Editor's note: This text-based course is a transcript of the webinar, Let’s Not Overlook Mood Disorders In Our Youth Population, presented by Tere Bowen-Irish, OTR/L.
*Please also use the handout with this text course to supplement the material.
Learning Outcomes
- After this course, participants will be able to differentiate the diagnoses that are considered mood disorders.
- After this course, participants will be able to evaluate modifications, accommodations, observations, data gathering, and treatment to help this individual access daily life demands.
- After this course, participants will be able to examine the specific signs of bipolar disorder in children based on the DSM-5.
Introduction
I'm looking forward to presenting today because I often find that we can become so focused on labeling children with diagnoses that we lose sight of the bigger picture. With recent shifts in diagnostic criteria, I wanted to provide an overview of what mood disorders look like in youth in the 21st century. This topic sparked my interest as I began noticing an increasing number of children with cycling moods.
I work at a school designed for students who struggle in public school settings. Many of these children have emotional disorders, psychiatric diagnoses, or neurodevelopmental conditions such as autism and ADHD. For various reasons, they have difficulty functioning in traditional educational environments. I visit the school once a week, where I teach yoga and mindfulness and incorporate occupational therapy when needed. While they have a full-time occupational therapist, I supplement their program and bring my two therapy dogs, which has been a valuable part of the experience.
Over the years, I’ve witnessed the evolving landscape of childhood mood disorder diagnoses. I’ve been in this field long enough to remember when bipolar disorder was a recognized diagnosis for children, only for it to be removed, and now we’re seeing discussions about its reemergence. This shift led me to become more deeply involved in this area.
The Children's Mental Health Resource Center has been an incredible resource. Their website offers webinars, study groups, and even a book club, all dedicated to supporting professionals working with children facing mental health challenges. Over the past year, I have participated in their study groups, and I highly recommend them as a current and comprehensive resource for understanding and addressing the needs of children with mood disorders.
Mood Disorder in School-Age Children and Adolescents
When examining mood disorders in school-age children, bipolar disorder is one of the key conditions. Bipolar disorder presents with extreme highs and lows, while persistent depressive symptoms characterize bipolar II. Interestingly, bipolar II is being reconsidered for inclusion in the DSM after previously being set aside.
Why does this concern me? If a child is truly bipolar but misdiagnosed, it creates a ripple effect that impacts everything—their approach to tasks, the types and dosages of medications they receive, their behavioral plans, and the overall therapeutic approach. Another major category of mood disorders is major depressive disorder, which presents as a depressed or irritable mood lasting at least two weeks. With younger children, depression often manifests differently than it does in adults. Instead of sadness, they may appear angry, irritable, upset, or aggressive.
Seasonal depression is another common mood disorder in children, often overlooked but very real. Persistent depressive disorder is a chronic, low-grade depression that lasts at least a year, and like major depression, it can also present with irritability. Then there’s disruptive mood dysregulation disorder (DMDD) and premenstrual dysphoric disorder (PMDD), both of which have unique implications for childhood and adolescent mental health.
I’ve covered all of these disorders broadly, but I will go into more detail about each and discuss how we, as therapists, can deepen our understanding. This is crucial for two reasons: first, so we can plan more effective treatments when these children are on our caseloads, and second, so we can play an active role in questioning whether a child has been diagnosed correctly.
Children with mood disorders are often miscategorized under other conditions such as ADHD, oppositional defiant disorder (ODD), conduct disorder, or even personality disorders. However, an accurate diagnosis makes all the difference in helping a child engage in the occupations that give their life meaning. This is why outside consultation—with a physician, psychiatrist, or counselor—is often necessary. While school-based professionals such as guidance counselors and social workers provide critical support, these are 24/7 disorders that extend beyond the school day.
In IEP meetings or annual reviews, we need to consider what happens in the 18 hours a child is outside school. Is the family receiving adequate support? Is the student? When a school-based support system is strong, we can gather meaningful data for external providers. Observations across different settings—classroom, lunchroom, hallways, playground—offer invaluable insights into how children interact with peers and adults, how their energy levels fluctuate, and how they engage with their environment.
Being a “fly on the wall” in these unstructured environments is incredibly insightful. Here, children's true behaviors and coping strategies emerge. How they transition between activities, their level of impulsivity versus hesitation, and whether they engage with their surroundings or withdraw are critical observations that help shape a more accurate picture of their needs.
When treating children with ADHD, I often ask the team if we can obtain a release from the child’s doctor so that we can provide regular checklists to track changes in behavior, stability, or medication effects. Collaboration between the school team and medical providers ensures a more comprehensive approach. Growth spurts, in particular, can significantly affect medication titration, so maintaining open communication helps prevent unnecessary setbacks and ensures that each child has the best possible experience in school.
Major Depression
Let's start with major depression, which is fundamentally different from typical childhood sadness. It is often a predictor of chronic depression in adulthood, making early identification and intervention critical. The etiology can be genetically based, but psychological factors may already be embedded, along with environmental variables that contribute to its development. These environmental factors can include neglect, bullying, undiagnosed anxiety, trauma, or loss—all of which shape a child's emotional landscape and influence the symptoms that emerge.
