Wintertime Blues – PediaCast 397

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  • Our “Pediatrics in Plain Language” panel returns to the studio as we explore the wintertime blues. We consider some reasons for “feeling down” this time of year, including decreased sunlight and physical activity, sleep problems, school trouble and relationship issues. We talk about the depression-suicide link and share smart ideas for recognizing depression and getting help. We hope you can join us!

Topics

  • Wintertime Blues
  • Seasonal Affective Disorder
  • Depression
  • Suicide

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Transcription

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.

It's Episode 397 for February 15th 2018. We're calling this one, "The Wintertime Blues". I want to welcome you to the program. It is mid-February and we are definitely in the thick of winter here in Central Ohio. Although, we got a little break today, it's like 60 degrees but it's still rainy and cloudy, and up until now it's been pretty cold and there's still cold weather coming. We're not, It's not spring yet although all of us wish that it were spring.

But the other thing about mid-February means that the Olympics are on and we have been, we've been kinda binge watching the Olympics in our house. Now you know, as a pediatrician, you know, my usual advice is do some active things with the family, you know, face-to-face, dinner together, play some games, get outside if it's warm enough for you.

And really, you know, try to stay away from the screen time as much as you can especially since we're on screen so much just with daily living, and technology, and schoolwork, and work-work. So when you do have family time together, you know, spend it doing something.

But I think you get a pass on that when the Olympics are on because it's a lot of fun to sit around and watch those and talk about it.

00:02:00

So giving a little bit of a pass right now because of the Olympics. And, you know, the thing that I've been loving the most this year has been the snowboarding stuff. Although, I have to cringe every time they, you know, do a jump and a trick where they're going up the halfpipe and they're coming back down. Because unlike many of the Summer Olympics sports, I mean, you can get seriously hurt or even die with the Winter Olympics stuff.

I mean, they're going 80 miles an hour down luge, just you know, there's little room for error. And you know, as you watch downhill skiing and so there's some dangerous stuff there but has also is, has been compelling to watch and we've really enjoyed it as a family. And maybe, you have too.

The other thing about mid-February, as I mentioned, cloudy days, mostly cold temperatures but we did get a break from that today. But we were still seeing lots of kids with the flu and common colds. And, something else that's really common this time of year is just sort of feeling down. Hence the name of today's episode, "The Wintertime Blues"

Now some would blame those feelings on decreased light exposure, you may have heard of the term, "seasonal affective disorder". But can the amount of sunlight and the time of year really cause the blues and feeling down? Or are there other things at play like underlying depression that gets worse this time of year?

Could decrease physical activity and staying indoors play a role? Maybe you're not getting enough sleep, academic problems, school stresses, they can certainly come into play. And can genetics make a difference? Could you be born with an increase likelihood of feeling down in the winter?

Of course, there is not one right answer to all of this. Each child and family and situation is unique. Making it even more important and challenging to sort through symptoms and situations, academics, relationships, friends, the home environment, as we consider kids and teens who are feeling down

00:04:00

And this is true regardless of the time of year. We're calling this episode, "The Wintertime Blues" and we will talk about this concept of seasonal affective disorder. But we'll also consider ordinary depression which is much more common and affects folks in the winter just as it does the summer. And, we'll consider how depression intersects with other mental health conditions.

It's a big chore because this can be a complex problem and in many cases, as I mentioned, there is not a single right answer as we try to help those who are feeling down any time of the year. However, as big as the task might be, I do have a terrific panel of guests joining me today. And to make matters more fun, we've invited our Pediatrics in Plain Language panel back to the studio to help us walk through the wintertime blues and what it means for your family.

You'll remember our panel from episode 388 back in October when we talked about influenza, known simply as the flu. We also talked about flu shots. That episode, by the way, is still very relevant today as we sit here in the midst of flu season. So if you wanna know more about the flu, be sure to check that one out. Again, Episode 388 over at pediacast.org.

So what do we mean by Pediatrics in Plain Language? Since that's the panel that's gonna be here to talk about "The Wintertime Blues". You know, we always try to explain things on Pediacast in terms that parents can understand. But when our plain language panel joins me, they keep it real. And, we try to hold each other accountable as we walk through a complex topic and attempt to keep the terminology as simple as possible or at the very least, pausing to explain as we go.

Now we don't have a buzzer yet, to sound off every time someone uses a technical word but we thought about it and who knows what the future holds. Maybe we'll introduce the buzzer next time they visit the studio, that could be fun. It could get annoying, too.

00:05:54

So who exactly is on our panel? Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both with ambulatory pediatrics. So they are primary care pediatricians here at Nationwide Children's Hospital. We'll get to formal introductions with them in a moment.

First though, I do wanna remind you, if there is a topic that you would like us to talk about or if you have a question for the program, or you wanna point me in the direction of a news article, maybe a journal article. Whatever it is, whatever is on your mind, it's easy to get in touch. Just head over to pediacast.org and click on the contact link.

Also wanna remind you, the information presented in every episode of our program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast terms of use agreement which you can find at pediacast.org. So let's take a quick break, we'll get our Pediatrics in Plain Language panel settled in to the studio and then we'll be back to talk about those wintertime blues. It's coming up right after this.

[Music]

00:07:34

Dr. Mary Ann Abrams is an assistant professor of pediatrics at the Ohio State University-College of Medicine and a pediatrician with the Hilltop Primary Care Center at Nationwide Children's Hospital. She has a particular interest in Health Literacy and served as co-editor for a publication from the American Academy of Pediatrics entitled, "Plain Language Pediatrics: Health Literacy Strategies and Communication Resources for Common Pediatric Topics".

We're very happy to have her on our Pediatrics in Plain Language panel. So, let's give a warm welcome to Dr. Mary Ann Abrams. Thanks for being here today.

00:08:05

Dr. Mary Ann Abrams: Great. Great to be here, thanks.

Dr. Mike Patrick: Really appreciate you stopping by. Dr. Alex Rakowsky is an assistant professor of pediatrics at the Ohio State University-College of Medicine and a pediatrician with the Olentangy Primary Care Center at Nationwide Children's. He also serves as Associate Program Director for pediatric residency training program and he is the other distinguished member of our Pediatrics in Plain Language panel here on Pediacast. So let's give a warm welcome to Dr. Alex Rakowsky. Thanks to you, too, for stopping by.

Dr. Alex Rakowsky: Thanks, Mike.

Dr. Mike Patrick: Really appreciate it. So let's begin, Dr. Rakowsky, just a definition of, well first, actually, let me step back. So before we even get into the wintertime blues, I just wanna make one last pitch, again, I know I talked about this in the introduction about Pediatrics in Plain Language.

Dr. Abrams, what do we mean by Pediatrics in Plain Language? What is this all about?

Dr. Mary Ann Abrams: That's a great question, thanks. So Plain Language just means that we are being clear and we are using the right number and right kind of words that make whatever we're talking about clear to the listeners that we are trying to reach.

Dr. Mike Patrick: Yes.

Dr. Mary Ann Abrams: No fancy words. We try to avoid technical terms. If we have to use them, we try to explain them. So that we don't just assume that people understand.

Dr. Mike Patrick: And you are gonna hold us accountable today. So if we, I don't have a buzzer but we talked about it. Maybe we'll have one for next time and then, you now, if we are saying words that are little more difficult to understand that we, and we're not explaining it, then you hold our feet to the fire, right?

