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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 to Nimble Youth, the podcast designed to provide expert insights and valuable resources for parents navigating the complexities of their child's mental health. I'm your host, Matt Butterman. And today, we continue our close look at ADHD, examining specifically how clinicians treat ADHD, which is a very complex chronic condition. And my guest today and for, our whole three part series on ADHD is doctor Gretchen Hoyle, a pediatrician based in Winston Salem, North Carolina. And before we start, we can 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 professionals for any concerns or questions regarding your child's mental well-being. And, please do always seek the advice of your doctor or other qualified health provider with any medical concerns. So doctor Hoyle, in our previous episode, we discussed the initial initial diagnosis of ADHD, in children. And And today, we're diving, more into the ongoing care aspect of of the condition. Can you start by explaining why, ADHD is considered a a complex chronic condition?
Sure. So, you know, ADHD is, you know, we consider it a chronic condition because, you know, typically, it will manifest itself throughout the child's developmental years, and that means that it doesn't mean, like, it always looks the same. I mean, a lot of times, kids will have more evidence of, you know, increased hyperactivity or impulsivity as they're when they're younger, and then those, those symptoms will become more inattention or sort of academic underperformance or struggles as they get older. But we do find that, like, it tends to persist through that time, And patients will often ask me or parents will often ask me, okay. Well, so we're gonna start this process.
We're gonna diagnose them with ADHD, and then we're gonna start treating them. And are they gonna be on, you know, medication forever? And I totally understand that question because, like, it seems like it's overwhelming. Right. And and what I tell people is that, for most people with ADHD, when they are engaged in an activity that is that is inherently rewarding to them Yeah.
Then they do not necessarily need, you know, to have medicine or anything else to manage their ADHD, right? And so a lot of what that and so so I've seen, you know, all sorts of different patterns in different kids as to what we wound up doing over the course of their time from their diagnosis all the way through college. And I've just, you know, I've been doing this now for twenty five years, and so, one of the blessings of that is that, you know, I've been able to take care of kids all the way from birth, all the way, you know, through elementary age and made their diagnosis and got them off to college. I mean, it's just a, it's a long term chronic thing, but, you know, it's it's it's given me the perspective of somebody who has seen it at all different stages. And so, what I find in elementary school is that sometimes, kids who have a diagnosis with ADHD, that that, you know, that we need to do medicine or some some sort of specific therapeutic during some periods of some years in in in their schooling.
And then some years, they will be with a teacher or in a classroom setting or in some other sort of educational setup where the the what they're doing in the classroom setting is so engaging that they need a lower dose or they don't need medicine or, you know, we kinda go back and forth as to, like, as their hyperactivity starts to turn down, then, you know, if they're not if there's if that's not as much of a problem and they're more engaged and interested in what's happening academically, then they are able to, you know, engage with that without additional help. Doesn't mean they don't have ADHD. It just means that we, you know, are able to modify what we're doing at any given time. And I will see kids who, you know, as they get into high school, that they have been coping and then we start I mean, that that 15 year old year to me is a really important year because that's a lot of times when kids are learning to drive or they're getting their permit, and Mhmm. And sometimes it's a little older.
I mean, that's sort of been moving around a little bit. But I would say that when we talked about executive functioning in the previous podcast, that learning to drive requires a lot of executive functions. It does. Right? I mean, so learning to drive.
So I think a lot of times as adults, we think about driving as sort of this, like, task that we do that, you know, sometimes you feel like you can get in your car and then you Reflects it. You don't even yeah. You don't even remember getting there, but now you're at work or Right. Grocery store or whatever. But when you're learning how to drive, there are multiple layers of things that have to happen.
Right? So there is, you know, being able to actually control the car itself, and that's why people, you know, recommend people start in a parking lot where there's not any, you know, just the child can learn how to or the teenager can learn how to control the car. And then you've gotta learn the when you get do get out on the road, like, learn the rules of the road so that you're, you know, behaving in a way that other drivers understand and that you're not, you know, cutting people off or turning across things or whatever. And then then there's the whole level of navigating, trying to figure out where you're trying to go. And so those are pretty, like, significant executive functioning things that have to happen for people to learn how to drive.
