Assessing Kid’s Mood
For the sake of simplicity, I’ll be discussing anxiety and depression with males vs females and other considerations. A huge factor with mood disorders is the age (before puberty) or little kids who usually don’t have the words to express themselves. Therefore, symptoms can physically be seen as grumpy, head “hurts”, frowns, crying spells, anger, throwing objects…etc.
A small child will not naturally say “I’m depressed, can’t focus, or I’m guilty”…etc. so the social and behavioral cues are important. Quick side note: the DSM-5 criteria for depression and anxiety is assumed for all ages.
Behavioral modifications/therapy can help with these symptoms but when should the provider be concerned enough to medicate? Here are my personal thoughts because most people, including providers, are against medicating a young child, so hopefully, this is helpful:
- Poor behavior is consistently unprovoked or unpredictable: yelling for hours and off/on, means the child is not able to learn or process information (because they can’t stop screaming).
- It’s affecting the quality of life (QOL): if the child is constantly getting punished due to bad behavior, frequently isolated (constantly in time-out), or unable to play… these are examples that can affect development and make the child’s mood/emotions get worse.
- The child is shutting down, less engaged, or motivated: this is when I’m the most concerned because the child needs to be working on coping skills and properly developing, again I’m worried about the delays/the lack of learning.
Who knows why a 4y/o gets angry, it could be a billion reasons but when a child is not able to play, have fun, express themselves, and get isolated that’s going to cause more distress, in addition to the bad feelings. Depression and anxiety may occur regardless of whether things are good or bad but families usually can’t differentiate and this is when psych becomes stigmatized/challenging.
Parents will ask well how can a child be depressed? or they got all A’s on the report card so I don’t know why there are any problems…etc. and that’s true! some things will blow over and do well without extra interventions. However, when the child is shutting down, less engaged, moody, etc. it could be that the entire world is telling the kid to smile when anxieties and depression are more than just feelings or a particular face. Truly look at the child’s QOL and the key points above are a great reason to start medications.
In the assessment, everything should be ruled out as much as possible before starting on medications but you only have like 10min to decide in reality. There are so many options and directions but my best tip is to go from little to bigger changes and that’s with diagnosis and medications.
I normally address either ADHD or ODD first, depending on the behaviors: if the child is very hostile, I start treating ODD but if the child is non-threatening, I generally assess for ADHD. There are many situations where the child presents with both diagnoses, but try to treat the worse dx first to not mix/confused the treatment plan or avoid starting with a bunch of pills. Plus sometimes treating one behavior can also treat the other symptoms. However, with kids, it may be their first time seeing a psych provider so I’m trying to discuss usual situations…
This is why I do genetic testing and r/o ADHD in the intake, you can easily see how this can add up to 3+ medications. It’s much to consider when trying to treat 2-3 conditions and the child already has issues or delays, so you want as little room as possible for errors.
I have other parents that ask me to convince other providers to do genetic testing and I just give them our test kit and hope for the best because I can’t just start randomly treating other kids… I try to pack each visit with as much productivity so genetic testing can make things easier but here are some other things to consider with small kids (in each visit):
- Assess SLEEP: yup again the 5th vital sign in mental health so you’ll hear me say this A LOT. Emphasize healthy sleep habits including r/o bedwetting. More information about sleep.
- What Worked: sometimes I inherit kids that already have medications that are working for them, so if there’s no major problem, maybe all you need to do is increase the dose, the frequency, or address things that are still ongoing such as a lack of focus or sleep.
- Target Parenting: try to get the family to focus on POSITIVE reinforcements. Sometimes the parents would spend the entire time talking about how horrible the kid is when the poor child is just sitting there…I somewhat ignore things that are dramatic and redirect back to the plan. Get the parent to see that if you only give a child attention when they do something bad then they will continue to do bad things. Discuss “real” red flags like harming self or others and if they do something bad such as destroying the property reinforce boundaries and consequences. After all the bad things the kid did and the parents didn’t set any rules, boundaries, or expectations then why should I (the provider) do anything?? This is the part where you tell them, that medications are half the battle and remain objective (focused on the treatment plan). I’ll do another post about parenting. Quick sidenote: I also don’t want the child to think mental health care is only when you do “bad” things because they may grow up resenting to get help, try to keep the meetings positive because YOU may be the only good thing they hear.