Dr. Alex Rakowsky: And I'm happy to play the unaccountable role.

Dr. Mike Patrick: Yeah.

Dr. Mary Ann Abrams: Sounds good, thanks.

Dr. Mike Patrick: So, let's start with what we mean by this concept of the wintertime blues.

Dr. Alex Rakowsky: So if we're honest about it, I think all of us get a little, sort of, a funk in the wintertime and it's kinda hard to find funk. But it's colder, it's darker, you tend to work, well, a lot harder, in the wintertime because, you know, depending on your job, if you may have actually more, sort of, things to work on.

The holiday season tends to be over so then you have, sort of, a let down after that and I'd always get sick.

00:10:07

So a lot of us get to sort of feeling that you just aren't your normal jolly, happy self.

Dr. Mike Patrick: Yeah.

Dr. Alex Rakowsky: So I think in general, wintertime blues affects, I think, everybody. And then, there's a percentage of people, to kinda work your way up, to have more serious symptoms. And then in that kind of situation, they get less active, less engaged, and they're just not their normal, usual, sort of, interactive selves.

And then what we will be talking about today a lot is, you know, even a smaller subset of patients who, or people, who just really struggle with changes during the wintertime.

Dr. Mike Patrick: Yeah

Dr. Alex Rakowsky: And they really struggle with their mood during that time.

Dr. Mike Patrick: Yeah, absoltuely. And you know, I've practiced here in the mid-West for many years. I also have spent some time in Florida. And even practicing in Florida, when the sun is shining everyday and you know, it's at least 60 degrees in the middle of winter, still in the midst of school season and there's, you know, you've got homework and you've got sports, and still, flu season is still flu season. Even in Florida in the wintertime.
And so, we still can have folks who have the wintertime blues even in places where it's sunny.

Dr. Alex Rakowsky: Yeah, I'm very grateful that you brought that up because I think a lot of people, kind of, think wintertime loses only for cold, dark, places. And, you now, studies have shown that it's actually worldwide and it really seems to be kind of dependent on just the pressures that we have during certain times of the year. And here in the States it tends to be more wintertime.

Dr. Mike Patrick: Yeah. Now, I think, an important thing is really recognizing especially on our kids when they're feeling down. Like, you know, because there's some that I think that a parent, sort of, radar goes off that, "Something's not quite right" and maybe you've even recognized it on yourself as a parent. But it's especially important as we think about pediatrics and our kids.

So, Dr. Abrams, sort of, what when we say feeling down, what are some of the ways that that can look? I mean, what should get a parent's, you know, the gauge that "Hey, something not quite right here". What does that look like?

00:12:02

Dr. Mary Ann Abrams: That's a great next question cos we have the wintertime blues and then we're talking now about feeling down. And, that's a general set of words that really can reflect how somebody's feeling maybe not quite right. And that, depending on the individual themselves or their age, or their culture, or whether they're a man or a woman, or a girl or a boy, that can be reflected in different ways.

They may just feel really tired. They may be more active and almost restless sometimes. They may wanna eat more, they may wanna eat less, they may sleep all the time or be active. A lot of times, people will say they just don't have any energy. They can feel sad or down in the dumps and maybe not really know why.

Also, having trouble focusing whether it's on their homework or their job, or making a decision, that can be frustrating. They can have trouble sleeping, they can be irritable, and they may, some people may reach out to talk to friends and others may tend to kind of circle the wagons and cone in on themselves because they don't have the energy or feel like being social.

And, people sometimes feel bodily aches and pains or upsets their stomach or headaches, just general things that they can't quite put their finger on. So all those things can occur and all these, as Alex said earlier, may experience that but then it ultimately comes down to how long, how often and whether it affects how we are functioning in our day-to-day life.

Dr. Mike Patrick: Yeah and the longer it lasts, the more days during the week that you're seeing those kinds of symptoms. And the more that they're interfering with your school work and your ability to interact with your friends and your family, and any other extra-curricular, you know, things outside of school, that you would do as a family. When it starts to really interfere with that, then we would say that this is becoming more of a problem.

00:14:04

Dr. Mary Ann Abrams: Something that we're all concerned about, yeah.

Dr. Mike Patrick: Now, what are some of the, so as we think about that set of symptoms, you certainly don't have to have all of those symptoms. And each child, it may be a little bit unique and that doesn't necessarily mean that there's depression there or something like seasonal affective disorder which we'll talk more about.

But there are lots of things that could cause those sorts of feelings. What are, kind of, the laundry list of things that are possible?

Dr. Mary Ann Abrams: Well, as you said, sometimes you can have a mental health concern or problem whether it might be depression or a seasonal issue, or anxiety, or other psychological problems. But also, as you said, there may be other things going on that could actually have a physical illness.

Maybe a problem with their thyroid or a sleep problem, or an eating disorder, those things can contribute. They may have an underlying illness or maybe they're getting one cold and they just got over that and they get another one, and they just feel like they're constantly being sick and dragged down.

It can also come from, maybe, having problems with school. Grades, grades can suffer when you don't feel well but sometimes grades suffer and then you don't feel well as oppose to the cart before the horse.

Dr. Mike Patrick: Yeah, they can really kinda feed in to one another.

Dr. Mary Ann Abrams: Exactly and they can build and make, create, kind of, a vicious cycle. Kids can be having problems with being bullied and this is a way of our bodies and our minds, kind of, responding to that especially when they don't wanna tell somebody about that or they're afraid to. There could be issues of substance problems whether it's tobacco or alcohol, or other drugs.

There are a lot of kids, as you know, are exposed to violence and stress whether it's at home or in the news. And with so many people watching, and looking at television and devices, we're exposed to those kinds of stresses. In our communities, a lot, and sometimes it's hard for kids to filter that and know when they're safe and when they're not.

00:16:12

So a lot of different things can lead to that feeling down, those blues.

Dr. Mike Patrick: Yeah, and as you mentioned those, it comes to my mind that often it's not even one of those things. That they're often, it's just a complex mix of these different things going on. So, you know, if you did have little bit of depression to begin with, that's underlying, and then you're not doing well in school, and maybe you're not meeting your parent's expectations of what your grade should look like.

And then, you know, you hear these stories in the news of people bringing guns to school and that can be, you know, cause anxiety and fear. And so, these things all kind of play into one another and it's not always a one item deal right?

Dr. Mary Ann Abrams: Exactly. And say, a parent doesn't recognize this is feeling down and so they are working to help their child be more motivated and, "Do your homework and get this done, and blah, blah, blah", which then creates more stress and tension. And again, as you said, can create a vicious cycle.

Dr. Mike Patrick: Yeah, now Alex, so you're a primary care pediatrician. Mom comes in with her 12-year-old kid and says, you know, "I feel like he's feeling down". How do you begin, even, to figure out what's going on when there are so many different possibilities here in terms of causes and even the symptoms that could be 'feeling down"?

Dr. Alex Rakowsky: I can't stress enough time and it's something where in the current system pediatrics, we were all always in such a rush in primary care that if this comes up as a triage question, try to schedule this family like towards the end.

Dr. Mary Ann Abrams: Excuse me, Alex, you wanna let people know what "triage" means?

Dr. Alex Rakowsky: Triage, yes, that's good catch. So, triage means when they call to see the nurse line or schedule with an assistant just to kind of, they kinda let you know what the main reason for the visit is.

