An Integrativedynamic Model Of The Difficult Child

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Our understanding of the ''difficult'' child is based on our perception of three major components: (a) the integration among personality components, (b) the interaction between the child and the environment and (c) the dynamic of these processes.

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. In addition, and important to the same degree, is the interaction that develops between the child and his/her environment, starting with his/her parents and ending with large social systems. These interactions determine the development of the difficult child's characteristics, 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 of these processes, it may be expected that there will be multiple diagnoses. In fact, 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 aetiological source, the same child is likely to be diagnosed differently at different stages in his/her development. Here dynamism, the third component of the model, enters the picture.

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 time 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 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 development is dynamic, the child progressively changes from one point in time to another. This stems from two reasons.

First, the biological clock acts differently in different situations, so that different syndromes and disorders, including innate ones, appear at different points in time and modify existent interactions. Over and above these changes, there are also environmental changes, which are synchronized with time, for example, school entry, passing from one grade to another and accompanying changes in academic requirements, entry into social frameworks, such as youth groups, etc. These changes may seem artificial (not built-in), but since they are environmental, and the environment has a tremendous impact on phenomenological development, they are no less important than innate organic factors. These changes are time-dependent, and their existence exacerbates or discourages further development of the ''difficult child'' phenomenon as well as determining its final form.

Second, the same disorders existing at a certain age are likely to appear totally different at another point in time, again due to changes in the interactions they create between the child and the environment. Therapy constitutes an additional factor, which creates different interactions, biological, as well as psychological and social. In this part of the continuity factor it is possible to include the concept of risk factors and protective factors, or alternatively the currently more acceptable concept of resilience. 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.

It is interesting to compare the time motif in the development of the ''difficult child'' with the time motif in normative development. In childhood, there exist two opposing concepts of time: ''maternal time'' and ''paternal time''. Paternal time deals with external, real time, and is in many senses unavoidable; it reflects the laws of 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 the child's internal experience, and his ability to experience change and cope with it. Abnormal development means that these two times gradually separate, so that the child cannot experience from within the changes and demands that are perceived as imposed from without, leading to a disconnection and ''freezing'' of time in various pathological ways. While working with children, we frequently observe how parents encountering different organic difficulties of their child, as well as various systems that deal with the child, attempt to cope with the child's difficulties by means of the time continuum, in other words, by stopping the progress of time and its demands, so that it will be in accord with the child's development. A typical example of this is keeping a child in the kindergarten for another year, although he is supposed to advance to first grade. The explanation given by the parents and the system is ''to allow the child to mature'', but this explanation is problematic, since maturity means the creation of renewed harmony among the different developmental axes. Thus, harmony should be achieved by closing gaps, by treating organic difficulties and by processing traumas, not by artificially intervening in the time clock. This intervention in systemic frameworks is an illusion, since it creates the impression that it is possible to stop time. This is a dangerous illusion in itself, but it is even more dangerous when it encourages one to ignore a constant ongoing time-dependent dynamic process. This is liable to be the ultimate factor in the development of the ''difficult child''. This is due to the fact that the child who has suffered until now from ADHD or an untreated traumatic syndrome will gradually become a child whose environment cannot support him or her, and who gets no enjoyment out of his or her development.

A significant principle stems from recognizing the time element and its importance: that of equilibrium. The child's functioning is based on equilibrium, which constitutes the different protective and risk factors that make up the child's different characteristics and the interaction among them. The importance of time lies both in the existence of a constantly fluid process and of key points that mark changes within this process. 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. However, as was stated above, we have here dynamic and not static equilibrium. It follows from this that 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. 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.

On the other hand, the fact of dynamism 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.

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.

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