It’s important to recognize that no single child will exhibit all symptoms, but there are key signs to be aware of. You might see sadness, irritability, or a noticeable loss of participation in activities—even in those the child previously enjoyed. This is a significant red flag. When you’ve observed a child in earlier years as actively engaged and enthusiastic, and then suddenly, that engagement disappears, it often indicates that depression has cast a shadow over their interests and motivation.
Self-deprecating language is another common sign. Just yesterday, while I was teaching yoga, I witnessed this firsthand. I praised a child for holding a pose longer than the rest of the class, and his response was, “Eh, I’m not good at it. I figured I ought to try it longer, but that doesn’t make me better.” This kind of dismissal of their effort and ability, paired with unnecessary guilt, can be revealing.
Changes in basic habits, such as sleep and eating patterns, often accompany depression. Personal hygiene is another aspect that stands out to me—but isn’t always immediately listed in diagnostic criteria. If a child comes in repeatedly wearing the same clothes, appearing unkempt, or with a noticeable body odor, it may signal that their ability to care for themselves is declining.
You may also observe reactiveness when providing direction or even simply checking in with them. Some children exhibit severe sensitivity to inquiries about their well-being, responding with irritability or shutting down completely. And perhaps most concerning is when a child expresses suicidal ideation—comments like, “The world would be better without me.” These statements, whether subtle or direct, should always be taken seriously.
Recognizing these signs allows us to intervene early, ensuring children receive the right support before their symptoms escalate.
Seasonal Depression (SAD)
Seasonal depression is something I can personally relate to, especially being up here in New Hampshire, where this time of year naturally encourages hibernation. As the days grow shorter and the amount of natural light decreases, we see noticeable shifts in mood, energy levels, and an overall sense of negativity. While seasonal depression is often discussed among adults, my research in this area highlighted how surprisingly common it is in students and children as well.
Seasonal depression can present as a pattern within a larger diagnosis of major depression. A child who is already struggling with depression may experience an intensification of symptoms due to environmental and weather-related factors. The reduction in daylight can disrupt circadian rhythms and affect the body’s natural regulation of serotonin and melatonin, which play crucial roles in mood stability and sleep.
One promising intervention for children experiencing seasonal depression is light therapy, which mimics natural sunlight and can help regulate energy levels. By addressing the physiological effects of seasonal changes, we can support children in maintaining better emotional balance throughout the darker months.
Interventions for Major and Seasonal Depression (SAD)
Let’s pause on reviewing for a moment because I really want to dive into some interventions based on what we’ve just covered. Now that we have a clearer picture of the signs and symptoms a student may be exhibiting, it makes sense to consider how we can intervene in ways that are both functional and sustainable.
Establishing routines and consistency—particularly around diet, sleep, and daily structure—is foundational. When a child’s home environment lacks structure, or if they’re largely left to manage on their own, it can exacerbate their symptoms. In some cases, the parent may also be struggling with depression, further impacting the child’s ability to maintain stability. A simple way to gain insight into their routine is by engaging them in conversation: “What time do you go to bed? What do you usually eat for dinner? What does a typical night look like for you?” These kinds of informal interviews can provide valuable information about potential gaps in support.
Another important intervention is getting the child outside. Even short periods of sunlight, movement, and fresh air can help regulate their natural hormone cycles. At school, this could be something as simple as a brisk walk, which might already be included as a movement accommodation in their IEP. I once worked with a student who was responsible for raising and lowering the school flag each day. It was a small, predictable task, but it got him outside, provided a sense of purpose, and introduced movement into his daily routine.
We also need to be mindful of academic demands. Going easy on rigid expectations while still encouraging engagement can help prevent them from feeling overwhelmed. Instead of structuring tasks for the child, we can guide them in breaking things down themselves—provided they have the cognitive capacity to do so. For example, if they have a paper to write, we can ask, “What do you think we should tackle first?” This approach turns therapy time into an opportunity for them to develop problem-solving skills. Depression often dulls motivation and cognitive flexibility, making it difficult for them to initiate or complete tasks without point-of-performance coaching.
Another key indicator is withdrawal from previously enjoyed activities. When a parent or teacher mentions, “She used to run track, but she doesn’t want to anymore,” or “He loved soccer but doesn’t want to sign up this year,” it’s a red flag. Instead of waiting for them to re-engage on their own—because they likely won’t—we can actively support a gradual return to these interests. Reigniting engagement in meaningful activities can be a powerful way to help them reconnect with themselves.
Persistent Depressive Disorder (Dysthymia/PDD)
Now, let’s move on to persistent depressive disorder (PDD), also considered a low-grade but chronic form of depression. It occurs twice as often in women as in men, though I couldn’t find research confirming the same ratio in girls versus boys. What we do know is that it shares many symptoms with major depression, and individuals can experience both simultaneously.
Though I hadn’t heard of it framed this way before, some researchers refer to this co-occurrence as “double depression.” PDD affects approximately 1.5% of the population and tends to present with a more lethargic affect, along with psychomotor symptoms. A defining characteristic is its duration—a persistently depressed mood lasting at least two years. And, much like with major depression, children and adolescents with PDD often exhibit more irritability, anger, and contrariness than adults.
