The Difficult Child I. Manor, S. Tyano
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
The disorders forming the syndrome Separate or Additive Mostly additive
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)
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).
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
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
Initial assessment Or How do we approach the difficult child
Referrals Paramedical staff teacher Councilor pediatrician parents Child and adolescent psychiatrist
Assessment • What is the difficulty • Where is the difficulty • To whom is one difficult • Does one feel the difficulty
Child and adolescent psychiatrist: D.D. and Comorbidity Disruptive Disorders PTSD Affective Disorders Psychosis Neurological/Medical
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
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
Stage I: Clinical Examination • History • Heredity • Psychiatric status • Getting to the differential diagnosis
Stage II: specific measures • Questionnaires • Rating Scales • Neurocognitive tests • Continuous Performance Tests (CPT) • Imaging
Final Diagnosis Single or in comorbidity Integration
The specific syndromes Etiology Clinical picture prognosis
Early Age ADHD The first symptoms include: 1. Unregulated sleep and appetite 2. Early motor development 3. Tendency to inattention, a need ofparents’ attention and holding
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
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.
Early Age ADHD: Comorbidity • Preschool children with ADHD are likely to exhibitODD, anxiety, or mood disorders • Many children with ADHD also showdevelopmental disorderssuch as:fine motor skills disorder, language disorder, etc.
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
Childhood ADHD • Thetime factorbegins to be critical(before adolescence) • There is high frequency ofcomorbidity, which increases with age.
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 amono-nucleusdisorder
Age Dependent Most Important Features High comorbidity Sociability Response to ritalin
Co-occurring Disorders in Children (n=579) Oppositional Defiant Disorder 40% ADHD alone 31% Tics 11% Conduct Disorder 14% Anxiety Disorder 34% MTA Cooperative Group. Arch Gen Psychiatry 1999; 56:1088–1096 Mood Disorders 4%
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 diagnosedand being treated, especially by medications
ADHD in adolescence Apart from what is seen in children, there are two important comorbid states: • Alcohol and substance abuse • Delinquency
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
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 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
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)
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.
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).
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.
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.
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.
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
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.
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”.