THE DIFFICULT CHILD – AN UNDERESTIMATED AND INCORRECTLY ASSESSED REALITY

Assessment of preschool children diagnosed with diseases such as ADHD, Asperger’s disease or autism involves a joint effort of physicians, psychologists and family to deepen the issues related to the clinical aspects of slippages, often genetically programmed.

Projective tests using appropriated tools show both cognitive-affective and volitional dysfunctions. This is why the specialists have limited intervention options.

Labeled as „difficult”, these children can and should be helped to bring forth outstanding areas opening to communicate with an alter ego

Understanding and assessing children with developmental disorders

It is well known and widespread the phrase “X is a normal child” – it would mean the average development of physical and intellectual characteristics together with an ability to adapt to environmental conditions. When disabilities in mental development are seen in children, in behavioural plan as well as adjustment difficulties, they are labelled as deficient or children with SEN. For these children need specialist educational intervention in order to educate them and also to help them recover. Consequently, for the intervention to be effective, it is important to know and assess the children’s needs, as well as their potential.

The nursery/pre-school teachers, when they do not have a diagnosis established by a psychiatrist for understanding and assessing the child with “developmental disabilities” needs more information about a set of data that we are trying to rank according to our experience and to current references in the specialist literature.

The first chapter is constituted of necessary information about:

The child and family of origin:

• etiologic factors involved,
• living conditions of the child,
• responsibilities of parents in their child’s education and their attitudes towards the child’s behaviour.

Documentation is achieved through a set of interventions that include both discussions with parents or with persons in the immediate environment of the child, and home visits, the administration of psycho diagnostic tests and questionnaires or projective tests specific to the actual age of the child.

Health and physical development:

• medical opinion is required to track diseases confirmed by the family doctor,
• weighing, anthropometric measuring of the child – such actions are seemingly trivial   but are important for the growing baby.

Motor behaviour including cognitive development:

• volume, variety and coordination of movements,
• control and self-control of hand as well as leg movements,
• flexibility and execution of movements.

This information may be obtained through careful, systematic observation of the child during physical education classes, manual arts activities, graphic training, and free games, when the child goes up and down the stairs, etc.

Intellectual activity refers to thorough surveillance on:

perception – tactile, visual, auditory;

• representation – accuracy, completeness, whichever prevails: visual, auditory or motor;
• elements of mechanical memory, voluntary, logic;
• qualities of attention: concentration, distributivity;
• language – with emphasis on the way of pronouncing, ability to articulate words and to formulate short sentences;
• thinking – although it is within concrete limits, we shall try to capture the level of understanding and the elements of establishing causal relationships, attempts to solve easy problems – according to the child’s age.
• imagination – type of images used in order to work with them, how the child combines them, the mental reflection in the child of the relationship between reality and fiction.

Socio – affective integration and the child’s behaviour:

• sociability – inter-individual relationships of the type child-child and child – adult;
• elements of socio-emotional adjustment in the group;
• receptiveness and reactivity to tasks, to rewards and punishments;
• ability to exercise;
• intensity of emotions, elements of the ability to control emotional – affective states.

Developing personality:

• identification of positive – negative character features;
• observation of the elements that make up the future skills as well as the characteristics of temperament;
• ability to communicate and cooperate, dominant notes;
• independence in solving tasks correctly;
• reactivity word – action, but also emotional reactivity.

Much of this information can be obtained from the curriculum palette where the child is involved, from the games, the drawings made during arts activities.

After collecting these data, each teacher develops a general picture of a particular child’s development and then proceeds to establish customized intervention programmes.

Knowing that the pre-schooler is like a “receptacle” that can assimilate much information, gestures, behaviours through imitation, teachers can find ways of engaging the child in activities even if he/she has not obtained a diagnosis from a psychiatrist. There are elements available in all mental sections that the child can learn later by means of exercises, supervised by the adult.