One of the biggest challenges for children with PDD is their inability to see beyond their symptoms. For them, life feels stuck—there’s no way out, no relief. They also experience anhedonia or an inability to feel pleasure. I worked with a student who embodied this symptom, and it was striking.
When I first met her, she was highly irritable in class—she would sigh heavily and react exaggeratedly to even the simplest requests from the teacher. Alongside this, I noticed sensory challenges, poor impulse control, and a constant stream of self-deprecating remarks. She struggled to find where she fit in school and within her family.
During a team meeting, the psychologist suggested an intervention that stuck with me: actively pointing out the moments when she appeared to be enjoying herself. The idea was that her ability to recognize positive experiences was so muted that part of our role was to help her register those moments in real time. If she smiled or laughed, we would say, “Hey, how does your body feel right now? Look at that smile on your face.” If she was engaged in an activity, we used a technique I call broadcasting: “I love seeing you laugh!” or “Oh, you think you’re beating me?” Even at the end of a session, we would briefly review the fun she had, reinforcing the idea that she was capable of experiencing joy.
A funny memory stands out with this student. She loved to draw, so we often ended our sessions with five minutes of free drawing after completing sensory work. We had done some Ed Emberley step-by-step drawing activities to support her fine motor dexterity. One day, she told me she just wanted to draw a picture. When she finished, she showed me a face with lots of curly hair, detailed eyes, nose, and earrings—ones that happened to look just like mine. But the face was covered in lines.
I said, “Wow, tell me about this one.”
She grinned and replied, “It’s you.”
I laughed and said, “Huh, look at you! You drew a portrait of me. And look at all those lines on my face!”
Without missing a beat, she said, “Yeah, you got a bunch of them.”
I smiled and told her, “I earned every single one of those through laughter.”
That caught her off guard. “What do you mean?” she asked, and we went back and forth, discussing how laughter leaves marks in the best way. It was a small moment, but it was also a breakthrough—a way to connect, to subtly challenge her worldview, and to plant a seed that maybe, just maybe, life wasn’t all bad.
Disruptive Mood Dysregulation Disorder
Disruptive Mood Dysregulation Disorder (DMDD) is another diagnosis worth examining, and the Cleveland Clinic has provided some compelling data on mood disorders in children. Many kids we see in classrooms have wildly disproportionate reactions to the situation. One of the common interventions in these cases is helping them differentiate between a big deal and a little deal, but for children with DMDD, that distinction often doesn’t register at the moment.
These children experience severe temper outbursts at least three times per week, and their baseline mood—at home, at school, and in the community—is one of chronic irritability and anger. Unlike occasional emotional dysregulation, their symptoms are severe, persistent, and significantly impairing, affecting approximately 2–5% of children. Though DMDD typically emerges around age 10, it can appear earlier.
I think of Sam, a nine-year-old student in my yoga class. Whenever he struggles to hold a posture, he tantrums. Despite all the preemptive cueing—reminding the class that yoga isn’t about perfection but simply about moving and feeling good—he still reacts as if his inability to hold a pose is a catastrophic failure. He throws himself on the ground, seemingly disregarding any calming strategies I introduce.
What I’ve started tracking, however, is his recovery time. While my introductory remarks don’t appear to resonate much in the moment, I’ve noticed that his ability to re-engage after a tantrum has improved. I’ll say something like, “Didn’t get it this time? That’s okay. Here’s another challenge for you.” And within 5 to 60 seconds, he’s often back with the group. Most importantly, he’s no longer needing to be removed from class by his aide.
Children with DMDD may present with symptoms of Oppositional Defiant Disorder (ODD), but their outbursts tend to be more extreme. Compared to bipolar disorder, their episodes are contained within specific triggers rather than occurring in cycles. DMDD only became a formal diagnosis in 2013, and distinguishing it from other mood disorders is crucial for treatment planning.
In Sam’s case, I use a structured script at the start of class: “Sometimes this will feel easy, sometimes not so easy. You may get it today, or you may not. That’s okay. You’re on your way.” The 21st-century child, in general, struggles with perseverance, and for a child with depression or mood dysregulation, the instinct to give up is even stronger. Instead of saying, “This is hard,” they internalize it as, “I’m worthless.” That distinction is critical; our interventions should focus on breaking that mindset.
So, how do we help students with DMDD regulate? Here are some possible accommodations:
1. Movement Breaks Before Seated Tasks
This is my mantra. Priming the pump with movement before requiring stillness makes sense physiologically—exercise releases endorphins, increases oxygen to the brain, and improves overall alertness.
2. Breaking Tasks into Manageable Parts
Even if students know how to complete an assignment, shorter bursts of work can extend their stamina and help them stay engaged longer.
3. Providing a Coping Menu
Recognizing early warning signs—pencil flipping, grunting, head on the desk—allows for preemptive intervention. Having a familiar menu of coping strategies helps, as students can choose an exercise they already know and trust.
One strategy I’ve used is called Heart Rock. It’s simple: arms crossed over the chest, shifting weight back and forth like a slow rocking motion. Ideally, it is done standing, but it works seated as well. Students can count softly, repeat a calming word, or even say their name under their breath. Some students respond well to physical motion, and others respond well to verbal components.
