Elliott knows it can be difficult for parents to come to grips with mental health issues their child may be experiencing.

“Regardless of the reason for the mental or behavioral health illness, we have to be responsive to our children immediately,” Elliott said. “Parents sometimes wait until it’s too late to seek help before harm comes to the child or someone else, simply hoping the problem resolves itself over time.”

Parents have reported not knowing where to turn for help or having the time and funds to navigate obtaining appropriate care.

Childhood mental illness occurs in about 20 percent of all children in any given year, according to the U.S. Surgeon General. Nearly 5 million children in America have some type of mental illness, yet experts estimate that only 20 percent of them will receive treatment.

“Early identification and treatment is critical and can be a lifesaver for the child,” Elliott said. “In addition, treatment can be beneficial for all of the child’s relationships and success in school.”

Elliott offers these early warning signs:

1. Significant mood changes, including sadness, depression, withdrawal, irritability or rages
2. Intense feelings with little ability to manage the feelings, including anxiety, fear and panic symptoms
3. Behavior changes including aggressiveness, dangerous behavior, and homicidal thoughts or changes in appearance, friends, interests
4. Physical harm including self-harm and suicidal thoughts/attempts
5. Substance abuse
6. Lack of self-care including, lack of cleanliness, not eat or over eating, sleep disturbances, weight changes, pays little attention to physical health, doesn’t care about homework
7. Change in functioning including inability to concentrate, easily irritated/frustrated, gets into fights/arguments, unable to get along with others, cannot complete projects/work

If parents note any of these changes they are encouraged to speak to their child’s doctor or find a specialist such as a psychiatrist, psychologist, social worker or licensed counselor.

“A proper diagnosis is essential for guiding treatment; and this process may include a health examination and/or psychological testing,” Elliott said. “Treatment may include medications, psychotherapy which includes teaching your child coping tools and how to respond to challenging situation, as well as helping parent training/skills.”

Other resources that provide information to help parents include www.watchdenton.org, National Alliance on Mental Illness (NAMI), National Institute of Mental Health, Mental Health America.

I think in “Inside Out,” Riley’s family is always trying to be positive and give Riley joyful memories throughout her childhood. As the family moves and life starts to unfold negatively, we see other emotions; fear, anger, sadness and disgust, start creeping up in.

We see Joy work harder to keep Riley’s emotions as joyful as possible. Joy is an important part of our memories that we like to revisit. As a child life specialist at Cook Children’s, I try to help normalize the day and make joyful memories with patients and families.

These memories will help children cope with other struggles that they overcome and find joy in their life. As adults, we have a hard time with this because we have so many experiences with sadness, fear, anger and disgust it’s hard for us not to project our feeling on children especially when they are in the hospital.

Children that come into the hospital may experience different emotions, but joy can be found through these emotions, even when as adults we may think there is no joy.

Sometimes kids find so much joy that they don’t want to leave Cook Children’s because it has become a fun and not so scary place. We need to remember to look for joy with all that may go on in a hospital setting.

We might not think children do a great job at a procedure because maybe they cried. However, they may have held still and been able to recover with playing by the end of procedure. This can create a joyful memory with having families at the bedside showing comfort.

Sometimes going through these different periods of our life while growing up and experiencing many things good and bad allow our emotions to interact.

In “Inside Out,” we see that the character Joy realizes toward the end of the movie that you can mix your emotions and this can be considered normal. Joy realizes that you can cry tears of joy. So as a child life specialist we help families realize that tears in a difficult experience may help a child in the future to help to control his or her different emotions. The tears also allow us to look at our long-term memories and see how there might have been joy in that moment after all and change that core memory to be better than we thought.

This allows us to empower children with all these different emotions, especially joy, in their daily lives, in or out of the hospital. Joy is a great emotion which we all deserve to look for daily in our lives and others that live with us. What Joyful memory do you have?

Previous stories in our "Inside Out" series:

• Anger
• Disgust
• Sadness
• Fear

Heather Bayers is a Child Life specialist at Cook Children's. We know that a child’s illness or injury can impact a family physically, emotionally and financially. Fortunately, you don’t have to face these challenges alone. We provide a growing number of services for patients and families, all designed to help support, heal and encourage you through every step of your journey.

These moments can be quite amusing to watch because, let’s face it, we can all relate to having angry outbursts!

Anger is many times perceived as the ultimate negative emotion, however “Inside Out” gives us an interesting perspective that could teach us a few things. When Joy introduces us to Anger, she describes him as someone who “cares about what is fair.” If we really think about it, most of our anger is the result of feeling as if we have been wronged by someone or when a situation does not go as we feel it should.

