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Psychiatry, 157, 818–820. 184 ____________ EARLY DETECTION AND MANAGEMENT OF MENTAL DISORDERS _________________________ 6 The ‘‘Difficult’’ Child: Main Underlying Syndromes and Differential Diagnosis Sam Tyano and Iris Manor Geha Psychiatric Hospital, Petach-Tikvah, Israel INTRODUCTION Of the referrals to child outpatient mental health clinics, the highest percentage is represented by children who are defined as ‘‘difficult’’ and are described more specifically as exhibiting various beh avioural problems. ‘‘Difficult’’ children are those who are not easy to live with. They are the opposite of ‘‘easy’’ children; that is, they create difficulties for the environ- ment in which they live, are a nuisance and draw a lot of attention. Under this label we can find children who are sad, maladjusted, impulsive, post- traumatic, psychotic and so forth. All of them present difficulties to those around them, yet they are totally different from one another. The common denominator of all these children is a behaviour which is unpleasant, strident to the environment, and creates provocation and friction. Most of them are violent. A large number of them will start off as children with certain difficulties, will develop into annoying and/or infuriating children, and will end up as violent children. Some of them will be diagnosed as psychopaths, a diagnosis that does not exist in current main classifications, but includes those who are emotionally ‘‘burnt out’’ and derive pleasure from violence. Others will be mistakenly diagnosed as psychopaths, since their smooth, unemotional surface conceals depression and anxiety. Other children will be diagnosed under other headings, if they even manage to get that far, and do not remain in the ‘‘garbage can’’ of the generalization ‘‘violent children’’, which in many people’s opinion does not necessitate further attention. Early Detection and Management of Mental Disorders. Edited by Mario Maj, Juan Jose ´ Lo ´ pez-Ibor, Norman Sartorius, Mitsumoto Sato and Ahmed Okasha. &2005 John Wiley & Sons Ltd. ISBN 0-470-01083-5. _________________________________________________________________________________________________ CHAPTER A ‘‘difficult’’ child is sometimes one who experiences himself or herself as difficult. A large number of children experience themselves as a heavy burden and are extremely critical of their own behaviour and functioning. Several of these children develop ‘‘self-fulfilling prophecies’’ since, with time, they indeed become hard to handle as a re sult of the depression and behaviour disorders they develop. The most sensitive question is distinguishing between the ‘‘easy’’ and the ‘‘difficult’’ child. When does the child’s behaviour lose the quality of ‘‘easiness’’? Every child has occasional outbursts and sometim es hits others, but continuity of difficult behaviour turns the child into a ‘‘difficult’’ one. As opposed to the normal child, who presents outbursts from time to time, the ‘‘difficult’’ child presents these behaviours over time, and even if not continually, at least most of the time. Another element is that of surprise or, alternat ively, suddenness. The ‘‘easy’’ child is likely to have outbursts, lose concentration and be hyperactive and violent in certain circumstances, for example in the event of tiredness, severe emotional stress, etc. On the contrary, the ‘‘difficult’’ child is subject to surprising, unexpected outbursts without any apparent provocation. Thus, when this behaviour appears, it shocks others and angers them by the very fact of its being unexpected. The third element is the setting: the same behaviours that cause the child to be ‘‘difficult’’ are liable to appear in any setting. It is impossible to expect these problems to be confined to the school or any other oppressive external framework; they will appear in a large variety of frame works. Of course, perceiving the child as ‘‘difficult’’ depends not only on the child’s behaviour, but also on the parents’ patience and tolerance of this behaviour. A child’s behaviour may be perceived by one family as normal, and by another family as ‘‘difficult’’, disturbing and even threatening. In our estimation, for all practical purposes, the boundary between ‘‘easy’’ and ‘‘difficult’’ is the tolerance line. Any time the child’s be- haviour becomes oppressive and causes suffering to the environment and to himself or herself, he or she is a ‘‘difficult’’ child. Oppression constitutes a necessary, if not sufficient, factor in diagnosing a child as ‘‘difficult’’. The factors that make the child ‘‘difficult’’ will be significant not only for the diagnosis itself, but for the treatment, which will focus on changing these factors, whether they are ‘‘child factors’’ or ‘‘family factors’’. On the emotional level, the ‘‘difficult’’ child arouses frustration and feelings of indignity and anger, and places the adult who is struggling with him or her in a position of insufficient knowledge, lack of control and doubt. Thus, the ‘‘difficult’’ child stimulates a vicious circle perpetuating difficulty and distress. Accordingly, when we deal with