4. Teaching Mindfulness and Self-Awareness
Beyond basic breathing exercises, helping students recognize negative thought spirals is key.
5. Creating a ‘Getaway Spot’ to Regroup
Providing a designated space for a student to self-regulate can prevent escalation.
6. Rewinding the Tape
After an outburst, I often do a post-mortem with students. I’ll say, “Let’s rewind. Walk me through what happened.” Recently, a teenager told me, “I punched a hole in the wall because my mom wouldn’t let me see my girlfriend.”
I asked, “What led up to that?”
Eventually, we uncovered the full sequence—he hadn’t completed tasks his mother asked him to do before school, she enforced a consequence, and he reacted explosively. Recognizing his frustration without excusing his behavior helped him process the situation.
7. Reinforcing Effort and Building Worth
These students need more praise than we might be used to giving. Not hollow encouragement, but intentional reinforcement: “I see you trying. I see you working. You’re not lazy, and you’re not crazy.”
Ultimately, we aim to help these children build self-regulation skills that will serve them far beyond the classroom. It’s not about extinguishing their emotions but helping them develop the tools to manage them more effectively.
Premenstrual Dysphoric Disorder
Premenstrual Dysphoric Disorder (PMDD) has a strong genetic component and is also associated with factors such as lower education levels and smoking history. Symptoms typically begin about a week before menstruation and subside three to four days after the period starts. What makes PMDD distinct from other mood disorders is how drastically the individual’s presentation shifts outside of this timeframe.
When we think about mood disorders, this kind of cyclical pattern is significant. During the symptomatic phase, you may hear expressions of hopelessness or sadness, heightened self-criticism, tearfulness, and complaints of extreme fatigue. Cravings or binge eating, along with disrupted sleep patterns, are also common. Additionally, there can be notable physiological symptoms, including joint pain, breast tenderness or swelling, headaches, and bloating.
PMDD can significantly impact high school and even middle school students, and it’s important to recognize that what might be dismissed as having an attitude could be a physiological condition requiring attention. Addressing PMDD properly can provide relief, which may lead to increased participation in school and social activities.
While this may seem outside the typical scope of practice for educators or therapists, simply being aware of the diagnosis allows us to offer valuable observations about mood fluctuations. Many students are unaware that their cycle could profoundly influence their emotions. Interventions from counselors, parents, and even peers can help students recognize patterns and develop strategies for symptom management. Sensory strategies for discomfort relief, nutritional education, and basic accommodations can be simple but effective tools.
Sometimes, all it takes is a conversation to help a student understand how to self-regulate and alleviate symptoms. By providing these early supports, we can help young people build awareness and coping mechanisms that improve their mood and overall energy levels.
Bipolar Disorder
The last mood disorder we’ll look at is bipolar disorder, which was the focus of my recent study group. What stood out to me in those discussions was how the diagnosis of bipolar disorder is evolving once again in the DSM. One of the key takeaways was that there isn’t a single defining characteristic that confirms a bipolar diagnosis—there’s no easy checkbox or test to stamp a person as bipolar. Instead, the diagnostic process has become much deeper and more comprehensive.
Clinicians now consider various developmental factors, including medical history, childhood illnesses, milestone progression, and even early temperament. For instance, they might ask: Did the “terrible twos” last longer than a year? Was there early intervention following birth? And, of course, family history plays a significant role.
What surprised me in the study group was the emerging view of bipolar disorder as a metabolic condition rather than purely a psychiatric one. There is new research exploring the use of ketogenic diets as a treatment intervention. While still in its early stages, studies are showing promising effects on mood regulation, sleep, and daily functioning for individuals with bipolar disorder.
This caught my attention because years ago, I worked with a student who was placed on a ketogenic diet—not for bipolar disorder, but for a benign brain tumor. At the time, research was exploring how ketosis could shrink tumors, and in this case, it did. That student is now 27, and the concept was still fairly novel back then. Now, we’re seeing this same dietary approach being studied for mood regulation in children with bipolar disorder.
Another fascinating finding is that individuals with bipolar disorder often exhibit thermoregulatory dysfunction. This can show up as excessive sweating, sometimes even when they haven't engaged in physical activity. These children may wake up drenched in sweat, or they may dress inappropriately for the weather—preferring T-shirts and shorts in the middle of winter, even when there’s snow on the ground. This thermoregulatory component is now part of the in-depth inventory assessments being used to better understand the condition.
Sleep disturbances are another key factor. A history of night terrors, difficulty self-soothing, and chronic poor sleep is often present in children who later receive a bipolar diagnosis.
Much of the cutting-edge research in this area is coming out of Stanford University, where scientists are increasingly linking psychiatric disorders like schizophrenia and bipolar disorder to metabolic deficits in the brain. Their hypothesis suggests that these conditions stem from dysfunctional neuronal excitability, which could be improved through metabolic interventions. The idea behind the ketogenic diet is that it provides ketones as an alternative fuel source to glucose, potentially stabilizing brain metabolism and improving neuronal function.
