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Welcome to the Nimble Youth podcast, where we provide expert insights and valuable resources for parents navigating the complexities of their children's mental health. We empower parents to nurture healthy minds in children, teens, and young adults through real conversations.
Our team of seasoned professionals, including physicians, therapists and educators, delve into pressing topics, share research-based strategies, and offer practical advice for fostering mental and emotional well-being within your family.
Welcome back to Nimble Youth, where we unpack the challenges and breakthroughs in raising emotionally resilient kids in today's world. I'm your host, Matt Butterman. And in today's episode, we're diving into a topic that has come under some media scrutiny recently, and it urgently needs our attention as well, the rising rates of anxiety and depression amongst teenage boys and young men. And isn't just a blip on the radar. It's a growing public health crisis.
Did you know that suicide is now the second leading cause of death for boys aged 15 to 24 in The United States? And while girls tend to report higher rates of anxiety and depression, boys are far less likely to seek help with studies showing that young men are over sixty percent less likely than young women to access mental health services even when they're struggling. The result of all this is countless boys and young men are suffering in silence. In this episode, we'll explore why emotional vulnerability is still so stigmatized among young males, how cultural norms in social media play a role, and what we as parents, educators, and clinicians can do to spot the signs and offer real support. My guest today is doctor Gretchen Hoyle, a pediatrician with a special interest in youth and adolescent mental health.
We'll talk about what depression and anxiety can look like in boys, hint, it's not always what you think, How to open up nonjudgmental conversations at home and how to get them the help they need early on. If you're raising a son, working with young men, or simply care about the next generation, this is a conversation you won't wanna miss. Before we get into it, we remind you that the content of this podcast is intended for informational purposes only and should not be construed as medical advice. While we aim to provide valuable insights on pediatric mental health, it's important to consult with a qualified health care professional for any concerns or questions regarding your child's mental well-being. Always seek the advice of your doctor or other qualified health provider with any medical concerns.
Welcome back to Nimble Youth, doctor Hoyle. There's been a lot of media buzz about the mental health crisis facing teenage boys, and one of the best examinations of the crisis is found in a book that both you and I are familiar with. It's called Of Boys and Men. It's by Richard Reeves, was published back in 2022. And Richard Reeves, was for many years a public policy expert and journalist on staff at the Brookings Institute for a long time.
And while he's not a medical professional, he is the father of sons himself. And so he wanted to take a closer look at the issues facing boys today, from the perspective of a policy expert. In the book, Reeves argues that the advancement of women's rights in the changing job market, which now tends to value cognitive skills over physical strength, that that shift has left some men feeling insecure and uncertain about their place in the world. And specifically regarding teenage boys, he highlights the difficulties boys face in education. There's a growing performance gap between young women and young men.
And it suggests that boys are not performing as well academically as girls, which definitely can affect their future opportunities, and it contributes to an overall sense of frustration. So doctor Hoyle, why are we seeing such a sharp rise in anxiety and depression among adolescent boys, over the past decade? Yeah. So that's a great question. I think a lot of people are trying to take a look at this.
And, you've referenced, you know, one of the experts in the field, so Richard Reeves. And then also to sort of, come back to the book that we talked about when we were talking about adolescent girls and rates of anxiety and the anxious generation by Jonathan Haight. And, Haight actually references Reeves quite a bit in the chapter that he has on boys. And the way that he sets it up as far as, like, what's happening with boys especially in, like, the Gen z group is that there has been, in the during the sort of what we what he calls the great rewiring, which happened in the sort of the first half of the February, you know, we had this shift from the play based childhood to the phone based childhood. And, and that has caused, you know, a variety of different problems, but the effect on boys and girls has been somewhat different.
And for boys, he sets it up as being this idea that there's this push pull, of that shift that is shifting boys from having experiences in the real embodied world and into the virtual world. And as it turns out, you know, having experiences in the virtual world as opposed to in real life is just not the same experience for your brain, especially the developing brain. It's really important to be able to have real world experiences, and specifically for males the opportunity to take risks and learn from those risks as to how to handle that in the real world setting. And being able to do that makes you feel competent and confident in the real world. And so, we'll talk about this when we talk a lot about free play and stuff, but, because males in this generation have been sort of pushed away from the real world and pulled into the virtual world, then their development, for, like, the Gen z group has been, you know, fairly different from what it had been in previous generations.
