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Icebergs are deceiving because what you see on the surface is usually only a small fraction of what lies below. Observing the behavior of an anxious child is sometimes like looking at the tip of an iceberg: underlying the anxious behavior are layers of emotions and experiences. Therapists often illustrate this idea with an image like this:

While the image above can be eye-opening, there's a huge assumption that parents can actually recognize that tip of the iceberg or look at a child's behavior and say, "Yup, that's anxiety." Here's the reality: anxious behavior in children is not uniform.

Your child might ask repetitive questions for reassurance and no matter how many times you answer, the question repeats. You might have the perfect child at school that comes home and constantly picks fights with you or siblings. You may have a child that can't focus, motivate, or even loses sleep at night. Or maybe your child is downright angry. Anxiety, in fact, can manifest in a multitude of forms. In our work at GoZen!, we see anxiety showing up 8 different ways. This makes the iceberg look more like this:

Let's try to understand why anxiety manifests in these ways by taking a deeper dive into each:

1. Difficulty Sleeping

Anxiety and sleep problems have a chicken and egg connection. Research has shown that anxiety can lead to sleep disorders and chronic sleep disruption can lead to anxiety. In children, having difficulty falling asleep or staying asleep is one of the hallmark characteristics of anxiety. In many kids, trains of anxious thoughts keep them awake long after they should be asleep. Others have anxiety about falling asleep, thinking they will miss their alarm or be tired in the morning.

2. Anger

The link between anger and anxiety is an under-researched area, but in our work, the manifestation of anger in anxious children is clear. Here are some hypotheses as to why there is a link. Anxiety occurs when there is an overestimation of a perceived threat (e.g., a test or a party) and an underestimation of coping skills (e.g.,"I can't handle this."). When our kids are chronically and excessively worried and don't feel like they have to skills to manage the anxiety, they feel helpless. Helplessness leads to frustration which can show up as anger.

Anger and anxiety are also both activated in the threat center of your brain. When the brain perceives a threat, the amygdala (a small, almond-shaped cluster of neurons in the brain) activates the flight-or-fight response which floods your body with hormones to make you stronger and faster. This genetic wisdom protects us from threats and danger. Because anger and anxiety are both activated from the same brain region and have similar physiological patterns (rapid breathing, heart racing, pupils dilating etc.), it's possible that when your child feels like there is a threat (e.g. going to a party), the fight or anger response is activated as a form of protection.

Finally, one of the markers of generalized anxiety is "irritability" which is also part of the anger family.

3. Defiance

There is nothing more frustrating to a child with anxiety than feeling like their life is out of control. As a way of feeling secure and comforted, they seek to take back control, often in unexpected and peculiar ways. For example, a child already experiencing the flood of stress hormones at the prospect of going to bed, lashes out at being given an orange cup instead of a blue one. Unable to communicate what is really going on, it is easy to interpret the child's defiance as a lack of discipline instead of an attempt to control a situation where they feel anxious and helpless.

4. Chandeliering

To borrow a term from renowned social scientist, Brené Brown, chandeliering is when a seemingly calm person suddenly flies off the handle for no reason. In reality, they have pushed hurt and anxiety so deep for so long that a seemingly innocent comment or event suddenly sends them straight through the chandelier. A child who goes from calm to a full-blown tantrum without a reason is often ill-equipped to talk about their anxiety and tries to hide it instead. After days or even weeks of appearing "normal" on the surface, these children will suddenly reach a point where they cannot hide their anxious feelings anymore and have a disproportionate reaction to something that triggers their anxiety.

5. Lack of Focus

According to the Centers for Disease Control , 6.1 million children have been diagnosed with some form of Attention Deficit Hyperactivity Disorder in the US. In the past research has suggested that ADHD and anxiety often go hand in hand. But studies have shown that children with anxiety don't necessarily have ADHD more often. Instead, these two conditions have symptoms that overlap - a lack of focus and inattention being two of them. Children with anxiety are often so caught up in their own thoughts that they do not pay attention to what is going on around them. This is especially troublesome at school where they are expected to pay attention to a teacher for hours at a time.

6. Avoidance

As humans, we have a tendency to avoid things that are stressful or uncomfortable. These avoidance behaviors happen in two forms - doing and not doing. If you are trying to avoid getting sick, you may wash your hands repeatedly throughout the day (doing). If you are avoiding a person that makes you feel uncomfortable, you may skip a party or meeting (not doing). The only problem with avoidance is that it often snowballs. Children who are trying to avoid a particular person, place or task often end up experiencing more of whatever it is they are avoiding. If schoolwork is the source of a kid's anxiety, they will go to great lengths to avoid it and in the process end up having to do more to make up for what they missed. They will have also spent time and energy on avoiding it in the process, making it the source of greater anxiety in the end.

7. Negativity

From a neurological standpoint, people with anxiety tend to experience negative thoughts at a much greater intensity than they do positive ones. As a result, negative thoughts tend to take hold faster and easier than positive ones, making someone with anxiety seem like a downer all of the time. Children with anxiety are especially prone to these patterns because they have not yet developed the ability to recognize a negative thought for what it is and turn it around by engaging in positive self-talk.

8. Overplanning

Overplanning and defiance go hand in hand in their root cause. Where anxiety can cause some children to try to take back control through defiant behavior, it can cause others to overplan for situations where planning is minimal or unnecessary. A child with anxiety who has been invited to a friend's birthday party may not only plan what they will wear and what gift to take, they will ask questions about who else will be there, what they will be doing, when their parent will pick them up, what they should do if someone at the party has an allergy, who to call if they get nervous or uncomfortable, who they can talk to while they are there... Preparing for every possibility is a way a child with anxiety takes control of an uncontrollable situation.

Have an anxious child? Take a deep dive into the animated GoZen! programs to teach your kids skills of resilience and well-being.

References

https://adaa.org/understanding-anxiety/related-illnesses/sleep-disorders

https://www.cdc.gov/ncbddd/adhd/data.html

https://www.cambridge.org/core/journals/psychological-medicine/article/childhood-attention-deficithyperactivity-disorder-in-adults-with-anxiety-disorders/C54916B9CC9B1578DAFCB2EA08550186

https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1469-8986.2010.00997.x

https://www.psychologytoday.com/us/blog/in-practice/201303/why-avoidance-coping-is-the-most-important-factor-in-anxiety

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8 Ways A Child's Anxiety Shows Up as Something Else | GoZen!

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Icebergs are deceiving because what you see on the surface is usually only a small fraction of what lies below. Observing the behavior of an anxious child is sometimes like looking at the tip of an iceberg: underlying the anxious behavior are layers of emotions and experiences.

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ASCA National Model - American School Counselor Association (ASCA)

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School counselors design and deliver school counseling programs that improve student outcomes. “The ASCA National Model: A Framework for School Counseling Programs” outlines the components of a school counseling program that is integral to the school’s academic mission and is created to have a signi…

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Treatments for bipolar disorder include medication and psychotherapy or counselling. Using a combination of these approaches may help reduce the dose of medication required to stabilize a patient's mood swings.

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Bipolar Disorder Resource Center
Last updated August 2018
Bipolar disorder is a brain disorder that causes severe or unusual shifts in mood, energy level, thinking, and behavior. People with bipolar disorder experience episodes of mania where they have overly happy or extremely irritable moods and increases in energy. They can also have episodes of depression. While everyone has good and bad moods, the unprovoked and intense highs and lows of people with bipolar disorder can be unpredictable, extreme, and debilitating. Bipolar disorder occurs in all age groups, young and old. Until recently, bipolar disorder in children and adolescents was thought to be an extremely rare condition, but it may, in fact, be more common than previously thought.

Many parents are challenged by a child who has extreme changes in mood, energy, thinking, and behavior. Careful evaluation will find that some of these children are suffering from a mental disorder. Yet, only a very few of those will have bipolar disorder.

For additional information see:
Choose a topic:
AACAP's Facts for Families provide concise up-to-date information on issues that affect children, teenagers, and their families.

AACAP Practice Parameters
AACAP's Practice Parameters for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder aids mental health professionals and physicians in their clinical decision making. The Practice Parameters show the best treatment options available to families living with childhood and adolescent mental illness. These parameters were published in 2007 but are the most updated version. Because they are more than five years old and have not yet been updated to reflect current knowledge and practice, in accordance with national standards, including those of the Agency for Healthcare Research and Quality's National Guideline Clearinghouse, these parameters can no longer be assumed to be current.
Practice Parameter for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder
Information about Choices in Psychotherapy Treatment
Treatment for bipolar disorder comes in the form of medication and psychotherapy treatment. Both are important elements of a comprehensive treatment plan. For children and adolescents with bipolar disorder, getting enough sleep and developing skills to monitor moods is an essential part of effective treatment. There are several psychotherapies that are being studied for children and adolescents with bipolar disorder, such as cognitive-behavioral therapy (CBT).