To me, this is absolutely fascinating—what was once considered strictly a psychiatric disorder may have a biological and metabolic underpinning. The mental health field is shifting in ways that could open up new, non-pharmaceutical treatment avenues, and that’s something worth keeping a close eye on.
More Facts
Here are some additional key facts about bipolar disorder that add to the complexity of diagnosis and treatment.
There is no lab test that can definitively determine a bipolar diagnosis. Instead, clinicians rely on comprehensive evaluations, including developmental history, behavioral patterns, and family history. The average age of onset falls between 12 and 24 years old, and fewer than 15% of cases are diagnosed before age 18. However, emerging research suggests that early-onset bipolar disorder can appear as young as age 6—but diagnosing it in young children is particularly challenging.
This difficulty arises because children naturally exhibit developmental behaviors that overlap with some symptoms of bipolar disorder. A young child with bipolar disorder may present as hyperactive, excessively energetic, prone to tantrums, or display grandiosity—all behaviors that can also be seen in neurotypical childhood development. In some cases, these children also experience rapid cycling, where mood shifts occur much more quickly than adults.
Because of this symptom overlap, many children with early-onset bipolar disorder are frequently misdiagnosed with disruptive mood dysregulation disorder (DMDD), ADHD, generalized anxiety disorder, or a form of depression. For the past 20 years, bipolar disorder in children wasn’t widely considered as a possible diagnosis, leading to underdiagnosis or misclassification. But now, with the growing body of research, bipolar disorder in youth is being revisited, and clinicians are looking more closely at how to distinguish it from other mood and behavioral disorders.
Possible Classroom Behaviors
In the classroom, students with bipolar disorder may exhibit a range of behaviors that can sometimes be mistaken for other conditions. You might notice goofy or giddy behaviors, an exuberance that seems excessive or out of place. At other times, they may appear irritable, aggressive, defensive, or hyperactive, sometimes reacting with tantrums that seem disproportionate to the situation.
Their reactivity can be intense, and they may struggle with poor sensory processing, appearing overwhelmed by sounds, textures, or visual stimuli. Sleep disturbances are often a persistent issue, contributing to oppositional behaviors and dramatic mood shifts that can occur suddenly.
These students may also exhibit ruminations or perseveration, meaning they have difficulty letting go of a thought, idea, or grievance. You may hear self-deprecating remarks as they struggle with low self-worth. Anxiety can be another key feature, particularly when it comes to transitions between activities or environments, which may trigger resistance or distress.
One of the most challenging aspects in a classroom setting is poor listening and difficulty following directions, which can sometimes be misinterpreted as defiance rather than a symptom of underlying mood dysregulation. Understanding these patterns can help educators and therapists implement appropriate supports to help these students regulate their emotions and behaviors more effectively.
Differences in Manic and Depressive Episodes
Differences in the manic episodes from the depressive are as follows. Intense happiness and mania, short temper, fast-talking, hypersexuality, racing thoughts, poor sleep, impulsive and risky activities, grandiosity, and poor judgment. So I had a 9-year-old kid at the school where I work, and I was walking with him. Now, this kid has rapid cycling. They are in the process now of treating him as if he is bipolar, even though it's not a diagnosis in children in the DSM yet, but it's on its way. They were saying that he was talking sexually to several of the girls in the class, like you're hot, and oh, I couldn't wait to get my hands on you. And he's nine, so what do we normally do? We may think, What is he watching on TV, and what do his parents like at home? However, this study group pretty much said that that would naturally occur. It's almost like the brain turns on to something, and they just are; it's not a learned behavior. It just starts showing up that their sexual thoughts are there. It's like an intuitive thing, which I thought was fascinating. Depression for bipolar looks like frequent sadness, irritability, hostility, lots of somatic complaints, achy, don't feel good, excessive sleep, they have a Hard time getting up, they have a hard time falling asleep, and then they can't wake. They want to sleep for hours. Poor concentration, feelings of hopelessness, possibly suicidal, and very low energy.
False Belief That Kids Under 18 Can Not Have Bipolar
There has long been a false belief that children under 18 cannot have bipolar disorder. However, when you witness extreme mood swings and rapid cycling that significantly impact daily living activities, it becomes clear that these mood changes are not typical. Unlike emotional shifts stemming from specific events or triggers, these episodes often arise unprovoked and seemingly untraceable without warning.
Medication management further complicates the picture. As I mentioned earlier in the lecture, misdiagnosing a child and placing them under the ADHD umbrella simply because there isn’t another clear diagnostic category can lead to serious consequences. If a child with undiagnosed bipolar disorder is prescribed a stimulant, it can inadvertently trigger or worsen a manic episode. This is why careful observation, data collection, and a deep understanding of the complexity of symptoms are crucial in guiding an accurate diagnosis.
Much of the diagnostic process relies on behavioral patterns observed in multiple settings. We can gather data through individual or group sessions, classroom observations, PE and playground settings, and formal and informal interactions. Additionally, interviewing parents provides key insights—what’s happening at home? How are they at night? Are they experiencing night terrors? While we are not diagnosticians, our role in collecting this information is critical. By understanding how children navigate their daily occupations—school, play, and family interactions—we provide essential data that can help inform an accurate diagnosis and ensure that, if medication is needed, the correct treatment is pursued.