Right. And so one one, I guess, issue is, that the lure of the online world is so great. And, so it seems like the changes in the workplace and in an educational system has made the real world seem less welcoming. Correct. Yeah. Voice.
Is that right? Yeah. So that part is the push. And so hit like, the idea here is that there have been factors that have been going on for, you know, long before we had phones, that were making it feel to boys that the real world was sort of less hospitable to them. And so that push out of the real world, and sort of in Haight's assessment is that it was happening, you know, as early as, like, the late twentieth century, so the eighties and nineties.
And he equates that to some degree in the rise of something he calls safetyism. And so I do wanna sort of point out that, you know, what I've absorbed from his information in his book is going to be somewhat biased from my perspective. Right? So as a female person and as a person who is who is a, you know, a mother and somebody who then sees, children and adolescents in the in the, in the pediatrics clinic, I'm gonna have my own sort of, like, perception of what is being, discussed in in the book. So I'm just gonna go ahead and put that out there as a little bit of a disclaimer.
He does talk a good deal about safetyism and the rise of safetyism, like, in the eighties and nineties. And the idea here being I think one of his overall ideas is that we have started to very much, like, over control and over supervise what children do in the real world. But we have under supervision what happens in the virtual world. Right? So that's a real problem.
And so, and so when he talks about safetyism and the rise of that in the, like, eighties and nineties, the idea there being that, you know, adults were becoming, like, concerned about things that children were doing when they were unsupervised, and that caused some additional sort of layers of, you know, protection that were being afforded to children, in order to prevent sort of bad outcomes. And so just, you know, in full disclosure, I have two quick little anecdotes that I wanted to share from, like, from my personal experience that sort of explains my perception of what this actually looks like from a female perspective. So, you know, so I was, you know, born in 1970. So my childhood years were in the seventies, and my teen years were in the eighties. And so even though safetyism was happening in the eighties, like, I don't think that I was old enough that it really didn't catch up with me.
Right? And so I remember having, you know, I had that sort of I think what we a lot of us in generation x think of as this sort of idyllic childhood where we were able to, be for sort of free range kids. I was able to, like, ride my bike around the neighborhood and meet up with other kids and no one ever knew where we were and we would do all sorts of different things and we had a lot of opportunity for agency, a lot of opportunities for independence. But one of the things that happened during that time is I was around, like, 13 or 14 and there was a young man who lived in the neighborhood who was 21 who started hanging out with us. And to us, he was just another, you know, kid on his bike And, and so when I then, you know, invited him over to my grandmother's house at one point to go swimming in the pool, she met us in the driveway and immediately looked at him and said, you know, how old were you?
And he was like, well, I'm 21, and she sent him on his way. Right? So I think that, like, at the time, I was just perplexed. I was like, well, I don't, you know, understand this, but I also did not argue because also that was another thing I think that happened in generation x that we were typically not arguing with Right. We didn't question authority as much as today's generation.
I don't feel that we did, and and I feel like maybe it was because, like, we had so much freedom that when an adult was intervening on your behalf for some reason It was a serious mess. Right. Yeah. That something was off. And so and so I just tell that story.
I mean, nothing happened to me. It was a completely, like, benign, like, interaction, but I would consider that as an adult looking back on it, I would consider it a near miss. Right? So there is a decent chance that that could have gone south. And, and I feel like I just wanna sort of give the framework of what that what growing up in that time was like, because I also feel like I probably was a bit of a safetyist with my own kids.
Right. Because I would look back on experiences. I mean, the other quick experience I was gonna share was that, and sometimes these seem comical in retrospect. But, I have a set of friends that we've been friends with for, like, fifty years. And when we were in our teens, we were in a youth group setting at the beach, and, three of us, met up in an arcade with some young men that were in military uniforms that we thought looked cool, and we went walking with them on the beach.
And we had no idea who they were. We had no phones. There was no way to know where we were or what we were doing. We had a curfew to get back at the bus that we missed. But, when I think back on that, I sort of think, well, that potentially is a near miss.
And those women and I that we had that experience together, we still meet up at once a month for dinner and we are just bewildered about, you know, how we got ourselves in that situation. And we were so we felt like, wow. It's great that those were nice guys and nothing happened. But I would say in retrospect, I'll potentially consider that a near miss. And I would also say that, like, when we think about that, we all have daughters now, and it would be completely out of the question that our children would have, you know, had the freedom to have that kind of thing happen.