It eventually becomes more automatic, but I have a lot of 15 year olds where, you know, they were hanging pretty well in, like, ninth grade, and they were really interested in what they were doing, and they weren't having hyperactivity anymore, and they were impulsives were under control. And they were doing ninth grade okay, and we're and we weren't doing medicine. But then when they got their permit, it became very apparent that they needed, you know, they needed to be able to focus better in order to learn how to drive. And so that's a big time that people will, you know, will sometimes if we weren't on medicine, we'll go back on it or we'll change it or we'll go in upper up on the dose because it's I think that that task in teenage years is, like, one of the most important things that we need to be able to learn how to do, and it takes a lot of executive functioning. Right.
And then I would also say that, like, I'll see, you know, sort of anecdotally, I'm taking care of kids all the way through college, and I'll see kids where, when they're in the first two years of college and they're doing their gen ed requirements and stuff, like things that they may not have specifically, you know, chosen to take, but it's part of the requirement for, you know, for their graduation. And so they will be taking classes from departments that aren't particularly interesting to them, and so they're sort of still on their medicine like they were in high school. And then the second two years, they're in their major, and everything that they take is something that they are super excited about. Right? And then they don't need it at all.
And so so it really has a lot to do with what is internally motivating to that person. Right. And and so that is why having ongoing care and sort of frequent follow ups with your, you know, ADHD medication provider person Yeah. Is really important because, you know, the the strategy will change based on what you're doing and whether it's summertime or whether you're going to, you know, sixth grade where all of a sudden, you know, in fifth grade, you're in the same classroom, the same teacher all day. I mean, some fifth graders change classes and stuff, but it's not like sixth grade where every hour you're going to a different setting and you have to keep up with all of your stuff and what each teacher wants and all of the social aspects of that and just finding your way around the school, and those things are take a lot of executive functioning.
And so They do. It, yeah, it sort of waxes and wanes throughout their education and their life as to, you know, what they need and when, and that's why typically for us, like, in in my clinic, I try to set it up so that, I like, sort of my baseline is to see a kiddo in the summer for their checkup regardless of when their birthday is. So if they're if they're in in school age and we're not, you know, we're at the place now we're doing once a year well checks, then I'll see them in the summer, talk about how the year went, come up with a plan for the fall, and then see them about a month into the school year to see if that plan is working. If it's not working, then I'll make, you know, adjustments to what we're doing for them and then see them back until they're therapeutic. We can talk a little bit more about what that means, in the fall, and then I'll see them again in the spring.
So it's at least three times a year Right. If you're getting so that's why it's sort of a chronic condition. So you're gonna get, you know, intervene and, interact with your physician. You're gonna wanna you're gonna wanna do it a lot because, the the treatment is dynamic just as ADHD is dynamic. It's always changing.
Exactly. Very changing. And so you have to, you know, frequently see your your your health care provider to, you know, change things as needed, I suppose. Mhmm. So in in in the next episode, we're gonna talk a lot more about specific types of medication.
As a clinician, finding the right medication and dosage for a child with ADHD is a lot of it's trial and error. It's a process. Yeah. Right? And how so how do you work with parents, to figure out what works best for the child?
Yeah. Especially, you know, in in the, the the first few visits that you see them. Right. So, you know, a lot of times I will you know, once we kinda have a diagnosis and depending on, like, the sequencing of that, whether that's made all at one visit because I've already already have the measurement scales of the Vanderbilts that we talked about in the first episode. If I have both of those from the parent and the teacher and I'm able to make a diagnosis, then I will usually sort of say to a parent, okay.
This is your child's score because they'll remember, like, 18 questions scored zero to three. So top of possibly, you know, 54 as the, you know, as the highest number you could get. Right. And so and then I would say to them, okay. Well, this is your child's score, whether it's 41 or 36 or 28 or whatever it is, and say, okay.
