Mike (Host): Welcome to Pediatrics and Practice, a CME podcast. I'm Dr. Mike, and joining me is Sarah Gould, a clinical psychologist from Children's Mercy. Today we will be discussing seasonal depression and focusing on practical strategies for pediatric care. Dr. Gould, welcome to the show.

Sara Gould, PhD: Thanks. I appreciate being here.

Mike (Host): What signs should pediatricians look for when screening children for seasonal depression? And how do these differ from, say, typical winter blues or other mood disorders?

Sara Gould, PhD: Sure. One of the most important things to know about Seasonal affective disorder is it is actually a subtype of major depressive disorder, and so it's not much different from a lot of the signs that pediatricians are already. Looking for screening for in patients. And so one piece of it, just like with other emotional concerns, to differentiate a bit from something like more of that kind of post-holiday lull in mood or things like that, is the severity and the impact of the symptoms.

So if they're interfering with functioning in life for kids or if it's leading to high distress in the child or in their family. And so those common symptoms like depression are isolation, tearfulness, or irritability. A change in academic performance, social interactions, things like that. Also, for it to be a true seasonal disorder we do need to see that pattern.

And so getting sad or more symptoms. One early winter season is not quite enough to tip it over into that classification.

Mike (Host): So, What screening tools or protocols do you recommend for primary care, and how often should these be used during these high risk seasons?

Sara Gould, PhD: Screening is always important, especially as we're working with young people where new concerns can develop. The good news there is that most of the screening tools already commonly used in practice such as the PHQ two or nine, are just as effective as picking up the symptoms of seasonal affective disorder as general depression.

The caveat would be to add on that to make a note of what time of year did these things start. What happened last year around this time or in previous years? And then also a good question is, is there a family history of seasonal mood difficulties? Whether or not seasonal affective disorder itself was diagnosed?

Mike (Host): Now with, uh, at least pre-teens, you know, maybe into early teenage years, during the holiday months, there's a lot going on. You got finals and stuff like that at school. then they get excited for a Thanksgiving break and a Christmas break, but then when they have to go back, I think most kids don't like that and seem a little depressed.

How do you distinguish that kind of stuff from true seasonal depression?

Sara Gould, PhD: Sure. Part of it is looking at again, that impact. Are they still wanting to hang out with their friends? Are they still interacting with family about the same as grownups? Don't necessarily like going back to work right after a good vacation either. And so that can be a good convenient comparison as well.

And to take note of how quickly do kids adjust back. Into that school schedule, that routine, and are there things that they're looking forward to, or are there even those things that previously or typically they enjoy, not so much fun or not as interesting to them?

Mike (Host): Yeah. And I think you made a good point. Compare it to the previous year, right? If this is how they usually are during this time, but you know, they get over it and they're right back in school and they're with their friends. Maybe this is just, not seasonal depression.

It's just, they were having a great holiday season, right?

Sara Gould, PhD: Yeah. And that can be a really good indicator. As always with mental health, part of what we're trying to understand is what's going on now for a kiddo, but also how has it changed? How has it evolved? How does it compare to how they've always been?

Mike (Host): are the most effective FirstLine interventions for seasonal affective disorder in kids?

Sara Gould, PhD: Two of the most common and the most effective are light therapy and cognitive behavioral therapy, which also can be used in combination. So light therapy. Is trying to simulate longer day times, which really does have an impact on our biology, and some are more susceptible to that impact, and it's to be around a light of a certain intensity of 10,000 ls shortly after waking up.

To be around that light for at least 30 minutes. I recommend up to 60. And you don't have to stare at the light. It shouldn't stare at the light really at that intensity, but to glance at it once in a while, face it. And so kids can go about their routine.

They can do it while they're doing their makeup, having breakfast, gathering their things, things like that. But that consistency can really help reset some of those biological processes that can be protective. Against those new difficulties. And then cognitive behavioral therapy is increasing those coping skills to be able to manage emotions more effectively overall, which can also help in this context.

Importantly, light therapy is useful while it's being used. It is not protective in the next season, versus CBT actually can be because those skills don't. change as the light changes. Another intervention that has support is Bupropion. That's the only medication that's specifically labeled for preventing seasonal affective disorder. But the other SSRIs are also helpful similarly to other presentations of depression

Mike (Host): Now with the light therapy. So these are at home. Light boxes basically. Right. So any advice for parents who, wanna do this for their kids? Maybe it's been suggested by their physician. how do you know you're buying a good light box?

Sara Gould, PhD: That is a little tricky. I think one important factor that we can depend on is to make sure that. The intensity is the right intensity. And so looking for something at that 10,000 lux is a great first step. And then talking to networks, looking at reviews, things like that.

'cause there are a variety. There are also even lights, but they're part of a visor, so you can wear it around the house. The products get pretty creative and unfortunately, like anything, sometimes we have to try a couple to see what fits us best. But that can be really helpful.

And the side effects are minimal to none. And so it can be a low risk thing to try.

Mike (Host): So the key thing is the brightness, the lux I think you said at least 10,000. Is

Sara Gould, PhD: Mm-hmm. That's correct.

Mike (Host): Now, as far as the medication goes do most physicians start with light and behavioral and move to the medication if necessary? is it truly, you first line for a lot of doctors?

Sara Gould, PhD: Yeah, that's a great question. I think we use the tools that we have and then we know of, but in the literature, light therapy and CBT really are the first line. And just caveat, I am a psychologist and so, I'm not in a position to make recommendations about dosing or prescribing medicines that did wanna make sure to share.

That one in particular has the labeling for this condition.

Mike (Host): Yeah. How can pediatricians collaborate with families? To create, home-based strategies that support mental health during, the winter months.