00:17:59

And so, if they come back and say, "I'm worried about my child's behavior. I'm worried that he may or she may be down", they really try to schedule them in a longer slot.
Just from experience, you can't get this down in ten minutes visits.

Dr. Mike Patrick: Yeah.

Dr. Alex Rakowsky: And then, a lot of it really depends on having both the family and the child, think about it with some sort of probing questions. There are some good screens out there but I usually kinda work my way through, like Mary Ann mentioned, physical problems, environmental/home problems, school problems.

And then, working your way through, "Does this feel like a more behavioral or psychiatric issue?" And for physical issues, are there any signs of anemia, signs of a thyroid issue, or you're having problems with your sleep hygiene, or you actually eating poorly.

Christmas season came through and then New Year's, and then Valentine's day, and we probably cheated and ate stuff we shouldn't have but if you're in a consistent sugar high, you're probably not going to, you know, feel good after you kinda come down from it.

Dr. Mike Patrick: Yeah.

Dr. Alex Rakowsky: Just lack of exercise or lack of inertia is another question to ask. And then, I usually ask a family or the child, or teenager, "What are you thinking may be causing this?" and, it's been very enlightening to kinda have someone turn around and say, "I don't eat well and this is why I don't eat well" or "I don't sleep well and here is why"

And then I'll kinda probe into the more, sort of, environmental, any changes at home. Mary Ann mentioned bullying in school. Pressure is in school. "I have a senior in high school this year, he's going into the pressure of trying to get to college. And, he's kind of a chill guy to begin with but, you now, it's kind of strange to see him all of a sudden, like you know, I gotta get into a college and, you know, maybe get some, sort of, funding to help out with this."

And, you know, here's somebody who on the whole tends not to be like that. And, a lot of his friends are feeling that pressure. So it's pressures we tend not to think about. And in middle school, and now he's in a school play or something.

00:19:55

And then, finances in the family especially in the wintertime, you're paying heating bills, you've just gone through Christmas season. There may be some changes; there may be some illnesses and I always ask what illnesses in the family is. Was there a death? Is there somebody ill?

Because, we see a lot more of the chronic illnesses kinda flare up because of the viral season. And then, we finally ask them about family issues. Is there anybody in the family have a history of depression or history of anxiety, or bipolar etc.?

They kinda probe around. One, to see how comfortable they are of this topic cos a lot of people are uncomfortable with it. And two, to see if what they have gone through themselves because that can help you then decide next steps, as far as how aggressive am I gonna be of the probing questions and how aggressive am I gonna be at the therapy.

Dr. Mike Patrick: Yeah.

Dr. Alex Rakowsky: If it's the first time, the family has never heard about anxiety before, it may be a longer, a couple more visits to kinda really get in one go.

Dr. Mike Patrick: Yeah, I found that personally when I'm engaging with families that there is, you know, as you're trying to get that whole picture and figure out what's going on, sometimes there is resistance about the mental health piece of it. That there must be some other things that are going on especially physical illnesses.

And certainly, we would want to rule those out. I mean, we don't wanna confuse a mental health issue when there's really something physical info, like thyroid, for example. Anemia, as you mentioned, but at the same time, there sometimes is that resistance that can't be a mental health issue. There's something else going on. How do you, kind of, break that barrier?

Dr. Alex Rakowsky: That's a tough one. I work in a clinic that has a lot of immigrant families. And, a lot of them come from the Middle East where they're sort of cultural, not to kind of think about these things. They almost have a certain resistance to it.

So, I'll usually start off with some basic facts where, you know, in the States about 4 out of 10 teenagers will struggle with some behavioral, emotional concern at some point during high school.

In families, you can have up to 30-40% of adults having some kind of issue during their lifetime. I think once you frame it in the way that this is not uncommon, this is a lot more common, and it's something that doesn't mean that the child has a lifelong problem, that's something that we can work on.

00:22:03

I think it makes it a lot easier. And we've actually have great interpreters in our clinic. One who actually took some classes in behavioral health so she can understand us better. And, you know, she can turn around and say, you know, she explains anxiety in a way which is so much better than I can do.

And you know, she's kind of, "Let me explain it, I understand Hispanic, I know what she's saying" in just such a nicely done way to say it. It has really helped out.

Dr. Mike Patrick: Yeah, the other thing, too, I think is to show that even with things like anxiety and depression, there really is still, I would say, organic but that's probably not a good word to use. I mean, it's still based in chemicals in the body so when we say there's a thyroid problem, there's an issue with certain chemicals in the body that relate to the thyroid gland that can affect energy levels, anemia, red blood cells, in which carry oxygen. And, if you don't get enough oxygen, you can feel, sort of, tired.

But at the same time, there are chemicals in the brain. So it's not like someone is choosing to be anxious or choosing to be depressed, or the fact that it's in the middle of winter and they're choosing to feel down. And I think when we, kind of, push this as it's a mental health issue, there is that sub, you know, in the back of our minds, we think, well, maybe they're choosing to do that. But there's still, there's chemicals involved and it's still a real disease.

Dr. Alex Rakowsky: And, I also bring up the fact that this is still your child. I mean, this is still the child that you love. And just like they could have a sprained ankle, or you know, a broken bone or a pneumonia, they can sometimes have behavioral issues and/or emotional issues. And, it's really just not defining who they are. It's really part of what's happening to them.

And, I think a lot of families are sort of like, "Here's my anxious child" or "Here's my depressed child". It should be, "Here is my child who has struggled with ear infections, broken bones, and now struggling with depression and we'll work on it". So try to really change the frame of, the framework of how you approach in the family.

Dr. Mike Patrick: Yeah, I really love that.

00:23:58

Dr. Mary Ann Abrams: I think that's really important because what you're doing there, as you said, you try to normalize it and let the family know that a lot of kids feel this way and help. As you also said, make about, that you may not be able to see it but there may be chemicals in the brain and other parts of the body that are causing this or making it a little bit worse, exaggerating what they're already feeling so that it removes, because you can't see it.

It's so easy to blame the child or the teenager and say, "Why don't you just, you know, get with it" or "Work harder", or "Get up", or "Do this". And then that, again, feeds that vicious cycle. So by breaking, clear, and helping everyone to understand that this is a real thing even though you can't see it, goes a long way toward leading to those next steps of accepting it, loving your child, and working on it in whatever way is best for that condition.

Dr. Alex Rakowsky: But you need the time, I can't stress that enough. You need the time of the family. You can't rush with this.

Dr. Mike Patrick: Yeah and sometimes, as a provider, you need to be an advocate to get that time. Because, there's always someone who, you know, is looking at times and the pocket book, and you know, reimbursements and things. But, we really need to be advocates for our patients to say, "No, we really do need this time to discuss this issue."

Dr. Alex Rakowsky: Yeah.

Dr. Mike Patrick: Yeah. One of the, sort of, it really is a chemical issue that this is a true condition is seasonal affective disorder and also known as SAD, seasonal affective disorder. It's clever, huh? So what exactly is that?

Dr. Alex Rakowsky: I mean, let me break down the term. So, seasonal essentially means different parts of the year. So, it's spring, summer, winter, that, you know, basic seasons. Affective means not that you're like hugging people but affective essentially means emotional. So, it's an emotional, sort of, issue that seems to be affected or seems to be impacted by the time of year that this shows up.