And so my experience and the data shows that we want to shoot for getting those symptom scores to about 18. Mhmm. Okay? That's my goal. Right.
And so and what that means is that all of those questions are occasionally or lower. Right. You may have one or two that are often or even very often, but if it averages out to be, like, 18 or below, then I consider that therapeutic. And so so I do think it helps for parents to recognize that we have a starting point. This This is the score that we have as the starting point.
Sometimes the teacher score is higher than the parent score, sometimes vice versa. But usually they're I mean, it's honestly, it's pretty impressive like how close they often are. Right? And so usually they're within five or six points of each other. And so my my goal is to say, okay.
This is where we are and this is where we're headed, and let me tell you the options of what we can do to try to alleviate those symptoms. Because we know that if we leave the symptoms alone and we don't manage the condition that there are, you know, risks to taking that approach. Sure. Sure. Yeah.
Certainly. Yeah. So there's there's a long term there's a long game at the beginning here. Oh, yeah. But then there's also a short game, you know.
Mhmm. In a child's life, you know, they're changing, classrooms. Right. They're changing, activities and so forth. So it's a it's a a difficult condition to to get a get a hand on.
So, and then it brings up another point. So much of of, you know, treatment for ADHD is is based on school performance. Mhmm. So how do the classroom dynamics and, you know, teacher fit play into play into long term management? And can you give an example perhaps of how this might impact, a child's ADHD symptoms?
So if you if you have a teacher you don't like or something or just just not a not a good fit, it seems like it's gonna be problematic perhaps. Yeah. It is. And then a lot of times, I think what happens is that the child's perception is that that they themselves are not liked by the teacher. Right?
Which is probably not true, but it's it it but it is their perception. And the reason for that is because they are kind of repeatedly getting called down for doing something that, you know, I think for a lot of these kids who have ADHD, like, it feels to them that they are getting in trouble for things that they could not help. Right? So when their when their brain is presented with the opportunity something, a lot of times and they're able to articulate this sometimes or they're like, you know, by the time my brain had a chance to think about making a good choice, I had already done the thing that was gonna get me in trouble. You were five chapters ahead of that.
Exactly. And so and and so they just didn't get a chance to, like, I mean and and that's really hard for them because they feel like they're constantly kind of getting berated for stuff that that that that really it's almost feels like it's involuntary. I mean, it's, you know, obviously, it's voluntary whether you touch something or run to something or do I mean, those are all voluntary muscle movements. But as far as their executive functioning at being able to to control the impulse to do something that they're not supposed to be doing at that moment, it feels involuntary to them, and so when they're sort of constantly getting, you know, corrected, especially publicly, so the other kids can see that. Right?
You know, because they're getting called down and, and so they they get the sense that, you know, the teacher doesn't like them, and that makes school really, really hard. Right? And so, and they start sometimes they'll start to resist trying you know, going or they'll build up sort of anxiety, and they have and that tends to once that it kinda tips over, then you you you know, things can get really challenging. Right? So, and since so that teacher fit, like, I will say there are lots of different teaching styles out there.
Some of it has to do with, like, you know, just teacher experience, which totally makes sense. Right? Right. And and, and then my my son is currently teaching. He's teaching high school, and it's so interesting to talk to him about, like, what that experience is like.
This is his first year teaching. And, and and it's just, you know, there there's just a lot of different styles as to how that can work. And so there are some teachers who just by their temperament or their experience, are really adept at managing a classroom with kids who have a lot of trouble with their attention or their behavior Behavior. Yeah. For whatever reason.
Right. I do think, you know, like, this may be a little bit controversial, I think, especially for older kids, though, that that maybe not so much, like, oh, this may be true at all levels, but I have sort of specific data on this high school age. And I do think that when I talk to my son about his ability to manage his classroom, even though he's a first year teacher, I think that because he is male, that that's an advantage. Sure. So I have found that to be true for some of my, like, kids with ADHD along the way where when they had a especially for male children, they have a male teacher that, that that that that sometimes the classroom experience for them just goes better Right.