Right. So there are some very positive aspects of safetyism, embodied in the name. You know, there's just greater safety when, you know, perhaps, children are under greater scrutiny from adults. Yeah. I mean, I think it is a really complicated thing because I definitely agree that the rise in safetyism, first of all, has been I mean, has been worse for boys than for girls.
Right? It has. I wanna offer my own anecdote here. Hate spends a fair amount of time talking about the role of these embodied experiences for boys in developing agency and sort of self governance and, you know, as a male of the Gen X also. I can remember, you know, neighborhood football games, basketball games, where we had, you know, sort of all the boys of the neighborhood would come over and we'd have these epic battles.
But they were, you know, there were no referees on the side, right? And so, we had our own set, our own code, you know, our own set of rules. And it usually was the eldest and the loudest, boy who enforced them. Right. But still, you know, there was this underlying code of conduct that everyone, for the most part, you know, paid attention to.
And when our experiences are so circumscribed by someone else. Right. You know, it takes away that sort of sense of self governance and and and freedom, which is really important, I think. Perhaps even more so for boys than for girls. And perhaps, you know, the positive aspects of safetyism, you know, are more telling on girls.
Yeah. Yeah. I think that's true. And and and I completely agree that so so we've got this push, you know, for boys, like, out of the real world and safetyism is part of that. And and so are the other things that you sort of mentioned in the, in the introduction is that, you know, there's that there's a there's a declining value in physical strength, which is part of the the sort of workplace structural issues that he talks about, that there's a rise in the service industry and that those traits that do well in that setting are often what we think of as, you know, female traits.
And of course, just to keep in mind, like, you know, this I don't wanna overgeneralize. Like, certainly, these are two populations that overlap a lot. But when we're talking about these sorts of general trends, it's almost like saying something like, well, men are taller than women. Right? So that doesn't mean every man is taller than every woman, but it does mean that from a general perspective that, you know, that height is the height potential is higher in men.
Right. And so we don't wanna devolve into, like, you know, this sort of Gender based determinism. Correct. Exactly. Yes.
And so so, but that being said, like, when you think about the service industry and what is helpful in that setting, it's things like, you know, being able to sit still and communicate openly with other people and listen to other people and have flexibility and fluidity. And I think a lot of times we think that, you know, the push is also, you know, sort of it out of the real world and into the virtual world. He talks a lot about the structural issues in education. There's a ton written about this. I think it's fascinating stuff, especially because, you know, my son is teaching ninth grade, you know, in Colorado, and it's very interesting to hear his perspective as a male teacher with, you know, male and female students.
But boys just in general have been having some significant declines in their performance in the classroom, like you mentioned in the, in the introduction. And I think that also those things make the real world seem less hospitable to boys. And there's also this idea of, like, when you look at boys and girls, as they're getting into puberty, we talked about with girls that a lot of times, you know, there's sort of two things that adolescents are often trying to do. One is to build agency and the other one is to build community. And both boys and girls want to build both agency and community, but the scales are sort of tipped towards agency for boys and towards community for girls.
Right. Right. So that is where we talk about social media and girls, like, you know, and how that sort of feels like such a community, but in reality, there's a lot of troubles with that. In the same way, we've got agency, you know, for boys where when we were in like our generation growing up prior to the rise of safetyism, there were a lot of opportunities in the real world embodied setting to build agency and the agency. Agency being the idea that you can make decisions for yourself without the, you know, influence of some other, you know, entity.
Right? Right. You can make your own decisions, you can decide how you're gonna behave. Agencies also goes along when you're talking about a group of people with this idea of self governance that you were talking about where, you know, you get together with other kids and you make the rules and there's certainly, you know, leaders within that group, but that sort of self governance is really important for, you know, for but all kids to make their way from being a child to being an adult. But those those opportunities for agency in that are that are probably a little more, you know, like important for boys at least at that age and that were happening in the embodied world in earlier decades or in earlier generations have sort of shifted into this more virtual setting, and that's kind of the pull he's talking about.
Right. Let's talk a little bit more about that pull. I think I mentioned it earlier, the lure of the Mhmm. The lures of the online world, and specifically, Hate mentions, two of them. One is online video gaming.
