Mood and Behavior
Understanding what is typical “moody” behavior in kids and teens versus what might be a mood issue or depression can be hard for parents to sort out. For those of us that have multiple children, we know that kids come out with their own personalities and sometimes kids can be wired as a “glass half empty.” You know, always, “No!” or just lack that flexibility that makes parenting oh so hard.
The question is, “Is your kid’s moodiness a clinical problem?” In order to better understand the source of your child’s behavior, you need to understand the signs and symptoms of mood disorders in children.
TABLE OF CONTENTS
What are Mood Disorders?
Mood Disorders is a term used to describe a group of clinical disorders whereby a person has difficulty regulating mood. No two people look the same with a mood disorder, as there can be internalizing symptoms (sadness, withdrawn behaviors, etc.) and externalizing behavior (anger, hyperactivity, etc.).
Mood disorders include a range of symptoms including persistent and prolonged periods of sadness, hopelessness, loss of interest in once enjoyable activities, as well as up and down periods of extravagant happiness or energy and severe sadness or hopelessness.
What are the Types of Mood Disorders in Children?
There are several types of mood disorders in children and adolescents. They include:
- Major Depressive Disorder
- Persistent Depressive Disorder
- Bipolar Disorder
- Disruptive Mood Dysregulation Disorder
- Premenstrual Dysphoric Disorder
- Mood Disorder Related to Another Health Condition
- Substance-Induced Mood Disorder
Major Depressive Disorder – Major Depressive Disorder is an extended period of sadness where the individual has lost interest in activities. A person with Major Depressive Disorder has significant sadness and even lack of motivation.
Persistent Depressive Disorder – low grade feelings of depression, irritable mood that lasts for at least a year. The depressive symptoms are more mild than Major Depressive Disorder.
Bipolar Disorder – Bipolar Disorder is classified by cycles of elevated mood followed by periods of depressed mood. The elevated mood must be significant and way greater than normal happiness.
Disruptive Mood Dysregulation Disorder – This condition is marked by extreme irritability and the inability to control behavior. Severe temper outbursts are common and an irritable mood most days is also typical.
Premenstrual Dysphoric Disorder – Premenstrual Dysphoric Disorder includes depressive symptoms, irritability and tension that happen before menstruation occurs. The symptoms associated with PMDD must be more severe than what is typically expected in a menstrual cycle.
Mood Disorder Related to Another Health Condition – Depression can be triggered from other various medical conditions. Some examples of conditions include cancer, injuries, and chronic medical illness.
Substance-Induced Mood Disorder – When substances are abused, such as drug use, medication effects and/or toxin exposure, depression can occur.
What are the Statistics on Depression in Children?
Depression has become a growing issue for children. During the pandemic, levels of depression (and other mental health issues) have increased across the globe. According to The World Health Organization, in the first year of the COVID-19 pandemic, global prevalence of anxiety and depression increased by 25% across all ages.
With children, from 2016 to 2019, 4.4% of children 3-17 years old were diagnosed with depression (CDC, 2022). That number equates to approximately 2.7 million children diagnosed with depression in the United States.
Another startling statistic explains how in the years 2018-2019, 15.1% of adolescents had a major depressive episode, and 36.7% battled persistent sadness and hopelessness (CDC, 2022). There is also a large portion of adolescents that have dealt with suicidal thoughts and attempts, as 18.8% reported to have seriously contemplated suicide, 15.7% had even made a plan of how they would do it, and 8.9% had made actual suicidal attempts, with 2.5% of those individuals needing medical assistance (CDC, 2022).
The recent COVID-19 pandemic has also impacted suicide rates for individuals. According to the the CDC, during February 21- March 20, 2021 suicide attempts were increased 50.6% in girls aged 12-17 years compared to the previous year. For boys, the suicide attempt rate increased to 3.7% (CDC, 2021)
What Are the Symptoms of Mood Disorders in Children and Teens?
The symptoms of mood disorders are different when comparing children and adults. Children’s mood issues may be masked by somatic symptoms such as stomach aches, sleep problems, and sensory issues.
Children and teens often lack the awareness and verbal skills to make the connection between body sensations, thoughts and feelings to the difficulties they are experiencing in everyday life. Parents often make the mistake that their bright child has the awareness and words to express their internal struggles, when it is rare for children to be able to do that. Unless you are living in a “high emotional IQ” home where families are talking about feelings and emotions all day long as an integrated part of parenting, kids won't have the connectedness or words to really express themselves.
