staying out late.
Authority conflict: stubbornness rebellion against authority wandering, running away, etc. (up to age 12)
This model actually builds up different forms of CD, better clarifying the development of the disorder in extremely problematic children.

39. 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.
As Hirshaw and Zupan point out, and as we ourselves discovered (Valevski& Tyano, 2001), prognosis is stable over time. The significance of this is that 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, and so on.

40. 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).
As Hirshaw and Zupan point out, and as we ourselves discovered (Valevski& Tyano, 2001), prognosis is stable over time. The significance of this is that 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, and so on. A development progression of symptoms such as this is called heterotypic continuity (Moffit, 1993). Clearly, 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.
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.
A different division of CD sufferers is possible between child-onset as opposed to adolescent-onset cases (McMahon, 1994). These two disorders differ in regard to symptoms, development of the disorder, relative severity, gender ratio and prognosis. As described by Hirshaw, 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
One of the most important topics is without doubt the ability to predict in those who exhibit symptoms of ASR the development of PTSD. There are both physiological signs, as described in Shalev’s (1999) article and psychological indicators.

44. 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.
One of the important questions in prognosis for the development of PTSD is the role of the parents themselves being post-traumatic. In a study from 2001 (Yehud, 2001), children of holocaust survivors were examined who were suffering from PTSD. 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.
An additional researcher that confirmed these findings was Daviss (2000), who examined 48 children after accidents. A month after the event, 12.5% exhibited a full clinical picture of PTSD and 16.7% had partial (sub-syndromal) PTSD. When looking for high-risk variables for the development of the full syndrome, the researchers found that 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.
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
Terr (1983, 1988, 1990) looked at what happens to early memories of trauma in twenty youngsters who had suffered psychic trauma before age 5 years. She defined two basic types of response (1991): Type I trauma, which includes full, detailed memories, "omens", and misperceptions; Type II trauma includes denial and numbing, self-hypnosis and dissociation, and rage. Pynoos (1990) defined a traumatic event for young children as any direct or witnessed event that threatened his/her own and/or his/her caregiver’s physical and/or emotional integrity. In 1993 the first study was published that focused on post-traumatic reactions in children 0 to 3 years of age (Drell et al, 1993). Case studies were brought to indicate that 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 was stressed by the authors.

48. 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.
According to a recent review (Keren & Tyano, in press), until 1995, no studies have been conducted with children younger than 48 months of age to investigate whether the diagnosis of post traumatic stress disorder occurs in them after being traumatized. As shown by Scheeringa et al. (1995), criteria for diagnosing PTSD in standard nosologies (such as DSM IV) needed revision for use with children younger than 48 months of age. The authors suggested diagnosing PTSD of infancy when there is at least one of four main following criteria:
1. Re-experiencing: Repetitive post-traumatic play, distress with reminders, dissociation episodes.
2. Numbing of responsiveness, or interference with developmental momentum: Social withdrawal, restricted affect, loss of skills
3. Increased arousal: sleep disorder, short attention span, hyper-vigilance, startle response.
4. New fears and aggression: aggressive behavior, clinging behavior, fear of toileting and/or others.
Scheeringa and Zeanah (1995) analyzed the severity of PTSD symptoms in 41 children under 48 months of age in relation to variables of the trauma and of the children. The most potent trauma variable that predicted the development of PTSD in these children was not an event that was directed to their own bodies, but whether they had witnessed a threat to their caregiver. Children who were older than 18 months of age at the time of trauma, and suffered acute trauma, developed more re-experiencing symptoms than those who were younger than 18 months and experienced repeated traumas

49. PTSD in Childhood

50. 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”.
The clinic of the child suffering from PTSD is based on five groups of symptoms:
A communicative style of avoidance: difficulties in forming ties with people due to caution, tension, a fear of getting too close and a sense of lack of trust in others.
Depressive symptoms: a sense of sadness, hopelessness that there will be an improvement in their condition, lack of joy of life, lowered self-esteem (perceiving themselves as “bad” or “guilty”, a sense of loneliness.
A high degree of anxiety (stress syndrome).
A high degree of aggressiveness: violence (gestures, threats and light or serious injury to others), aggressiveness (irritability, argumentativeness, involvement in fights, bouts of rage), destructiveness, antisocial behavior (arson, theft, running away from home), impulsiveness (low frustration level, difficulty coping with deficiencies, limits and prohibitions, and with delaying reactions).
Suicidal tendencies: suicidal thoughts, threats, gestures and attempts; a tendency to take risks.
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,” since it is the externalized face of the distress, and this is what makes it difficult for others to cope with them.