Right. The other is, pornography. Right. Both of which have become just so easily accessible, through the rise of the Internet. And I might add a third one to the list of vices, and that would be sports betting Yep.
Which in the past maybe four or five years has become legal in more places. And, you know, the fact that it's accessible online just makes it easy in a sort of a financial hole that boys can fall into. Yes. But there are some, you know, reasons, strong reasons why, you know, boys are attracted to these things. And a lot of it's the dopamine rush.
Is that kind of a good idea? Yeah. I mean, I would say for sure, like, if we talk about, like, starting with, like, video games, especially, and especially, and I think it's just sort of important to, you know, point out that the gaming community would say that there are some, you know, benefits to doing video games. And so what they would point to is that there are some studies that show that there's some cognitive benefits, that there's some, you know, working memory that is helpful. I have a friend who's a surgeon who says that, you know, what they're doing, with sort of robotics and stuff, like, all the guys on residency now were, you know or men or women who were gamers Right.
You know, have some expertise in that area because and that's a lot of what's, you know, what how, that field is emerging. And so and and when you think about something like Minecraft, I think, like, when I talk to parents about video games, that one sort of comes to mind is like, oh, this is, you know, kind of a cool thing for them to be able to do. You know, like, it's a spatial relations thing and it's really super creative and My son was heavily into Minecraft and now he's an architect. Yeah. That's so cool.
Yeah. So, you know, I think that it's a complicated picture for video games. But what because there are some benefits. I would point out though that, like the platforms like, the goal of the games themselves and the people who design them is to keep your child engaged on that platform for as long as possible. So if there happen to be some incidental positive things that are happening, then that's great.
But the core, you know, goal in the design of these is to be engagement. Right? Right. So, even though, you know, they'll say things like, oh, well, you know, you can. This is a social thing because you can play video games with your friends or people who are in another country or, you know, there's some of that. But in reality, the main structure of those experiences is to keep the person on the platform for as long as possible.
Right. And there are some, some definite, bad things that come from this sort of compulsive consumption. Correct. So there are definitely effects on relationships, and emotional development. That's pretty evident, with pornography use.
True. Yeah. Yeah. It's hard to think of necessarily a positive thing that comes from that. But also, you know, gaming as well.
Yep. So talk a little bit about how emotional development is adversely affected. Right. So I think the, like, the biggest thing is that when we talk about agency and, and boys having a drive to develop agency and community, but agency maybe a little bit more. The, like, video games are extremely good at allowing for virtual experiences that feel like that's meeting their need for agency.
Okay? So, you know, for example, a lot of video games that, you know, boys get really into are set up for doing, like, exploring of virtual worlds, competing with other, you know, players, physical, like, like, what sort of fighting stuff, like like, playing at war, like, fighting kind of and and that can be, like, feels like agency in a virtual setting. And then just mastering skills in general. Right? So, so that is really appealing to boys and of course we talked about dopamine, we were talking about ADHD and, and you know, when you are doing something that is really intrinsically rewarding to you, that it activates dopamine in your brain and it causes, you know, allows you to maintain your attention to that and causes you to have this sort of sense that other things in your environment may sort of fall away.
So it's the kind of thing when you're doing something that's that engaging, you tend to lose track of time and you are not spending time in the embodied world and you're maybe not doing your homework and all of those things are sort of happening with boys a lot, because these games are really designed to, again, like, hold their attention and keep them on that platform for as long as possible. Right. And so they're kind of back to those four fundamental harms that Haight talked about, like about, like, social deprivation. So it's not just that they're, you know, having these experiences online and on video games that are not really helpful in being able to help them understand how to navigate and regulate in the real world. It's also that they're spending so much time on these systems that they are, you know, depriving themselves of embodied experiences.
Right. And that and that affects friendship development. Yep. You know, many many boys are finding, you know, some, quote, unquote, friends, you know, in the online gaming world, and, you know, now with virtual reality, you can sort of create a girlfriend online, right, which is crazy. But, you know, I think back to my own experiences growing up in a time before the online world really blossomed.
And, you know, the friends that I made through these external experiences, whether it's athletics or artistic pursuits, those have been my lifelong friends. Right. And it seems that, you know, the friendships engendered by the online world are more fleeting and, you know Yeah. So He talks a lot about that too. I mean, like, the idea that it's really hard for this generation to set down roots in community the way that previous generations did because a lot of them, you know, are trying to meet their need for community, but they're doing it in the virtual setting.
