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Raising a Moody Child

How to Cope with Depression and Bipolar Disorder

The Guilford Press

Difficult, Temperamental, Impossible

THE CHALLENGE OF RAISING A MOODY CHILD

Kevin is ten. Although the past ten years have been mostly happy and uneventful, his parents say Kevin has always had a hard time handling disappointments and unexpected events. They've learned to warn him about schedule changes to avoid brief, but sometimes explosive, tantrums. The entire family has gotten used to tiptoeing around Kevin whenever things don't go his way.

Academic success has usually come easily to Kevin, although he has always worried a lot about doing well. Kevin tends to be a worrier in general. His parents have learned to keep the television off during the early evening news so that Keving won't worry about things he hears on the broadcast and have trouble falling asleep. He has lots of good friends at school, in the neighborhood, and on his sports teams.

Starting a couple of months ago, Kevin's parents, Bob and Cindy, noticed that their strategies for helping Kevin cope with changes and disappointments (such as giving him advance warning and providing lots of time and space) have not been enough. He cries easily at the slightest disappointment and has been having more frequent and longer tantrums in response to things not going his way. Although he typically enjoys playing games and spending time with the family, lately they have needed to coax him out of his room during the evenings to join the family in watching a movie or playing a favorite game. He has been complaining about stomachaches almost daily. His teacher sent a note home because she was worried about him; her previously eager and efficient student had not been finishing his work. Kevin's parents have tried asking him what's wrong—whether he feels sick, or whether something happened at school or with one of his friends—but he just grunts and seems to be irritated by the questions.

Over the past couple of weeks, Kevin has gone from staying by himself in his room and mumbling sullenly to snapping at everyone, from Mom and Dad to his eight-year-old sister, Abby, and even his beloved dog, Max, who has slept with Kevin since Max was a puppy. One morning when Max jumped up on Kevin to greet him, Cindy was shocked when Kevin pushed Max away and cursed at him.

Kevin has also begun isolating himself on weekends, reluctant to go to baseball practices and games that formerly he had considered the best parts of his week. He also started turning down invitations to play with his friends. Kevin has started worrying so much about doing well at school that he recently begged his mother to let him stay home—he was convinced that he would fail his social studies quiz if he went to school that day.

Bob and Cindy feel paralyzed. For the last couple of months they have tried everything they could think of, from reading the latest self-help books and magazine articles to doing Internet searches, taking a parenting course through their church, and comparing notes with relatives and friends who have kids. Nothing has helped. In fact, things just seem to be getting worse. Bob was distraught when Abby began complaining that her parents favored her big brother over her. Cindy secretly worries that the family tension will cause her husband, who has not touched alcohol in five years, to begin drinking again—a problem that she does not want to recur.

Kevin's parents have always thought of Kevin as "moody," but they're starting to realize that this seemingly benign term that everyone seems to use does not fully capture what they and their son are experiencing. What could they have done to make Kevin so unhappy? What's really wrong with Kevin?

Feeling at the end of her rope, Cindy made an appointment with Kevin's pediatrician, who ruled out medical problems and referred them to a psychologist. The psychologist did a thorough evaluation and diagnosed Kevin with depression. Knowing what was really wrong was a considerable relief for Bob, Cindy, and even Kevin. Kevin wasn't just "moody," and his parents were neither incompetent nor cruel. Like hundreds of thousands of other American children today, Kevin is depressed. Now he is taking Zoloft, an antidepressant, and attending a combination of individual and family therapy focused on helping Kevin and his parents understand depression, how to manage its symptoms, and how to work together to combat the illness. Things are starting to get better.

Kevin has depression, a mental illness. Reading this book will help you get comfortable with the term mental illness and recognize that mood disorders are treatable illnesses. The more comfortable you are with using this and other technical words we introduce in this book, the more you will be able to conquer stigma and to be the best advocate possible for your child.

But what are mood disorders? When we refer to mood disorders, we are talking about two sets of related illnesses: depressive disorders and bipolar disorders. Depressive disorders involve a sad or irritable mood that may last anywhere from a couple of weeks to several years. Bipolar disorders involve alternations between depression and mania, an extremely high mood that can be angry or euphoric. Switches between mania and depression can occur infrequently (e.g., one manic episode during a two-year period) or extremely frequently (e.g., multiple cycles from manic to depressed during a single day). We describe the different depressive and bipolar illnesses in detail in Chapter 2.