- Focus on how well the child is learning: Make sure the child is responding and engaging appropriately and r/o ADHD. So if the child isn’t destructive and appears to not listen or pay attention, the child will have educational delays so treatment is important ASAP. Think about ADHD like a CVA, time is brain! and we want to minimize the damage of not learning and processing information. Focusing on parenting again, I sometimes ask the parents what educational activities are being done at home? discussing the home environment can also get the parent to see how you can’t blame everything on a kid and learning needs to always be prioritized.
Personal Go-To Treatment for Kids
Boys (escitalopram, sertraline), Girls (sertraline, fluoxetine). If the child has numerous medical conditions i.e. autoimmune, POTS,…etc. sertraline has been the most helpful, 2nd line is escitalopram. If the child is having frequent crying spells and difficult moods fluoxetine is my life savor, especially with females. For special needs i.e. ASD, escitalopram, and sertraline are what I usually use, and I’ve inherited some on trazodone but I normally don’t start with it. These are antidepressants that can also effectively treat anxiety and are well researched in kids.
If antidepressants don’t work, i.e. the child is still moody, destructive… then an antipsychotic is my next go-to, and mood stabilizers are my 3rd line. They both have pros: with antipsychotics, you can easily microdose and start/stop or PRN, which may be a good option if you’re concerned about metabolic side-effects, the kid is small, or sensitive, or simply trying to avoid over-medicating. The mood stabilizer advantage is how you can wean the child off the anti-psychotic or unhelpful medications to target the mood and agitation. The cons are the side-effects of anti-psychotics (weight gain, akathisia, sedation) and mood stabilizers (blood draws, sedation, and weight gain) kids are relatively healthy but check labs and an EKG and with all meds -remember start low and go/titrate slow.
Assessing Teenage Anxiety and Depression
I’m going to try to make this as nice as possible but I’m convinced that teenagers need to be placed in a separate human category. They make and break their own rules and then lash out at everyone… so yup let’s help them. This pandemic was brutal but I think teens took the hardest hit, they are really struggling to cope and do right in a world where everything seems chaotic So with every assessment you have to rule out anything concerning.
As always try to see if the mood issue is related to something external: bullying, abuse, relationships, substances, medical conditions or PMS, puberty, poor grades, winter season…etc They are many other factors but with mood disorders, if there’s a source, it may not need medications or your treatment may focus on something different. For example, if the teenager has poor grades and not concentrating, I may go in the direction of treating ADHD, which can also help improve the mood.
Now if you get the teenagers who are really mouthy, rude, and act like they know it all while failing school then continue focusing on the signs of bad behavior. These are things that you can treat without having your child feel like the “bad guy” (remember to try to keep the visits positive) such as targeting poor sleep, focus, restlessness, irritability aka agitation…etc. I still plan on making a list of secret code words and phrases but you get the ideal, target the “side-effects” of this bad behavior.
I had a patient constantly refusing medications until I started treating him for ADHD and now the person is more adherent and doing well. This patient yelled, screamed, and everything at me but I never reacted to the behavior. Ignore/do not respond to the tantrums because you will BOTH look crazy, let these kids be the kids…
Another teen just threw a bag of meds at me that someone else prescribed but after making some changes, he’s doing much better and started taking his medications again. Give the teens some hope, let them be included in their treatment plan even if they are difficult so they can start getting better. I treat teenagers like an adult since they want to act like one and just guide them in the process of making good decisions, it doesn’t have to be a train wreck.