Children with mood disorders may display purposeful behaviors and are often labeled as “bad kids” or “difficult” when in reality, they struggle with self-regulation of mood and behavior.
Symptoms of Major Depressive Disorder in Children:
- Feelings of boredom
- Lack of interest in friends or enjoyable activities (social isolation)
- Persistent feelings of sadness (including tearfulness)
- Decreased energy
- Lacking self-esteem
- Problems being able to concentrate
- Increased school absences or drastic drop in grades
- Drastic changes in diet or sleep patterns
- Overwhelming sense of hopelessness
- Suicidal thoughts or actions
- Self-harm behaviors
- Increased tantrums or more severe tantrums
- Significant worries or fears about death
Symptoms of Major Depressive Disorder in Teens:
***The symptoms above and
- More risky behavior (substance use, provocative or sexual behaviors)
- Struggles decision making
- Motivation decreases (even with activities once enjoyed)
- Short temper or angry outbursts
- Avoidance of social situations
- Overwhelming sense of guilt that may not be proportionate to situations
- Low self-esteem or deep sense of worthlessness
- Excessive tiredness and overall fatigue
- Suicidal ideation
- Weight and appetite changes
- Aches, pains, headaches and stomach problems not better explained by another condition/reason
Some other specifiers for diagnosing children and teens are: feeling inadequate or having low self-esteem, feeling guilty, feeling like they would be better off dead, no longer enjoying activities or hobbies, running away or threatening to run away and being hypersensitive to rejection
Lastly, most children and teens display some physical symptoms including changes in sleep or weight patterns, complaints of headaches, stomachaches, and either significantly increased or decreased energy.
Children with mood disorder experience emotions more intensely and are often highly sensitive to their environment. They also are more likely to experience sensory overload, which feeds into their mood and behavioral problems. Modulating sensory information and managing task demands can be quite a challenge in daily life.
Children with mood issues are typically inflexible and resistant to transitions. That makes their daily life filled with a lot of redirection and potentially conflict as adults try to help them with daily tasks.
Children and adolescents with mood regulation issues lack coping skills and thus experience tantrums and prolonged episodes of anger, frustration, or upset. These episodes often are triggered by the word, “no”, transitions, or frustration and each episode can occur for extended periods of time, frequently.
Children with mood disorders don’t recover quickly when upset and typically lack insight into their behavioral triggers or behavior in general.
When looking at chronic low level depression, such as Persistent Depressive Disorder and Disruptive Mood Dysregulation Disorder, it may be harder to distinguish symptoms because of the long-term mild symptoms. Many parents may not think their child has depression because the symptoms have become routine, albeit difficult to manage, and really that they become used to them.
Diagnosing Mood Disorders in Children
A diagnosis of a mood disorder is typically made for both children and adults with a clinical interview with a physician or mental health provider. And in the case of children and teens exhibiting signs of mood dysregulation, it is usually a parent or caregiver who is the one bringing up these concerns.
Concerns are heard and questions are asked of parents and hopefully the child. In some cases a rating scale is administered. The Beck Depression Inventory is one such depression rating scale that can be administered to children to ascertain their level of depression and to rule out any suicidal ideation.
Depression Rating Scales for Children and Teens
BDI: Beck Depression Inventory is a scale that uses 21 self-reported items that are used to measure various characteristics of depression. It takes around ten minutes to complete this test and is found in many different forms such as computer versions, card forms and paper copies (APA).
BASC: The Behavioral Assessment System for Children is a multidimensional, multimethod approach that evaluates the child or adolescent’s emotional or behavioral disorder.
The diagnostic components of the BASC scale include:
- Structured Developmental History
- Student Observation System
- Self-Report of Personality
- Parent Rating Scale
- Teacher Rating Scale
- Parent Relationship Questionnaire
The scale aims to help give accurate differential diagnosis of emotional and behavioral problems for individuals 2-21 that can help clinicians develop treatment plans. The scale incorporates traditional and new constructs to help achieve an accurate diagnosis (Development…, 2015).
CDRS: The Children's Depression Rating Scale was developed in 1979 to diagnose children 6-12 years old with depression. A score between 20-30 indicates borderline depression while a score of 30 indicates significant depression (Shanahan et al., 1987).