Children and teens who are dealing with an illness, injury, and/or hospitalization have MANY reasons to feel as if they have been put into an unfair situation. They are missing out on events with friends and family, missing school, having to endure sometimes painful and scary procedures and experiencing so many things that they have so little control over.

The first step in helping kids cope with anger is to acknowledge why they feel angry and to let them know they have a right to feel angry about a difficult situation.

Big life changes and overwhelming situations can shake up our emotions and cause them to go into panic mode as they try to make sense of what is happening. This is what we see with Riley’s emotions when her family moves away. However, when Anger is able to fully take over Riley’s control board, she makes an impulsive and unsafe decision to run away in an effort to feel better and to fix what she sees as an unfair situation. She breaks her hockey stick, rolls her eyes, yells at her parents and is disrespectful. When children begin to show these negative behaviors (even when they are sick or hurt), they need clear reminders of what behaviors are not acceptable while validating the feeling behind them. Say to your child, “It is OK for you to feel angry. It is not OK for you to hurt yourself, hurt others or be disrespectful.”

But if we are going to remove the only way they know how to express anger, we must replace it with an acceptable and healthy outlet. Some simple activities may include punching a pillow, pounding play dough, breaking ice cubes outside, participating in sports or outdoor activities, taking deep breaths or tearing up paper. Providing these options prevents anger from being bottled up and eventually blowing up!

Is there a positive side to Anger?? Definitely. Anger is strong, determined, passionate and protective. Those are all things we want children to be. Children can learn to see things that are not fair and stand up for themselves and others. Anger can be an excellent motivator for change and reaching solutions. If we can teach a child to use their anger in a positive way, we can empower them to overcome difficult situations.

Related "Inside Out" topics:

• Disgust
• Sadness
• Fear

About the author

Angie Bradley is a Child Life specialist at Cook Children's. We know that a child’s illness or injury can impact a family physically, emotionally and financially. Fortunately, you don’t have to face these challenges alone. We provide a growing number of services for patients and families, all designed to help support, heal and encourage you through every step of your journey.

She is especially protective of Riley when looking out for her well-being. She’s on vegetable alert. Remember the peas and broccoli pizza? Disgust also acts as Riley’s social situation monitor, helping her make new friends.

So what really is the value in our children's everyday lives of feeling disgusted? To feel disgust, means we are offended by something, or have an extreme dislike.

When was the last time you said, “That’s disgusting!”? Was someone acting in a way you felt was inappropriate, or was there food on your plate that you truly didn’t want to eat? We can see disgust acted out in kids all the time.

Food sometimes just has to look like it doesn’t taste good, for them to turn up their noses and say, “yuck, not eating that!” Think about all the times you’ve tried to get your child to take medicine that they refuse, or spit back out at you. Those may not seem like the most positive examples, but they’re probably the most realistic. But, if disgust is protective, then it may also keep your child from eating something they shouldn’t, such as bugs, plants or medicine that’s not theirs.

Disgust in the role of acceptable social behaviors has the potential to be very important. If we teach our children there are certain values that are important, and morals to follow, they have the potential to be offended (disgusted) when behaviors opposite to their values are displayed. It may keep them from getting involved in substance abuse, risk taking actions and becoming sexually active. If disgust helps them to live up to the expectations they know are important, then it plays a very positive role with the voices inside their heads.

Disgusted behaviors aren’t always the most positive if you look at sarcasm, being snarky and generally thinking they know everything. We may laugh when we see children react to situations with some level of egocentrism, except maybe when they are our children and we think they’re being rude. So, lesson learned, how children (and adults) display their disgust is important. Just like anger, it’s OK to feel disgusted, but there may be certain behaviors that are unacceptable, such as throwing peas, when we are expressing our disgust. Providing examples of what is acceptable behavior when disgusted, such as using words, not actions, is definitely a teachable moment.

Disgust, in all her green-ness in Inside Out adds a certain level of humor that is probably better understood by adults because it’s subtle and mature. But, don’t we all want to have a little bit of her humor in our heads every day? I know I do.

Related 'Inside Out' topics:

• Sadness
• Fear

About the author

Jill Koss is director of Family Support Services and Child Life at Cook Children's. We know that a child’s illness or injury can impact a family physically, emotionally and financially. Fortunately, you don’t have to face these challenges alone. We provide a growing number of services for patients and families, all designed to help support, heal and encourage you through every step of your journey.