A child with Asperger disease with moderate retardation, with emotional disorders or with behaviour disorders needs to be thoroughly known and respected regardless of his/her native heritage , or IQ , he/she must be treated as a whole, as a system in which “cognitive, emotional, motivational treasures as well as social relations” may be rediscovered and modelled”. This child must be helped to change from “a passive receiver” into an organism actively prepared for the need to adapt to life complexities.

Every child has the right to be treated according to his needs, educated at home or in an institution where there is openness, friendliness, and flexible curriculum. Often, even if he does not understand what is happening around him, since he does not “own” a “personal decoder”, the child with “problems” still receives attitudes, feeling the tone of the voice, decoding especially the inflections of the voice of adults. It may be that pre-schooler reacts for a moment, but he just as well could “scan”rdquo; in his memory, keep some events, and may have a similar behaviour in a particular situation.

In communicating with children, especially with those diagnosed with ADHD or Asperger’s disease, for the transmission of knowledge, in explaining certain rules of living, it is good for the teacher to use an even, calm but firm voice so as not to stimulate the child’s tendency to speculate or to “negotiate “ with his teacher. The child must feel that the adults around him have confidence in him, that he is not ignored or neglected, is perceived correctly by those responsible for his recovery and psychological maturation .

In the nursery school, the teacher’s valuing attitude towards children in general is based on a good knowledge, on differential treatment and, in addition, in the case of children with disabilities, on collaboration with the family and, not least, it is influenced by the treatment prescribed by the psychiatrist, who is the one who secures the diagnosis. Valuing the child as an attitude and as educational act is not itself oriented towards a measurement of capabilities of a subject but rather an “appreciation” of such capabilities which should foster the child’s desire to manifest them, to correct and develop them in order to feel happy and loved through what he is.

In organizing an activity, each teacher must anticipate how she will be able to value each child. For example, she can find a role for him in a certain game, it is not necessarily the best solution but the distribution even in a very minor role in a group activity will be enough to value that child, from a different perspective. Children with ADHD cannot complete what they have started and do not have the capacity to correct themselves so that they end by not being interested in the mistakes they make. These children often need more stimuli, reinforcements and guides to stay focused in pursuit of a “demonstration” of the teacher or in performing a task

The right to an objective reward is a need which all children have. The objective reward results in the reinforcement of positive behaviour. According to the pace of work and individual particularities, to the child’s clinical picture, it is assumed that he expects that his qualities will be “discovered”, that his successful activities will be noticed and rewarded.

Rehabilitation, education of a child with attention deficit and hyperactivity disorder is a real “touchstone” for any teacher. Children with hyperactivity and attention deficit tend to externalize an “active negligence” and become a prominent figure in the team of children in a negative way. Preschoolers with ADHD need “a built environment, support and cultivation, consideration, mutual contribution, a sense of belonging, protection, acceptance, encouragement and understanding” (as cited in Sura Hart & Victoria Kindele Hodson , 2006)

It is recommended that children in general, but particularly those with disabilities, should be perceived by teachers as human beings with their own thoughts, feelings, needs, interests and sometimes with accomplishments to share, they can and must be «discovered» through being valued by the  adults around them.

Drawing, as tool used in therapy

Children who have been traumatized psychically, verbally and physically in the preschool period, have received the message and have it engraved in their mind that undergoes o process of development. By drawing they can translate what they have felt and may expose trauma, even if they do not recognize or are not allowed to recognize it. We shall give the example of a drawing by the subject PA aged 6. This girl, at the age of 3 years and 5 months was subjected to inappropriate treatment verbally and physically, then threatened by a caretaker that “if she says what has happened something bad will happen to her”, which led to the emergence of self-harm behaviour: biting and hitting her hands and hitting his head against the wall, using threatening language at her mother, who took her to the nursery school. She threatened her mother that if she still takes her to the nursery school, she will kill herself and will kill mother, too. This child suffers from denial as defence mechanism against the memory and emotional load she experienced, produced by the traumatic physical and verbal abuse.