Despite being ancillary providers, we offer a unique perspective. Sensory processing challenges often co-occur with mental health conditions, and I have seen firsthand how proper medication management can lead to improved self-regulation. Sensory processing difficulties sometimes become less prominent when the right medication is introduced and titrated appropriately. Shifts in alertness, self-expression, and energy levels are visible in real-time.
For example, when working with children in a structured activity like yoga, I observe key behaviors: Can they independently roll out their mats and retrieve stretchy bands? Are they staying on task or impulsively snapping their bands at peers? Are they overly fixated on the therapy dogs and unable to be redirected? These small but telling signs provide valuable insight into their regulation, impulse control, and ability to engage appropriately in structured activities.
As therapists, our observational skills are one of our greatest tools. We don’t just look at isolated behaviors; we take in the whole picture, considering the environment, sensory input, emotional state, and overall participation. This holistic approach allows us to be key players in identifying children who may be struggling with bipolar disorder and ensuring they receive the support they need.
Case Studies/Setting the Scene
Let’s set the scene.
Fia is a sixth-grade student with a diagnosis of major depression. In the same class, Thomas has been diagnosed with ADHD. Stimulant medications have been trialed for Thomas, but they haven’t made a significant difference in his attention and focus. His behavior fluctuates—some days, he’s highly active and unfocused, while others, he appears lethargic, disconnected, and sad. Given this variability, I’m considering the possibility that his presentation aligns more closely with bipolar disorder than ADHD alone.
The next two weeks' curriculum assignment involves following a structured rubric to research and report on an endangered species. The rubric requires the student to select an animal, describe its habitat, and complete several additional steps. Looking at this assignment in the context of Fia and Thomas’s needs, I start thinking about the most effective ways to support their engagement and success.
Fia receives services for self-regulation, poor work completion, low energy levels, and difficulty with peer and teacher interactions. She has one pull-out session and one session within the classroom. Her motivation and social engagement challenges are factors to consider when structuring her approach to the assignment.
On the other hand, Thomas has been in special education services since kindergarten. His interventions focus on self-regulation, social interactions, emotional control, and organizational skills. He is also receiving therapy. His fluctuating energy levels and difficulty sustaining focus add another complexity when planning interventions.
With both students in mind, I aim to find ways to support their participation, motivation, and ability to complete tasks while considering their unique regulation and engagement challenges.
How Can We Support?
So, how can we support these students? These are my ideas, but I encourage other perspectives as well. We all bring creativity to how we engage kids; that flexibility makes interventions meaningful.
One way to scaffold their learning is by helping them narrow their focus when selecting an animal for the project. Thomas might struggle with decision-making and become overwhelmed, so giving him a choice of five animals could make the process more manageable. The same strategy could benefit Fia, ensuring she doesn’t get stuck in the initial stages.
A day planner could help break down the rubric into smaller daily assignments. This way, they work on the project a little each day rather than reaching the deadline with nothing completed. Movement and learning breaks before seated work could also be beneficial, ensuring they’re physically and mentally prepared to focus. If parents are on board, a daily check-in at home could reinforce accountability and help maintain consistency.
Pull-out sessions could be used for the hands-on portion of the assignment. Co-therapy with speech, occupational therapy, or even physical therapy might be beneficial—especially if they can integrate movement, such as acting out animal behaviors like flying like an eagle or walking like an elephant. These kinds of sensory-based, embodied experiences can deepen engagement and retention.
Encouraging peer support and collaboration is another key strategy. At this age, peers are central to a student’s sense of belonging. If they work together, they may naturally supplement each other’s strengths and build one another up. Broadcasting their successes—whether in problem-solving, organization, or making connections—reinforces their progress meaningfully.
When considering the impact of their conditions, including lack of momentum, volition, and engagement, the way we interact with them matters. For Fia, we might say, “I know you're feeling disconnected today. What might help you get started?” For Thomas, who may be particularly physical that day, we could offer, “You seem full of energy. How about we work the next 30 minutes standing up and using a more hands-on approach?” These adjustments help them access their curriculum in ways that meet their unique needs.
A behavioral reward system, in my opinion, might not be effective. We’re really aiming for sustained attention and focus, as well as the intrinsic satisfaction of seeing progress. More than external rewards, recognizing their own work and contributions is often the most fulfilling reinforcement.
More Ideas
Another key connection in this process is with the teacher, as they are central to helping students engage with the curriculum meaningfully. Sometimes, when looking at an assignment, I’ll ask the teacher, “If they leave with anything, what are the three most important things you want them to take away?” This helps focus our support and ensures the student engages with essential elements rather than getting lost in unnecessary details.
For students like Fia and Thomas, small adjustments in structure and timing can make a big difference. Could they watch other students present before their turn to help reduce anxiety or overwhelm? Are we observing their mood and energy levels daily to determine which tasks they’re most likely to succeed in?
A great example of this came from an endangered species project where a student with severe ADHD and high impulsivity chose an eagle as his research topic. The speech-language pathologist and I collaborated—she worked with him on preparing and practicing his verbal presentation while I incorporated movement through yoga.
