1. Mood problems often constitute a primary reason why parents
seek professional help for their children or adolescents. Most
often, mood problems include irritability, sadness, or anger. A
certain amount of moodiness and impulsivity is normal during
childhood and adolescence; therefore, it makes it exceptionally
difficult to diagnose children and adolescents with conditions
such as clinical depression or bipolar disorders. One of the most
challenging elements in counseling is objectively assessing
whether a child or adolescent has a mood disorder. Cultural and
family factors are one reason this is challenging. At times, these
factors are directly the cause of the mood disorder or contribute
to the stress or distress of children and adolescents. Therefore,
it is important to use a systematic, objective, and dispassionate
procedure for gathering data about children and adolescents
when conducting assessments.
For this Discussion and subsequent Discussions, consider these
questions: a) Where does the child’s or adolescent’s problem
originate from, and b) Does the problem stem from the child or
adolescent, or is it the family or other factors? By asking these
questions, you can more accurately assess a child’s or
adolescent’s problems and create evidence-based interventions
to address the right problem effectively. Select a case study
from the Child and Adolescent Counseling Cases: Mood
Disorders and Self-harm document from this week’s resources
and consider the child’s or adolescent’s presenting problem and
where the presenting problem may originate. Conduct an
Internet search or a Walden Library search and select
one
peer-reviewed article related to the interventions that might be
used to address the child or adolescent in your case.
With these thoughts in mind:
By Day 3

2. Post
a brief description of the presenting symptoms of the child or
adolescent in the case study you selected. Then, explain one
possible reason the child’s or adolescent’s problem exists and
why. Finally, explain one evidence-based intervention you
might use to address the child/adolescent in this case study and
how it will be used. Be specific and support your response using
the week’s resources and your research.
Required Readings
Bosmans, G., Poiana, N., Van Leeuwen, K., Dujardin, A., De
Winter, S., Finet, C., ... & Van de Walle, M. (2016). Attachment
and depressive symptoms in middle childhood: The moderating
role of skin conductance level variability.
Journal of Social and Personal Relationships, 33
(8), 1135-1148.
Greville, L. (2017). Children and families forum: Suicide
prevention for children and adolescents.
Social Work Today
. Retrieved from
http://www.socialworktoday.com/archive/SO17p32.shtml
Pirruccello, L. M. (2010). Preventing adolescent suicide: A
community takes action.
Journal of Psychosocial Nursing and Mental Health Services, 48
(5), 34–41.
As you review this article, focus on how a community takes
action to prevent adolescent suicide.
Document:

3. Child and Adolescent Counseling Cases: Mood Disorders and
Self-Harm (PDF)
Select one case study from this document to complete this
week’s Discussion.
Document:
DSM-5 Bridge Document: Mood Disorders and Self-Harm
(PDF)
Use this document to guide your understanding of mood
disorders and self-harm for this week’s Discussion.
Stebbins, M. B., & Corcoran, J. (2016). Pediatric bipolar
disorder: the child psychiatrist perspective. Child and
Adolescent Social Work
Journal, 33
(2), 115-122.
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2007).
Tough kids, cool counseling: User-friendly approaches with
challenging youth
(2nd ed.). Alexandria, VA: American Counseling Association.
Tough Kids, Cool Counseling: User-friendly Approaches with
Challenging Youth, 2nd Edition by Sommers-Flanagan, J.;
Sommers-Flanagan, R. Copyright 2007 by American Counseling
Association. Reprinted by permission of American Counseling
Association via the Copyright Clearance Center.
Checklist of General Suicide Assessment Procedures Table 8.1
(p. 179) (PDF)These documents will guide you as you think
about suicide assessment to determine suicide risk in
conjunction with common risk factors and warning signs.
Hallab, L., & Covic, T. (2010). Deliberate self-harm: The