00:25:58

So SAD, it seems to be, a majority of psychiatrists and psychologists classified as a sub-type or, sort of, like a sub-class of major depression or of depression in general. But it's, it has different manifestations to some people. But in majority of people's depression that either gets worse in certain times of the year. Or, it's depression that will show up only at certain times of the year.

Dr. Mike Patrick: Yeah.

Dr. Alex Rakowsky: And, that's, so in a short definition, SAD really is a depressive, sort of, symptoms that only show up during certain times of the year or flare up during certain times of the year.

Dr. Mike Patrick: Yeah, and why would that be, Mary Ann?

Dr. Mary Ann Abrams: Well, a couple things. Interestingly enough, we think of seasonal affective disorder, SAD, as a wintertime condition and, but there's actually two kinds. There's fall onset or dark months onset but there's also a spring and summer onset.

So, and that can vary but there are two distinct conditions. When you have the wintertime form, you tend to sleep more, eat more, or maybe crave, you know, carbohydrates and things like that, and actually to gain weight. And, they even talked about that. It's almost being an exaggeration of the hibernation, that some, you know, bears experience.

So maybe there's some deep relationship there. But in terms of what would cause this, there's several kinds of ideas. One, we have a daily rhythm in our bodies that affects when we wake up and when we sleep, and we produce different hormones or chemicals that make our body function or start to go to sleep.

And those have a lot of things that make those kinda run on time but they're also influenced by sun, by light and dark. So as the, it's not so much the temperature but as the amount of light changes during the day and night, and seasons, that may throw off that cycle in our bodies.

00:28:02

And then that in turn leads to adaptations or changes in how our body produces the sleep hormones and other bodily chemicals and that gets disrupted out of order and doesn't work well. So, that's one idea behind it.

Dr. Mike Patrick: Yeah. So just a pause real quick. So as light comes in through the eye and gets through retina, this sends signals, you know, through the optic nerve, which connects the eye to the brain. And then, that's gonna go to some really deep structures in the brain.

So things like the hypothalamus, fancy word, the pineal gland, but these are all things deep in the brain that control chemical pathways. And so, if there's a change in those chemical pathways, especially folks who may be genetically programmed differently to respond to that changes in those chemicals, then the degree and amount of light that you get can affect the chemicals which then could cause some depression symptoms in some folks but may be not in others. And so, there's still a genetic component to this, too.

Dr. Mary Ann Abrams: Right. So, there's a lot of studies still being done to determine how much of an effect genetics has on it. You mentioned the retina or the back of the eye, the nerves that capture the light and send it then on to the brain that stimulates us to see things and act, or to produce different kinds of hormones or chemicals, or what we call neurotransmitters.

You may have heard that term. Those are the chemicals that connect the different nerves together in our brain and in our bodies. And, one of those people may have heard of called serotonin seems to play a big role in mental health and depression, and seasonal affective disorder.

So that, that could be altered or changed when these seasons and amounts of light change that make an impact on our body. And there's some people that they think may actually have that retina, the back of their eye, may be more sensitive or less sensitive to light and that can also cause some of these changes.

00:30:03

So, they're still working on the specific causes but I think there's a common threat in what we're talking about that these all works together in a complex way. And, some people are more susceptible or more likely to be affected by that than others. And, they may be the ones that experience these symptoms.

Dr. Mike Patrick: So how do you figure out that that, this sort of thing could be going on? So you have a family that comes in and you have a kid that's, you know, feeling down and has these symptoms that we've been talking about. And you, you know, go through their whole history. What's going on at home? In school? And, you know, with friends and academics, and everything?

How do you begin to get the sense that seasonal affective disorder could be what's going on? And the opposite of that, how do you know that, "Yeah, that's not what it is"?

Dr. Alex Rakowsky: That can be tricky. And I think, the most important things is just to see, like you mentioned, is there anything else, kind of, contributing to this? And again, seasonal affective disorder is also found or seen in children who actually have, you know, more major depression. You'll see in children who have anxiety.

So there's probably a large percentage of kids who actually gets SAD, who actually have something else going on. So then the question is, is this like a solo entity? Or, is this something that may be, sort of, related to another entity?

And I think it makes a difference when you kinda think about the therapy. So I tend to see it as more of a, not a solo entity in some kids and in some kids could actually be just the time of year. And if it's a time of year, then maybe it'll be a little bit easier to, kind of, clear because you have more of a definite set point of how you're gonna treat this child.

If it's a child who actually seems to flare at certain times of the year, that may be a little bit more difficult. You may need some help from, you know, your therapist etc., to kinda help out.

Dr. Mike Patrick: And in a kid who really does seem to be cyclic, so the family could say, "Yeah, this happened last winter and the winter before. And, it just seems to be getting worse each year and that's why we're coming in".

00:32:01

And, there's a family history of this then that may sort of direct you a bit more in that direction. But you still wouldn't wanna discount the fact that other things could be going on.

Dr. Alex Rakowsky: Yeah.

Dr. Mike Patrick: So how do you go about treating seasonal affective disorder?

Dr. Alex Rakowsky: So there's a lot of approaches here. I'm a big believer to, kind of, start with being human first. So there's some nice studies that show if you just go outside for 15-20 minutes and then go for a walk. And, is it the light that does it? And if you go, let's say, a walk in the evening, or is it more of just you walking outside and blowing off some steam?

So there's just getting some activity. Do a little bit activity in the days that you have off. Try to relax. And, a lot of kids just don't get that time in the winter. Just, kind of, try to relax. Eat better. Spend more time as a family.

So there's some, I think, human element that we tend to forget and just kinda jump into, "Let's do medications or boxes, etc." But, you know, I think you have to start off, eat better, sleep hygiene, get exercise, talk to your friends, talk to your family.

Do something fun. I think we'll talk about "fun" later on. And then, the next step is, if it's a mild seasonal affective disorder, you can usually get away with light box. And, the light box is produced, like this artificial light that's supposed to mimic the sun.

And, it's about 1/5 to 1/10 of a sunny day and you, kind of, use the box for about half hour near you. There are other folks who have said you can go for a smaller amount but for a longer period of time which I think we may have time to get into. If you have a teenager who's just rushing off to go to school, it may be hard for them to find the time.

You try to get that light box done first thing in the morning. That may be difficult for some people, but again, you try to get the light box. And that seems to be like one of the primary, sort of, ways to treat it.

For people who have more moderate to severe SAD, then you're probably looking at adding a medication. And, you do the more common anti-depressants and they're called SSRIs. And, some common names are Celexa, Wellbutrin, or Prozac, or Zoloft. And, Prozac probably has one of the most pediatric experience.

00:34:05

You start off on a low dose but I, you can probably start it with the same time you try the box but definitely make the human changes first.

Dr. Mike Patrick: Yeah and there's a, well, for counseling too because even though we may be able to spend, you know, a great amount of time, hopefully, with these visits. They even need more time than what we can give them just to sort of work through other things that could be going on especially for those more severe cases.

Dr. Alex Rakowsky: And don't forget also family counseling cos I notice, at least personally, with the kids I've seen through the years with SAD, a lot of times the parents also struggled with this. So they're struggling with the child who seems to be depressed and they themselves aren't doing well. And sometimes it's good to have the whole family sit down and say, "We all, kind of, struggle with this".