To learn more about the types of psychotherapy that are available to help children and adolescents with mental illness, click here.

Information about Choices in Medication
Parents who have a child or adolescent with bipolar disorder, or any mental health condition, are often left facing difficult decisions regarding medication.
Learn more about how psychiatric medication is used to treat children and adolescents
L earn more about the types of psychiatric medication that are available to treat children and adolescents with mental health disorder
View up-to-date information about advances in psychopharmacological treatment for mood disorders

AACAP has produced medication guides to help patients, families, and physicians make informed decisions about obtaining and administering appropriate care for a child with ADHD, depression, or bipolar disorder.

Rating Scales to Assist in Diagnosis
The Child Mania Rating Scale-Parent Version (CMRS-P) is an assessment tool that helps clinicians differentiate bipolar disorder from other childhood behavioral disorders, such as ADHD. This rating scale collects information from parents and can be completed in approximately 15 minutes. Child Mania Rating Scale Parent Version.

Practice Parameters
AACAP's Practice Parameters for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder aids mental health professionals and physicians in their clinical decision making. The Practice Parameters show the best treatment options available to families living with childhood and adolescent mental illness. These parameters were published in 2007 but are the most updated version. Because they are more than five years old and have not yet been updated to reflect current knowledge and practice, in accordance with national standards, including those of the Agency for Healthcare Research and Quality's National Guideline Clearinghouse, these parameters can no longer be assumed to be current.
Practice Parameters for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder Journal of the American Academy of Child and Adolescent Psychiatry
A ssessment of a Person-Level Risk Calculator to Predict New-Onset Bipolar Spectrum Disorder in Youth at Familial Risk
Hafeman DM, Merranko J, Goldstein TR, et al.
JAMA Psychiatry. 2017; 74(8):841-847

he Bipolar Prodrome: Meta-Analysis of Symptom Prevalence Prior to Initial or Recurrent Mood Episodes
Van Meter AR, Burke C, Youngstrom EA, Faedda GL, Correl CU.
J Am Acad CHild Adolesc Psychiatry. 2016; 55(7): 543-555

Correlates of Overweight and Obesity Among Adolescents with Bipolar Disorder in the National Comorbidity Survey-Adolescent Supplement (NCS-A)
Goldstein Bl, Blanco C, He JP, Merikangas K.
J Am Acad CHild Adolesc Psychiatry. 2016; 55(12): 1020-1026

Differentiating Bipolar Disorder-Not Otherwise Specified and Severe Mood Dysregulation
Kenneth Towbin, David Axelson, Ellen Leibenluft, Boris Birmaher
Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 52, Issue 5, p466-481

Child- and Family-Focused Cognitive-Behavioral Therapy for Pediatric Bipolar Disorder: A Randomized Clinical Trial
Amy E. West, Sally M. Weinstein, Amy T. Peters, Andrea C. Katz, David B. Henry, Rick A. Cruz, Mani N. Pavuluri
Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 53, Issue 11, p1168-1178.e1

An Unquiet Mind: A Memoir of Moods and Madness
Kay Redfield Jamison

Brandon and the Bipolar Bear: A Story for Children with Bipolar Disorder
Tracy Anglada

The Dark Side of Innocence
Terri Cheney

Turbo Max: A Story for Siblings and Friends of Children with Bipolar Disorder
Tracy Anglada

For more bibliotherapy resources, visit Living with Mental Illness: Books, Stories and Memoirs.
Marbles: Mania, Depression, Michelangelo, and Me: A Graphic Memoir
Getting help is the most important thing that parents can do for children and adolescents with a mental health concern. Parents should try to find a mental health professional with advanced training and experience evaluating and treating children and adolescents with bipolar disorder. Also, it is important to find a comfortable match between your child, your family, and the mental health professional.

A child and adolescent psychiatrist is a physician who specializes in the diagnosis and treatment of mental health disorders that affect children and adolescents. Child and adolescent psychiatrists have completed four years of medical school, and at least three years of residency training in medicine, neurology, or general psychiatry with adults, and two years of additional training in psychiatric work with children and adolescents.
Find a child and adolescent psychiatrist in your area.
To learn about accessing child and adolescent psychiatrists and other mental health professionals, please read Where to Find Help for Your Child.

Oftentimes, parents are unsure when to seek a referral to a child and adolescent psychiatrist. For more information on when to seek a referral, click here.

Related Websites
There are many organizations that provide support groups for families that have a family member or child with bipolar disorder. Two such organizations are the The Balanced Mind Foundation and the Depression and Bipolar Support Alliance.

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Bipolar Disorder Resource Center Last updated August 2018 Bipolar disorder is a brain disorder that causes severe or unusual shifts in mood, energy level, thinking, and behavior. People with bipolar disorder experience episodes of mania where they have overly happy or extremely irritable moods and increases in energy.

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Licensed professional counselor (LPC) John Duggan didn't plan on bipolar disorder becoming one of his specialties, but providing emergency room support gave him a close-up view of the consequences when the disease was left uncontrolled. Duggan, who is also a licensed clinical professional counselor (LCPC), noticed the escalation in manic and hypomanic crises that accompanied the increased light and time change in spring. He also saw people who had been diagnosed with depression but whose manic or hypomanic symptoms had gone undetected until they ended up in the emergency room with full-blown mania, psychosis or dysphoria.

Some of these individuals had no one to help them remain stabilized after leaving the hospital. Seeing the need for, as Duggan puts it, "boots on the ground," he began seeing more and more clients with bipolar disorder in his private practice in Silver Spring, Maryland. Duggan, who is now the manager of professional development at the American Counseling Association, says some of those clients came as referrals from counselors who didn't feel qualified to work with individuals struggling with bipolar disorder.

It is not uncommon for counselors to be hesitant to take on clients with a bipolar diagnosis, according to practitioners who specialize in the disorder. At the same time, there are many individuals with bipolar disorder who truly need the support of counselors and other mental health professionals to help them manage their condition. Although the public - and perhaps even some mental health professionals - may think that the disease is rare, the National Institute of Mental Health (NIMH) estimates that approximately 2.8 percent of U.S. adults currently have bipolar disorder and that 4.4 percent will experience it in their lifetime. NIMH also estimates that approximately 2.9 percent of adolescents currently have bipolar disorder.

Some mental health practitioners may buy in to the stereotype that clients with bipolar disorder are volatile and resistant to treatment, whereas others may be daunted by the disorder's elevated risk of suicide. The Substance Abuse and Mental Health Services Administration estimates that for those with bipolar disorder, the lifetime risk of suicide is at least 15 times higher than it is for the average person. However, Duggan and others who treat bipolar disorder say that counselors have a crucial role to play in helping clients manage the disease.
Bipolar basics
Counselors are already trained to obtain a detailed client history that includes, among other things, emotional symptoms, family history and sleep and lifestyle habits, all of which can be crucial to spotting bipolar disorder.

"Bipolar clients often seek help only when depressed. Because of this, their manic or hypomanic symptoms are often not reported or observed," explains Valerie Acosta, an LPC who counsels a number of clients with bipolar disorder in her Richmond, Virginia, practice.

A first step is for counselors to educate clients. Although they may be familiar with the symptoms of depression, they are much less likely to know how mania or hypomania present, adds Acosta, a member of ACA. Many clients think mania involves feeling very "up" and happy, but symptoms actually include intense irritability, anxiety and distraction, she explains.

Sleep patterns are also instructive when looking for evidence of mania or hypomania, says Regina Bordieri, a licensed marriage and family therapist in New York who specializes in bipolar disorder. "If they're not sleeping, are they feeling energetic or tired?" she asks. Most people feel tired after a short night's rest, but in hypomanic or manic phases, those with bipolar disorder feel energized despite very little sleep, Bordieri explains.Bordieri also asks clients about times when they weren't depressed. Did they have high levels of energy and feel like they could get a lot done? Depressed moods that alternate with periods of intense activity and feelings of almost limitless energy may be signs of bipolar disorder.

Because it can be difficult for individuals to recognize their mood and behavioral shifts, family members and partners can also play a significant role when it comes to identifying and gauging symptoms, Bordieri says. Then, of course, there is the other role that family plays in diagnosis - namely, family history. Bipolar disorder is strongly tied to genetics, so clients with a family history of bipolar disorder are more likely to develop the disease.