And so, you know, most of those people that they may be playing online games with now are really not gonna be in their lives for the next year. Right? And so it's hard to set down roots in a community setting the way that, you know, that we did in previous generations because you were having embodied real world experiences, and especially with things like, you know, sports and shared interests and stuff, that's really where our, you know, our sort of lifelong friends come from. And it's so important for that age group. I mean, this is one of the things that I think we realized after the pandemic is that, you know, that age, that sort of second decade of life, and to some extent into the third decade of life, you really are, developing the social relationships a lot of times that you are going that are going to you know, those are the people that are gonna be on the planet with you for the duration.
Right? And so it is such an important time. And so, you know, during the pandemic, we had, you know, cohorts of kids who got that experience interrupted for some reason, and that has caused a big shift in the amount of anxiety and depression that we're seeing because it's a natural stage of, you know, development that was interrupted. Right. So with these lures that the online world presents to young people today, they tend to perhaps stay in the basement or in their rooms, on these devices, whether it's the computer or their phones.
And so they're not, they're not getting out in the real world. But one effect of that has been a a, reduction in the rates of car accidents, fights, teen pregnancies. So again Yeah. It's interesting. It's a, you know, it's a mixed bag here, I suppose.
So I mean, on the surface, that sounds like good news, but it's really it's a lot more nuanced, a lot more complicated. Right? It is. I mean, so yeah. That so rates of things that we, you know, where would would be worried about, so car accidents and tickets and and, teen emergencies Brawls.
Yeah. And stuff. Right. All that stuff has gone down from Gen z. But another metric that he talks about that they are, following is, hospitalization for unintentional injury.
And, of course, nobody wants their child to be hospitalized for an unintentional injury. I mean, they don't want their child to be hospitalized at all. But, it is sort of a marker since those are really going down. Like, it is sort of a marker that says that the amount of, like, overall risk taking that's happening in the real world is going down. And that's probably not great.
I mean, like, that overall, that that is a concerning thing. It just tells you that we're having sort of a different experience for males who are going through adolescence during this post great rewiring and maybe even post pandemic that is different and has caused different results. And I think one of the things that really, like, caught my attention in in, in reading through the or reading this chapter is that, you know, when when when folks reach puberty, we expect that they're going to have some amount of sort of challenging, you know, behaviors, emotions, thoughts, things that are, that with it's sort of a stormy time, right, where your brain is changing a lot and it that causes a lot of sort of consternation and stuff. And so, traditionally, what has happened in puberty is that females would develop what we call internalizing symptoms, and those, mostly look like anxiety and depression. Right?
So, you know, for whatever was happening with them in the external world, they would often present with trouble that, you know, like sadness and and, and worries, anxiety, that kind of thing. And, again, traditionally, boys during that phase, when they had their sort of stormy behaviors and thoughts and anxiety and worries and stuff, they typically manifested as externalizing symptoms. Right. Right? So those externalizing symptoms are kind of the things that we're talking about that have been going down.
And so, like, it's like, you know, I mean, oppositional behavior like talking back to the teacher or to their parents or maybe they're actually getting in trouble like vandalizing something or driving too fast. None of these are good things, right? But it is a telling thing that, like, somewhere around 02/2010 and since then, that as children are reaching puberty, girls are still, you know, their stormy issues are turning internalizing. That's continuing. But boys, it's also shifting to internalizing symptoms.
Right. So anxiety and depression in boys, and that is kind of a new problem. That's a new problem. Yep. And so, you know, both boys and girls, for the teenage years can be tempestuous years.
Right? Sure. Absolutely. What the Germans would call sturm und drang - strife and struggle. And so that's pretty normal.
But, as a parent, how do you tell, and specifically for boys here, I guess, how do you tell, if your son is actually struggling with anxiety and depression because they aren't these externalizing behaviors Right. To to, be a marker of that. Right? Yeah. I mean, it's not as, you know, and maybe not it may be a fly on the radar longer, but by far, the biggest, like, sort of the canary in the coal mine is school.
Right? So, for better or worse, we can now parents can see grades in real time online. And, you know, I feel like if kids are doing fine that parents don't necessarily need to, you know, be like checking on that. But for kiddos who are struggling, that's often a really good, you know, indicator that their function is being affected by what is happening with them in term. So if, like so if the sort of the logical progression here is that they are spending you know, they've been pushed out of the real world and pulled into the virtual world, and that, like, includes gaming.