And Mary Ann brought up the genetics and sometimes family counseling really works because then you have the whole family, kind of, acknowledge it. And then like, "We should go for a walk" or "In the weekend we should do something fun". And instead of just saying, "Johnny has a problem", sort of like, "We all need to work on this". And sometimes it makes a big difference.

Dr. Mike Patrick: Yeah, absolutely.

Dr. Mary Ann Abrams: Let's take a second and talk about sleep hygiene cos I think that's so important to everything we're talking about today and also a whole lot of things we're not talking about today. And first of all, it's a really technical, cool sounding word, sleep hygiene.

It sounds like how do you keep your sleep clean. But basically, it means good sleeping patterns and we all suffer from that. And kids in particular, I think, with all the social media and phones, and devices, are very much, I don't wanna say addictive, that's another PediaCast.

But, just so engaged with those. And, if we can really work with our families and children, and teenagers, to work on having good sleep habits. So what does that mean? It means going to bed and getting up at the same time everyday, even on the weekends, which can be hard.

00:35:57

It really means turning off all the devices: the phones, the TVs, the laptops, the computers for homework half an hour to an hour before we go to sleep. Because, we do know that the light from those devices feeds back into the brain and affects those chemicals that we've been talking about.

And that's really tough. Kids may be doing their homework late, they're texting their friends, they may be setting the alarm on their phone but I try to ask my patients, "Set that alarm, turn it in, give it to your mom, do not fall asleep to the TV, really establish a good bedtime routine and stick with it." Cos that sleep, it influences so many other things as well, being overweight and eating patterns, and overall health.

Dr. Mike Patrick: Yeah, and I think just the fact that we're talking about a light box in the morning to help you get going, you know, that light stimulation kinda wakes you up and get you moving, that's the idea behind it. But doing it within the first hour or so of waking up, and then likewise, if we're staring at a bright screen, couple hours before we're gonna go to bed, I mean, that light is still stimulating that same part of our brain and those wake me up chemicals are going on and so.

Dr. Alex Rakowsky: It's like a little portable mini box that you're carrying in like, you know, in your pocket, yeah.

Dr. Mike Patrick: And putting it, right? So it may not be the ten thousand lux of light that the box is but you have it a lot closer to your face than the box is. And so, in terms of light energy, it's still, you know, it's probably not quite ten thousand but, you know, the idea though is that it's stimulating and it's a good training because,

Dr. Mary Ann Abrams: And the kids will say, "Well, its not that bright." It's part of the, science shows is that it's the wavelength that's the type of light that comes out of our devices. So, but I think that's a really good point that it's simulating.

And all those things that's stimulating or triggering are the things that wake us up, not put us to sleep.

Dr. Alex Rakowsky: If I can add one thing to Mary Ann's, sort of, list of sleep hygiene, afternoon naps where you see a lot of teenagers getting into the vicious cycle of going to sleep late cos they're on the phone or doing homework, get up early, go to school, high school starts early.

And then, they'll take a nap from three to five. And all of a sudden they're tired and the cycle just continues. And you always have to convince them, "You need to take, you know, your next three-day weekend, four-day weekend, break that cycle."

00:38:04

Cos afternoon naps are so hard to get rid of for a lot of the teens.

Dr. Mary Ann Abrams: And then, they drink caffeine at seven or eight o'clock at night because they realize now I have to get my homework done so I gotta stay awake. So as you said, it's to break that cycle and have that discipline to stick with it. Even on your day-off, you get up early and go to bed on time.

Dr. Mike Patrick: Yeah, I mean, there's a group of kids who, you know, this is not an issue in the summer because they can sleep until noon. They don't have the accountability of needing to go to school. And so, is it really seasonal affective disorder or is it that I'm not getting enough sleep?

Because, you know, I'm up doing things and I have to get up at a certain time in the morning and that could all just be corrected by improving that sleep hygiene?

Dr. Alex Rakowsky: Yeah.

Dr. Mike Patrick: Yeah, important stuff. One other thing on the light box before we move on, it is important that there is very minimal to no UV exposure with whatever light source that you are choosing to use. And so, you know, tanning, don't go to a tanning salon and think, "Well, I'm gonna get more light that way" cos that's gonna be dangerous.

Dr. Alex Rakowsky: You know, I would strongly recommend to kinda get it from an official place. So, you know, don't create your own light box at home. You know, the light box will tell you exactly how far you should be sitting from it. Don't look at it directly, you know. Another thing is, they'll come with the instructions.

And also, when I bring up dawn simulation devices which is sort of like a new, sort of, light box idea where you set this device to kinda slowly, sort of, cause a mini-dawn, rising of the sun in your room. It's not so much the amount of light that you're getting.

But for some people, it's just a matter of kinda waking up to the sun before they go back into the darkness to go to school, or work, or have you. It seems to help them out. And sometimes, that may be, sort of, a less aggressive form of light box that people can use. It's something to consider.

Dr. Mike Patrick: Yeah and with the smart bulbs and apps for those bulbs, you can set a time like, "Hey, I want my light at a hundred percent, my bedside light at a hundred percent at 7:30 in the morning and at 7 o'clock, it's gonna slowly start to come on".

Dr. Alex Rakowsky: Yeah.

00:40:06

Dr. Mike Patrick: And so that may be, and it's probably, even though hue bulbs and other smart bulbs are expensive, light boxes are expensive too.

Dr. Mary Ann Abrams: Yeah, exactly.

Dr. Alex Rakowsky: And I hear some new literature is coming out about that. So I think it's something to keep an eye on.

Dr. Mike Patrick: Yeah, let's move on from seasonal affective disorder, SAD. And it's really, and correct me if you guys think I'm wrong about this but I think that more often than not, what we're really dealing with if, you know, there's not a physical reason for feeling down, that more often than not it really is underlying depression that we're talking about here.

It may be worse in the wintertime but the true word's just seasonal and that's it. And there are no factors involved other than sunlight would be pretty rare compared to sort of normal depression in kids. Would you agree with that?

Dr. Mary Ann Abrams: Yeah, I think that's accurate.

Dr. Mike Patrick: And so, tell us, Mary Ann. Just about depression and kids, what, does it look just like other things that we've been talking about or does it look somehow different?

Dr. Mary Ann Abrams: Well, that's another good question. I'm gonna kinda talk through what sounds like maybe a long list of the symptoms and signs that can show depression in children and teenagers. But it's helpful to, kind of, think about them and, kind of, understand how they all work together when we wanna really formally call something depression.

First is, Alex said earlier, it's not an uncommon condition. There's lot of different studies at any point in time. We estimate it about 5% of teenagers are actively feeling that they have depression. And again, it depends on how long you're feeling it and how much it's bothering you.

So, if it's interfering with your schoolwork, your relationships with your friends and family, or a job you may have, that's more concerning. And also, thinking about it, "Oh, you're just depressed".

Well, depression can have serious implications.

00:42:01

If kids start isolating themselves, if their schoolwork fails, then they feel worse about themselves. They get in trouble. They may act out, all those kinds of things. So depression in of itself is a serious condition we should pay attention to.

So what do we mean when we talk about real depression? The way we think about it is, people who are truly depressed feel down, feel bad most of time, for most of the day, for at least two weeks in a row. And they have at least one of two main symptoms and then maybe four or five others.

So those two main symptoms are feeling sad or down, or hopeless. Just the sadness which interestingly enough in kids, can come across as being irritable, and cranky, and fussy, and frustrated, and annoying, and just unhappy. And also the second option there, the second of those two major symptoms, is just lacking the joy of life.