Duggan urges counselors who are treating clients with bipolar disorder to work closely with medical professionals. Consulting a client's primary care physician (with the client's permission) is particularly crucial during diagnosis so that physical causes such as sleep disorders, thyroid disorders or a reaction to medication won't be mistaken as symptoms for bipolar disorder.

Counselors - and clients - should also be aware of their ideas concerning which symptoms and forms of bipolar disorder are most debilitating, say Acosta and Bordieri.

"Bipolar II is not a milder form of bipolar I, but a separate and different diagnosis," Acosta explains. "Bipolar I is also not necessarily more difficult to treat. ... While the manic episodes in bipolar I can be severe and dangerous, the depressive episodes associated with bipolar II can be longer lasting, causing severe impairment to the individual. While clients with bipolar II have hypomania and not full manic episodes, their depressive episodes can be more debilitating than the depressive episodes of bipolar I."

Although the depression of bipolar II may take a greater overall toll and be harder to treat, the mania inherent in bipolar I comes with its own set of "baggage." In the popular imagination, mania - especially more extreme episodes - is the phase most associated with bipolar disorder and contributes to the perception that those who have the disorder are "crazy." Mania is also extremely disturbing for clients and is highly stigmatized, especially when it leads to hospital stays, Bordieri says.

Ultimately, however, each client's experience of bipolar disorder is different, Acosta says. "A therapist might be working with two people with bipolar II, and these individuals may present with very different symptoms," she says. "Helping clients and their families to understand the individual's unique symptoms, and have a variety of tools and strategies for managing their moods and specific symptoms, is essential for recovery."

The counselors interviewed for this article stress that because of the neurobiological nature of bipolar disorder, medication is an integral part of treatment. Cheryl Fisher, an LCPC practicing in Annapolis, Maryland, whose specialties include bipolar disorder, says that counselors should work closely with a psychiatrist when treating these clients. In fact, when Fisher sees new clients with bipolar disorder who are working with a primary care physician, she strongly urges them to begin seeing a psychiatrist. Fisher, a member of ACA, believes that psychiatrists possess the specialized psychopharmaceutical knowledge necessary for prescribing the medication "cocktail" that works best for each individual with bipolar disorder. And because counselors see clients more often (and for longer chunks of time) than their physicians do, Fisher thinks that counselors are in a better position to track the effectiveness and side effects of clients' prescriptions.

Counselors can also help clients become better self-advocates, says ACA member Dixie Meyer. Sometimes clients aren't comfortable speaking up at the doctor's office or are unaware that they are even experiencing side effects, she says. Counselors are in a position to spot such problems.

Meyer gives the example of a client who was showing signs of lithium toxicity. "I asked him when was the last time he had his blood levels checked [lithium requires regular blood testing to guard against toxicity]. He asked me what I was talking about. Somehow, he never knew he needed to have levels checked regularly."

Meyer, an associate professor in the medical family therapy program at the St. Louis University School of Medicine's Relationships and Brain Science Research Laboratory, says counselors should also be aware that clients with bipolar disorder might be given antidepressants for depression that can cause the onset of mania or hypomania.

"Clients might feel like, 'Wow, I'm really starting to have a good mood,'" she notes. "They don't really think to bring that up to the doctor, but the counselor can easily recognize the difference between remission of depression symptoms versus the development of manic symptoms. [Clients] might become more impulsive, snippier, their motor behavior more agitated ... Counselors and family members are often the best [resources] to spot mood shifts."

Sometimes clients don't want to take medication for bipolar disorder because they have experienced unpleasant side effects, says Meyer, who frequently gives presentations to counselors on the importance of understanding their clients' medications. She urges counselors to talk through this decision with clients. Meyer informs her clients with bipolar disorder that all medications have side effects, some of which may be temporary. She then asks these clients to give the medications some time and encourages them to talk to their physicians about which side effects might be permanent.

If the side effects of the medication aren't going to go away, Meyer talks with clients about whether the side effects are something they can live with. In some cases - especially with medications that cause significant weight gain - the client's answer is no. In those situations, Meyer says that she, the client and the physician go back to the drawing board and look for other medications or explore whether lifestyle changes might help reduce the side effects.

Meyer says all counselors should have a copy of the Physicians' Desk Reference on hand so that they can quickly look up any medication. She also recommends Drugs.com as an excellent online resource.

Sometimes clients with bipolar disorder get stabilized and decide that they don't need to take their medications anymore. When that happens, Acosta says that she "reflects back" what happened the last time the client stopped taking his or her medication. (Spoiler alert: It wasn't good.)

Fisher tries to educate clients about bipolar disorder, emphasizing that a biochemical reaction underlies their mood shifts and that the medication helps buffer that process.

Medication, however, is not the only tool in the box to help individuals with bipolar disorder. Counselors can provide the emotional and lifestyle keys that help clients manage and, hopefully, decrease their mood and behavior shifts.

Prevention and stabilization

Multiple research studies continue to demonstrate the link between the circadian rhythm and bipolar disorder. Researchers are still teasing out the specifics, but what is clear is that maintaining a schedule - particularly a sleep schedule - that hews to the circadian rhythm plays a key role in controlling the disease.

Research has shown that insomnia is not just a symptom of depression but can also cause it. Likewise, Bordieri says, disturbed sleep can be either a symptom of hypomania/mania or the trigger for an episode.

Sleep is one of the first things that Fisher investigates with all clients, but it is particularly important in those with bipolar disorder. "I ask them what their sleep routine is," she says. "How do you end your day? How do you prepare your body to rest? What is your sleeping environment like?" Fisher talks about how the blue light from devices such as smartphones and tablets disrupts sleep and advises clients to establish total darkness in their bedrooms.

Some clients reveal that a racing brain regularly prevents them from going to sleep. For these clients, Fisher recommends tools such as guided meditation or performing what she calls a "brain dump" - emptying the mind by writing down all of the thoughts that are keeping clients awake.

Acosta encourages clients with bipolar disorder to go to bed at the same time every night, wake up at the same time every day and take their medications at the same time daily. She has found this routine has a stabilizing effect.

Fisher and Duggan both believe sleep is so essential to mental and physical health that if good sleep hygiene isn't working, they advise clients to get a sleep aid from their physician.

Duggan has found that the changing of the seasons can also have a profound effect on bipolar disorder. It's a component of the bipolar resiliency program he came up with called SMART.

S - (Control) stress, sleep, maintain a schedule, seasons: Duggan asks clients with bipolar disorder to track their moods and sleep. He also teaches sleep hygiene and makes note of clients' responses to the different seasons. Summer, when there is a lot of activity going on and plenty of sun, is usually a good time for many clients with bipolar disorder. But as the season draws to a close, Duggan reminds them that once fall arrives and there is less light, they are likely to start feeling less upbeat and may feel overwhelmed. He urges these clients not to overschedule themselves in summer and to step up their self-care efforts when the calendar turns to September.

M - Medication as prescribed

A - Adjunctive treatment such as yoga, acupuncture, massage or other complementary or alternative practices: Duggan says these are all areas that are outside of his expertise but that clients have found helpful. He also works with clients on self-soothing techniques and meditation. If a client is going through a severe manic or depressive phase, however, he strongly recommends against mindfulness. "I don't want them to 'be' with the bad depression or the bad mania," he explains.

R - Recreation and relationships: Duggan urges clients with bipolar disorder to stay engaged socially and to "do things that bring you joy, that you love, that give you a sense of flow."

T - Therapy and counseling as needed

Fisher is a proponent of what she calls "nature therapy." Research has shown that nature has a beneficial effect on mental health, so she urges clients to find a way to get outside - even if only for a short time - every day.

"Encouraging clients to track their moods can be a very valuable tool," Acosta adds. "There are a wide variety of apps that clients can download to help with tracking their moods. Daylio is one that a lot of my clients like to use. By recording this information over time, clients learn about how their moods cycle, and this helps them to better understand the nuances of their moods, their triggers, and what helps and does not help with stabilizing their moods. I routinely review data from these apps - or paper mood charts - with my clients. I also routinely review symptom charts with my clients to help them monitor their symptoms."

Some of Acosta's clients have also had their own highly personal methods of tracking problematic mood changes. One client monitored her mood elevations by the number of packages that appeared for her in her apartment lobby (overspending). Another client could connect his manic symptoms to times when he would spend several days engrossed in building things (an increased focus on goal-directed activities).

Developing this degree of self-awareness can be beneficial for clients with bipolar disorder. "Linking symptoms to behaviors, thoughts and triggers can help to foster recovery," Acosta says.

Meyer also teaches clients to spot patterns. She has premenopausal women chart their menstrual cycles so they will be aware, for example, that three days before their periods begin, they will feel more depressed. Meyer instructs clients to note their moods throughout the day and record what was going on. She believes that when clients can identify these patterns and recognize that there was a specific reason they were particularly manic or depressed, it provides them a greater sense of control.