the ‘‘difficult’’ child, we are dealing with a complex child–environment model, which 186 ____________ EARLY DETECTION AND MANAGEMENT OF MENTAL DISORDERS continues to develop over time, and in which interaction soon becomes the central focus. In this chapter we will discuss those syndromes which are most frequently behind the profile of the ‘‘difficult’’ child and their differential diagnosis. We will devote space and attention to these syndromes according to their relative frequency, with the exception of organic disorders which, due to space constraints, will only be covered in the framework of differential diagnosis. ASSESSMENT OF THE ‘‘DIFFICULT’’ CHILD The classical presenting picture of the ‘‘difficult’’ child is that of a parent or a teacher rushing a child with deviant behavioural symptoms to the psychiatrist, while the child himself/herself is usually unaware or denying any existing problem. The first step in the assessment of the ‘‘difficult’’ child is history taking. This includes detailed medical, developmental and psyc hiatric history not only of the patient, but of the family as well. All sources of information must be used – the child, his/her pare nts, teachers, etc. – in order to create a picture as clear as possible of the child’s inner and outer world. As part of this history, there are several structured and semistructured interviews dealing with the history of the child. One of the most well known is the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) [1]. Thi s is a semistructured interview that examines many details, with room for clarifications regarding major symptoms of several disorders in the framework of the differe ntial diagnoses mentioned in this chapter. The next step would be a clinical examination, which should allow the evaluation of possible comorbidities, acute situations, central personality characteristics, strengths and weaknesses and the child’s self-perception as an individual and as part of the community. Clinical examination can be structured, semistructured or unstructured. Neurological and physical examinations are a must in this phase of assessment, mostly to rule out organic diagnoses. At this point, the clinician must assess the gathered data and check if diagnostic criteria of any of the disorders dealt with in this chapter are met. If not, follow-up may still be warranted according to the circum- stances and clinical picture. If diagnostic criteria for any disorder are met, the use of rating scales, neuropsychological tests and neuroimaging tools is indicated. Rating scales, also sometimes called behavioural checklists, allow quantitative ratings of the adult’s evaluation of the child’s behaviour and THE ‘‘DIFFICULT’’ CHILD ____________________________________________________________________ 187 are used as a cornerstone in the clinical evaluation of the child. Thei r drawback is their subjectivity, as well as the adult’s limited knowledge of the child’s acts and thoughts. Accordingly, they constitute an essential but insufficient evaluation tool. Rating scales demand judgement of the child’s behaviour in binary terms (yes/no) or in quantitative degree of severity. They are very easy to administer and encompass many functional areas, from internalizing conditions such as depression and introversion to externalizing conditions such as violence or delinquency. Prominent examples of such scales are the Child Behavior Checklist (CBCL) and the Revised Child Behavior Checklist (RCBP) [2]. Widely used scales to assess attention-deficit/hyperactivity disorder (ADHD) include the Conners Rating Scale [3] and the Swanson, Nolan and Pelham Ques tionnaire (SNAP-IV) [4]. The Eyberg Child Behavior Inventory [5] is used to evaluate conduct disorder (CD) and oppositional defiant disorder (ODD). Common scales for the assessment of post-traumatic stress disorder (PTSD) are the Children’s PTSD Inventory (CPTSDI) [6], the Trauma Symptom Checklist for Children (TSCC) [7], the Angie/Andy Cartoon Trauma Scale (ACTS) [8], the Pediatric Emotional Distress Scale (PEDS) [9], the Clinician-Administered PTSD Scale for Children (CAPS-C) [10], the Adolescent Dissociative Experience Scale (ADES) [11], the Chil- dren’s Perceptual Alteration Scale (CPAS) [12] and the Child Dissociative Checklist (CDC) [13]. The most frequently used rating scale for mood disorders is the Childhood Depression Rating Scale – Revise d (CDRS-R) [14], which is a modified version of the Hamilton Depression Rating Scale. Neuropsychological assessment is necessary when there is a suspicion of a brain disorder, or there is already evidence of brain damage and a need to estimate the nature and the extent of the influe nce of the damage on cognition, personality and behaviour of the injure d individual, or it is impossible to evaluate the situation using the conventional tools of the clinical interview or a regular psychological test. There are a number of comprehensive batteries of neuropsychological tests for children. The purpose of all of them is to assess various functions, such as short-term, medium and long-term memory, motor, visual and spatial perception, orientation, language, cognition, constructing and creating concepts, problem solving and more, by means of various performance tasks. The continuous performance tests assess the child’s ability to cope with a rela tively monotonous and boring task over tim e. This method is considered one of the most reliable ways of differentiating between children suffering from ADHD and normal children. There are a number of subtypes of this test: the Conners’ Continuous Per formance Test [15], the Test of Variables of Attention (TOVA) [16], and others. 