CDI: The Children's Depression Inventory is a scale used by mental health professionals that “measures the cognitive, affective and behavioral signs of depression in children and adolescents between the ages 7-17” (DiMaria, 2020).
Patient Health Questionnaire: Nine Items: Modified for teens – Uses self report measures to evaluate depression. There are 9 criteria and it takes around 5 minutes to complete (Kluwer).
RHRSD: The Revised Hamilton Rating Scale for Depression is used most often with adults and older adolescents. It takes approximately 5-10 minutes to complete (Kluwer).
RADS-2: The Reynolds Adolescent Depression Scale is used for 11-20 yr olds who present with symptoms of depression (Kluwer).
CES-DC: The Centers for Epidemiological Studies Depression Scale Modified for Children is helpful because it utilizes a 20 item scale and should be administered to children 6-17 years old. A score greater than 15 indicates significant depressive symptoms (Kluwer).
Unfortunately, diagnosing both children and adults with a mood disorder relies heavily on a subjective interview with typically a medical provider who has little training in understanding what depression looks like. Most physicians only have training in the pharmacological treatment of mood disorders and little else.
Even though the fundamentals of diagnosing a child and adult with mood disorder are largely the same, it takes a different approach when working with a child and their family. It is important for the parent and health care provider to be in communication with strong parent psychoeducation about the mood issue and how to manage it.
Whenever you are looking at if a child or teen has a mood disorder, you want to look at several areas, including:
- Physical exam
- Infectious disease
- Nutrient levels
- Hormone issues
- Gut issues
- Genetic issues and mutations
- History of anxiety
- Recent stressors
- Family stressors
- Learning issues
- School or academic issues
- Friendship issues
It is important to take a 360 approach to children’s mental health and rule out a number of factors before a diagnosis of depression can be made.
A full medical workup is important to rule out any medical reasons for mood and behavioral dysregulation. A deeper look at possible psychological reasons for a depressed mood is necessary as well with a particular emphasis on learning and academics, social functioning, and other clinical issues that could be the root cause.
Although diagnosing children may prove to be more of a challenge, being extra observant is a great way to pick up on any signs of a mood disorder. Parents should put their detective hats on and write down what happened when their child was upset. Thinking about antecedent triggers can help to identify easy to support the behavior.
Why Are Mood Disorders Hard to Diagnose in Children and Teens?
Mood disorders are tricky to diagnose in children and teens and there are several reasons why. Due to the internal nature of depression, the signs can be hard to see. It can manifest itself as physical symptoms such as sleep or gastrointestinal problems.
Kids with depression, especially those that are high performing academically, can be really highly functional kids on the outside but feeling sad and hopeless, and possibly suicidal in the inside. This can be especially hard for parents to understand and high performing kids with mood disorders often don’t get identified until there is a crisis.
According to the Children's Hospital of Philadelphia, mood disorders are underdiagnosed more than other health-related issues (The Children's Hospital of Philadelphia, 2014). Another issue is that depression can creep in and that means the behaviors occur gradually so families may miss the signs.
Confusing clinical mood issues with temperament, normal developmental crankiness and need for autonomy is also common. Moody behavior is a clinical issue when it is persistent and interferes with a child’s daily functioning at home, school, or in their relationships with others.
Thinking a child or teen who struggles with regulating their emotions and behavior will “outgrow it” is something that I frequently see but without direct psychological and parenting support, most kids never do. When the signs are there, parents should seek support for their child and themselves in how to manage behaviors.
Causes of Mood Disorders
We always think mood disorders and depression only result from genetics or when faced with a difficult problem. While those most definitely can be a source of a mood disorder, there are many reasons why children and teens can become depressed.
Common Sources of Mood Disorders in Children and Teens
- Trauma, grief and significant life stressors
- Anxiety or another clinical issue
- Infectious disease or toxin exposure
- Medical issues
- Poor diet or food restriction
- Head injury
- Genetics and brain chemistry
- Gut bacteria imbalance
- Genetic mutations
With children and teens who have depression, my clinical experience has been that some prolonged stressor, such as bullying or attention or academic problems, or another underlying mental health or medical issue tend to be a much more common source of depression than genetics.
Many teens with depression have long-term anxiety before they have depression. The constant “rev state” which means you are in a sympathetic dominant stress state, literally wears the body out. That cortisol overdrive taxes the adrenal glands, thyroid and interferes with blood sugar regulation and a healthy gut balance.
