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 behavioural 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 environment 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, posttraumatic, 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? Lopez-Ibor, Norman Sartorius, Mitsumoto Sato and Ahmed Okasha. ©2005 John Wiley & Sons Ltd. ISBN 0-470-01083-5.

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 result 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 sometimes 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, alternatively, 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 frameworks.

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 behaviour 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 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.

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