4. interplay between attachment and stress.
Behaviour Change, 27
(2), 93– 103.
As you review this article, focus on the relationship among
attachment, mood, and self-harm and how this might inform
your professional practice.
Van de Walle, M., Bijttebier, P., Braet, C., & Bosmans, G.
(2016). Attachment anxiety and depressive symptoms in middle
childhood: The role of repetitive thinking about negative affect
and about mother.
Journal of Psychopathology and Behavioral Assessment, 38
(4), 615-630.
Document:
Child and Adolescent Suicide Risk Factors and Warning Signs
(Word document)
This document guides you through a checklist of warning signs
and risk factors for children and adolescents that are at risk.
Focus on how you might use this document to assist you in your
assessments.
Required Media
Laureate Education (Producer). (2014b). Child and adolescent
counseling: Mood disorders and self-harm [Video file].
Baltimore, MD: Author.
Note:
The approximate length of this media piece is 21 minutes.
In this media program, Drs. John Sommers-Flanagan and Eliana

5. Gil discuss their experiences when working with children and
adolescents who demonstrate mood disorders and self-harm.
Accessible player --Downloads--Download Video
w/CCDownload AudioDownload Transcript
Transcript
Mood Disorders and Self-Harm Program Transcript [MUSIC
PLAYING] NARRATOR: Counselors who work with children
and adolescent clients must be prepared to respond to situations
involving suicide, cutting, and self-harm. Doctors John
Sommers-Flanagan and Eliana Gil talk about what they have
experienced in working with children and adolescent clients
who are experiencing symptoms of mood disorders and acts of
self-harm. JOHN SOMMERS-FLANAGAN: Eliana, there are
many different reasons why children and adolescents come for
counseling, are referred for counseling, and occasionally even
want to come themselves. And one of the prominent reasons has
to do with mood, or affect, and their ability to manage those
human experiences. And so I'm wondering some of your
thoughts about this recent development, where many children
and adolescents both seem to be engaging in some self-harm or
self-mutilation behaviors. And I guess, to start with, what do
you see as some of the differences between how children might
exhibit some self-harm and how adolescents might exhibit self-
harm? ELIANA GIL: Well I think that this issue about self-
mutilation is very complicated and very individualized. And so
it's really important to do a very, very unique assessment with
each child. Because I think we come into it, sometimes, with
assumptions. So there's lots of different possibilities. I think
that some of the kids that I've worked with—the older kids in
particular—are in a lot of pain. They have a lot of stressors. I
think that they're often involved in social relationships with

6. others where they share this kind of information. And the thing,
I guess, that really concerns me the most is that I think that kids
start talking about selfmutilation to each other. And suddenly
this begins to be part of their culture. That this is something
that's acceptable; it becomes almost normalized among the
teenagers that I work with. And so it's been interesting to
explore, because sometimes I used to think that the best thing to
do was to put kids in groups that had this particular issue. And
what we found was, that as kids start, sort of describing the
kinds of practices that they're using, that lo and behold the kids
come back the following week and they have the same kinds of
scarring or injuries or whatever it is that they heard about the
week prior. So I've kind of moved a little bit out of that group
model because of that, because I do think there's kind of a
contamination thing that can occur. And I think that looking at
the kids very much in individual therapy and maybe family
therapy, some of the reasons, I think, that kids do it may have to
do with their own discomfort with their affective state. So let's
say that they feel, for example, really angry, but they don't have
the mechanism to express that. And © 2016 Laureate Education,
Inc. 1 Mood Disorders and Self-
Harm so sometimes what they do is they will cut. And then
somehow after they cut, they feel that they have somehow
expressed something or discharged something. And they feel
better. So one of the things I've tried to track is what you were
doing and thinking and feeling right before, during, and right
after. And then you begin to get some patterns that show that
kids will feel sad, they'll feel despair, they'll feel worried,
they'll feel angry, and the cutting seems to serve the purpose of
somehow discharging the affect, making them feel better, more
relaxed, relieved, somehow not as tied up in knots. And then
suddenly, because that is effective for them, then they continue
to do it. When we do histories, either with teenagers or with
adults, and we say to them, “So when's the first time you
remember hurting yourself or experiencing pain or thinking
about pain as something that might shift some kind of emotion