From anamnesis we learned that the mother had problems during pregnancy: demanding, stressful job, which required her to spend a lot of time standing, to be available to the “boss”, to customers, who often used inappropriate language. After the birth of her daughter, mother lived with her in-laws who wanted to be involved in their own way in the child’s education, often to the detriment of the latter. There was no consistency in the rules, in the formulation of requirements. There was more than one instance when the little girl, still before going to the nursery school,  was “witness” to contradictory talks between mother and grandparents, the latter using a high tone, even with notes of verbal aggression, in which mother had to give up because  she was alone against the  “majority” (in-laws and spouse). Parents moved to their home after the girl showed behavioural disorders.

Moving the girl from two preschool institutions after her refusal to go to nursery school (at the moment of analysis being in the third institution) mother suggested to consult a psychiatrist. The girl was taken to the hospital and when she saw the white coat, she pulled at her mother’s hand and asked her to go home because she was not sick. In the nursery she was asked by the psychologist (who was not wearing a white coat and was playing a game with the young children) to help her organize the game because the little ones did not know it.

Mother was asked to participate in the group therapy together with other two girls from the small group who were also accompanied by their mothers. If, at first, each girl sat glued tightly to her mother, gradually they separated, found toys that drew them closer, thus being determined to socialize. Becoming somewhat “mature”, when she perceived the psychologist, the subject PA asked: “Why are we here?” the physiologist response came immediately: “I wanted to tell these moms how much you helped me to organize the game with their girls. Would you like me to tell them? “ PA smiled and continued her game.

In another day, the children were asked to draw a tree (Koch test). Our subject who was present in the classroom looked at children and at the children’s drawings. Of course all children’s drawings (the children were around 3 years old), have been appreciated positively because all children said they drew a tree even if there were only lines or two lines.

In the office, subject PA was asked to draw a tree. &ldquldquo;As I wish? As I know it? “her question came immediately. With calm, stimulating tone the psychologist answer followed. “As you wish” The girl looked at the psychologist carefully bit her lower lip with her teeth, took pen in hand and began to draw. She drew relatively quickly. While drawing, changes could be observed on her face mimic: frowns, twitch, and anxiety. At one point there was a sigh but she continued to draw. “Okay, I’m done !” She said. Again she stared at the psychologist. “Do you like it?” Although we hid a startle we said forcefully, “Yes! We like it. We will keep this drawing as a memory of you.”

The changing of the tone stimulated the subject to speak a little about her drawing. I recommended that every part of the tree in the drawing should be associated with family members what is core. What does the trunk represent? What do the leaves represent? We appreciate that, in the drawing, the girl has projected her psychic fears that were imprinted from the moment of the mental abuse she was subjected to, and her relationships with others who directly or indirectly were “co-partners” in trauma.

Andra draws using 3 colours and the tree has unusual shape, which resembles a stick – a fact that suggests a psychoanalytic interpretation. It may be the subject’s projection of intimate relationships between her parents, which we do not know if she caught sight of, and globally, it can be her defence mechanism: on the one hand to the trauma with the nurse, on the other the need for support from parents whom she wants much closer to her.

Analyzing the drawing, we can say that it indicates the decoding of a trauma experienced before the age of 6 years – that is, the tree trunk has a hollow in it. We appreciate that there are notes of impulsivity- aggression because of the way she drew the shape of the trunk like a tube or a rod. We understood that there is a blockage of emotional load. The leaves were 4-5 in number, resembled incisor teeth, and represented grandparents (grandma and grandpa) the trunk represents the parents (“Mom” and “Dad”), she believes the crown is similar to her, although it is of large dimensions.

By drawing, the subject has “communicated” her inside, her hidden emotions, frustration, fear, projected out her inner world and thus it was a real catharsis

For us, the test has signalled the existence of some problems of the studied child.

To our regret, the parents have not continued the therapy and were pleased with finding out the episode with the nurse. The girl goes to school now. She has finished the 1st grade.