They don't enjoy things they used to enjoy whether it's a hobby or their friends, or sports, or being with their family, or going to school. So the sadness, there's lack of joy, and then maybe irritability more than sadness.

And then, there's a lot of other things that can go on when you have true depression. Your appetite may change. Some people don't feel hungry at all and some people eat a lot more. So, they may gain weight, they may lose weight or if they're a younger child who is supposed to be gaining weight overtime, they just, their weight may stay the same.

Instead of growing and getting more mature, they just, kind of, plateau or stop growing. As we've talked about the sleep can be an issue, some people who are depressed sleep all the time or what seems like all the time.

00:44:00

And some really have trouble with sleep. They have trouble getting to sleep. They wake up early. They wake up in he middle of the night and they can't go back to sleep, or they just feel so sleepy all the time or sluggish, really tired.

Just can't get moving, can't get up, don't feel like doing anything and just, even have trouble with getting themselves out of the chair to talk a walk or to get to school, or to do their chores or their homework.

And then you move in to some of these feelings of how they feel about themselves. They may feel guilty. If they're feeling really bad, they may feel like they're worthless, they're not making any contribution to their family, or to the world, or just to themselves.

They can get confused and have trouble processing things whether it's doing their homework, or making a decision, or just can't focus, have trouble concentrating. They can be forgetful and that may even show up in how they talk, how they act, how they move around the house.

They may actually be really sluggish or they may be kinda restless and always fidgeting or kicking around, or can't sit still, or feel really bothered a lot. And then, as we get farther along, and even more concerning is if they start thinking that life isn't worth living.

The world, or I, or my family would be better off if I weren't here and then starting to have thoughts about suicide.

Dr. Mike Patrick: Yeah, absolutely. And we're gonna talk more about those thoughts of self-harm and suicide in a few minutes. The other thing with depression is that, oftentimes, there are other mental health things that can go along with it.

And, whether the depression is directly associated with those or those were their first and then, that leads to depression. I mean they, it can be kind of a complex interaction. But it really is important to seek help because there could be things going on like anxiety, bipolar with manic and then depression phases.

00:46:03

You know, lots of activity and then the depression. You know, there can be, eating disorders are common in teenagers that can be a part of this. ADHD can be an issue, learning disabilities. And so, it's really important that this is, you know, you just say, "Well, you just need to cheer up."

You really do need to get help and try to figure out what's going on, and what other things may be complicating it. Because, if you just treat it as depression but there are other mental health things going on and you don't deal with those, it makes it much more difficult to deal with the depression.

Now, in terms of causes of depression in kids, we kinda covered causes in terms as we were thinking about seasonal affective disorder. But really, it's the same sort of thing, right? With brain chemistry and our environment, in genetics, all of those things just play, there's complex interactions going on.

Dr. Mary Ann Abrams: Yeah, it really is tied up and a lot of research is still going on to see if we can tease a part what, if one area plays a bigger role than another. Clearly, we know there's some genetic or an inherited component because people who have parents who've been depressed, or attempted suicide, tend to be at high risk for depression.

So, we feel like there's some inherited component there. It's also possible that some of the stress factors that can trigger depressive feelings can also be more common in certain families depending on their circumstances if they're growing up in poverty, or high-crime areas, or financially challenged. Sometimes those kind of things can trigger depression, or if they're experiencing violence either in the home or witnessing in their communities.

Dr. Mike Patrick: Yeah, absolutely. And in terms of treating depression, really the same that we were talking about with SAD, just in terms of those lifestyle changes. You know, getting out, getting, you know, being more active, making sure you're eating well, making sure you're sleeping well.

All of those things are important. And then, you know, the counseling aspect. The family counseling, medication, it's really, it's all important, right?

00:48:05

Dr. Alex Rakowsky: You know, a lot it also depends on having the family by into it. So, a lot of times you're sort of like, "Oh, I'm depressed. Pop in a pill and I'll be fine." Or the family doesn't believe that the child is depressed. It's gonna be a long battle and it's gonna be multiple visits.

So, I try to pry in the family just to be aware of the fact that this is gonna be, you know, one, it exists. Two, we're gonna work on it, and three, we'll probably seeing a lot of us over the next or a lot other counselor over the next couple months.

Just to kind of get the family involved. And a lot of times, when I see people fail therapies for depressions because there really wasn't good buy-ins from either the patient, or the family, or both.

Dr. Mike Patrick: Yeah, and some of that really takes, sometimes, more than one visit and talking about it, and you know, really being engaged with that family.

Dr. Alex Rakowsky: Yeah, I definitely agree.

Dr. Mary Ann Abrams: And even if they, you know, the counseling is always very important. They're almost always important. But if medication is added to that regimen, even then, it's important that they know that that medicine is not gonna work overnight.

It takes a couple weeks for it to start to work and there's a lot of adjustment of the doses, and sometimes adjustment of changing to a different medicine. So really, I think not creating expectation but just making sure that there's an understanding that this takes time.

We're here for you. Hang in there. Let us know if it's not working well. We're here to work with you to make this successful. But the reality is, it doesn't get better overnight.

Dr. Mike Patrick: Yeah, absolutely. In terms of the feelings of self-harm and the risk of suicide in these kids, you know, for some families that can be difficult to decide how do you approach that topic.

Because, I think in some parents' minds but research does not bear this out. That if I mention suicide first, maybe I'll plant that idea in their head or give them, you know, the idea that that's something.

00:50:00

So, I'm gonna ignore it. But that's, research shows it's, we're best talking about it.

Dr. Alex Rakowsky: Agree.

Dr. Mary Ann Abrams: Right.

Dr. Mike Patrick: Yeah, and what's the best way for parents to bring that topic up?

Dr. Alex Rakowsky: I think it's just the openness. Just the openness to suicide unfortunately kills teenagers in the country than almost anything else. And, the openness to have the family, kind of, think about the child who's not doing well.

You know, I think every high school or every middles school has had a child at some point over the last few years that either contemplated suicide or has committed suicide. So families are aware of the fact that these things are out there. And it's just a matter of, sort of, saying that, you know, this isn't just some outlier. This could be, you know, your child suffering depression.

So, keep it in mind and be open to the fact that this may be something that the child is thinking about.

Dr. Mike Patrick: Yeah.

Dr. Mary Ann Abrams: I think it's important. It's hard because we know that teenagers are going through lots of changes. And, it's normal for a teenager to be moody or frustrated, or to pull away from their family because they're trying to establish their own identity.

And, having friends is very important. And, trying to find friends that are good friends that they get along with and accept them. All those things are part of normal development and normal setbacks. So we all, they all, feel bad when these things happen.

So, a parent is trying to figure out whether, "Is my son or daughter really seriously ill or depressed? Or is this just a tough, rough phase that they're going through?" And, so that's when you move toward making parents aware that depression is a real thing. Keeping those communication lines open no matter what and helping families learn how to talk with each other about these things.

And, letting them know that they're, it's normal to feel bad sometimes. Letting them know that we, as their child's physician, are here.

00:52:01

You can call us about these things and we can help you find things to do. And then, just say, "Well, how do I really know?" Here's the mom or dad, "What do I, okay that's great. What do I, how do I know?"

So then, tell them that kind of, start looking for other changes. So yeah, they're moody. They're irritable. They don't wanna go to see grandma for Sunday dinner, okay. But start looking at changes and behavior. Are they going into more risk taking behavior?