51. 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”.
PTSD children exhibit three groups of symptoms: a recurrent experience of the trauma, avoidance characteristics, such as emotional withdrawal, a refusal to deal with the trauma, etc., and arousal symptoms such as insomnia, irritability, lack of concentration and heightened startle response (Salmon & Bryant, 2002). This third group is what makes these children “difficult,” and includes them in the framework of the distinguishing diagnosis of this chapter.

52. Integration and specific disorders
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:
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 {{
לאור מורכבות המצב של הילד הקשה כפי שתוארה עד כה, נשאלת השאלה:
כיצד רצוי לגשת לטיפול בו ובמשפחתו?
האם רצוי ואפשרי לטפל בכל הבעיות והקשיים, בכל התחומים ובכל המערכות בו זמנית? או שעדיף לבנות תוכנית טיפולית המורכבת מרצף טיפולים בזה אחר זה. כך, בכל פעם יהיה מיקוד בסוג טיפול אחד, או נסיון לטפל באחת הבעיות ולפתור אותה בטרם פונים לבעיה הבאה. }}
בבואנו לשקול טיפול עבור הילד הקשה, עלינו לקחת בחשבון מספר עקרונות כלליים בהקשר הטיפולי.
ראשית,
הנחות היסוד שלנו מתייחסות לקשיים במספר מערכות: האישית, הבינאישית-משפחתית, המערכת הבית-ספרית, ואולי מעורבות גם מערכות נוספות. עלינו לבחון את כל המערכות מבחינת מערך הכוחות המאפיין אותן והבעיות הקיימות בהן ומולן.
בנוסף,
אנו מדברים על קושי רב-שכבתי. ניתן לתאר את קשיי הילד הקשה לא רק כקשיים הנוכחים זה לצד זה אלא גם באופן שכבתי, זה מתחת לזה. כאשר נתחיל לטפל ונעמיק בהבנת הקשיים של המטופל, יש לקחת בחשבון כי יצופו קשיים נוספים ש"הסתתרו" מתחת לקשיים הגלויים.
(??? דוגמה ל- Conduct ודיכאון שמתחתיו).
לבסוף, אנו מדברים על הבנה כי הילד הקשה הינו רב אבחנתי ויש לבחון היטב את האבחנות השונות וקשרי הגומלין ביניהן.
למשל, איזו בעיה מחריפה את ביטוייה הסימפטומטיים של בעיה אחרת, איזו פתולוגיה מיטשטשת לאור האחרות, ומהי השפעת קשרי הגומלין בין האבחנות השונות שמביאים בסופו של דבר למצבו הנוכחי של הילד.
לאור הנחות יסוד אלה, אנו רוצים להדגיש את העקרונות הטיפוליים הבאים:
רצף הזמן – לכל מטפל ידוע כי לזמן יש משמעות בטיפול. אנו רוצים להדגיש את רצף הזמן כגורם טיפולי. כלומר, כשאנו מתחילים לטפל בבעיות מסויימות או במערכות מסוימות, יש לשער כי ישתנו קשרי הגומלין שתיארנו זה עתה. מעגלים שליליים שהביאו להחרפה במצב הילד ואף הרחבת בעיותיו בין מערכות שונות, יכולים להשתנות ואף להשפיע בכיוון ההפוך לעבר שיפור. כך, לאחר תקופת טיפול, לא רק שיש שיפור בסימפטומים בהם בחרנו לטפל אלא ניכר שינוי גם במערכות השונות ובקשיי הילד כפי שמתבטאים בהן. ואז, במקרים רבים חל שינוי שמאפשר כיווני טיפול אחרים מאלה שבחרנו לראשונה.
עם זאת, ניתן לראות במקרים רבים כי כאשר סימפטומים מסויימים שימשו הגנה או נועדו להסתיר את מצוקת הילד, תיחשף כעת אותה מצוקה ויש סיכוי טוב יותר לטפל בה כעת.