Treatment for mood disorders is not, unfortunately, always as straightforward as in Kevin's case. Mood disorders in children are complicated problems. They are not easy to diagnose, in part because the symptoms that children display can look so different from those of adults with mood disorders. For example, children with depression are more often cranky and irritable, whereas adults tend to be melancholy or sad. Adults with bipolar disorder more often experience discrete periods of mania lasting for two to three weeks, followed by a period of depression that might last for several months, whereas children more frequently cycle several times each day between rage, euphoria, and desperate sadness. In addition, in many cases, it can be very difficult to make a diagnosis because the illness is still in the process of developing when an evaluation is completed. For example, if Kevin had been seen three months earlier, when he was struggling to handle changes and disappointments but was generally doing fairly well, depression would not have been an accurate diagnosis. Also, children with mood disorders often have accompanying problems, such as anxiety and behavioral disorders. Kevin is a good example. In addition to depression, he becomes overly anxious and worries excessively about his school performance, as well as about problems and situations that are unrelated to him (such as news items).

Even with treatment, life with a mood-disordered child can feel like a constant challenge—they can be difficult to get along with, seem "impossible" to handle, and generally wreak havoc with domestic tranquility. Their unstable emotional states can disrupt their schoolwork, their friendships, and their sibling bonds. They often need a lot of help to get along in the world, even when they are receiving good treatment.

Thirteen-year-old Caitlyn "never seems happy," according to her parents, and this emotional state is damaging every facet of her life—from her increasingly hostile relationship with her brother to alienation from her classmates (who mock her "Goth" outfits and her matching attitude). Out-and-out exhaustion has started to make her loving parents feel more and more distant from their daughter.

Tanisha, age fifteen, is so sad that she has difficulty speaking above a whisper and getting out of bed. She spends a lot of time crying and can't even pick up the clarinet that she plays with virtuoso skills. The former A student can't complete even short reading assignments. Though she feels guilty for feeling so sad despite what she calls a "great life," Tanisha lashes out in anger or irritation at her parents' constant attempts to comfort her. Her parents are feeling increasingly powerless and helpless.

Six-year-old Jeremiah's parents describe him as "Dr. Jekyll and Mr. Hyde" and then ruefully correct themselves: "He's more like Mr. Hyde and Mr. Hyde," alternating between restless, agitated harangues punctuated by outbursts of rage and slumps of hopelessness and profound sorrow. Their little boy has hit, kicked, and thrown things at his parents, and he has alarmed them several times by gyrating his hips provocatively toward his mother while telling her that he wants to "kiss with you, like in the movies."

Eleven-year-old Anya has shocked family and visitors to her house, running through the house naked, shifting in an instant from hysterical giggling to sobbing, and announcing to everyone who will listen that she can run faster than the cars on the street (and that she has done so) and that she can get 100 percent on all her tests because she can read her teacher's mind.

If any of the children we have described sound at all like your child, you are probably well acquainted with the term moody. You have probably felt lost, confused, powerless, and at times hopeless. The many hurdles you have encountered, some of which have seemed insurmountable, have probably overwhelmed you at times. Feeling blamed for your child's problems is exceedingly painful, yet you see blame in the eyes of family members, as well as strangers in the grocery store. Chances are you've felt anger—at your child, yourself, your spouse, your family pet, the person in the car in front of you, or God. The anxiety of not knowing where to turn and not knowing how to help your child can be almost unbearable.

If the children we've described and the feelings of confusion, powerlessness, and hopelessness sound familiar, this book is for you. You may be concerned about your child's behavior, unsure how to make sense out of what doesn't seem "right" to you, and worried about how to make it right. If you're wondering where to turn and don't know how to begin, or if you're getting conflicting advice, this book will help you understand what childhood mood disorders are all about—what they look like, how professionals diagnose and treat them, what you need to know about working with your child's school, and how you can manage better at home. In short, we hope that reading this book will help you become a better consumer of mental health care and will empower you to help your son or daughter and your family. Let's begin by replacing some "mood myths" with facts.

FACTS VERSUS MYTHS: CLEARING UP THE MISCONCEPTIONS THAT KEEP MOODY KIDS FROM GETTING HELP

Mood disorders in children—depression and bipolar disorder—are widespread, yet they frequently go undiagnosed and are significantly undertreated. Only about one-fourth of the nineteen million American adults with depression seek help. The statistics for children are worse. Additionally, a startling number of teenagers and children with depression are either undiagnosed or misdiagnosed or do not have access to treatment. The failure to identify and treat bipolar disorder in youth is also a significant problem. In a study of the frequency of bipolar disorder in adolescents by Peter Lewinsohn and his colleagues at the Oregon Research Institute, less than half of the teens with bipolar disorder had received any treatment. Current estimates suggest that approximately one-half of 1 percent of all children have bipolar disorder, and we know that one-fourth to one-half of children and adolescents with depression will develop bipolar disorder.