Meyer teaches clients to self-soothe on hard days by going for a walk, going to the park and sitting on a bench or doing whatever else makes them feel good in a healthy way.

"It's really important ... that our clients be empowered with a strategy for their symptoms," Fisher says. For instance, if clients with bipolar disorder are having a down day and feel as though they are shifting toward a depressive episode, they could start to manage the switch by making a plan to get together with a friend or even just calling someone close to them.

Acosta tries to equip clients with bipolar disorder against life stressors. "They need to find healthy ways to cope with stress," she says.

Acosta teaches clients mindfulness meditation and gives assignments outside of session, such as trying yoga or a new form of exercise. She believes that physical activity helps rein in racing thoughts. Acosta also recommends music for relaxation.

In addition to individual therapy, Acosta has found that group therapy is very effective for clients with bipolar disorder. She runs a monthly support group for adults over 18. "Some participants have been living with bipolar disorder for decades, and some have just been diagnosed," Acosta says. "This is an open group, so members are constantly joining and leaving the group. On average, we have three to 10 participants per group. Because this is a therapy group, participants bring in and discuss any issue that they're currently dealing with in their lives. Some of the topics of discussion include challenges such as the struggle to be on time for work or losing a job because of their bipolar symptoms, relationship conflicts, the side effects of medication, healthy strategies for managing symptoms, grieving the losses in their lives caused by their illness and building healthy living strategies."

Acosta also provides education as needed in the group on topics such as understanding symptoms, exploring apps to track mood and locating resources for further education and support. She believes the peer support is what is most helpful to group participants.

"Many people have never met someone else with bipolar disorder, and learning that they are not alone or the only person dealing with the challenges of bipolar disorder can be extremely comforting and helpful," she says. "Seeing peers recover, build healthy relationships and obtain their goals and dreams is most powerful."

Support for these clients is essential, agrees Meyer, who recommends that counselors help recruit family members and romantic partners as a kind of support team whenever possible. Loved ones can be there when counselors can't and are often the first to spot mood changes, she explains. "We also know when clients are in good, healthy relationships, it helps stress levels, and that helps keep them in good health," Meyer adds.

Sometimes support can come from the strangest of sources, notes Fisher, relating the story of a woman who was in particular need of connection. "I had a client who had a trauma history in addition to bipolar disorder, and she was engaging in really unhealthy behaviors and self-loathing. She was just not in good shape," Fisher says. "She came in one day, I did a checkup, and she showed really high levels of depression."

Fisher didn't think the client was in immediate danger, but she felt bad leaving her without another source of support, particularly because it was a Friday and Fisher was going away for the weekend.

"I asked, 'Who can you be with? Who can you talk to?'' Fisher says. "The client said, 'No one. There is no one.'"

The woman was estranged from her family, and her only "network" involved her sexual hookups.

Suddenly, Fisher had an idea. She had just bought a betta fish for her office, so she asked the client to watch it for her over the weekend.

Fisher saw the client the following Monday - sans fish - and asked how she was doing. The client replied that she was feeling better and more upbeat.

"Then she started talking about her weekend and spending time with 'Olive' and watching TV with 'Olive,'" Fisher continues.

She asked the client who Olive was. Olive was the name the client had bestowed on the betta fish. The client had neglected to bring Olive back because she didn't want to leave the fish in the car but promised to return her later in the week.

Fisher told the woman to keep the fish but was curious as to why she had named her Olive. The client said that Olive made her think of hope - like the olive leaf the dove brought back to Noah's Ark to show the waters were finally receding after the Great Flood described in the Bible.

What lesson did Fisher take away from this experience? "We have to get our clients to connect - even if it's just with a betta fish," she says.

Fisher urges counselors to overcome any reservations they might harbor about treating clients with bipolar disorder. "Get more training if you're uncomfortable," says Fisher, who encourages counselors to ask themselves why they might be uncomfortable and then to address those reasons.

Counselors already possess the skills needed to empower these clients, Fisher adds. "We have clients who are walking in the door with this diagnosis and identifying it with who they are," she says. "Bipolar disorder is not who they are - their diagnosis is not their identity. People think, 'My body is betraying me. I feel like crap. I've alienated all my friends - I am the monster.' Counselors can exorcise the demon of the [bipolar] diagnosis."

****
Additional resources
To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:
Books (counseling.org/publications/bookstore)
Podcasts (counseling.org/knowledge-center/podcasts)

"Bipolar Resiliency Program" with John Duggan (HT056)

"Depression/Bipolar" with Carman S. Gill
Practice briefs (counseling.org/knowledge-center/practice-briefs)

"Counseling Adults Who Have Bipolar Disorders" by Victoria Kress, Stephanie Sedall and Matthew Paylo

****

Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor:ct@counseling.org

****

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

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Finding balance with bipolar disorder - Counseling Today

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Licensed professional counselor (LPC) John Duggan didn't plan on bipolar disorder becoming one of his specialties, but providing emergency room support gave him a close-up view of the consequences when the disease was left uncontrolled. Duggan, who is also a licensed clinical professional counselor (LCPC), noticed the escalation in manic and hypomanic crises that accompanied the increased light and time change in spring.

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What is conduct disorder in children?

Conduct disorder is a type of behavior disorder. It's when a child has antisocial behavior. He or she may disregard basic social standards and rules. He or she may also:

Be irresponsible

Skip school or run away (delinquent behavior)

Steal or do other things to violate the rights of others

Physically harm animals or other people, such as committing assault or rape

These behaviors sometimes happen together. But one or more may occur without the others.

What causes conduct disorder in a child?

Experts believe that many factors play a role in conduct disorder. These are:

Brain damage

A traumatic event

Genes

Child abuse

Past school failure

Social problems

Some children with conduct disorders seem to have a problem in the frontal lobe of the brain. This interferes with a child's ability to plan, stay away from harm, and learn from negative experiences.

Some experts believe that a series of traumatic experiences occurs for a child to develop a conduct disorder. These experiences then often lead to depressed mood, behavior problems, and involvement in a deviant peer group.

Which children are at risk for conduct disorder?

A conduct disorder is more common in boys than in girls. It is also more likely to develop in children or teens who come from homes that are:

Children with these mental health problems are also more likely to have conduct disorder:

Children or teens who are considered to have a difficult temperament are more likely to develop behavior problems.

What are the symptoms of conduct disorder in a child?

Most symptoms seen in children with conduct disorder also happen at times in children without this problem. But in children with the disorder, these symptoms occur more often. They also interfere with learning, school adjustment, and sometimes with the child's relationships.

Each child's symptoms may vary. But the 4 main groups of behaviors are:

Aggressive conduct

Intimidating behavior

Bullying

Physical fights

Cruelty to others or animals

Using a weapon

Forcing someone into sexual activity, rape, or molestation

Destructive conduct

Intentionally destroying property (vandalism)

Arson

Deceitfulness

Violation of rules or age-appropriate norms

These symptoms may look like other mental health problems. Make sure your child sees his or her healthcare provider for a diagnosis.

How is conduct disorder diagnosed in a child?

A child psychiatrist or qualified mental health expert can diagnose a conduct disorder. He or she will talk with parents and teachers about the child's behavior and may observe the child. In some cases, your child may need mental health testing.

If you notice symptoms of conduct disorder in your child or teen, you can help by seeking a diagnosis right away. Early treatment can often prevent future problems.

How is conduct disorder treated in a child?

Treatment will depend on your child's symptoms, age, and general health. It will also depend on how severe the condition is.

Treatment for conduct disorder may include:

Cognitive-behavioral therapy. A child learns how to better solve problems, communicate, and handle stress. He or she also learns how to control impulses and anger.

Family therapy. This therapy helps make changes in the family. It improves communication skills and family interactions.

Peer group therapy. A child develops better social and interpersonal skills.

Medicines. These are not often used to treat conduct disorder. But a child may need them for other symptoms or disorders, such as ADHD.

How can I help prevent conduct disorder in my child?

Experts don't know exactly why some children develop conduct disorder. Things such as a traumatic experience, social problems, and biological factors may be involved. To reduce the risk for this disorder, parents can learn positive parenting strategies. This can help to create a closer parent-child relationship. It can also create a safe and stable home life for the child.

How can I help my child live with conduct disorder?

Early treatment for your child can often prevent future problems. Here are things you can do to help your child:

When should I call my child's healthcare provider?