We point out several manifestations of ADHD child attending preschool institutions – for the edification of those with less experience and practice in the field:

• impulsive behaviour during activities, play, coupled with hyperactivity and inattention;
• restlessness, frequent interruption of the continuity of the group activities;
• inability to maintain attention;
• diffuse/unfocused interest, shift from one activity to another without reason;
• actions once started remain unfinished;
• giving little time for an activity, moving quickly to another activity (also an inability to pay attention);
• inability to listen to the other person;
• volatility in formulating response;
• noisy games, disobeying the rules known or established by the group;
• unmotivated running, walking through the room during instructional-educational group activities.

Our subject, a girl LLE, a child diagnosed with ADHD was monitored during 2010-2012.

The assessment on the educational level focused on the method of observation and analysis of activity products and of adapted curriculum.

Assessment: Drawing: The Human Body

Date: September 2010

The “experiment” took place in the course of a drawing class. The children were asked to draw the “human body” with colour pencils.

The assessment of the works was done taking into account three items:

From the quantitative point of view (the children were asked to draw all body parts: head, eyes, mouth, nose, throat, ears, hair, forehead, eyebrows, eyelashes, shoulders, torso, hands, fingers, feet, a total of 15 parts);

In terms of quality (for each part of the human body points were awarded in relation to the correctness of execution on a scale of 0-1-2-3, there were a total of 45 points);

From aesthetic point of view (clothes and ornaments, as many as possible, each ornament or item of clothing was marked with 1 point).

After analyzing the drawings, the following results were found and the difference between preschool ADHD child and a “balanced” child (control sample) was clearly highlighted.

The girl was praised for her drawing, especially since she wanted to draw. After this activity she wanted to draw every day. Her joy was great when her work was displayed at the exhibition along with other works of the children.

We present an evolution of the representation of the human figure, from September, 2009 to May 2012 and analyzing the drawings we may note a quantum leap from the first sketch to the latest.

The first drawing is highly schematic, expressionless, and expeditious, only three colours were used, with blue dominating in the body. The second drawing is more «processed»: mother and the subject are drawn, in addition, a snowman appears with broom and body made ​​of circles, but the facial image is expressive due to the placement of the eyes and on the head there is a great red helmet.

The girl had drawn herself with four colours this time , the body is smaller but has strong hands, finished with fingers (all coloured in red); the head is much more shapely and colourful, desire to communicate being obvious according to the way she distributed the eyes, the nose and the mouth . The legs are also large relative to the size of the trunk, as in the first drawing, and the footwear is clearly delineated and coloured in blue. Mother appears in the drawing as being much taller, on the body she has an «M» to explain the drawing, and there are better the proportions between the head, torso, legs, hands. Mother is drawn in black only unlike the subject who portrayed herself in red, yellow, blue, and black.

Drawings 3 and 4 represent «My family», where she uses colours (blue, green, red, black, orange), and the characters have the following order on the page. The first is the father who is coloured, but has reduced dimensions, with a small torso but long legs and hands with thumbs, the head has hair, eyes, nose and mouth (large). Our subject follows, she is small, coloured in red and orange, respecting proportions. Above there is a crimson sky and underneath the girl there is much green. Following the girl there are mother and sister .

There are similarities between the way she conceived their bodies, but not total. Mom seems to be the shapeliest, differently coloured; on her face we may distinguish the eyes, nose, mouth and head with long hair. Sister is almost the size of the mother due to the length of the legs and trunk is small and is surrounded by an exaggerate quantity of green colour.

The relations between these family members seem to be more «solid» – between the subject, mother and sister and more distant from father. The intensity of colours leads us to consider the presence of elements of aggression type as well as of stereotypes that the subject probably learned at home and in nursery school, too.

