Difficult children. Prioritize personalized responses
Difficult children, hyperactive with or without impulsiveness, child kings or tyrants, future delinquents detectable from kindergarten. There’s no denying it: the education of our dear little darlings regularly causes the ink to flow! And when neurological disorders are excluded, it is not easy to identify the causes to tackle them.
However, it is to this task that Isabelle Roskam’s team has taken on, following from an early age the children who pose problems for their family and at school.
Early diagnosis of behavioral difficulties in children: this is precisely the challenge taken up by a multidisciplinary team from the Cliniques Universitaires Saint-Luc (UCL) in Brussels, involving psychologists, of course, neuropediatricians, child psychiatrists, speech therapists, and neuropsychologists.
“For several years, we have been meeting a large number of parents and children suffering in their relationship: faced with their very difficult child, the parents who were no longer coping came to consult specialists in our unit to understand what was wrong with them. Was wrong. When we had ruled out neurological causes or problematic personal situations, the only answer we could give was psychomotricity. But by observing the archives of the consultations, we found that this unclear answer encouraged them to embark on medical shopping to obtain a more precise. She and her team then decided to think about the best way to bring real solutions to patients and their families.
Hence, the idea of seeking to objectify the types of problems encountered by these families more precisely. “Since 2005, we have been recruiting children aged 3, 4, or 5 who present behavioral difficulties, such as aggressiveness, lack of obedience, impulsiveness, or restlessness. Contact is made via consultations at Cliniques Saint – Luc by parents who are no longer coping and come to ask for help. We exclude children who have clear neurological problems such as epilepsy, such as those who live in a problematic psychosocial context, have significant language disorders, or suffer from intellectual disabilities. This is why we work together with neuropediatricians or even psychologists who are responsible for detecting these cases,” continues Isabelle Roskam. She notes that while some disorders are now more easily diagnosed thanks to reliable tools, this is not the case for all, particularly motor and cognitive inhibition. They, therefore, had to adapt the tools used for older children to standardize them to be able to carry out reliable case comparisons.
Based on some 150 children enrolled, compared to 300 to 400 children from a control group recruited from partner schools in the project, Isabelle Roskam’s team determined four factors at the origin of the behavioral problem of these children. “First of all, a quarter of them have insufficient language development: they, therefore, do not understand the instructions, and therefore, what the parents or educators expect of them. If these instructions are not clearly stated or the children cannot express themselves correctly, aggression may occur.
The second factor is the inability to inhibit. That – is governed by a front area of the brain; if it is deficient, we can see in these children a failure to inhibit motor movements to respect instructions or wait until the adult has finished speaking to speak, for example. Children with ADHD or attention deficit disorder are most at risk in this area.
The third factor is emotional problems: the child seeks to notice his difficult behavior or an anxious profile. Children who have experienced an attachment disorder are particularly represented in this category.
Finally, there are the educational problems: overwhelmed parents do not set enough limits or lack consistency in the different decisions made or between themselves.
Based on regular consultations, all the children are evaluated for three years according to these four criteria. “After the initial complete assessment phase, which includes a psychological consultation, a speech therapy consultation, and a meeting at school, the child repeats this same triple consultation every six months for two years, and during the closing assessment, to observe its evolution. The children will then be seen again at 9, 12, and 15 years old to know their progress.
The team’s mission is to flush out the most contributing factors in each case and to give parents ways to adapt their attitude according to the situation, individually, even if the guidelines are the same. Indeed, it will be necessary to consider the family, social, educational, the socio-professional status of each family.
After more than three years of observation of this panel whose first recruits have completed the three years of study, what are the main lines that emerge?
“First, we have seen how difficult it is already to identify the real problem children … According to the person requesting an assessment ( the father, the mother, the teacher, another doctor …), the image given of the child can vary very strongly. Hence our question: who to believe? Who is the best informant? According to Isabelle Roskam, the parents’ vision is biased, in particular, because they often arrive in her service after a long journey made up of research on educational techniques discussions with relatives: they finally hand it over to a professional.