Call your healthcare provider right away if your child:

Feels extreme depression, fear, anxiety, or anger toward him or herself or others

Feels out of control

Hears voices that others don't hear

Sees things that others don't see

Can't sleep or eat for 3 days in a row

Shows behavior that concerns friends, family, or teachers, and others express concern about this behavior and ask you to seek help

Call 911 if your child has suicidal thoughts, a suicide plan, and the means to carry out the plan.
Key points about conduct disorder in children

Next steps

Tips to help you get the most from a visit to your child's healthcare provider:

Know the reason for the visit and what you want to happen.

Before your visit, write down questions you want answered.

At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.

Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.

Ask if your child's condition can be treated in other ways.

Know why a test or procedure is recommended and what the results could mean.

Know what to expect if your child does not take the medicine or have the test or procedure.

If your child has a follow-up appointment, write down the date, time, and purpose for that visit.

Know how you can contact your child's provider after office hours. This is important if your child becomes ill and you have questions or need advice.

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Conduct disorder is a type of behavior disorder. It's when a child has antisocial behavior. He or she may disregard basic social standards and rules. He or she may also: Be irresponsible Skip school or run away (delinquent behavior) Steal or do other things to violate the rights of others Physically harm animals or other people, such as committing assault or rape These behaviors sometimes happen together.

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ADHD symptom tests, ADD medication & treatment, behavior & discipline, school & learning essentials, organization and more information for families and individuals living with attention...

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Depression in Children and Adolescents - American Family Physician

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The Recovery Village Drug and Alcohol Rehab

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Jonathan Strum graduated from the University of Nebraska Omaha with a... read more

Medically Reviewed By Bonnie Bullock, BA, PHD

Bonnie is a medical communications specialist at Boston Strategic Partners, a global health industry consulting firm. Her recent work... read more

A mood disorder is defined by the National Institute of Mental Health as any disorder that regularly affects an individual's emotional well-being. Mood disorders can affect everyone, ranging from young children to the elderly. Mood disorders in childhood and adolescence are especially troubling, as they often overlap with a child's important formative years.

When it comes to mood disorders and children , young people are affected in different ways compared to adults and the elderly. It is important to be aware of the signs and symptoms of a mood disorder in children and adolescents. Depending on the specific disorder and its severity, treatment options vary.

What Are Mood Disorders?

What exactly are mood disorders ? It can be difficult to tell if a child shows signs of a mood disorder without professional help. Some mood disorders, such as major depressive disorder , are relatively common. Other conditions, such as premenstrual dysphoric disorder (PMDD), are much less common and only affect a small percentage of females.

Types of Mood Disorders in Children and Adolescents

There are numerous types of mood disorders in children, and each one has its own unique set of symptoms and treatment options. In many cases, are more susceptible to developing mood disorders than males. This would indicate that there are hormonal and genetic factors at play. In addition, a child with a parent or relative that is diagnosed with a mood disorder is more likely to develop one themselves.

Major Depressive Disorder: Major depressive disorder in children is also known as clinical depression. In this case, major depression is usually characterized by persistent sadness or irritability that can negatively impact a child's daily life. Being diagnosed with childhood depression can whether a child has depressive episodes in the future. Typically, cognitive behavioral therapy, interpersonal therapy, family therapy, and medication are recommended.

Dysthymia: The National Institute of Mental Health classifies dysthymia in children as a persistent depressive disorder . , also known as dysthymic disorder, affects girls more than boys. In order to be diagnosed with dysthymia, children must exhibit depressive symptoms for at least two years. Many of the same therapies that help treat major depression can also be used to treat dysthymia in children .

Bipolar Disorder: Bipolar disorder in children can be slightly different from bipolar disorder in adults or teens. Regardless, bipolar disorder is characterized by intense and sometimes sudden mood swings. Individuals may go from highs (feeling elated, supercharged) to lows (feeling depressed). Signs of bipolar disorder having a short temper, taking risks, inability to stay focused, not sleeping well or fixating on sexuality. During a depressive episode, children may feel sad, complain about their health frequently, feel hopeless and worthless or contemplate death. Bipolar disorder in teens is similar to the disorder in children, but symptoms can be more drastic and intense. Teens may struggle to maintain friendships or interact with family members. Typically, bipolar disorder in children or teens is treated with both individual therapy and various medications.

Premenstrual Dysphoric Disorder: Premenstrual dysphoric disorder (PMDD) is a condition that only affects females who have gone through puberty. While premenstrual syndrome (PMS) is a common occurrence for teenagers and women, is a more severe and debilitating form of PMS. Generally, symptoms of PMDD start before the menstrual cycle and can lead teenage girls to experience extreme moodiness, changes in appetite, sensitivity to rejection and overwhelming feelings. On top of the psychological symptoms, the painful physical symptoms of PMS like bloating, cramping, headaches, and breast tenderness are also present. For some women, PMDD can be managed well with exercise and diet changes. Other women benefit from the use of antidepressants or selective serotonin reuptake inhibitors ( ) in the latter half of their cycle.

Disruptive Mood Dysregulation Disorder: Disruptive mood dysregulation disorder (DMDD) is children who are angry and irritable on a regular basis and have emotional outbursts that ultimately impact their ability to function. For most children with DMDD , treatment is highly recommended because the condition can be tough to manage otherwise. For the diagnosis of disruptive mood dysregulation disorder in children , a child must exhibit symptoms for at least 12 months. Typical treatments for DMDD include a combination of psychotherapy, medication if necessary, parent training and computer-based training.

Mood Disorder Related to Another Health Condition: A child may exhibit symptoms of a mood disorder as a result of a co-occurring health condition . Some health conditions like traumatic physical injuries, severe infections, a diagnosis of cancer or other long-term diseases may trigger a mood disorder. In these cases, it is likely that treatment will depend on the specific mood disorder and co-occurring health condition.

Substance-Induced Mood Disorder: In some cases, children or adolescents may trigger a mood disorder through the use of substances. A substance-induced mood disorder can occur after an individual takes medication, is exposed to toxic substances or uses certain drugs. Treatment options will vary based on the mood disorder and the type of drug or substance that induced the disorder.

Symptoms of Mood Disorders in Children

There are many mood disorder symptoms . Symptoms of mood disorder in a child may not be easily recognized, or they may be attributed to an entirely separate condition. Children and adolescents may have trouble expressing or vocalizing how they feel, which can make diagnosis difficult. Signs of mood disorders can be different between children and teenagers, particularly with the added element of puberty.

Frequently feeling sad, helpless or lonely

Feeling inadequate or having low self-esteem

Feeling guilty

Feeling like they would be better off dead

No longer enjoying activities or hobbies

Problems sleeping

Changes in appetite

Problems with relationships

Attempting suicide or suicidal ideation

Frequently complaining of physical problems like headaches or being tired

Running away or threatening to run away

Being hypersensitive to rejection

Being aggressive or irritable

While most of the signs between children and teenagers will overlap, a few are more common in teenagers. Some signs of mood disorders in teenagers :

Similar, but more intense symptoms as children

Longer duration of symptoms

Not performing well in school

Always being angry

Exhibiting rebellious behaviors

Becoming problematic with family members

Problems with friends and acquaintances

Causes of Mood Disorders

There are many potential causes of mood disorders . However, the exact causes of mood disorders are generally unknown. It is likely that what causes mood disorders in children and adolescents comes down to a combination of biological, psychological, social and environmental factors.

Diagnosing Childhood Mood Disorders

In order for a child or adolescent to receive a mood disorder diagnosis , they must be seen by a clinical psychologist, psychiatrist or other qualified mental health professionals for a comprehensive psychiatric evaluation. Mental health professionals will often defer to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for a mood disorder and mental health diagnoses. The DSM-5 is a diagnostic tool that contains information about how to recognize and treat patients with mood disorders or other mental health conditions.

Determining the child's health and general medical history

Recording specific symptoms the child experiences

Noting how the child acts at home and with others in social settings

Identifying stresses in the child's life, both big and small

Receiving information from teachers and other people who regularly interact with the child

The child's history of mental health conditions, other conditions and medications used

How the parent would like to proceed with treatment, as well as a discussion of all treatment options

Treating Mood Disorders in Children

How are mood disorders treated in children? After a psychiatric evaluation, a medical professional will tailor treatment options that are unique to the mood disorder and the child or adolescent. Most mood disorders are treated with a combination of individual and family therapy, psychotherapy and medication. Treatment also encourages positive interaction and reinforcement at school.

Medications for children with mood disorders include:

These estimates show the outlook for children and adolescents with mood disorders is positive. As more research continues to be conducted on each mood disorder, it is likely that treatment options will continue to improve.