Depression is among the most common of psychiatric disorders, with 10 to 25 percent of women and 5 to 12 percent of men experiencing depression at some point in their lifetimes. At any point in time, conservative estimates reveal that approximately 6 percent of adolescents and 2 percent of preadolescent children are depressed. Depression occurs among people of all ages, income levels, ethnic groups, and cultures (even animals can get depressed). Bipolar spectrum disorders (we define the different types of bipolar disorder in Chapter 2) occur in 3 to 6 percent of the population and occur at equal rates among men and women. Bipolar disorder also occurs in about 1 percent of older adolescents. Approximately 5 percent of older adolescents have enough manic symptoms to cause problems, although not enough to be diagnosed with the full-blown disorder. Prior to adolescence, the rates of bipolar disorder are lower, although Janet Wozniak and Joseph Biederman and their colleagues at Massachusetts General Hospital have found that up to 16 percent of children seen in psychiatric clinics have bipolar disorder. These figures translate as up to 1.8 million teenagers and 600,000 children with depression at any point in time and at least 300,000 teenagers and unknown numbers of children with bipolar disorder.

For hundreds of thousands of mood-disordered children and their families, the costs—monetary and otherwise—associated with these disorders are significant. For children, the social price is sky high. If a child is irritable, lacks energy, or behaves unpredictably, other children may dislike her, avoid her, or just ignore her, which leads to many lost play opportunities. Over time these lost opportunities result in the child's falling further behind socially and becoming more and more lonely. Treatment can be expensive and can result in major financial strains for families; even for families with good health care coverage, co-payments for treatment and medication costs can add up quickly. Disagreement between parents about what treatments are necessary or how to discipline their challenging child can lead to marital discord. Tension created by trying to avoid the next crisis can lead to strained relationships and to siblings' feeling that their needs are secondary. Unpredictable or disruptive behavior such as the behavior exhibited by Anya can result in isolation, as the family avoids social gatherings with family and friends for fear of embarrassment.

This raises an important question: If childhood mood disorders are so widespread and their impact so great, why don't more people seek help? In addition to the complex nature of childhood mood disorders, these disorders are surrounded by many misconceptions that further impede access to treatment.

One primary misconception is that children do not get depressed. Children have no big cares and concerns as adults do, so what could possibly bother them to such a degree that they would get depressed, right? Wrong! Mood disorders in children have been recognized only recently—depression beginning in the 1970s and 1980s and bipolar disorder in the mid-1980s. The misconception that mental illnesses are always caused by psychological or environmental factors perpetuated the belief that children could not become depressed or manic. As the understanding of the role of biology, especially genetics, became better understood, childhood mood disorders have been recognized, studied, and treated.

Another myth is the belief that depression will go away quickly and on its own. However, a single episode can last from seven to nine months, an entire school year. And 40 percent of children who have had a single depressive episode will have another one within two years, 70 percent within five years. A single episode can wreak havoc with the life of a child and his family. Repeated episodes result in exponentially more damage. Just to make things more complicated, the course of depression and bipolar disorders is often unpredictable. Treatment can be helpful in reducing the frequency and severity of episodes, but families need to be on the lookout for signs of recurrence. It is clear that symptoms tend to worsen over time, making early and effective treatment particularly important.

The myth that "everybody gets that way" is common. Although we all have our good days and bad days, we don't all reach clinical highs and lows as a response to positive and negative life events. In Chapter 2, we provide a pictorial view of the different patterns mood disorders can take—that picture gives some perspective on the difference between normal variations in mood and the distinctly unhealthy vacillations that children with mood disorders experience. Take ten-year-old Kevin as an example. It is typical for kids to get upset in response to disappointment, but Kevin struggles excessively to recover and is unable to handle even minor disappointments. All kids can be silly and sometimes even claim superpowers as part of their play, but Anya's hysterical giggling punctuated by sobbing and her outlandish claims are outside the bounds of normal childhood behavior.

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Excerpted from Raising a Moody Child by Mary A. Fristad, Jill S. Goldberg Arnold. Copyright © 2004 The Guilford Press. Excerpted by permission of The Guilford Press.
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