So they may be experimenting but are they doing this more often? Are they disappearing and not want to tell you where they were? And, you have a sense that they're either driving too fast or they're out to late? Or, they're smelling like smoke or alcohol when you see them?

So these risk taking behaviors can sometimes be actually a marker of depression. Because, sometimes taking those kinds of activities is a way of coping with not feeling well because it gives you, kind of, a rush. So they feel a little bit better.

So looking at those kinds of behaviors, and then really dramatic changes in their mood, not just the ups and downs but, "Oh, my son used to be a happy kid and now he's in his room all the time." and just prolonged etc.

And then, listen to what they're saying. And if they're self-talk and they'll talk when they're fussy and angry, is talking about being a burden to other people, "Maybe it'd be better off if I wasn't here." Take those kinds of things as red flags to think more deeply about.

Sometimes kids will start listening to really morbid music or books, or even websites. So it doesn't hurt to check what websites and social media they're connecting with. It may be dealing with death or suicide, or suicide pacts, or other high-risk behaviors and to pay attention to those things.

00:54:00

And if you're concerned, don't hesitate to bring it up because we'd rather help now rather than later.

Dr. Mike Patrick: Yeah.

Dr. Alex Rakowsky: And don't forget other adults, like, to play a role. So for example, I, you know, a coach that the child feels comfortable with. You know, a youth leader at the church, a favorite teacher, and a lot of these people are trained to kinda look for these things.

Are they coaching basketball for years? And we had to go through training to look for behavioral issues and, in the teenagers. And, something where there's a good bond between that family and that coach to say, "I think something's wrong with her. What's going on?" Just to kind of open those questions sometimes.

Dr. Mike Patrick: Yeah. For folks who want to hear more about teenage suicide and the risks, and what to do, we did an entire hour-long PediaCast just on teen suicide. That was episode 315. We also did another entire podcast on cutting and self-harm. That was PediaCast 350.

And I'll put links to both of those episodes in the show notes for this episode 396 over at pediacast.org. Just so you can find those easily. But definitely, couple good resources if you would like to learn more about teen suicide, and cutting, and self-harm.

So you know, if a parent is concerned and in particular, if a child is having those thoughts of hurting themselves or they have thought about suicide, what should parents do, Alex?

Dr. Alex Rakowsky: They really should reach out right off the bat to their, either private pediatrician, or if it seems to be something urgent then go to Urgent Care-ER. You get some help involved. There is a national hotline we're trying to find here.

Dr. Mike Patrick: Oh you know, I have it for you.

Dr. Alex Rakowsky: Yeah.

Dr. Mike Patrick: So, and we're gonna, we'll put this in the show notes as well so folks can find it easily for 397, Episode 397, over at pediacast.org. But, the National Suicide Prevention Lifeline, 1-800-273-TALK or 8255. There's also the National Hopeline Network, they have a couple of different phone numbers. One of them is 1-800-SUICIDE. Another, 1-800-442-HOPE.

There's also other sites where you can get help immediately through the site, the Jason Foundation is one. The Kristin Brooks Hope Center is another one. And, we'll put links and we'll have all these phone numbers for you in the show notes, again, for this Episode 397 over at pediacast.org.

00:56:11

But ultimately, really do wanna reach out to your medical provider. Go to an emergency department. It's not something to wait until the next day. Get help right away if your child is having those thoughts.

Dr. Alex Rakowsky: It starts over being, of taking it seriously. And then, trying to decide, "Is it something that I can wait to see the doctor in a few days or is this something that I need to work on tonight?"

Dr. Mike Patrick: Yeah.

Dr. Mary Ann Abrams: And, if you really are concerned, there's a few things parents can do while they're reaching out. We all know the hazards associated with firearms and being in the home. So try to remove things that are highly dangerous.

Either get them out of the home or lock them up. And, not just out of sight but totally not accessible so that kids can't get that. Other things that can cause serious harm, and even some of the over-the-counter medicines that people don't realize can cause very, very serious illness and even death.

Things like Aspirin and Acetaminophen or Tylenol, sometimes kids will take those as what they think are sort of a suicide attempt. And in reality, that can actually be a completed suicide. So some things, and I probably suppose resources you're gonna share have a list of some of those things that you wanna have out of your home, totally inaccessible.

Dr. Mike Patrick: Yeah, things that you think would be safe because you can just buy it in a pharmacy without a prescription. And yet, Tylenol doesn't take, you know, a big dose to really be a problem with the liver and could kill someone, absolutely.

If you are looking for help and you live here in the Central Ohio area, our physician referral line if you need a primary care physician is 61-4722-KIDS. And, I'll also put a link to the ambulatory pediatrics page at Nationwide Children's at our website so you can find a clinic.

We have 10 clinics around town and of course, our primary care network is a great source of resources.

00:58:01

And then, we also have a very advanced behavioral health program here at Nationwide Children's and very exciting, the Big Lots Behavioral Health Pavilion which is being built with 50 million dollar gift from the Big Lots Foundation, slated to open in 2020.

It'll by a nine story, stand alone, behavioral health center. Largest in the country with outpatient programs, inpatient programs. And so, if you live here in Central Ohio, there's lots of ways to get connected and get help. And you know, should really start with your primary care provider unless it's an emergency.

Dr. Alex Rakowsky: And in all honesty, we can't keep up as a system. So even with the new Big Lots thing opening, we'll be overwhelmed. So we're, sort of, blessed with a lot of community resources. So for example, in the area, there's a lot of school counseling.

So regardless of where you live, think about community resources. There's an amazing number of smaller groups that help out in every city. And, get to know 'em as a pediatrician. And for example, we have a list like 10 or 12 that our clinic uses a lot and we've got to know them pretty well and vice versa.

Dr. Mike Patrick: Yeah, and that's a great advice. And, for folks, parents that's another reason why you really wanna start, unless it's an emergency, you wanna start with your primary care doctor because they're gonna know what resources are available in your area, which ones that they have a good relationship with. You know, that gets back to them and let's them know what's going on. And, it's part of, you know, a team effort.

And so, they're gonna know, sort of, you know, who to trust and maybe, or not to go in a particular community.

Dr. Alex Rakowsky: Sure.

Dr. Mary Ann Abrams: And since this is a Plain Language PediaCast, I think, just to clarify what the term behavioral health means. I think it's an interesting term. It sounds like, "Well, am I well behaved or am I not well behaved?"

Behavioral health is a term that we use in medicine to reflect things that, I guess, show in how we behave. But really are the kinds of things we've been talking about today. Mental health things and also things like, you know, drug abuse and overuse as well.

00:59:58

But, so, mental health and all the supporting systems.

Dr. Mike Patrick: Yeah, how I wish we could go back and not use the word behavioral health because "behavior" makes it sound like it's a choice. And for, you know, a lot of these kids, it is not a choice. But, you know, it is what it is. And you know, that's what it's called. But, it's a great point.

Dr. Mary Ann Abrams: And just so people know, I mean, if they're looking in, who knows, the yellow pages don't exist anymore. But, if they stumble on this term then who would know to look for behavioral health if you're going on the website, you know?

Dr. Mike Patrick: Yes.

Dr. Mary Ann Abrams: I'd be looking for mental health and maybe it's there, too. But, I just thought that's a good point to clarify.