7. for you?” They'll say things like, when I was four or six or
seven. And so it's been interesting to kind of keep that in the
back of my mind when I work with little kids. Because
sometimes with the little kids, we have what appears to be
accidental injuries. Or they come in and they just have a ton of
bruising on their legs, and kind of differentiating, there are very
energetic kids. And these energetic kids can have little
accidents and get all these kinds of marks on their bodies. But
there are other kids where it's almost—well it isn't almost—it's
not an accidental kind of situation that's occurring there.
Literally, prone towards these accidents and are having a kind
of different experience with pain and whatever happens after the
pain occurs. One of the other things that we find with self-
cutting is that often there's a secondary gain. So we have
children and adolescents who are really needing the attention of
others—whether it's peers or whether it's their family system.
But when I'm tracking what happens immediately afterwards,
one of the things that comes into play is that they'll go and talk
to their parents or they'll call their friends up. So I say, “Well
describe what happens then.” Well then they sit down and talk
with me, or then they really pay a lot of attention to me. Or then
I get to really talk to them about something that's important.
And it's almost like these things become a vehicle to get
something else. And that's really how I think about self-cutting,
that it's some kind of conduit to some outcome that they're
really looking for and needing. And we have to figure out what
that might be. JOHN SOMMERS-FLANAGAN: I hear you
saying that first, individualize, and that each child or adolescent
might have unique reasons for doing the cutting. I also hear you
saying, watch out for contagion. And sometimes if you work in
groups with these children, adolescents, you might actually see
them taking on some behaviors that are destructive, that other
people have modeled for them. ELIANA GIL: Exactly. © 2016
Laureate Education, Inc. 2 Mood
Disorders and Self-Harm JOHN SOMMERS-FLANAGAN: And
then I also—and it's kind of an interesting issue—but I hear the

8. issue of attention. And that maybe some of the behavior might
be attention seeking. And combined with that, that some of it is
maybe helping them regulate affect. ELIANA GIL: Exactly.
JOHN SOMMERS-FLANAGAN: And I know in my experience,
and I'm interested in your comments on this, I've seen some
young people—teenagers in particular—who are very private
about their cutting. And it has seemed to me that they are more
inclined to be doing it for the affect regulation, whereas others
seem to like a little more attention, or public display. ELIANA
GIL: Sometimes my association is, red badge of courage, you
know? JOHN SOMMERS-FLANAGAN: Almost as a display.
ELIANA GIL: As a display. And then the kids who are doing it
very privately—and I think I started out by saying that I think
there's a lot of pain involved with all of these kids in some way
or another. And there may be some very unique factors
involved. Like one of them that I encounter a lot—partly
because I think I work mostly with kids who've had trauma in
their life—is this aspect of depersonalizing. And the fact that
sometimes the kids are in these kinds of existences where they
don't feel like they're really present. And they are in an altered
state of consciousness. And that may be their best defensive
mechanism. And sometimes the cutting actually serves the
purpose of bringing them back to reality, making them feel
something that makes them feel present again. And so that's a
very private, personal use of cutting. So that's why the
assessment becomes so important because unless you know
really what's going on, it's very hard to help with that. And I
think that there's lots of variables right now. I think kids are
exposed to the Internet. There are actually websites on cutting,
how to cut. I saw something recently about teens kind of
sharing this experience of implanting objects into their bodies.
And so this information is pretty available to them. And I think
it creates almost a hyper-arousal, because there's all this
explicit information. And kids talk to each other. And they form
groups. And they begin to feel kind of bonded to each other. So
I think the Internet, for all its wonderful things that it provides