“And since they want their request to be taken seriously, they expose the problems from their worst angle, recount the most negative experiences. These isolated problems give a picture that sticks to their representation, but is it reliable?
Teachers then? Often more structured, because they are not emotionally involved like the parents, their request differs and their judgment. But there is no bad point of view, hastens to add Isabelle Roskam: “The child is a synthesis of everything that his entourage tells us. Sometimes the child is difficult at school and not at home and vice versa. It is also different at the consultation, even if there are cases of difficult children always and everywhere …” But she underlines that the problem of the specialists consulted is that they can only trust the person who comes to consultation for lack of time and money: ideally, it would be necessary to have the “sound of a bell” of various speakers…
“We did not expect to note so many differences. For example, for the diagnosis of ADHD, if the specialist sticks to a single version, the disorder would affect 25% of 3-year-old children; if the child is studied in two different settings, the figure drops to 2.5%! We must therefore remain humble….”
Another important lesson: the impact of language disorders. 25% of difficult children would be concerned. However, simple measures can already have a considerable effect, such as effective communication with these children: getting down to their level to capture their attention, giving clear instructions, communicating simply and effectively teaching them these steps. And when the situation normalizes, the behavior of many of these children improves.
With the idea of stating clear instructions, these must be clear in their verbalization and consistency. “Parents sometimes use different techniques to make themselves obey. As a result, there is a lack of educational consistency, and the child will always know how to get what he wants from one or the other. Likewise, these parents make unrealistic threats; therefore, the child remains insensitive and does not change his behavior. Another scenario: they simultaneously try all sorts of techniques to gain respect, so that there is no guideline anymore .”
In some cases, it will even be necessary to break down a negative image that the parents may have of their child, for example, if he was not wanted, or if it was a boy when the parents wanted a girl or vice versa. It will then be a question of working on the representation of the child, for example, by emphasizing his skills recognized by the teachers or his progress.
For its part, speech therapy will be useful for correcting language disorders. “As for the lack of inhibition, psychomotricity can be useful, but also small games that are very easy to play with the family, such as “neither yes nor no” to exercise cognitive inhibition or, “Jacques said, “for motor inhibition . What’s more, it’s a positive moment in the relationship with the child …”, stresses Isabelle Roskam. And if these measures are not enough, if the child’s behavior impacts his school career, medication may be considered for children over six years old on the decision of the neuro pediatrician, and sometimes on the advice of the research.
And then, there are the cases of affective disorders. “This is the most difficult aspect to work on: it requires a lot of questioning during family sessions. Mother-child therapy is also considered if there has been a bonding problem..”
Finally, parental guidance sessions are organized for parents ready to question their attitude to reframe education methods. In short, a form of educational coaching is scheduled for 5 to 10 evenings, individually or in groups. Important clarification: it is essential to have the support of both parents so that they form a team to deal with the problems, that they can pass the baton when necessary and decide on appropriate measures. It has the effect of restoring confidence: the parents feel able to act again. The child will benefit from these therapies and will no longer feel rejected, positively affecting his self-esteem.
Review Every Three Years
The children supported in this study who followed these corrections adapted to their specific problem are now six years old. “Good news: no difficult 3-year-old child is condemned to remain so! There is a potential for help for everyone“, likes to underline Isabelle Roskam.
Therefore, the theory of future delinquents from kindergarten is erased with a sweep of the broom! “We need to develop tools to work with parents and networks, but also to reduce stress in the family or the couple, so as not to remain in a vicious circle. General interventions such as psychomotricity now offered must be replaced by targeted measures.
A study like the one conducted by Isabelle Roskam and her team, as useful and effective as it is, has a significant cost “The parents did not have to pay anything , and around 85 % stayed with us . If we had made them pay , those who would have gone had it not been – what a little better would have already left … We therefore need funds to continue this study , to find financing .”