What Parents Should Know

There are a few things that parents should remember about mood disorders in children:

Treatment involves the whole family, not just the child diagnosed with a mood disorder

There is nothing parents could have done to prevent their child's mood disorder

Parents should educate themselves about the differences between mood disorders in children, teens, and adults

If you or a loved one is struggling with a mood disorder and a co-occurring addiction, The Recovery Village can help. Contact us today to discuss how a mood disorder and addiction can be treated together.
Medical Disclaimer: The Recovery Village aims to improve the quality of life for people struggling with a substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare provider.

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Mood Disorders in Children: Types and Symptoms | The Recovery Village

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Jonathan Strum graduated from the University of Nebraska Omaha with a... read more Medically Reviewed By Bonnie Bullock, BA, PHD Bonnie is a medical communications specialist at Boston Strategic Partners, a global health industry consulting firm. Her recent work...

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Learning to live with multiple sclerosis (MS) can trigger feelings of fear, grief, anxiety, and depression, especially in children and adolescents.

Although some children and teens with MS experience these feelings in an ebb-and-flow cycle, many others can develop a mood disorder.

In many cases, mood changes may start after receiving a diagnosis. A child's mood can also change as the disease progresses, because MS affects parts of the brain that control these feelings.

This article will explain what we know about these mood disorders, particularly in children ages 10 to 17, plus describe symptoms and give tips about counseling for children - all with a special focus on the unique needs of children with MS.

Children and teens with MS face a variety of physical symptoms.

In addition, it's estimated that nearly 30 percent of children and teens diagnosed with MS experience:

memory problems

issues with complex attention and processing speed

language

They're also at an increased risk of developing a mood disorder.

Some of the more common mental health conditions for those with MS include:

depression

anxiety disorders

panic disorder

bipolar disorder

Parents and caregivers should keep in mind that just because a child is feeling sad or anxious, it doesn't necessarily mean they have a mood disorder.

If you have concerns about your child's moods or behavior, it's important to talk with their doctor. The doctor may use a specific set of diagnostic tools to help determine whether your child has a mood disorder.

Depression

Clinical depression is one of the most common symptoms among adults with MS. Although there hasn't been as much research into its impact on children and teens living with MS, it appears to also be extremely common for them. In a of 23 children and teens with demyelinating conditions, depressive disorders occurred in 3 (27 percent) of them.

The most common depression symptoms include:

sadness and irritability

a loss of interest in things around them

appetite and sleep changes

difficulty concentrating

feelings of worthlessness or helplessness

thoughts of suicide

A child has to adjust to a great deal of uncertainty when living with this condition, which impacts their quality of life.

If your child is showing symptoms of depression - especially if the symptoms are getting worse or interfering with daily activities - consider contacting a healthcare professional.

Anxiety

While not as common as depression, anxiety disorders are estimated to be three times greater in people with MS than in the general population, according to a 2019 review.

Generalized anxiety disorder is the most common anxiety disorder in MS patients, followed by panic disorder.

Since MS is an uncertain, unpredictable disease, there's a higher prevalence of clinically significant levels of anxiety in people living with the condition.

Symptoms of an anxiety disorder in children or teens with MS include:

apprehension

fear

tension

persistent worry

rumination

a preoccupation with physical sensations

Similar to depression, if the symptoms worsen or begin to interfere with daily activities, you should contact a doctor.

Bipolar disorder

Bipolar disorders in children and teens involve extreme changes in mood and behavior - for example, feeling very happy or energetic (manic episode) followed by feeling very sad or down (depressive episode).

According to a 2016 cross-sectional study of adults, the prevalence of bipolar disorder is higher in people with MS than in the general population.

Symptoms of a manic episode include:

intense happiness

being extremely irritable

talking fast

having trouble sleeping or staying focused

racing thoughts

being overly interested in pleasurable or potentially harmful activities

doing things that show poor judgement

Symptoms of a depressive episode include:

unprovoked sadness

anger and hostility

increased complaints about pain, especially stomachaches and headaches

a noticeable increase in time spent sleeping

feeling helpless and hopeless

difficulty communicating or maintaining relationships

little interest in activities the person usually enjoys

If your child is showing signs of bipolar disorder or a worsening of manic and depressive episodes, consider reaching out to a healthcare professional.

Treating mood disorders usually involves a combination of psychotherapy (talk therapy) and pharmacological treatment (medication).

Often, a therapist will use a form of psychotherapy called cognitive-behavioral therapy (CBT) to treat depression, anxiety, and bipolar disorder.

However, one of the challenges in identifying and treating mood disorders in children with MS is that it relies on the child or teen to self-report. According to a 2016 review, mood disturbances are more frequently reported by parents than the child or teen.

Sometimes, even if a child doesn't meet the criteria for a mood disorder diagnosis, they may still benefit from counseling. If you have concerns about your child's moods or behavior but aren't sure how to proceed, it's always a good idea to talk with the child's doctor.

When looking for a mental health specialist for your child or teen, it's best to start with a psychologist, psychiatrist, or counselor trained to work with this age group. They have training focused on psychiatric disorders and treatment specific to this population.

That said, a qualified mental health expert who works with adults can also be a good option for children and teens, particularly if that expert has experience dealing with people with chronic conditions.

Your first step is to talk with your child's primary care doctor or MS treatment team. They may have recommendations for therapists who have additional training with MS and children.

If your child or teen needs medication, a psychiatrist can provide therapy and prescribe medication.

The American Academy of Child and Adolescent Psychiatry has a tool on its website that allows you to locate psychiatrists who provide care for children and adolescents.

Additionally, the following online locators can help you find a mental health expert in your area.

Treating your child's or teen's mood disorders with medication is often a decision their treatment team will make.

Ideally, this conversation should involve:

the mental health expert treating your child

their primary care doctor

a neurologist

This is important to help avoid any potential interactions with medications your child or teen is already taking for their MS.

With that in mind, according to the American Academy of Child and Adolescent Psychiatry, some of the more common medications for treating mood disorders in children and adolescents include:

antianxiety medications

antidepressant medications such as SSRIs, serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs)

mood stabilizers such as lithium, valproic acid, lamotrigine, carbamazepine, and oxcarbazepine for the treatment of bipolar disorder

Side effects

Side effects from mental health medications can range from mild to severe.

Because children and teens with MS may react differently to these drugs than children or teens who don't have MS - and because they may also be taking MS-specific medications that could interact with some mental health medications - it's critical to have approval from the doctor treating your child's MS before starting treatment.

It's also important for parents and children to closely monitor their experience and note any unexpected changes in mood, behavior, or other side effects once they begin taking these mental health medications. If you notice any changes, report them to your child's doctor or mental health specialist as soon as possible.

For many children and teens, the physical symptoms of MS are often more visible than the emotional symptoms.

Changes in mood are normal for all kids, especially children with MS.

But if the changes are persistent, increasing in severity, or interfering with daily activities, your child may have a mood disorder.

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Pediatric MS: Common Mood Disorders and How to Manage Them

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Learning to live with multiple sclerosis (MS) can trigger feelings of fear, grief, anxiety, and depression, especially in children and adolescents. Although some children and teens with MS experience these feelings in an ebb-and-flow cycle, many others can develop a mood disorder. In many cases, mood changes may start after receiving a diagnosis.

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What are eating disorders?

The term eating disorders refers to a variety of conditions that involve abnormal eating behaviors. Eating disorders are serious mental health problems that can be life-threatening, so they require clinical care by a physician or other healthcare professional. Two of the most common eating disorders among adolescents and young adults are anorexia nervosa and bulimia nervosa.

What is anorexia nervosa?

Anorexia nervosa, also known as simply anorexia, is an eating disorder that involves self-starvation. Anorexia is characterized by the following main symptoms:

Low body weight (less than 85 percent of normal weight for height and age)

Distorted body image

Amenorrhea (absence of at least three consecutive menstrual cycles)

Intense fear of gaining weight

What is bulimia nervosa?

Bulimia nervosa, usually referred to as bulimia, is defined as uncontrolled episodes of overeating (bingeing) usually followed by purging (self-induced vomiting); misuse of laxatives, enemas, or medications that cause increased production of urine; fasting; or excessive exercise to control weight.

In the case of bulimia, binging means eating much larger than normal amounts of food in a short period of time (usually less than two hours). Eating binges occur at least twice a week for three months and may happen several times a day.

Who gets anorexia and bulimia?

One out of every 100 females between the ages of 16 and 18 years old suffers from anorexia, and five to 10 percent of teens diagnosed with anorexia are males. Anorexia is found in across all socioeconomic groups and a variety of ethnic profiles.
The majority of bulimics are female, adolescent, and from a high socioeconomic group. Bulimia has been found in all westernized industrial countries, and it is estimated that 1 to 4 percent of females in the United States have bulimia.