9. to us, also has these areas that we need to stay aware of and
help the kids with. So I think that's one of them. And I think
there's popular movies that kind of throw the cutting in as
normalized. And that's just what people do and that type of
thing. It's the overstimulation, I think, from the media often that
gets these kids kind of thinking in these particular directions.
And then the © 2016 Laureate Education, Inc. 3
Mood Disorders and Self-Harm access
to the social support system that kind of validates this as
something that's kind of cool. The other is bisexuality. That
somehow, within the teen population, became kind of a cool
thing to do. And it's much more prevalent now as a—I don't
know if you even think of it as a right of passage, but as
something that kids get more involved with than, for example
my age group or other times when kids were a little bit—the
experimentation was of a different nature. So I think that those
are some of the things that come into play in terms of this
problem, and how pervasive it seems to be at this point. JOHN
SOMMERS-FLANAGAN: It seems like lots of exposure,
overstimulation, and then there's kind of a social movement
where, for one reason or another, children and adolescents
actually feel supported in doing some self-harm. ELIANA GIL:
Exactly. JOHN SOMMERS-FLANAGAN: And then your
comment about how sometimes functions to bring someone to
reality out of their numbness, I think is a really interesting idea.
And I've also heard some young people say just the opposite.
That they're feeling too much and it helps to calm them
down.ELIANA GIL: Absolutely. JOHN SOMMERS-
FLANAGAN: And so that individualized assessment and
treatment that you started with, I think it's a crucial thing for us
to think about. ELIANA GIL: Yes. And I also think that putting
our assumptions to a side. Because I've worked with clinicians
or talked with clinicians that say, “Well they're just trying to
get attention. That's not a big deal.” And so they're dismissive
of it because of something that could be a factor, which is a
secondary gain. But the reality is that the kids are doing it for

10. that reason. That's important in and of itself. The other is that
some people jump to the conclusion that it's suicidal behavior
and so they treat it as such. Where for some children, it's
actually life affirming for them or it's a way, a vehicle, to
regulate their emotions or just cope in general. So we need to
know exactly what it is before we can start trying to really
assist that person in a way that's going to engage them and in a
way that's going to be effective for them. JOHN SOMMERS-
FLANAGAN: And so you've jumped right into what I wanted to
ask you next. And that is, what is the relationship between some
self-mutilation, cutting, self harm and suicidal behavior because
the two are clearly not the same? Some people who cut are
clearly not focused on killing themselves. ELIANA GIL:
Exactly. And I think that it's a very interesting problem to
assess. Because again, we are so worried when we encounter it.
And some of the things that kids do to themselves, you know
we're sitting there going, “Oh my goodness, is there any way I
can”—If it helped to say, “Just stop it,” we would do that. And
then the kids would stop. But it doesn't work that way. You
have to actually really listen and be sure that they're engaged in
some way that you don't push them in the wrong direction.
Probably their families are already saying to them, “Stop that.
That's not OK. It's inappropriate.” And we have to be careful
about that because if we become another person who just simply
says, stop it, that's not going to work. So the assessment around
cutting, for me, is really important in terms of what is the
outcome and the value to that child of it? So that's why I try to
track those behaviors and figure out, are there patterns? And
what do we see as the primary outcome? And then, if that's
something I can identify, I can help with it. When kids are
suicidal, I think there's much more a sense of despair and
isolation. So these are not kids who are involved in social peer
groups and getting validation from their friends about what
they're doing. They're disconnected. They're much more flat.
The cutting sometimes, when kids describe it to you, almost has
a hyper-arousal component to it. Where they're kind of excited

11. and they're-- I think on some level—thinking they're exciting
you. When kids are suicidal, there's—from my point of view and
the experience I've had—there's much more of a subdued, flat,
disconnected despair that you can really feel. And so when you
start talking to kids, the pain is overriding and what they're
talking about is really not wanting to feel that pain anymore.
And having arrived at the conclusion that the only possibility,
the only thing that they can possibly do to get this pain to stop,
is to actually take their own life. Now with those children, often
they've thought about how to do it. They have access to how to
do it. They've looked at the Internet about suicide and what
works and what doesn't and what's the most effective thing to
do. They have access that, when I was a kid we just didn't have.
There's access to drugs from friends. They can get the things
they need if they want to kill themselves. And there's other kind
of aspects that become interesting. Like kids who are hanging
themselves. That's another little subculture, where there's an
autoerotic piece to that that kids are experimenting with. And
sometimes kids hear about that and then that becomes maybe a
mechanism for them. And so now we're in a—I think—a very
precarious time because of that. But I see a qualitative
difference in the kids where the cutting is serving some other
purpose and the kids who are really suicidal. Not to say that I
haven't worked with—I've worked with a couple of kids who
started out by cutting and then the cuts got dangerously close to
places in their bodies, where there would be a large
disbursement of blood. And they started flirting with the idea of
really doing more damage to themselves. And so sometimes it
can be on a continuum, where kids can shift. If other things
don't come into play, like they start getting some relief or
learning other ways to regulate their affect or getting the
attention or the nurturing or whatever it is that they need out
there from the environment. JOHN SOMMERS-FLANAGAN: I
think the research absolutely supports what you're saying in
that, for many of the kids who are cutting, it's just an affect
regulation, numbness or affect-related activity. But for some