About Treatment for Teenagers
I usually ask teens about their beliefs about medications to clear up any confusion and misconceptions. I also would ask if they have a loved one or know someone who had mental health treatment. This is to reduce the stigma and help them realize that they’re not alone and it’s okay to get seek treatment. Build the rapport to start discussing medications… Again for the sake of simplicity, I’m separating males/females:
Males
- Depression: here’s an unpopular opinion, I sometimes stay away from SSRIs and Trazodone. I try to avoid things that will cause sexual side-effects in males older > than teenagers. However, they are my go-to for special populations like substance abuse, autism, and certain conditions like OCD. Unless antidepressants worked prior or it was requested then I’ll prescribe them but with most of my male adult /teenage patients, I don’t start with SSRIs even if they worked due to the sexual AE because they may stop taking them and risk having a higher form of depression. I just go to a newer or different class of medications such as cariprazine, vortioxetine, buspirone, bupropion, mood stabilizers, stimulants…etc. Some literature suggests drug holidays or reducing the dose, but you risk the med being ineffective or the teen being more depressed. Some guys don’t mind the decrease in sexual urges but that’s rare and I’m not prescribing vasodilators…
- Anxiety: here’s another unpopular opinion, try to get males to avoid marijuana. Teenagers usually don’t have a medical card but got all these risky behaviors so who knows what they’re really smoking or drinking and it can easily be laced with crack. They may claim that “marijuana helps” and yet they’re in the office because of these “panic attacks” and uncontrolled anxiety. Be bold and let them know, that marijuana is NOT helping and can be making it worse. I medicate male anxiety like I’m possibly treating addiction and frequently use propranolol, hydroxyzine, and clonidine. If the patient does not smoke or drink I still use these medications and reinforce staying away from substances.
- Agitation: I wanted to add this extra tidbit, in particular with young males or teenagers, I usually express avoiding high-impact sports. Activities that may cause frequent LOC, a decrease in personality/memory/emotions/mood, should be avoided or take precautions. Sports like football, boxing, extreme sports, wrestling… etc. I try to tell parents to be extra careful or consider discontinuing risky activities to reduce harming the kid’s mental health. However, here’s information regarding aggression with kids.
Females
- Depression: difficult moods and crying spells or conditions PMDD, PMS -fluoxetine or sertraline is my first line. They both help with PMDD and I plan on making a separate post about treating female conditions, including menopause but overall SSRIs are the best. If females are having agitation, aripiprazole has helped but risk akathisia s/e like with all antipsychotics. Sometimes if a female has terrible PMS or PMDD I would dose the antipsychotic as a PRN just to cope. I had a mother ask about birth control, but I simply responded to f/u with PCP like that’s not a psych NP’s scope. Take precautions with putting a child on anything affecting fertility, it’s a liability so I personally wouldn’t risk it. Anyway, back to depression, SSRIs work well with females and I don’t get as creative with them as my males. However, if I have a patient with major genetic interactions or if there not responding to the usual treatment, other great options include desvenlafaxine (it goes through the kidneys), non-stimulants, and bupropion can help as adjuncts.
- Anxiety: here’s my last unpopular opinion, drum roll please: clonazepam honestly works the best but mainly for adult females. Now, this is not my go-to, but if it’s debilitating, severe low QOL or functioning, and everything else has failed, it could be a really great PRN consideration. I’ve used it one time as first-line but after many failed medications (so she already tried the usual anxiolytics with other prescribers). It’s in this category simply because it could’ve been a great option if you didn’t have to worry about diversion and addictions! unfortunately, it’s too many conflicts and risks, therefore, it’s not the best for teens/kids but I do have college students on them. Also, with females r/o pregnancy or try to stay away from meds in the 1st trimester, I avoid stimulants throughout the whole pregnancy. However, overall there are still many great options for >teenage females such as SSRIs, hydroxyzine, or bupropion and with ALL ages, don’t forget to keep targeting SLEEP.