For whatever reason. Right? Sure. Sure. And so a lot of it does depend on that, and there is still, like because of the modern age that we are in right now and where we are with school funding and what is available to try to help, in the classroom setting and how much support teachers get or do not get and whether there are, additional you know, whether there's a teacher's aide there or if there's somebody working one on one with a kiddo that there's in that classroom who has special needs and all of the things that sort of dictate what's happening in the classroom setting are gonna have an effect on every child in there and and that includes the kids who have ADHD.
Right? So there are some years that are just better than others. There are definitely educational, environments that are better than others. Some of those are accessible for folks. Some of them are less accessible.
There are, you know, obviously private schools where the classroom size is smaller and and there is more support for the teacher. So instead of one person, they pretty much always have two. I think still it's pretty standard in kindergartens to have a teacher's aide in the classroom as well, but, you know, once you get to first grade, it's typically one person. And so and so the style that that person uses and how that works is, has a lot to do with, you know, the fit as to as to how that's that's gonna go. And so that, you know, that's part of why we get together, you know, three or four weeks into the school year and be like, okay.
So tell me about your day. You know, what greater what grade are you in now? What's how things are going with the teacher? The parent can chime in as to what, you know, how they feel like things are going. And then if they're change changing classes, it's always very interesting to me to find out, like, what order do you have your class in?
And I really feel like no one should have math at the end of the day, but somebody has to have math at the end of the day, right, because that's the math teacher still teaching and so, and so that has an impact, you know, what the order of their classes are. There's just a ton of different variables that dictate, like, how any individual kid whether they have a diagnosis or not of something or whether they whether they are typical, like, developmentally and, or whether they have challenges, you know, all there's tons of variables that affect, you know, how school goes for them. For sure. For sure. So we we touched on, you know, medication, therapy for for ADHD, which we'll discuss more next next episode.
Mhmm. But, talk to me a little bit about how working with a therapist Mhmm. Can potentially be beneficial for a child with ADHD, particularly if they have these sort of comorbidities like depression, anxiety. How does that help you? Yeah.
So there are, I mean, I do think that there are there is well, first of all, I will say that, like, you know, the the evidence as far as, like, trying to manage ADHD with as as its own condition without a comorbidity that you're trying trying to target, but if it by itself that, you know, the what we've got the best evidence on is medication and or therapy, I mean, and therapy. There are some things that therapy can address that are that are sort of core ADHD components and so the biggest thing is sort of behavioral therapy. So for kids and we do this a lot with, like, play therapy with young children, there's also something called parent child interaction therapy Mhmm. And and basically, it's sort of a strategies for behavior modification to help a kid with ADHD just be better able to, first of all, have reasonable expectations about what is is going to be happening around them and then how to, you know, function in that setting. Right?
So the the PCIT, which is parent child interaction therapy, that's very helpful, you know, in the home setting because and that's, you know, where they are a good part of the time, that they have been through that and that's something that, you know, that that the parent does with them, with the therapist, and it can just help kids and parents have a more, like, productive functional relationship as far as that child's behavior. Yeah. Right? And so being able to, you know, help control their impulses and hyperactivity and if they're aggressive or any of those things, you know, trying to be able to get to a good place with that knowing that the natural history of that is that it does get better because your executive functioning each month that goes by, you know, gets a little bit better, a little bit better, a little bit better, and so we're trying to really maximize that as much as possible for kids. The the the side note to that is that when you're looking at the issues of inattention, right, so this this difficulty with being able to attend to the agenda of another person's, you know, theoretically the teacher, right, or to some extent your parents too, but, like, but, like, the inattention part of it, it's really hard to do therapy for that.
Right? Like, so it's that you really there's not really a way to get people to be able to pay more attention to stuff. But even if you tell them, you know, you know, when you talk about how important it is that you get your homework done, that is still not gonna get the homework done most of the time. Right? So because they just don't have the motivation to do other or the it's not intrinsically, like, rewarding to them.