חשוב להדגיש כי השינויים במצבו של הילד נגרמים לא רק ישירות כתוצאה מהטיפול שניתן לו, אלא מהשפעת תוצאותיו של טיפול זה על המערכות וקשרי הגומלין ויוצרות מעגלים חיוביים שמתחילים להשפיע.
דוגמה: ילד עם הפרעת התנהגות, שהתנהגותו במסגרת ביה"ס משתפרת כתוצאה מטיפול תרופתי. המערכת המשפחתית שהיתה מוצפת קודם לכן ומיואשת מהקשיים בנושא ביה"ס מעודדת כעת ופנויה לראות את קשייו ולהתגייס לטיפול בו. בנוסף, גם בביה"ס גוברת האמפתיה כלפי הילד וניתן להבחין שהפרעת הקשב והריכוז וקשיי הלמידה, מביאים לתסכול ויש לטפל בהם. (???)
מגוון טיפולים – עקרון זה, לפיו נציע מגוון טיפולים לאורך שלבי הטיפול השונים, נובע ישירות מתוך הנחות היסוד, ומתוך השפעתו של רצף הזמן. מאחר ואנו מדברים על ילד רב-בעייתי, ההשפעה ההדדית בין בעיותיו ואבחנותיו השונות מחמירה את קשייו. מכאן, שעלינו להתאים לאור הבנה זו את מגוון הטיפולים המוצעים.
שינוי בהתנהגות, מוביל לשינויים בדינמיקה התוך-אישיותית של הילד, בדינמיקה המשפחתית, במערכת הבית-ספרית והחברתית.
טיפול בבעיה החריפה של הילד יכול להגביר את מודעותו של הילד, הוריו ובית הספר לגבי קשיים אחרים שאולי הובילו מראש להתנהגות הקשה.
שינויים במוקד הקשיים והטיפול – לאורך תקופת הטיפול הראשונה יכול המוקד הטיפולי לעבור מאבחנה לאבחנה או ממערכת אחת לאחרת.
שיפור ספונטני – פעמים רבות נראה כי בעקבות טיפול בסימפטומים מסויימים, בשל התהליכים שפותחו לעיל, חל שיפור ספונטני בביטויי הסימפטומים האחרים גם ללא טיפול.
ג מ י ש ו ת הכוונה בתוך התהליך הטיפולי לגלות גמישות לצרכי המטופל אשר משתנים לאורך זמן, למוקדי הקושי העולים ומשתנים ולשינויים במערכי הכוחות האישיים והמשפחתיים.
בין שלב לשלב בטיפול, הכרחי לבחון את המצב בקרב המערכות השונות.כמו כן, יש לבדוק בכל מעבר בין שלבי הטיפול, את האבחנות וארגונן בשכבות לשם הערכה מחודשת של המשך הטיפול.
חשוב לזכור כי אנו עוסקים במערכת מאד מורכבת, ויהיה לנו קשה להעריך מראש את השפעת ההתערבות שלנו.

56. Treatment Algorythm Socio- Pharmaco- What is the major problem Therapy
(Why doesn’t the child function)?
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-
שיפור חלקי
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
Young children: stimulant not always allowed legally.
According to studies: good response, although not so much as in older children. More side effects
Adults: stimulants have very good response, the specific stimulant should be chosen according to needs ( few hours a day, many hours a day, infrequently)

60. Disruptive Behaviour Disorders: Treatment Approaches
Psychological Interventions
Dynamic therapy
Cognitive behaviour therapy
Family therapy
Other non-drug interventions
Preparing the teacher
Behaviour therapy:
operant conditioning (reward and punishment)
classical conditioning (systemic desensitisation)
Cognitive behaviour therapy:
self-instructional training
the anger coping program
promoting alternative thinking strategies (PATHS)
Family therapy:
family functioning therapy
multisystemic therapy
Pharmacological
Interventions