Adolescents who develop bulimia are more likely to come from families with a history of:

Eating disorders

Physical illness

other mental health problems (ie., mood disorders or substance abuse)

In addition, teens with bulimia often have other mental health problems, such as anxiety or mood disorders.

What are the dangers of anorexia?

Medical complications that may result from anorexia include, but are not limited to, the following:
Cardiovascular (heart)
While it is difficult to predict which anorexic patients might have life-threatening heart problems resulting from their illness, the majority of hospitalized anorexic patients have been found to have low heart rates. Myocardial (heart muscle) damage that can occur as a result of malnutrition or repeated vomiting may be life threatening. Common cardiac complications include the following:

arrhythmias (a fast, slow, or irregular heartbeat)

bradycardia (slow heartbeat)

hypotension (low blood pressure)

Hematological (blood)
An estimated one-third of anorexic patients have mild anemia (low red blood cell count), and leukopenia (low white blood cell count) occurs in up to 50 percent of anorexic patients.
Gastrointestinal (stomach and intestines)
Normal movement in the intestinal tract often slows down with very restricted eating and severe weight loss. Gaining weight and certain medications can help restore normal intestinal function.
Renal (kidney)
The dehydration often associated with anorexia results in highly concentrated urine. Polyuria (increased production of urine) may also develop in anorexic patients when the kidneys' ability to concentrate urine decreases. Renal changes usually return to normal when the patient returns to their normal weight.
Endocrine (hormones)
In females, amenorrhea (cessation of the menstrual cycle for at least three consecutive months when otherwise expected) is one of the hallmark symptoms of anorexia. Amenorrhea often precedes severe weight loss and continues after normal weight is restored. In addition, some anorexic patients have reduced levels of growth hormones, which can help explain growth retardation. Normal nutrition usually restores normal growth.
Skeletal (bones)
Persons with anorexia are at an increased risk for skeletal fractures and broken bones. In addition, if the anorexic symptoms start before the patient has achieved peak bone formation (usually mid to late teens), the risk of osteopenia (decreased bone tissue) and/or osteoporosis (bone loss) increases. Anorexia patients often have low bone density and low calcium intake and absorption.

Can eating disorders be prevented?

Specific procedures or programs for preventing anorexia and bulimia have not been identified at this time. However, early detection and intervention can reduce the severity of symptoms, enhance the adolescent's normal growth and development, and improve the quality of life. Encouraging healthy eating habits and realistic attitudes toward weight and diet may also be helpful.

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Pediatric Eating Disorders | Children's National Hospital

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The term eating disorders refers to a variety of conditions that involve abnormal eating behaviors. Eating disorders are serious mental health problems that can be life-threatening, so they require clinical care by a physician or other healthcare professional. Two of the most common eating disorders among adolescents and young adults are anorexia nervosa and bulimia nervosa.

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What Are Anxiety Disorders?

Anxiety disorders cause extreme fear and worry, and changes in a child's behavior, sleep, eating, or mood.

What Are the Kinds of Anxiety Disorders?

Different anxiety disorders can affect kids and teens. They include:

generalized anxiety disorder

separation anxiety disorder

social anxiety disorder

panic disorder

selective mutism

specific phobias

Generalized anxiety disorder (GAD). GAD causes kids to worry almost every day - and over lots of things. Kids with GAD worry over things that most kids worry about, like homework, tests, or making mistakes.

But with GAD, kids worry more, and more often, about these things. Kids with GAD also worry over things parents might not expect would cause worry. For example, they might worry about recess, lunchtime, birthday parties, playtime with friends, or riding the school bus. Kids with GAD may also worry about war, weather, or the future. Or about loved ones, safety, illness, or getting hurt.

Having GAD can make it hard for kids to focus in school. Because with GAD, there is almost always a worry on a kid's mind. GAD makes it hard for kids to relax and have fun, eat well, or fall asleep at night. They may miss many days of school because worry makes them feel sick, afraid, or tired.

Some kids with GAD keep worries to themselves. Others talk about their worries with a parent or teacher. They might ask over and over whether something they worry about will happen. But it's hard for them to feel OK, no matter what a parent says.

Separation anxiety disorder. It's normal for babies and very young kids to feel anxious the first times they are apart from their parent. But soon they get used to being with a grandparent, babysitter, or teacher. And they start to feel at home at daycare or school.

But when kids don't outgrow the fear of being apart from a parent, it's called separation anxiety disorder. Even as they get older, kids with separation anxiety disorder feel very anxious about being away from their parent or away from home. They may miss many days of school. They may say they feel too sick or upset to go. They may cling to a parent, cry, or refuse to go to school, sleepovers, playdates, or other activities without their parent. At home, they may have trouble falling asleep or sleeping alone. They may avoid being in a room at home if their parent isn't close by.

Social phobia (social anxiety disorder). With social phobia, kids to feel too afraid of what others will think or say. They are always afraid they might do or say something embarrassing. They worry they might sound or look weird. They don't like to be the center of attention. They don't want others to notice them, so they might avoid raising their hand in class. If they get called on in class, they may freeze or panic and can't answer. With social phobia, a class presentation or a group activity with classmates can cause extreme fear.

Social phobia can cause kids and teens to avoid school or friends. They may feel sick or tired before or during school. They may complain of other body sensations that go with anxiety too. For example, they may feel their heart racing or feel short of breath. They may feel jumpy and feel they can't sit still. They may feel their face get hot or blush. They may feel shaky or lightheaded.

Panic disorder. These sudden anxiety attacks can cause overwhelming physicals symptoms, such as feeling shaky or jittery, trembling, a racing heart rate, and shortness of breath. Panic attacks can happen any time. They're more common in teens than kids.

Selective mutism. This extreme form of social phobia causes kids to be so afraid they don't talk. Kids and teens who have it can talk. And they do talk at home or with their closest people. But they refuse to talk at all at school, with friends, or in other places where they have this fear.

Specific phobias. It's normal for young kids to feel scared of the dark, monsters, big animals, or loud noises like thunder or fireworks. Most of the time, when kids feel afraid, adults can help them feel safe and calm again. But a phobia is a more intense, more extreme, and longer lasting fear of a specific thing. With a phobia, a child dreads the thing they fear and tries to avoid it. If they are near what they fear, they feel terrified and are hard to comfort.

With a specific phobia, kids may have an extreme fear of things like animals, spiders, needles or shots, blood, throwing up, thunderstorms, people in costumes, or the dark. A phobia causes kids to avoid going places where they think they might see the thing they fear. For example, a kid with a phobia of dogs may not go to a friend's house, to a park, or to a party because dogs might be there.

What Are the Signs & Symptoms of Anxiety?

A parent or teacher may see signs that a child or teen is anxious. For example, a kid might cling, miss school, or cry. They might act scared or upset, or refuse to talk or do things. Kids and teens with anxiety also feel symptoms that others can't see. It can make them feel afraid, worried, or nervous.

It can affect their body too. They might feel shaky, jittery, or short of breath. They may feel "butterflies" in their stomach, a hot face, clammy hands, dry mouth, or a racing heart.

These symptoms of anxiety are the result of the "fight or flight" response. This is the body's normal response to danger. It triggers the release of natural chemicals in the body. These chemicals prepare us to deal with a real danger. They affect heart rate, breathing, muscles, nerves, and digestion. This response is meant to protect us from danger. But with anxiety disorders, the "fight or flight" response is overactive. It happens even when there is no real danger.

What Causes Anxiety Disorders?

Several things play a role in causing the overactive "fight or flight" that happens with anxiety disorders. They include:

Genetics. A child who has a family member with an anxiety disorder is more likely to have one too. Kids may inherit genes that make them prone to anxiety.

Brain chemistry. Genes help direct the way brain chemicals (called neurotransmitters) work. If specific brain chemicals are in short supply, or not working well, it can cause anxiety.

Life situations. Things that happen in a child's life can be stressful and difficult to cope with. Loss, serious illness, death of a loved one, violence, or abuse can lead some kids to become anxious.

Learned behaviors. Growing up in a family where others are fearful or anxious also can "teach" a child to be afraid too.

How Are Anxiety Disorders Diagnosed?

Anxiety disorders can be diagnosed by a trained therapist. They talk with you and your child, ask questions, and listen carefully. They'll ask how and when the child's anxiety and fears happen most. That helps them diagnose the specific anxiety disorder the child has.

A child or teen with symptoms of anxiety should also have a regular health checkup. This helps make sure no other health problem is causing the symptoms.

How Are Anxiety Disorders Treated?

Most often, anxiety disorders are treated with cognitive behavioral therapy (CBT). This is a type of talk therapy that helps families, kids, and teens learn to manage worry, fear, and anxiety.