When it was time to present, he stood before the class and confidently shared his research, describing the eagle’s traits. Then, he led the entire class in movement—we all flew like eagles, sat in our nests, balanced on a wire, and then transitioned into eagle pose in yoga. He was proud of himself, and the entire class was engaged and connected through the experience.
After a diagnosis, our role is to help students understand their patterns and recognize their mood and energy shift cycles. Tools like Zones of Regulation or How Does Your Engine Run? can be useful in helping students self-monitor. Over time, with the right support, they can self-report their states and develop better strategies for engagement and self-regulation.
Adding to Their Toolboxes
We could also have a menu of tools that work for self-regulation, such as brisk walks, six deep breaths, chair yoga, or other simple movement-based strategies. I often ask metacognitive questions to gauge where a student is in terms of attention and focus. Questions like How is your body feeling? Or what do you think you need today to help you work on this? allow them to reflect on their state. I might also ask, What has worked before for you? or What might make a difference today? to encourage them to access past strategies that have helped.
Sometimes, co-connection with a therapist or counselor can be as valuable as the intervention. Building a connection doesn’t always need to start with structured work. It could be as simple as batting a balloon back and forth or playing a quick round of a card game like War—just something to break the ice, create engagement, and build trust.
Once that initial connection is made, transitioning into work becomes easier. A simple acknowledgment of “We had our break, we’re alert, we’re ready” sets the stage for focus. By blending structured learning with moments of movement, connection, and self-awareness, we create an approach that allows students to access their curriculum to meet their unique needs.
Mind and Body Exercises
Before we conclude, I want to finish with some exercises to help soothe and center the mind. These techniques may also stimulate the vagus nerve, improving regulation and aiding in building connections, which we’ve discussed as essential for engagement and learning.
The first exercise is called It’s All on Your Head. Place two fingers at the sides of your head where your temples are and press as lightly or firmly as feels good to you. I’ll count to ten—one, two, three, four, five, six, seven, eight, nine, ten. Now, take a deep breath and let it out.
For level two, place your hands in the middle of your forehead, fingertips touching, and gently pull back. Again, apply the amount of pressure that feels right for you. Some people like to extend this motion down the sides of their face. If that feels good, go ahead and do so.
The last part of the exercise involves placing your hands on the top of your head and pressing gently. You can also move to the two small spots at the back of your neck, applying circular pressure with your thumbs. Some prefer to massage their entire scalp. A student once told me, “My mother would never do that—it would mess up her hair.”
Another exercise I find especially accessible is sleeve breathing. Place one hand in the opposite palm, ideally resting your elbows on your lap or a table. Slowly glide your hand up the forearm toward the elbow, then back down. Switch hands and repeat. You can count softly—one, two, three, four, five, six, seven, eight, nine, ten.
One of my favorites, which is included in your handouts, is Push, Pull, and Pause. Sometimes, I do this exercise backward, sometimes forward, but here’s the general structure. Start with your palms up. Breathe in as you push away from your body. The key here is the exhalation—notice how I blow out my breath. The longer the exhalation, the more calming it is. The inhale is quick, but we focus on extending the breath out. Let’s try it again—breathe in and push away. And again. And one more time.
With all of this knowledge we’ve covered about moods, specialized observations, and classroom engagement, it’s important to reflect on how to apply it. Maybe some names from your caseload have come to mind. What can you do to go back and start questioning patterns?
Classroom observation can be considered a treatment if you're directly seeing students. Watching how students engage in their daily environment provides invaluable insight into how well they are meeting their IEP goals. For example, if I think about Thomas, I might go into his classroom and observe how he manages independent work. If I see erratic movements, cycling between silliness and withdrawal, or hear self-deprecating statements like “I can’t do this” or “I don’t like this”, that gives me data on how to fine-tune his treatment plan. If I notice him frequently leaving the room, perhaps heading to the bathroom multiple times, that also signals something worth investigating.
The same applies to Fia. If I know she presents as withdrawn and disengaged, are the interventions I’ve been using working for her? How can I help boost her when I’m not physically present? Observing her during group work might reveal whether she is passively sitting back while others take over or if she is contributing—even in small ways. Noting the quality of her participation helps determine whether adjustments to her interventions are necessary.
Taking time to observe before intervening can shape more effective strategies. When I see students individually, I often reference my observations in a supportive way. I might say, “I watched you during independent work, and you seemed to have difficulty settling. Was I right?” This can open up dialogue. If they respond with something like, “Yeah, I didn’t like the paper. There was too much writing, and I knew I wouldn’t get it right”, I can then work with them to problem-solve strategies for breaking tasks into manageable steps.
If I had been present in the classroom at the time, I might have physically helped break the task down for them. But later, in our private session, I can shift the focus to self-advocacy: “How could I have helped you in that moment? How could you have asked for help?” and guide them in developing those skills.
For younger children, observations might require additional interpretation. Checking in with the teacher can provide further clarity. Asking, “Is this behavior typical for them?” helps establish patterns. If a teacher expresses frustration over a child constantly putting their head down or failing to complete work, or if they note that another student is frequently up, wandering, or copying from peers, that signals difficulty with classroom engagement.