Dr. Mike Patrick: Yeah, no, and a great way to wrap up an episode of Pediatrics in Plain Language. Before we go, I did want to get some ideas from you guys on fun activities that families can do in the winter. You know, we, I'll go first. We've been watching a lot of Olympics.

So we've not really been doing a lot of activities. But as soon as the Olympics are over, we'll get back to doing more, you know, away from the screen and doing more family fun stuff. And, for us here recently, we've been back to, my wife and I, cos our kids are a little older now.

We've been playing card games again in the evening. And, there's one in particular called, "Dutch Blitz", which is really a fun card game because you, you're both playing it at the same time. So there's really a lot of action involved. And then, then you count up the score and then you can talk, and engage, and interact.

Because, I guess slower games, there's more chances that you can actually communicate with each other. But we have had fun with it and so I would just mention indoor activities. You know, we've been doing some card games: UNO, Phase 10, you know, those sorts of things.

Dr. Alex Rakowsky: We Monopoly a lot. And so, we try to carve out like two to three hours on a Sunday just to play Monopoly. It always runs over and it always gets very loud. Or Trouble, which is another one where it's a very simple game but it always ends up being people screaming and yelling, waving their hands.

It's just a fun game and we really try to just, Sunday, you know, we sit down in afternoon up to three hours just to goof off.

Dr. Mike Patrick: Yeah, no, and everybody looks forward to that too. So is it classic Monopoly or do you go with one of the specialty boards?

Dr. Alex Rakowsky: We had a classic but I think the dog, our dog ate the majority of the pieces. I'm not sure. So, if you see we're getting her stomach pumped then we know why.

00:02:08

Dr. Mike Patrick: Yeah.

Dr. Alex Rakowsky: So, it's actually a mix-up. We have an OSC one in the Star Wars one. And so we have, it's really a combination. The board is classic but the pieces, you know, we have like Obi-Wan Kenobi at the dog in a hat. And all sorts, you know, it's a mix there.

Dr. Mike Patrick: Oh yeah, no. I love that. I never thought of mixing them up. Yeah, that is great. Mary Ann, what do you guys do in the wintertime?

Dr. Mary Ann Abrams: I've got two ideas. One, catch phrase, that's another game where, you know, you have to have a couple batteries and it gives me a little push. But, and you can play it with two, well, probably needs at least four people. But, you can also play it with twenty people at Thanksgiving.

And, even though it's a word game, it's surprisingly physical. Because, people get excited and they're like trying to guess what the word is. They'll try to pass it before the buzzer goes off.

So I try to think of things that are not only fun, entertaining, a little competition to get people going, and also active. And then, for younger kids, I think making obstacle courses is great, you know. What can you do inside that's active, that won't break a lot of stuff?

So get those cushions, get all kinds of, you know, strings and balls, and come up with all kinds of things that kids can go over and under. And, how they can beat the clock, I think that's another really great thing.

Can you stand on one foot? Can you hop on one foot? Can you, and dancing. And, kids love their music so dance, dance, dance.

Dr. Mike Patrick: Yeah, no. That is great. Great advice, they could be fun.

Dr. Mary Ann Abrams: And, Nerf balls. They won't break the lamps but you can, lots of active stuff altogether.

Dr. Alex Rakowsky: And for people with limited budget, catch phrase is for free you can get on your cellphone.

Dr. Mary Ann Abrams: Oh, I didn't know that.

Dr. Alex Rakowsky: Yeah, we just played it over Christmas time and I think there were like 20 people screaming and yelling at each other and all for free. Free screaming, yelling.

Dr. Mary Ann Abrams: Awesome.

Dr. Mike Patrick: And with those obstacle courses, they just stay away from the stairs, kinda safety stuff in mind, all that business too. And otherwise, our safety people would be calling me. Telling me the same.

Dr. Mary Ann Abrams: Yeah. Don't climb up and down things. Just keep stuff on the floor.

Dr. Mike Patrick: But that does sound like a lot of fun.

1:04:01

That really does, great ideas all around. So thanks again to our Pediatrics in Plain Language Panel. I know you guys are coming back late spring, early summer. We're gonna talk about summer safety. So folks can look forward to that. And until then, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both with Ambulatory Pediatrics here at Nationwide Children's Hospital, thanks so much to both of you for stopping by today.

Dr. Alex Rakowsky: Thank you.

Dr. Mary Ann Abrams: It was fun. Thanks.

[Music]

1:04:56

Dr. Mike Patrick: We are back with just enough time to say thanks, once again, to all of you for taking time out of your day and making PediaCast a part of it. We really do appreciate that.

Also, thanks to our guests, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both with Ambulatory Pediatrics here at Nationwide Children's Hospital.

Don't forget you can find PediaCast in all sorts of places. Not sure how you stumbled across this today. But we're also in iTunes, the Apple podcast app, on all iPhone and other iOS devices. We're in Google Play, iHeartRadio, Spotify, and you can find PediaCast in most mobile podcast apps.

If you do come across an app that does not contain PediaCast with, in it but there are other podcasts, let me know. Just use that contact page over at pediacast.org and we'll try to get the program added to their line-up.

You can also find us at our landing site, pediacast.org. Our entire archive of past programs is there waiting for you. Also, show notes for each episode, transcripts of the program, our terms of use agreement and of course, that contact page.

By the way, it's very helpful if you leave us a review in iTunes or the Apple podcast app. Wherever it is that you regularly listen to your podcasts because folks read those reviews.

1:06:09

And really, just about anything I do these days, whether at Amazon, looking at something, the Best Buy app, you know, where, and again, for me it's gonna be a little bit more geekery, you know. So those are the places that I'm looking at reviews. But also in the podcast that I think about listening to, I take those reviews into account.

And so if you can help promote the program, you're getting a great evidence-based podcast. Hopefully, you think it's great if you've gotten this far into the episode. And you'd wanna share your feelings with others, that would be immensely helpful and we really would appreciate that. It's all we ask in return for this free resource.

Don't forget we are also on many social media channels so you can connect with us there including Facebook, Twitter, Google Plus, even Pinterest, LinkedIn as well, just search for PediaCast. LinkedIn, it's Dr. Mike Patrick. It's how you would find me.

But otherwise, it's, it would be under PediaCast. And of course, we always appreciate those face-to-face referrals. Please do let your family, friends, neighbors, co-workers, babysitters, grand parents, anyone who has kids or takes care of kids, please let them know about the program.

That would include also your child's teacher and his or her pediatric medical provider. And then when you're sharing the show with them, just let them know, you know, other families may be interested in this resource.

We do also though have a podcast for pediatric providers, for pediatricians. If you have the practice docs, residents, medical students who are interested in pediatrics, certainly nurse practitioners, physician assistants, really, anyone who takes care of kids as a medical provider. We do offer a program called PediaCast CME that stands for "Continuing Medical Education"

It is similar to this program. We turn up the science a couple notches. And, we offer free Category 1: Continuing Medical Education credit for those who listen. Shows in details are available at the landing site for that program, which is pediacastcme.org.

That program, by the way, is also on iTunes, Google Play, iHeartRadio, Spotify, most mobile podcast apps. Again, simply search for PediaCast CME.

Thanks again for stopping by and until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody!

[Music]

01:08:43

Announcer 3: This program is a production of Nationwide Children's. Thanks for listening! We'll see you next time on Pediacast

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