Right, exactly. So so that I think I think people often be like, well, we wanna start with therapy for for their child's ADHD and I'm like, I am fine. I'm great with that behavioral therapy. I think it'd be great for you to do this program or see this therapist, or, you know, work on behavior modification and I think that will help. But at the end of the day, if you're talking about like being able to pay attention, especially for kids who that's their primary problem, so there's a whole group of kids out there who really don't struggle with the hyperactivity or the impulsive stuff.
These are typically older kids. A lot of times, it's girls where they, you know, just, I guess, societally or just hormonally or whatever, just are not don't have the same motor challenges, you know, that younger younger male patients have. But you can't really talk somebody into paying attention to something that they're not, you know, interested in. And so that is that's but you can definitely, there's a huge role for therapy for kids who have ADHD, especially if, you know, I feel like, you know, around second or third grade, like, somewhere in that time frame, if they've got ADHD and they have not you know, it's not well managed and they're having paper cuts, like, emotionally, psychological paper cuts have sort of added up, and now they have some anxiety about school and they have big worries about themselves. And so seeing a therapist to address that is very helpful.
For sure. Yeah. Absolutely. And so and and but but, ultimately and I know we're we're gonna get into the specifics of different types of medicines, like, with the next conversation, but just in the big sort of scheme of things of the concept of medicine, I think, like, it may be worth me just sort of putting this out there in that, like, our best information, like, evidence wise, is that, for most kids that that a trial of medication is warranted if they meet the criteria. Sure.
Okay? Sure. And and so, and and I realize that that is a somewhat controversial statement. I totally understand that. I have personal experience with my own child doing this, and so I understand that, like, this is, you know, it's a big step for parents.
A lot of times parents don't agree with each other about it. Yeah. That's a challenge. Yeah. And and, again, if I could wake up in a world where nobody needed medicine, I would love that because, you know, that would mean that we can accommodate all sorts of different brain and learning styles and behavioral things.
We can accommodate all of that in our, you know, utopian education system. Right. But that's not where we live. It's not where it's not the world we live in. Yeah.
Exactly. And so and so my goal when I talk to parents about what are my goals for treatment and why do I think medicine is gonna be most effective at getting us there, then we're kinda back to those numerical, like, we call measurement based treatment to target. So we're gonna measure your symptoms and then do an intervention and see if that we measure them again if they're better. Right. Right?
And so that's sort of the the goal. But, you know, I feel like for a lot of kids that or for a lot of parents, you know, the idea of, you know, embarking on medicine is is, you know, it's it's a little a little It's daunting. Yeah. Right. Exactly.
And I totally understand that, and I understand there are side effects. And I think that it's it's important though that I think that it I do think that it is important for folks to understand though that when you're thinking about just ongoing management of ADHD in general is that we you want to be ideally with a provider who is or who is who is willing and able to discuss all your options Right. And give you pretty clear, like, goals for treatment and then be willing to, you know, see you frequently enough to make sure that, you know, we're getting we're we're getting we're getting to a therapeutic place where the child is, you know, maximizing their functioning in the classroom setting, and then minimizing the side effects. Right. So we are trying to do I'm trying to do as little medicine as I can get about get away with, but that keeps them functional and making progress academically and in their home life and in their social experiences.
All of those things are really important to me as a provider because that's really what I'm, you know, trying to do. You're trying to build this little person and their little brain into a, you know, a functional place as they get older. Right. Right. Well, that this sort of segues nicely into, what I wanna talk about next.
So we we've discussed a little bit of about medication and then the role of a therapist. Talk to me about the collaborative care model, which I know is is a a subject close to your heart. So tell me what that is and how it, results in in often better outcomes. Yeah. So it has been recognized, I think, over the last several years that that a lot of times, you know, I think I think for medicine, we try to fit everything into a specific pattern of treatment.
And so, you know, in pediatrics, we do a lot of well child care, we see newborns, and there's a certain pattern to what happens with them. You know, they lose weight and then they gain weight and then they're off to the races. And then you have, like, like, what we call, you know, it's like quick sick visits where the those the things that people often associate with pediatric, which is like, oh, my child has a stroke throat or an ear infection Right. Something like that, and those are all sort of discrete, you know, sort of one off things Yeah. That need to get taken care of.