In drawing 4, the whole family picture is different. The order is changed: sister, mother, the subject and father. There are fewer colours and they tend to give contour to each body shape. This time, the sister seems to be younger and the subject drew herself in a long skirt up to the toe, coloured in red and is placed near her father who looks tall and skinny. Anyway, they all have their faces coloured in yellow, like after tanning. Mother, although placed between the two girls, has the most respectable size. All of them have quizzical facial expressions, which leads us to think of the subject’s need to communicate.

In this drawing , the projection helps us hope indirectly that the  mental age of the subject and her chronological age are close.

In the  number 5, the girl is shaping her own universe: she is the main character with more harmonious body parts, emphasized by her care to draw garments with details (buttons, a red ribbon in blond hair and in her hand a heart-shaped balloon). In the drawing there are also flowers, bugs, grass, the sun (humanized with eyes, nose and mouth) and a dog on which she  puts a bag made ​​of two hearts.

Overall, we know that drawing is always a projection, regardless of age, sex, school education and family situation. In our case, the subject, LLE, whom the physician diagnosed with ADHD, made obvious progress, being closely supervised by the teacher who is also an experienced psychologist. The drawings have diversified, the attention seems to be more stable over several minutes to the drawing and other activities, and the subject begins to acquire the reflex of a control within the limits of the concrete, of shapes, sizes and of her interrelations which she did not endure initially because of her very low resistance to frustrations.

The hyperactive subject, with a very big energy «reservoir», feels the need for action almost all the time. The girl was made accountable more than other children, thus consuming her energy constructively, this method also contributing to increased self-esteem. She was actually helped to learn, to increase as much as possible her ability to pay attention, and this could be done by her actual involvement in a number of activities and games that had such an aim. Another way of inducing positive discipline is to use granting rewards, verbal praise and public acclaim for appropriate behaviour and sanctions for negative behaviour. Involving the child in sports activities she enjoyed and which had occupied her time in an attractive way was the right approach for our subject.

Establishing the basic level of behaviour

For this purpose, we recorded the:

• frequency,
• site,
• time,
• social situation,
• triggering events,
• description of the behaviour problem,
• duration of the problem behaviour,
• «severity» of behaviour,
• consequences for the student,
• consequences for others.

In relation to developing a behavioural plan in the classroom, we can show in particular that appropriate behaviour should be encouraged and sometimes taught. The first step in any behaviour modification program is to identify the problem behaviours and of the desirable ones.

Highlighting the qualities of this child and encouraging her progress in personal activities stimulated her self-confidence, made her remember the rules in games started by her peers and teacher,  determined her to “increase” the waiting period (i.e. her turn in a game), to listen to a fellow,  to express her own opinion, etc. The girl was rewarded with the display of her photo at the panel called “Child of the Day” in the lobby of the institution. “A child’s behaviour that brings rewards will be repeated – a behaviour that does not benefit the child will disappear.” (as cited in Green, Ch. Chee, K., 2009). Emotional rewards such as positive appreciation, enthusiasm, praise or parental pride influenced the behaviour change in the girl .

In the nursery school (classroom), the points, the stars were awarded for one action each, during a period when the little girl acted according to the rules, a stage or a task she solved as required (to draw, to arrange toys, clothes, etc.) with a little help, or without help. The rewards accumulating, they made together  ​​a consistent award, the roller skates (bought by the parents). We note that the results were due in part to ameliorative measures, too as well as to those of psycho – pharmacological origin.

Conclusions

We appreciate that the frequency of diagnoses such as ADHD, autism spectre syndrome, Asperger syndrome, have increased dramatically in the last decade, which requires not only the evaluation of the child, but rather the establishment of a complex treatment where professionals (doctors, psychologists, psychotherapists, social workers) should be involved besides the family, the school, the nursery school, respectively the community, as the experience of other countries has shown and which started to become visible in Romania, too.

The co-operation of the four educational factors: family – nursery school – psychiatrist – , psychologist, without neglecting the role of peers in the group, resulted in our case in the improvement to a large extent of behavioural problems: attention, hyperactivity, mild aggression and emotional reactions .

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