We've touched a little bit on pornography. I think it's important to sort of, you know, address the fact that, like, a lot of exposure to that and a developing brain is obviously a problem. Right? And there is some pretty good evidence that it's causing relationship problems. Absolutely.
Yeah. Yeah. And that a lot of that evidence is coming from adult men, but you kinda have to assume that they had exposure when they still had a developing brain. Right. And, you know, it it was always, pre, you know, easy access to pornography.
It was always, you know, a challenge to ask a girl out. Right? It was, you know, you got butterflies in your stomach, and it was a challenging thing to do. Now teen boys go into their basement. Right.
I think that's that. Engage with porn. So And that's a a real problem, you know, for male female Right. Relationships. It's gonna hijack that evolutionary drive.
So, like, you know, the idea that that males would sort of put up with those that butterflies in your stomach and that sort of social risk of having to try to, you know, talk to a, you know, a female classmate or ask them to the dance or, you know, as they get older, potentially work on, you know, a relationship, that kind of thing, you know, that was being driven by the, you know, evolutionary drive for, you know, romantic and or sexual, you know, experience at whatever level was happening that was, you know, hopefully appropriate for that age group. Right? But, you know, that drive has kinda been hijacked now because that has been, like, that those needs, quote, unquote, are often met in the virtual world because they've been pulled into the virtual world for this. And it also causes, you know, like, a lot of difficulty with relationships because the expectation is just, you know, probably not gonna be met. If your expectation is what's happening in pornography, then that's probably not gonna be met in a real world person.
Yeah. Exactly. And it turns out that, like, you know, both of these things are so, you know, so for pornography and video games have such a huge lure and I think the gambling thing, especially for young men, I mean, it is becoming more legal. Most places, there's at least some sort of age limit on it, but these kids are sort of smart a lot of the time. They're getting around that.
Right. Exactly. And so, and so boys are getting pulled more and more into the virtual space, and it's just not the same experience for your brain. And I think that the fact that they're now having internalizing, you know, symptoms, is kind of alarming. Right?
I mean, you know, I hate it, I mean, I'm glad that they're not having car accidents, but I'm also like, well, this situation is probably not quite. It's not psychologically healthy. Right. Exactly. And so then they you know, a lot of times what sort of brings them into me so the idea here is that, you know, they're part of the phone based childhood. They are now pulled completely into the virtual world or, you know, out of proportion in the virtual world, and now they're having internalizing symptoms.
Then they're gonna look like, you know, somebody with anxiety and depression and oftentimes that then, you know, creates trouble with their function. Right? And so typically functioning wise in this age group, you know, the first thing that goes is their school performance. Right? Which can be really problematic for, you know, for, this generation, especially when things are so insanely competitive.
I mean, I feel like that, I meet kids every day who are taking, like, eight and nine APs in their high school experiment. It's like, that's, you know, like, they're basically in college. I don't, it's just a very strange shift. And, and so academic pressure is a really big one that they will cite. And if that starts to sort of tank because their attention is so drawn into the virtual world, then oftentimes that comes to the attention of their parents and, you know, that may prompt a visit Coming in to see you.
With me or, you know, potentially one of my, you know, another provider. Sometimes people will pick a male provider because I'm completely fine with that. Like, I think that, that sometimes that's a reasonable thing to do. But I will say that like, that's often the thing also, you know, social relationships, you know, if your child is really just not interacting like they're not doing most with friends and then they sort of then withdraw even more where they're not doing much with family, I mean, that's that's a red flag. Yeah.
It is. That needs to be addressed. Right. And you mentioned, you know, making an appointment to see a male therapist. That goes back to something that Richard Reeves talked about in his book.
One of the issues that is facing boys and young men is that there are there's a lack of positive male role models, particularly in education. Right. And so, the more that they can be around men Right. Who who, you know, fill this, perhaps, need in their developing lives. Right.
That's a very, very good thing for them. So going back to, talking about, when boys come into your office with an identified behavioral issue, how do you determine, whether that's anxiety, depression, some combination of both? And one of the things that you use are are or two of the things that you use are what you also use for the girls, the GAD seven Right. And PHQ nine questionnaire. So talk a little bit about that process.