CBT teaches kids that what they think and do affects how they feel. In CBT, kids learn that when they avoid what they fear, the fear stays strong. They learn that when they face a fear, the fear gets weak and goes away.

In CBT:

Parents learn how to best respond when a child is anxious. They learn how to help kids face fears.

Kids learn coping skills so they can face fear and worry less.

The therapist helps kids practice, and gives support and praise as they try. Over time, kids learn to face fears and feel better. They learn to get used to situations they're afraid of. They feel proud of what they've learned. And without so many worries, they can focus on other things - like school, activities, and fun. Sometimes, medicines are also used to help treat anxiety.

How Can I Help My Child?

If your child has an anxiety disorder, here are some ways you can help:

Find a trained therapist and take your child to all the therapy appointments.

Talk often with the therapist, and ask how you can best help your child.

Help your child face fears. Ask the therapist how you can help your child practice at home. Praise your child for efforts to cope with fears and worry.

Help kids talk about feelings. Listen, and let them know you understand, love, and accept them. A caring relationship with you helps your child build inner strengths.

Encourage your child to take small steps forward. Don't let your child give up or avoid what they're afraid of. Help them take small positive steps forward.

Be patient. It takes a while for therapy to work and for kids to feel better.

Helping Your Child Manage Anxiety

Feeling nervous, worried, or uneasy at times is a normal part of growing up. You can help prevent anxiety from becoming a bigger problem by learning how to help your child feel more in control and ways to cope with stress.

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Anxiety is a normal part of growing up, and all kids experience it. But when it becomes extreme, it can interfere with a child's overall happiness.

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It is usually expected that all children will experience some fear or anxiety from time to time.

New situations, challenging tasks, and even unfamiliar people can all lead to some anxiety in most children.

Other age-appropriate fears include:

stranger anxiety beginning at 7 to 9 months of age

fear of the dark, monsters, insects, and animals in preschoolers

fear of heights or storms in younger school-age children

worry about school and friends in older school-age children and teens

It takes a little more than occasional anxiety, which can be normal, to indicate true symptoms of an anxiety disorder, though.

As much as it is common to have occasional anxiety, it is also common for children to have anxiety disorders. In fact, anxiety disorders are more common than ADHD or childhood depression and are the most common psychiatric disorders in children.

Children with true anxiety symptoms have them on most days and they can include:

restlessness

fatigue

trouble concentrating

irritability

muscle tension

trouble sleeping (insomnia)

As part of a diagnosis of a generalized anxiety disorder (GAD), a child should have one of these symptoms for six months or more, and they should be triggered by more than one thing, such as being anxious about work, school, and friends.

Also, a child with a generalized anxiety disorder will have trouble controlling her feelings of worry and it will cause her distress and some kind of impairment. For example, she may be so irritable from not sleeping that she is having trouble keeping her friends or her grades are dropping because she can't concentrate.

Children with generalized anxiety disorder may also have somatic symptoms, such as headaches, abdominal pain, and muscle aches and pains.

In addition to a generalized anxiety disorder, children can have more specific phobias.​

They become anxious and worried, but only after very specific triggers, such as a thunderstorm, spiders, being left alone, or going in a swimming pool, etc. Although these children may cry and may cling to their parents if they are around or think they will be around something they are really afraid of, fortunately, most kids outgrow this type of anxiety disorder.

Like adults, children can also have other anxiety disorders, which range from separation anxiety and obsessive-compulsive disorder (OCD) to panic attacks.

While symptoms of separation anxiety are typically easy to recognize, a child who refuses to go to school, sleep alone, or go anywhere without a parent, other anxiety disorders can be a little harder to detect.

Children with OCD, for example, may have either recurrent consuming thoughts or impulses (obsessions) about certain things or repetitive behaviors or mental acts (compulsions) that they perform, such as washing their hands a lot, checking things over and over, or repeating certain words or phrases to themselves.

Although uncommon in children, panic attacks are another type of anxiety disorder that does become more common in later teen years. In addition to intense fear or discomfort, children having a panic attack should have four or more of the following symptoms:

palpitations or a fast heart rate

sweating

shaking

feeling short of breath

feeling choked

chest pain

nausea or abdominal pain

dizziness

numbness or tingling (paresthesias)

chills or hot flashes

fear of losing control

a feeling of unreality (derealization) or being detached from oneself (depersonalization)

Of all of the anxiety disorders in children, selective mutism is perhaps the one that is most commonly overlooked, as people think these children are just extremely shy. Children with selective mutism actually refuse to talk though and may only talk to close family members at home. At school or in other situations, they often become anxious and very uncomfortable when they are expected to talk.

Your pediatrician, a child psychologist, and/or a child psychiatrist can be helpful if your child has persistent anxiety symptoms.

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Common Childhood Anxiety Symptoms All Parents Should Know About

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It is usually expected that all children will experience some fear or anxiety from time to time. New situations, challenging tasks, and even unfamiliar people can all lead to some anxiety in most children.

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It is a natural thing to have anxiety. It is normal for very young children to be afraid of the dark, or for school-age children to worry about making friends. But sometimes normal childhood anxiety morphs into something more serious. A young girl might be afraid to ever leave her mother's side, even to get on the school bus, or an anxious boy may need frequent reassurance over things that happened a month ago.

Kids can develop an anxiety disorder. Eventually the disorder can start interfering with a child's friendships, life at home, and work in school. Even so, the anxiety still might not be noticeable to parents and caregivers.

For one thing, being anxious doesn't necessarily mean that you can't function-it might just make some kinds of functioning more difficult. A homework assignment that should take twenty minutes might take an hour, for example. With anxiety, it's important to remember how internal it is. It dominates a child's thoughts, but it might not be obvious to the people around her.

It's also worth noting that in my work as a child psychiatrist I see a lot of anxious kids who are still basically happy and enjoying life. Maybe they are only struggling in certain situations, which may make their anxiety all the easier to overlook.

Outward signs of childhood anxiety

When anxiety is expressed outwardly, there can be a wide range of signs and symptoms, which often complicates identification.

Kids may have trouble sleeping or complain about stomachaches or other physical problems.

They may become avoidant and clingy around parents or caregivers.

They might also have trouble focusing in class or be very fidgety-I like to say, "Not all that moves is ADHD," even though that's often the first thing we suspect from a hyperactive or inattentive child.

They may have explosive outbursts that make people think they are oppositional, when their fight-or-flight mechanism is triggered.

The words we use to describe our anxiety can distract, too. People use a lot of different words to describe what they're feeling-kids might say they are self-conscious, shy, apprehensive, worried, or afraid. These words do a good job capturing what they are struggling with, but fixating too much on them can distract from the fact that anxiety is underlying factor-not some personal failure in personality.

Consequences of untreated anxiety

If you look at the prevalence rates of anxiety disorders, you'll see that the numbers rise as children get older. That makes sense because anxiety disorders are cognitive, so they develop as our cognitive ability develops. Separation anxiety, for instance, develops early, whereas social anxiety disorder usually develops after puberty. A study of more than 10,000 kids, interviewed by trained professionals, shows that more than 30 percent had developed an anxiety disorder some time before they were 18.

Anxiety frequently recurs, too, and childhood anxiety is often a precursor for adult anxiety, especially for kids who don't receive treatment. The same study showed that 80 percent of kids with anxiety do not get treatment. Many adults seeking help for anxiety remember feeling anxious when they were younger, which means that they've been struggling for a long time and could have benefited from treatment as children.

Avoidance reinforces anxiety

Kids with untreated anxiety also begin to develop poor coping skills. A common example is avoidance-people who are very anxious will try to contain it by avoiding the thing that makes them anxious. It's a short-term solution that unfortunately reinforces their anxiety instead of acclimating them to it.

Similarly, untreated anxiety can lead to lower self-esteem, academic dysfunction, and self-medication through substance abuse.

Anxiety leads to depression

People living with anxiety for extended periods of time are also more likely to develop depression. It isn't uncommon to meet patients who come seeking treatment for depression or depressive symptoms and it turns out that they have been dealing with lifelong anxiety as well. In cases like this people need treatment for anxiety and depression.

Fortunately, we know a lot about how to treat anxiety. It responds very well to cognitive behavior therapy, and there are medications that work, too. Getting help makes a big difference, and treatment doesn't need to be a lifelong thing-although its positive effects will be.

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Detecting Childhood Anxiety Disorders | Child Mind Institute

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It is a natural thing to have anxiety. It is normal for very young children to be afraid of the dark, or for school-age children to worry about making friends. But sometimes normal childhood anxiety morphs into something more serious.