12. others, they progressively move toward more dangerous and
more dangerous activities. Probably related, to some extent, to
the level of despair and depression. But one thing you said
earlier that I think is really important for us to talk about
briefly is the whole concept of it being an effort to deal with
some psychological or emotional pain, and that they begin to
see suicide as a viable alternative to this misery and pain that
they're feeling an experiencing inside. ELIANA GIL: It's a very
pervasive sense of helplessness. And I think that suicide
becomes so attractive because kids think to themselves, the pain
will stop. And actually I think, in terms of treatment, that's one
of the things that we can focus on, is that there are other ways
to stop pain that are not permanent. And to have kids really,
kind of walk through with you the permanency of some of the
actions that they're considering. Because I don't think kids think
about anything other than the here and now, the pain is
intolerable, I've got to stop it. Little kids, when they're talking
about suicide, talk about things like going to sleep for a really
long time or not waking up. They don't necessarily have the
methods or maybe can't access that as well. But they start
thinking about just going to heaven. I've had little kids who
make pictures of how beautiful heaven would be. And this is a
place where they don't feel pain and where the stressors are not
present. And again, having worked with a lot of trauma, and in
particular interpersonal trauma, where someone's hurting them,
it's almost like there's nowhere else to escape. They really don't
have a way to stop what's going on, to figure out how to share
that with anyone. And so their despair just kind of grows. And
their sense of isolation grows. And they stop reaching out to
others. And it's a really sad and unfortunate place to be. And the
little kids often, again, can do things like begin to think about
collecting pills or—you I read a study where sometimes kids
were throwing themselves in front of traffic and things like this.
So little kids may not be able to get all the methodology down,
but they do things that are distressing, like drinking things they
know to be bad for them or putting themselves in harm's way.

13. So with the little kids it's a different kind of assessment, but
still very worrisome to see that the pain can lead them to think
that there's just nothing else they can do. JOHN SOMMERS-
FLANAGAN: Do you have particular warning signs or risk
factors in children versus adolescents that you really look for in
your practice? ELIANA GIL: Well I think that with the little
kids, I like to use a lot more of the expressive therapies with
them. I like to listen to their stories. So I may provide them
with puppets and I may give them sand trays in which to make
stories. But the idea is that often the stories that they tell are
catastrophic. The stories that they tell are ones of hopelessness.
There are no resources that can be found anywhere in their
environment. So if you ask them to talk about, or to let you
know about, the people who love them in their lives, there are
none. But definitely you begin to see real signs of a pervasive
sense of hopelessness. No ability to think about the future. Like
even with little kids, if I say, so in five more years, how old
will you be? And they say things like, maybe not here or I don't
know. And they can't be future-oriented. So with little kids I
look for that. And then also the pictures they draw, the stories
they tell, their behaviors at school or with others, changes in
their behavior. So those are the things I look at with little kids.
And I think the teenagers are much more apt to do a greater
range of acting out behaviors and get the attention of school
personnel or others. And then it's a question, again, of doing
individualized assessments. So I use some of the same activities
with the teens, but sometimes their behavior speaks louder than
words in terms of the acting out whereas the little kids may go
quiet more, so they're less likely to be spotted by others.