61. ODD/CD Therapeutic Principles
Psychotherapy
Pharmacotherapy
CBT
Dynamic Psychotherapy

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
Interaction between the child and the environment
The dynamic of these processes
Understanding the phenomenon called the “difficult child” is based on our perception of three major components:
Integration among personality components
Interaction between the child and the environment
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.
Therefore, there is an integration of the ever evolving personality, and the interrelations which been developed while the difficult child is formed.
In other words, in light of all that was said in this chapter up to now, it is clear that 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 integration of continually developing personality, while the interrelations that develop in this interaction are the basis for the development of the difficult child.

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, and important to the same degree, 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 determine the development of the difficult child’s characteristics in the same measure, and in fact constitute a central factor in formulating the diagnosis, whether it is ADHD, ODD/CD or PTSD. Not surprisingly, in light of the complexity and totality of these processes, it is reasonable to assume that there will be multiple diagnoses. This stems from the fact that these diagnoses are only descriptive, that is, they describe symptoms, and their developmental process is common in more fundamental ways. In addition, since frequently there is a common etiological source, the same child is likely to be diagnosed differently at different stages in his development, exhibiting different metamorphoses of the same common source. Here dynamism, the third component of the model, enters the picture, which until now we have dealt with only indirectly.

69. 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.
Not surprisingly, in light of the complexity and totality of these processes, it is reasonable to assume that there will be multiple diagnoses. This stems from the fact that these diagnoses are only descriptive, that is, they describe symptoms, and their developmental process is common in more fundamental ways. In addition, since frequently there is a common etiological source, 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 we have dealt with only indirectly.

71. 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

72. 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.
In our view, alongside the integration of the three axes, there is an additional important component in understanding the difficult child: the time continuum. The subject of timing is raised often in matters such as the time when the symptoms appeared and the developmental process of the disorder, since development is dynamic by definition. Furthermore, continuity is referred to, for example in the area of ADHD. One of the criteria of DSM-IV deals with the importance of the presence of at least some of the symptoms before the age of seven. This 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 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

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

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 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.
That is also why each “final product” of the difficult child is different from the others.

79. The change that occurs is ongoing, continuous and inevitable.
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
That is, 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. In other words, 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. As was stated above, we have here dynamic and not static equilibrium. Risk factors are those in which equilibrium is upset, which is likely to happen at any time, but especially at key points. For example, a risk factor is when a child with ADHD enters first grade and is expected to do things that were not demanded of him in the past. Naturally, additional factors enter into the set of “considerations”: intelligence, strengths, additional traits, the existence of an additional diagnosis, the fact of the child’s diagnosis before he enters school, whether he is being treated, etc.

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.
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.
In a situation in which equilibrium is upset, symptoms appear, so this is the time when it is possible to make a diagnosis and begin preventive treatment (according to DSM-IV, it is impossible to offer treatment until distress is evident). On the other hand, at this stage the symptoms are liable 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 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.
In the same time, that model being dynamic provides an advantage and protection, since in the same way as equilibrium may be upset, so can it be righted when there is continual change. Diagnosis, the beginning of treatment or changes in it, different living conditions, and so forth 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.

82. Conclusion
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”.
Assessment and treatment alike refer to the child in a certain moment and in a certain dynamics.
A necessary conclusion from what was stated above is that in opposition to different psychiatric or psychological diagnoses, the difficult child phenomenon is itself time-dependent, and is definitely likely to be temporary. The same child who was difficult yesterday is likely to be an “easy” or “normal” child (or any other opposing judgmental expression) tomorrow, according to the place at which his equilibrium system is located in the field of motion.
מולטי אבחנות: אי אפשר להסתפק בילד קשה באבחנה אחת היות והיא לא תיתן מענה לכל התמונה הקלינית ותהיה שגויה מעצם היותה אחת. חייבים תמיד לחפש כמה אבחנות. יש לזכור גם שתחת טיפול חלק מאבחנות אלו ידעכו מעצמן.

83. 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

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
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.
Thus, we create a specific and individual mosaic plan every single time

86. That’s all fellas