188 ____________ EARLY DETECTION AND MANAGEMENT OF MENTAL DISORDERS ATTENTION DEFICIT/HYPERACTIVITY DISORDER (ADHD) ADHD is conceptualized as a disorder affecting several life spheres, in- cluding learning and social behaviour. However, in light of its prevalence and characteristics, Koschack et al. [17] and others consider it a trait, and present it as a differentiated style rather than a dysfunction. A comparison betwee n the ICD-10 and the DS M-IV demonstrates the different ways this disorder is perceived and the difficulties involved in understanding it. According to the DSM-IV, ADHD belongs to a group of behavioural disorders, also including ODD and CD. According to this system, children fulfilling the criteria for both ADHD and CD are a separate group with different aetiological, clinical and prognostic characteristics. On the other hand, the ICD-10 identifies the group of hyperkinetic disorders, subdivided into a ‘‘disorder of activity and attention’’ and a ‘‘hyperkine tic conduct disorder’’. The ICD-10 makes no mention of pure attention deficit disorder, and the basic requirement for the diagnosis of hyperkinetic disorders is a combination of attention deficit and hyperactivity. This dif- ference from the DSM-IV is significant, because the ICD-10 system actually ignores 30% of the children who suffer from attention difficulties, i.e. 2–3% of all children in the general population. From the American point of view, this means ignoring the difficulties and distress of many children while, from the European point of view, an inappropriate attitude towards those children is prevented. It is clear that this divergence is due to different ideological points of view regarding the appropriate way to define dis- orders in children. Epidemiology From a review of the relevant literatu re published during the past four years, it seems that the prevalence of ADHD ranges between 7% and 16% [18–22]. This large range of percentages is probably the result of having examined differen t ages as well having employed different diagnostic tools. Moreover, the possibility of underdiagnosis or overdiagnosis should also be considered. A research study conducted in Israel [23] with adolescents who were at the initial stages of examinations prior to military service (thus, a healthy population sample) found a prevalence of ADHD of 4.9%. Thus, we are discussing a disorder that is prevalent among a population which is defined as heal thy. In clinical studies, the diagnosis of ADHD is more frequent among males than females, with a ratio of 9:1, compared to only 4:1 in epidemiological studies. Part of the gap between boys and girls may be explained by the fact THE ‘‘DIFFICULT’’ CHILD ____________________________________________________________________ 189 that the disorder is much more easily identified in boys, due to their marked hyperactivity, i.e. the gap is in part the result of selective referral of boys to clinics. Nevertheless, the fact that a difference between boys and girls was also evident in epidemiological studies indicates that boys have an intrinsic greater tendency to develop ADHD. ADHD is prevalent among all social strata, with no relationship to social or economic status. In clinical studies there is indeed a higher prevalence of patients from lower socioeconomic status, but this is probably due to the more frequent referral of these patients to public clinics, which can be more easily monitored. Contrary to what was belie ved in the past, ADHD does not disapp ear in adolescence. The most frequent diagnostic age is the elementary school, when the disorder becomes evident due to educational and social require- ments. Another wave of referrals is at junior high school age, when there is an increase in the number of adolescents who are diagnosed as having a pure attention deficit disorder, detected as a result of increasingly complex school requirements. The accepted estimate to date is that two-thirds of ADHD children continue to suffer from it in adulthood, although the hyperactivity component fades somewhat, whereas in a third of subjects the disorder partially or totally fades [24,25]. Clinical Picture Early Childhood The three components that constitute the basis for the diagnosis of ADHD, both at school age and earlier, are inattention, impulsiveness and hyper- activity. Nevertheless, levels of activity and attention in infancy are totally different from those at the kindergarten or school stage. In most cases, a suspicion of ADHD is not raised before the age of 2 years. When a 1-year-old baby is very active, does not sleep very much during the day, wakes up frequently at