The Gut-Brain and Depression Connection
Many might be surprised to know just how important a healthy balance of gut bacteria is for mental health.
A healthy gut microbiome is necessary for neurotransmitter production, serotonin and dopamine, which are two neurotransmitters needed for good mental health. When there is an imbalance of bacteria in the gut, serotonin production is seriously affected.
The neurotransmitter serotonin helps to regulate many functions of our brain and body, and low levels (serotonin deficiency) is associated with depression, as well as with anxiety, and OCD. 95% of serotonin production is in the gut, so maintaining a healthy microbiome through diet and direct supplementation with probiotics is important when a child or teen is depressed.
Mood and Autism
Autism is an increasingly common developmental disorder characterized by difficulties with social skills, repetitive behaviors, limited interests, speech, and nonverbal communication. Abilities and behaviors occur along a spectrum with some children having cognitive impairments and others having normal or high intelligence along with these specific behaviors, but all children with ASD have a functional impact on their daily life, socialization, and often attention, executive functioning, learning, and language skills.
When it comes to mood and those with autism, it is a common occurrence. Autism brings increased sensory sensitivities, rigid thinking and behaviors, and sensitivity to their environment and that can lead to increased irritability, mood swings, and emotionality.
A low frustration tolerance is often the trigger because without explicit support for problem-solving and coping skills, it can lead to a behavioral pattern of upset or moodiness when things don’t go as expected. Kids with autism who don't know how to manage their frustrations are simply more prone to anxiety and low frustration tolerance.
Suicide and Depression
There is a definte link between depression and suicide. When kids and teens feel depressed, thoughts of suicide occur. According to the CDC, in 2019, a total of 18.8% of students reported having seriously considered suicide. It is the second leading cause of death amongst children, second only to gun violence.
There are risk factors that make one more likely to attempt suicide that parents and providers should consider.
Key Suicide Risk Factors to Consider:
- The client has a plan to harm self or others
- The client is unable to manage feelings of harm
- Has a future orientation
- Prior suicide attempts
- Family history of suicide
- Exposure to recent suicide (another individual)
- Substance abuse
- Diagnosis of Bipolar Disorder
- History of Developmental Trauma or PTSD
- Impulse Control Issues
- Age of client (pediatric, teen, or adult)
- Putting affairs in order, such as giving possessions away
Other Suicide Factors to Consider:
- Suicidal Ideation – Can be on continuum from passive to nonspecific ideation (e.g., “I wish I had never been born”) to active specific ideation with intent and/or plan
- Availability of lethal, agents (e.g., firearms), exposure to negative events (e.g., physical or sexual abuse, violence)
- Has there been a recent crisis, relationship problem, bullying, or other significant school problem?
- Comorbid psychiatric disorders (e.g., disruptive disorders, substance abuse)
- Agitated behavior
- Frequent mood changes
- Chronic episodes of sleeplessness
- Actions or threats of assault, physical harm or violence
- Delusions or hallucinations
- Unusually risky behavior (e.g., unsafe driving, abuse of alcohol or other drugs)
- OCD, anxiety, or another mental health issue without treatment success
- Lack of access to mental health treatment despite having a long-term issue
Treatment for Mood Disorders in Children
There are a variety of treatments available to children and teens with mood disorders beyond psychiatric medications. SSRI medication may be the treatment of choice for depression in kids but they should never be the first line of treatment with developing brains. Medication may or may not support an individual’s neurotransmitters but they definitely don’t teach skills.
Kids with mood issues lack stress tolerance and coping skills and teaching them how to tolerate uncomfortable sensations, thoughts and emotions is critical.
Having a calm brain and regulating behavioral responses is the foundation that skills are built upon. There are several evidence-based ways we can calm the brain of a child or teen with mood issues.
Once the brain is calm and regulated, then one is able to learn and retain new ways of thinking and acting. Changing faulty thinking is hard for kids and must be done in a way that they can digest and not feel so much shame about. The right type of psychotherapy paired with parent coaching is critical for sustained changes.