“Inside Out,” the new hit movie, helps us to understand, however, that sadness is just as important to our world and our perceptions, as joy and anger and all of the other emotions we encounter as human beings. We cannot pretend that sadness isn’t there. We cannot ignore it and hope it will go away. There is a reason for our sadness and if we don’t experience that feeling, it gets stuck inside where it grows and festers and can then prevent our other feelings from being realized.

We’ve heard the idea that we can’t know true joy without having known sorrow. The point in the movie where things change is when Riley’s parents stop and listen to her feelings. Riley tells her parents that she misses her old home and she wants to be with her old friends. Nobody is trying to change the way Riley feels. Nobody is trying, including Riley, to cover up her sadness with something else. Riley is allowing herself to feel the sadness and her parents are there with her, allowing her to feel. They are supporting her feelings and are listening to her.

As parents, we want our children to be happy. We want to protect them from pain. Unfortunately, that isn’t always possible. Once we understand that our children must go through pain and sadness, our job is to be there for them in those times.

We must allow those feelings to be experienced and we will likely experience the same feelings with them. Sometimes children (and adults too!) can’t put words to what they feel, but luckily words aren’t always necessary. As parents, we need to realize that at times silence is better. Don’t try to solve the pain. Don’t try to “make it better.”

As hard as it may be, let it happen.

As kids experience their feelings, they will begin to heal. Ask your child what they’re feeling and let them find their own way to tell you. They may not want to talk, so just be there. Hug them. Sit quietly with them and make sure they know you are willing to be by their side no matter what they are feeling. When they do talk about it, validate them. Tell them that it is okay to be sad, or angry, or confused. They need to know that whatever they are feeling is okay; it isn't wrong.

Here are a few examples of validating language that you can use:

“That sounds like it is really hard for you.”

“I can see that ___________ made you feel __________.” (Use their words for these blanks)

“I’m guessing you might have felt ______________ when _______________happened.” (When they aren’t providing you with answers of their own.)

Try to avoid these phrases/comments which invalidate someone:

“It’s not that big of a deal.”

“Don’t worry about it, you’re going to be fine!”

“You’ve got to be a big boy/girl, we’re not going to cry.”

Previous 'Inside Out' topics:

What 'Inside Out' teaches about fear

About the author

Shea Ingram is a music therapist at Cook Children's. At Cook Children's, music provides a creative intervention for children and young adults individually or in a small group format. It allows our young patients an outlet for the physical and emotional challenges they face in their lives.Music as an outlet and/or therapy aids communication and can be helpful to those who find it difficult to express themselves in words. Research supports music effectiveness in many areas such as: overall physical rehabilitation and facilitating movement, increasing people's motivation to become engaged in their treatment, providing emotional support for patients and their families, and providing an outlet for expression of feelings.

Depression is a biological illness with a strong hereditary link. Generally, 35 to 40 percent of depressed children have inherited their disease. Usually, parents notice that their child is depressed around the teen years. 

Teens with chronic illness, such as depression, are no different than any other child and generally want to be treated just like any other kid. But they should receive professional help and be assessed for anxiety and depression. 

Parents should watch for any change in mood like sadness, depression, hopelessness, irritability, anger and hostility. You may see more tearfulness and changes in activity level. Watch for more withdrawal from friends and family, change in friends and loss of interest in activities once enjoyed. Other signs include sleep disturbance, change in appetite, restlessness, agitation, fatigue, lack of energy/motivation, feelings of worthlessness and guilt. Depressed kids may have difficulty concentrating, making decisions and may even see a drop in grades. 

Always be aware of signs of depression and keep a close eye on your child. Never ignore symptoms.  If you see signs of depression, contact your physician and obtain referrals for a psychologist or therapist who is trained in pediatric and adolescent care. 

Children threatening suicide may be trying to get attention or may be struggling with depression. But it doesn’t matter. You must take the threat very seriously. If a child is talking about suicide, get help immediately. It is critical not to ignore this cry for help regardless of their reasons. 

Know that if your child is struggling with a chronic illness, including depression, it will impact the entire family. Families will require a lot of support: emotional, financial and physical. Most importantly, the support needs to be ongoing. It’s important to allow family members to vent frustration and grieve. Therapy is very helpful. If your teen is struggling with this problem, the entire family will need help to get through it. The good news is it’s available. If you feel your child needs help, please call 682-885-3917 for a referral into Cook Children’s Psychology department.

About the author

Lisa Elliott is a licensed psychologist and clinic manager of Cook Children’s Behavioral Health, located at 3201 Teasley Lane, Ste. 202, Denton, TX 76210. To make an appointment, call 940-484-4311. Cook Children’s Psychology provides care focused on children’s behavior, from ages 3 years through 17.