night, does not have regular biological rhythms and does not play on his/her own, the tendency is to diagnose a difficult character, in other words, a variation within the norm, and not ADHD, which is a deviation from the norm. When there is in addition a disturbance in senso-motor regulation, a diagnosis of regulation disorder will usually be made [26]. In a longitudinal research study from birth until the age of 7 years, Palfrey et al. [27] found that only 3% of parents of infants up to the age of 14 months expressed concern regarding inattention or hyperactivity problems in their children, compared to 13% of parents of children aged 14 to 29 months. Forty percent of children showed varied levels of ADHD up to kindergarten age, while only 5% continued to suffer from it lat er on. 190 ____________ EARLY DETECTION AND MANAGEMENT OF MENTAL DISORDERS [...]... & Sons Ltd ISBN 0-4 7 0-0 108 3-5 212 EARLY DETECTION AND MANAGEMENT OF MENTAL DISORDERS knowledge about precursors or ‘‘forerunners’’, which may constitute risk factors in the causal chain of events, provides an opportunity to identify vulnerable populations Furthermore, understanding the precursors and early manifestations of the eating disorders may lead to better informed and more effective... In outcome studies of hospitalized and clinic populations, a third of BN patients take a chronic course Despite heightened public awareness of the burden of eating disorders, their prevalence has not declined The major argument of this chapter is that Early Detection and Management of Mental Disorders ´ ´ Edited by Mario Maj, Juan Jose Lopez-Ibor, Norman Sartorius, Mitsumoto Sato and Ahmed Okasha &2005... Grados M., Bandeen-Roche K.J., Bryan R.N., Denckla M.B (1998) Premorbid prevalence of ADHD and development of secondary ADHD after closed head injury J Am Acad Child Adolesc Psychiatry, 37, 6 47 654 Zeanah C.H., Boris N.W (2000) Disturbances and disorders of attachment in early childhood In: Zeanah C.H Jr (ed.) Handbook of Infant Mental Health Guilford Press, New York, pp 353–368 54 55 56 57 58 59 60... 60 61 62 63 64 EARLY DETECTION AND MANAGEMENT OF MENTAL DISORDERS _ CHAPTER _ 7 Precursors, Prodromes and Early Detection of Eating Disorders Regina C Casper Stanford University Medical School, Stanford, CA, USA INTRODUCTION Anorexia nervosa (AN) and bulimia nervosa (BN) pose significant health problems for female adolescents and young adult... at a satisfactory 206 EARLY DETECTION AND MANAGEMENT OF MENTAL DISORDERS integration into his/her immediate environment in order to develop with the maximum utilization of the creative and intellectual potential at his or her disposal It is necessary to begin this diagnosis as early as infancy, so as to warn the environment regarding the existence of a disorder and help the family arrive at... 25 26 27 28 29 30 31 32 33 34 EARLY DETECTION AND MANAGEMENT OF MENTAL DISORDERS of attention-deficit hyperactivity disorder: screening method and pilot results Can J Psychiatry, 46, 931–940 Barbaresi W.J., Katusic S.K., Colligan R.C., Pankratz V.S., Weaver A.L., Weber K.J., Mrazek D.A., Jacobsen S.J (2002) How common is attention-deficit/ hyperactivity disorder? Incidence in a population-based... reality that are a combination of natural and man-made laws The child grows, he or she secretes hormones, learning requirements change according to age, while social demands change as well On the other hand, maternal time reflects 204 EARLY DETECTION AND MANAGEMENT OF MENTAL DISORDERS the child’s internal experience, and his ability to experience change and cope with it Abnormal development means... 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 7 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 Since... will be in accordance with the child’s age and developmental stage The age of onset of ODD is early childhood, whereas the age of onset of CD is early adolescence, although it is possible to diagnose it as early as at age 8 There are researchers who see a developmental progression between the two disorders, but this issue remains open to research The age of onset seems to be earlier in children who... experience of the event is at least as important as any objective characteristics of the trauma [34] 194 EARLY DETECTION AND MANAGEMENT OF MENTAL DISORDERS As opposed to what was thought in the past, there is evidence now that children are more likely to develop PTSD than adolescents and adults [35,36] This tends to be more true of girls than boys, although this finding is still questionable [ 37, 38] . ____________ EARLY DETECTION AND MANAGEMENT OF MENTAL DISORDERS MOOD DISORDERS Mood disorders in children and adolescents are often severe and liable to cause significant morbidity and mortality. rebellious and negative behaviour. There is a gradual appearance of quarrels with adults, and outbreaks of 192 ____________ EARLY DETECTION AND MANAGEMENT OF MENTAL DISORDERS rage, anger and resentment,. explosive temper and mood lability: a double-blind, placebo-controlled crossover design. Am. J. Psychiatry, 1 57, 818–820. 184 ____________ EARLY DETECTION AND MANAGEMENT OF MENTAL DISORDERS _________________________ 6 The