Right. So the GAD seven is a screening questionnaire for anxiety. It's got seven questions on it. The first two questions, like, the first one is, like, have you been feeling over the last two weeks nervous, anxious, or on the edge? And it can be scored as either a never, which is a zero.
You can say several days of the last two weeks, which is a one. Or over half the days, which is a two, or nearly every day, which is a three. And so all so there's seven questions that are sort of anxiety driven. You can score zero to three, so the highest total score would be 21. And then we stratify that out, you know, based on their total score.
And so anything over a 10 is kinda like, you know, you probably something's happening there. Right. And so, you know, we'll think about what's happening with them anxiety wise. Certainly, when you get up, you know, 16, 17, 18, then we start to really start to think that helps us decide kinda what our modalities of treatment are gonna be. I will say I still use the scared questionnaire in males this age and and in females I mean, it's normal for folks, you know, I think age four to 17 and so I will definitely still do that questionnaire in, you know, 13, 14, 15 year olds.
And it is an anxiety screener and it helps sort of divide things into different subsets of anxiety. So like we talked about in the previous podcast, there's, like, the generalized anxiety idea, which is, like, I'm worried about the future or, you know, those kinds of things. There's, like, somatic complaints. So I'm having a lot of headaches or abdominal pain, which, of course, is a real common way that people present with their anxiety. Still need to work those up, but a lot of times that's what gets them in to see me.
Social anxiety, which is super common, you know, in this cohort of kiddos who are struggling, especially, separation anxiety is a little more common in younger kids. And then school avoidance. And so we can kinda get a sense as to which of those subsets is positive and how to then address it. And then I also will screen for depression, at the same time because those anxiety and depression are kinda two sides of the same coin. Right?
So, that's done with a tool called the PHQ nine and that's got so nine questions also scored zero to three, same scale, so the, you know, highest possible score would be 27. And so there's a way to stratify based on the total score as to whether it's, you know, no anxiety or mild or moderate or moderately severe or severe. And so that'll also give me an idea as to where that is. The other thing that I will do with both males and females, but maybe, you know, maybe a little more diligent about it with males is to screen them for ADHD too. So a lot of times, some of these folks have already had a previous diagnosis, like when they were in elementary school and we were managing it at some point for that at that time.
And then, and then they were kind of able to, you know, do what they needed to do as they got a little bit older and so we got away from, you know, doing sort of routine management for that. But now that they're in high school and they have these sorts of pressures and they're sort of struggling with their pull into the virtual world, then sometimes, you know, sort of revisiting that diagnosis and deciding whether we need to do anything about that is also helpful. Right. And sometimes the consequences of untreated ADHD can actually Mhmm. Cause, you know, both anxiety and depression as well.
It all overlaps Yeah. Big time. Yeah. So once a diagnosis has been made, oftentimes, therapy is the first line of treatment as opposed to something like ADHD where perhaps medication is more readily drawn towards. Correct.
Yeah. Especially for inattentiveness. Right. Right. So talk a little bit about how the role of therapy is in treating.
So therapy is, like, extremely important in this. And I feel like and and I do think that just in the same way that I feel like, you know, female therapists can be really helpful for I mean, it can go either way. But, again, it's like this idea, like, you know, most likely, men are taller than women. Like, it is not true for every person, but I do feel that a gender matched therapist is often a preferred situation. And so, fortunately, we have great male therapists in our community, who can meet with these boys who have a lot of experience, and take a little time to get in.
It just, it is but that tends to be a really positive experience for most of them on a number of levels. So they're able to process it with a person who is, you know, of their same gender and has had, you know, somewhat similar life experience, but also has the idea of being able to see the difference between the the world in which they that child is or that Gen z person, teenager is growing up and going through adolescence in comparison to what it used to be. And so, you know, the therapy part of it is super helpful. Sometimes they really benefit from things like academic coaching, especially if academic underperformance is a big part of the problem. And, of course, it's super easy for that to happen because, again, you're getting pulled in, like, on purpose by these tech companies who want your attention all the time.
Right? And so having somebody who is external to the parents who can help put some framework around how we are going to accomplish what we need to do academically can be very helpful. And then there are some, you know, additional modalities that are sort of arising too that I think we're gonna spend, you know, potentially some other times to talk about on podcasts that are helping folks with Alternative therapies. Yeah. Alternative therapies.