When students struggle to access their curriculum, it indicates that more support may be needed. In some cases, that means being in the classroom more frequently. In others, it means working closely with aides to provide accommodations and modifications. The key is to ensure that interventions are practical, functional, and tailored to each child’s needs.
Conclusion
I hope this has added to your toolkit and encouraged you to think more critically about the students who may be exhibiting signs of bipolar disorder or other mood disorders but have been misdiagnosed. When that happens, their treatment may not be as targeted or effective as it could be. We can ensure they receive the right support by sharpening our observations, questioning patterns, and considering the broader picture of a child’s regulation, engagement, and mood fluctuations. Our ability to recognize these nuances can make a meaningful difference in helping students access their education and develop strategies for success.
Exam Poll
1)Which type of mood disorder is characterized by chronic, low-grade depression or irritable mood for at least 1 year?
2)Why is it important to have a correct diagnosis?
3)Which is NOT a symptom of major depression?
4)What is an intervention for major and seasonal depression?
5)Which is NOT a classroom behavior seen in children with bipolar disorder?
Questions and Answers
Is the ketogenic diet the same as the keto diet?
Yes, it is.
Have you come across many cases where females were misdiagnosed with bipolar as teens but were later diagnosed with autism, ADHD, or both?
I have not personally come across an overdiagnosis of bipolar disorder in girls, but that is an interesting concept. It could make sense, given that ADHD and autism diagnoses have historically been more geared toward boys.
Are children being diagnosed with ADHD instead of bipolar disorder?
Yes, that does happen. Bipolar disorder is being more carefully evaluated in the DSM, with clearer diagnostic criteria being developed. It is not surprising that some children are initially diagnosed with ADHD when their symptoms might later align more closely with bipolar disorder.
What is the best way to redirect a child who refuses to return to an adult-led activity after a break?
I am not a big proponent of behavioral rewards, but I do believe in understanding the underlying reason for the refusal. It is important to ask whether the child is feeling insecure, experiencing depression, or seeking attention from peers. Using a "first-then" approach can be helpful, but I also consider reversing the order, such as taking a break and completing the task. It depends on the situation and the child’s needs.
Do you have a reference link for a particular topic?
I’m not sure what you’re referring to, but if it is in my references, you should be able to find it in the research handout.
Are more children being diagnosed with bipolar when it is autism?
I am not sure about that.
Do you work with medication management?
No, I do not. The only role I have in medication management is being aware of what a child is taking. If I see medications like lithium or Abilify on their chart, I know that they have a confirmed bipolar diagnosis.
What about a plant-based diet?
I do not have research-based information on that, so I can’t comment.
Can depression be seen in children as young as six to eight years old? What are the major signs?
Absolutely. Signs of depression in young children can include disorganization in their approach to tasks, irritability, anger, or general uptightness. Some children may also appear disengaged, saying things like "whatever" but then struggling to complete tasks. Lack of motivation, poor-quality work, and a need for constant prompting are also indicators. External factors like poor sleep or inadequate nutrition can also contribute.
What condition do you believe is the most overdiagnosed in children?
I believe ADHD is overdiagnosed, especially in boys. Many boys are naturally more active and struggle with meeting early academic expectations, such as reading 35 words or sitting still for extended periods in kindergarten. This sometimes leads to premature ADHD diagnoses.
Where can I find the reference article on the ketogenic diet?
The Stanford study is listed in the bibliography and may be linked in the provided materials.
I have a client who dislikes taking deep breaths and struggles with self-calming. Any other suggestions?
Deep breaths are not always necessary for self-regulation. Tactile input can be effective, such as applying deep pressure to the arms or making circular motions on the shoulders and elbows. Another strategy is simply noticing the breath without trying to change it. Dr. Dan Siegel suggests placing one hand on the heart and one on the belly, closing the eyes, and observing the breath.
What should I do if a teacher is not implementing the skills that were instructed?
That is a much larger conversation. I recommend having a discussion with the teacher to understand the barriers. The resistance may not be intentional—it could be that the teacher is overwhelmed or unable to integrate the strategies. Problem-solving together may be the best approach.
Can someone with ADHD experience suicidal ideation?
Yes. Many individuals with undiagnosed ADHD experience depression, which can lead to suicidal thoughts.
What is a good way to talk down a child with autism before or during an emotional breakdown?
The key is recognizing early signs of dysregulation, which I call "whispers" of behavior. These may include changes in activity level, language, or increased chaos in their movements. Instead of waiting until they are fully dysregulated, start by asking simple questions like, "Hey, what’s up?" Dr. Dan Siegel describes the brain’s emotional regulation as a balance between the limbic system and the prefrontal cortex—if something triggers emotional distress, a child may "flip their lid," losing the ability to reason. The best approach is to intervene early when you first notice signs of distress rather than trying to reason with a child in the middle of a full meltdown.
References
Please refer to the additional handout.
Citation
Bowen-Irish, T. (2025). Let’s not overlook mood disorders in our youth population OccupationalTherapy.com, Article 5788 Available at www.occupationaltherapy.com