Neurofeedback is a safe and effective way to regulate over (stressed, anxious, angry) or understimulated (unfocused, slow processing) brainwaves. Through the process of measurement and reinforcement with computers, the brain gets reinforced for producing a healthy combination of brainwaves. When the brain is calm and regulated, one can think, pay attention, and take purposeful action. For a depressed person, neurofeedback can help alleviate symptoms. Research shows neurofeedback can be helpful for those with treatment resistant depression.
PEMF (Pulsed Electromagnetic Field Therapy) is designed to enhance cell to cell communication so that cells have healthier communications for improved body functioning. Similar to charging a battery, PEMF stimulates cells and generates microcurrents running along nerve pathways. These currents help promote self-healing and wellness. PEMF helps depression by improving cellular communication, reducing inflammation, and bringing one out of a moody, stressed sympathetic dominant state into a calm, regulated parasympathetic state.
There are many evidence-based supplements for mental health that can improve mood and stress. Magnesium is an essential supplement for calming the brain that is heavily used by the body to support the nervous system. When one is depressed, the body easily gets depleted of nutrients that support the nervous system, so direct supplementation is an important part of a care plan.
Eating nutrient dense food gives the brain and body what it needs and can reduce mood and stress-related issues. Good nutrition also helps reduce inflammation that has been linked to mood disorders. An anti-inflammatory diet or more specific diets such as iIntermittent fasting, Paleo, or GAPS can be helpful tools that people can see real change in their life.
Movement and exercise are very important and can help mood disorders by supporting neurotransmitter production. Even small amounts of movement can produce endorphins and support inflammation reduction.
Psychotherapy is a very helpful tool for people battling depression, especially in challenging faulty, negative thinking. When it comes to therapy with children, finding a skilled child or adolescent therapist is important.
Practicing gratitude is a great way to help individuals with anxiety and depression. Incorporating small acts of gratitude each day helps individuals with depressive symptoms. Gratitude activates the anterior cingulate cortex, the medial prefrontal cortex and the amygdala. Improving these areas helps improve self-regulation and self motivation for individuals.
What Parents Should Do to Help a Moody or Depressed Child?
Parenting a moody child is no easy task. It can be overwhelming and disheartening to have a child who is often resistant and challenges even simple requests.
Educate Yourself About Mood Disorders
The first step in supporting a child or teen with a mood disorder is to learn about it and how it affects the brain. A lot of parent frustration comes from not understanding the moody brain and what is the mood disorder and what is normal behavior. When you have a clearer understanding of your child’s abilities, you can better harness their strengths and support their needs.
Get Parenting Help
When you work with a therapist who specializes in child development, they give you tools that work to guide your child’s behavior. Most parents just don’t know how to reinforce desired behaviors, so kids can learn a new way of behaving. A good therapist should be a good resource for helping your child tolerate stress and gain coping skills.
Look at Science-Backed Solutions
Parents are the CEOs of their children's and families’ physical and mental health, and that means they should look at science-backed solutions that are effective and safe. Tools such as neurofeedback, PEMF, supplements, nutrition, and psychotherapy should be the first line of defense in supporting a child with mood disorders, not psychiatric medication.
Manage Your Own Stress
Parents need their own support because managing symptoms of mood disorders in your child can be emotionally taxing. The best way to take care of your child is to take care of yourself, so that you can be a role model for your child and be better equipped to handle daily stress.
Things to Say To My Depressed Child?
If you think your child or teen is depressed or struggling with mood, spending time with them and trying to do physical activities, such as crafts, cooking, or athletics, is the place to start. Asking a lot of questions is never a good idea, especially if they are rapid fire questions that require a yes or no answer.
Starting with, “I can see you are having a hard time and I know what that is like, what can I do to help you?” helps kids to feel supported in a non-judgemental way. Concentrating on resolving physical sensations, such as chest pain, sleep problems and helping kids to understand that is how stress shows up can open up the dialogue too.
Keep the conversation focused on supportive statements that aren’t critical or judgemental and relate as much as you can with your own experiences. Paint the picture of what help looks like and what the plan is to get it.
There are treatment options available for children and their families. It is all about finding the right treatment path for your child and family. Even if it seems your child may be experiencing lesser depressive symptoms, getting them help is important before it develops into a full blown crisis.
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Disclaimer: This article is not intended to give health advice and it is recommended to consult with a physician before beginning any new wellness regime. *The effectiveness of diagnosis and treatment vary by patient and condition. Dr. Roseann Capanna-Hodge, LLC does not guarantee certain results.
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