Like emerging technology. The MDR and ketamine, as well. Yeah. Those things and that I would sort of reserve for folks who, you know, that I'll see, who are really in a sort of a significant anxiety and typically depression. Sometimes they will have suicidal ideation which is of course a whole another topic, but, but those emerging technologies are becoming really helpful for people that we sometimes consider to have, like treatment resistant depression or anxiety.
But, of course, if, you know, if if for young men, if they are if they're in these sort of internalizing anxiety, depression type situations and they meet criteria for a diagnosis, and presumably, we're gonna move forward with therapy, but sometimes, you know, traditional medications can be helpful. We talked about these two classes in our, pre in our podcast about females. But, you know, the SSRIs are sort of the first line. And so based on their scores and their assessments and what their function is, I will, you know, sometimes prescribe those. The three that we use the most often are, Lexapro, Prozac, and Zoloft.
And so, you know and and I'll often ask parents if there's anybody in the family who's already had experience with any of those and whether they have positive or negative experiences and that will help me make a decision, as to what to do with that. There's also a group of medicines that we'll use sometimes called SNRIs and I think it's important to point out to folks that in the abbreviation SSRIs, that stands for selective serotonin reuptake inhibitors. So those are only working on serotonin, which is the neurotransmitter in our brain that helps us have sort of a sense of well-being and, being able to sort of have a positive mood and also helps us, with being sort of flexible in that, you know, if things happen that we weren't expecting that we're able to sort of find the ability to deal with that. Right? And so, and so those things are, can be helped by elevating serotonin.
The SNRIs are ones that stand for serotonin norepinephrine reuptake inhibitors. So it's working on two different neurotransmitters. So we talked about norepinephrine a little bit and we talked about ADHD, but as it turns out that has some, some elevating that can help with mood as well. And then sometimes, depending on sort of the patient's, you know, ability and willingness to to do therapy and kinda where they are with school and what's going on with them just in life in general, We have some some emerging models, care models that we're using, like, I think we're gonna talk about next with the collaborative care model where you can have these sort of weekly check ins with somebody who is in our office, their behavioral healthcare manager, who can then help sort of make these, you know, intermittent assessments and also give some skills based training as to how to help that person sort of deal with either acute anxiety, or set goals for what they need to get done, keeping in mind that their brain is very much pulled into this virtual world. Right.
Right. And so for the parent who has a son who's kinda fallen into the abyss of the virtual world Mhmm. What are some, just steps that that parents can take to sort of help their child emerge? Obviously, taking them to see you or another qualified healthcare professional is important, but are there some things they can do at home that, would help? Yeah.
I mean, I think the obvious thing is to try to limit the exposure. Yeah. Right? And set limits on access to devices if you can. Yeah.
And I will say again, like I say, every single episode I think is that there's no reason for your child to have their phone at night. Yeah. Right? And so that that is, and if I could do it over with my own kids, that'd be the one thing that I wanna make sure of. Like, I just did not I was so I'm not judging anybody from this because I did not was not on top of this either.
I totally understand. You know, you're like, oh, well, you know, you might be texting your friends right before you go to bed, and that's a good thing, or, you know, you need to use it for your alarm to wake up. But as it turns out, like, that is not a good enough reason. Right? So, and and I think that one of the fundamental harms that he talks about is sleep deprivation.
Right? So because these things are so, like, have such a strong pull, that it makes it so that folks will stay up at night and not sleep, and so then you have all the other sequela of that, you know, during the day. And so, and so those are sort of short, like, sort of initial things that can be done, setting limits on that. But I do think that for most adolescent boys that, that if if you're seeing functional impairment that getting professional help kinda as soon as possible is a good idea And and I, you know, would definitely not I I think that a good therapist is sort of like a great place to start, but sometimes what you need is help finding that person. And so some of the care models that we're using are assistant assistance in doing that.
Right. Yeah. And so, the therapist can often help boys begin the journey to engagement with the real world again, which I think is important for, you know, sort of complete recovery, is to have these real world embodied experiences. Right. Well, thank you, doctor Hoyle, for the discussion today.
You'll be back with us next time. We're gonna talk about the collaborative care model, which we've touched on, in previous episodes, but, we're gonna talk about why that is such an important emerging trend. And we'll see you next time on Nimble Youth. Until then, take care and be well.