Sara Gould, PhD: I really appreciate that question because I think holidays they're special, but there are so much going on, like you referenced finals, all of the theater performances, band concerts, all of those things as well as the holiday gatherings and parties gets piled into really a very short time period, and that is fun and stressful.

Also, for some families, holidays have hard memories associated with them, and they're bringing that past into this season as well. And so one really important thing to be mindful of is to set realistic expectations. We can't do everything. Maybe if we're dealing with something this season, we can't fit in all of the traditions that we're used to.

So can we prioritize? Can we talk together as a family about what we're going to include this season and what we are not? And to be really mindful of overcommitment, both because of the hassle and stress that and juices, but also because that can impact sleep and all of us are at more risk if we're not getting enough rest.

Another piece of that can be to make sure that we're prioritizing connection over kind of just numbing activities. So an example of that is even if we just limit the discussion to screens, watching a movie together or playing a video game collectively is very different from everyone sitting in the room on their own device doing their own thing.

Finally, I would suggest with these short days make the most of the daylight there is, so thinking about scheduling certain activities at certain times where we all get the most exposure that we can.

Mike (Host): that was some fantastic advice. Of course, the hard part about getting that sunlight is if you live in a really cold place, that's tough.

Sara Gould, PhD: It is. And so even in those times that we can make use of our windows or car rides or bundle up and check which part of the day is gonna be the warmest and be out even for 15 minutes can make a difference.

Mike (Host): Now let's talk a little bit about teachers, school performance and pediatricians obviously. Kids with seasonal affective disorder with specifically depression, their performance isn't gonna be maybe where it should be. So how should pediatricians work with teachers?

Sara Gould, PhD: Yeah. This is another area that is similar to other types or presentations of depression because you're right, if our mood is hard, if motivation is really. A tough fight to gain. Then academics are gonna take a hit most likely, as well as social functioning at times. And there are a lot of academic demands in this part of the year.

And so asking for things like when possible, a reduced workload, for example, in algebra, if the student can do five of the 10 assigned problems perfectly. Could we skip the other five? Asking for things like extended deadlines or for coping breaks in schools. Being able to step out of the situation briefly, take some breaths, use some skills, and be able to step back into it.

Those things can make a big impact. I also think the more everyone, parents, pediatricians, educators, coaches can communicate that the focus should be on effort. Or a process, an experience over performance, that can be really helpful because there are so many evaluative situations and experiences piled on each other in these few weeks.

Mike (Host): in your experience, do you find that schools, teachers, administrators are more open in today's world to extending deadlines, as you said, maybe shortening some of the homework? Or is that a, challenge?

Sara Gould, PhD: I think most schools are pretty aware these days that our kids are struggling in a lot of ways, and that everybody needs a helping hand at some point. Including US adults. And so part of it schools know best what resources they do have, and so it's great to have a communication style that is focused on what is the goal rather than a particular accommodation.

We can suggest them, but to also be very open to what can schools offer, what do they already have? Readily available that they can slide in quickly for kids and that might change depending on the school, their personnel, the resources, et cetera. But yes, most schools are very open to these conversations and really are interested in how helping kids succeed and these conversations help them know how to do that.

Mike (Host): When we look at risk factors specifically, I want to talk about family history and coexisting conditions. Is there a family history, and I think you touched on this a little bit at the beginning. Is there a family history connection here to seasonal depression?

Sara Gould, PhD: There is like most mental health concerns. There seems to be genetic or biological vulnerability that doesn't automatically, a condition will present itself or that the same condition will present itself in a child as in a relative, but it does increase the risk or can help us know what to look for.

And so knowing that family history. Again, even if it's not diagnosed, some families will say like, oh yeah, I always have trouble in January. Okay, let's take note of that and ask a few more questions to understand what that looks like and if that could have implications for our patient.

Some other things to consider is one kids or teens that already are dealing with depression. It might not be labeled as seasonal affective disorder if it happens year round. But the season or the change in light can have an additive effect, and so they might need additional support this time of year.

And one thing to note too is daylight is linked to this. And so the farther north a family lives or a provider's practicing, there is increased risk of these disorders versus farther south.

Mike (Host): now coexisting conditions. Can we run through that again? Like, Are these connected to. Some other mood disorders throughout other seasons, et cetera.

Sara Gould, PhD: Yes, it's primarily related to depressive disorders, whether that's DYS or the various versions of major depressive disorders. However, bipolar disorder can also have a seasonal subtype. So that is a condition, certainly more rare in kids, but to be aware of that.

Mike (Host): And when should pediatricians refer? Patients to a mental health specialist like yourself.

Sara Gould, PhD: Sure. One thing to remember, and I do think pediatricians are very aware of this, is it should not be the generalist's burden to sort everything out. And so if there's a question that is a fine, a totally appropriate time to refer, to get a mental health person in there to help sort out the details and help select the best evidence-based.

Interventions based on the concerns and also the family situation, resources, all of those things to be able to individualize care in that way. And definitely if there is impact on family or other domains of functioning for a child, that would be a really good time to pull in some additional resources.

And the care itself looks very similar to that. Of just care for depression, with the exception of course of the light therapy. So again, recommending therapy, ideally cognitive behavioral therapy, families can find those light boxes online pretty easily. And then considering if for this patient, medication might be an additive help, whether that is managed by the PCP.

Or referred on to psychiatry or something like that. And please also do remember Children's Mercy. Psychiatry is available for consultation if pediatricians would like to run a case by them, particularly as pertains to medication use.

Mike (Host): Dr. Agul, this has been fantastic. I'm very impressed with the amount of information that you share today, so thank you so much. For more information, please visit CM KC DO link slash CME podcast. If you enjoyed this podcast, remember to share it on your social channels and explore our entire podcast library for topics that interest you.

This is Pediatrics and Practice. I'm Dr. Mike. Thanks for listening.