And then there's sort of chronic care management. Yeah. Right? And so when when I think about chronic care management, I think about a lot about mental health, because of the statistics that you shared in, you know, in this in these conversations because, you know, that is an enormous, like, issue right now for this generation of kids and it seems to be growing. And so, you know, those three kind of core conditions that I think about, I feel fairly strongly that, you know, the the primary care doctor so your primary care doctor would be your pediatrician, your family practice doctor, or the person that's, you know, your first line folks that are not necessarily specialists.
Right. But I do think that there really needs to be, for primary care doctors who see children, they need to have some fairly significant competency in managing the three most common mental health conditions that we see in the pediatric population, and those are ADHD, anxiety, and depression. Okay? And so as it turns out, managing those conditions is often doesn't really feel qualitatively the way that it feels like when you go in and see somebody who's got an ear infection, right? So you go in and you see somebody and they have a history, you know, over the last three days that this is, you know, they're having some fever and congestion and now they're screaming all night, and you can do a physical exam and make a diagnosis and then give, typically, you know, prescribed medicine, and then we've kind of wrapped that into a nice bow and we're like, okay, you know, that was a discreet visit and it was a problem that we've taken care of.
Okay. So these other, like, chronic conditions, so the mental health ones, and I would say asthma is in that group of conditions. Mhmm. I think to some extent sort of abdominal pain slash constipation, which is something that is super common in kids and overlaps a lot with these mental health things, that sort of a chronic condition, and so all of those things really qualitative qualitatively to me as a as a pediatrician and I think to parents, it's like, well, this is one conversation in a series of conversations that we were gonna have about this problem because we're not gonna end it with a course of amoxicillin. Right.
Right? So it's gonna be an ongoing conversation. It's not take two of these and call me in the morning. Correct. Exactly.
And and so knowing that, I think that the system has started to recognize that, that the the individual, like, interaction that the patient and the parent and the pediatrician have in that office visit is really not enough to, like, manage the condition as a whole, and so we're starting to recognize that there are a lot of additional supportive things that can be done between visits that are extremely helpful. And so the way for us to get that done is to have an another team member within our, you know, practice or in the in the system who is called a behavioral health care manager. Right. And that person will do things on behalf of, you know, the doctor or the patient that can really make a huge difference and make it so that it was we're better able to long term manage this condition. And so a good example for kids with ADHD is, sometimes it is really hard for parents documentation that I need, so the Vanderbilt form from them, and they would like us to do that on their behalf instead.
And that is fine. Yeah. Okay. So a lot of times, the reason for that is because, the teachers so sometimes the the parent will hand them the form, and then the teacher is in a little bit of a quandary because they're going to then fill out that form. It's gonna it's gonna reveal a lot of concerns and then they have to hand it back to the parents.
Right. Right. Then the parents gonna look at it and be like, I didn't know this was going on, and we need to talk about it right now or in the middle of the, you know, drop off line or whatever. And that's not that's not a great system. And so so that so having an intermediary Mhmm.
Where they can where I can get somebody to go to to talk to the of course, you know, we we have the parents sign a release of information so that we can talk to the school and the school can talk to us, but we'll I'll have them talk to the school and get the information that I need. Sometimes that also means talking to the guidance counselor and finding out what's happening what else is happening with that child at school that may or may not really be known to the parent for any number of reasons. There are kids out there who have different plans in place at school, things like IEPs, which is an individualized education plan. Sometimes they'll have something called a five zero four plan, which is doesn't modify the curriculum, but it does make accommodations for kids, and parents may or may not be aware. In theory, they're supposed to be aware, but it depends on sometimes there's a different caregiver who's got them.
So they they got their IEP when they when their mom was with them, and now they're with grandma, and we don't really know what's happening at school. And so those are conversations that my behavioral health care manager can have with the school to gather information, you know, for me in order to be able to make the best possible decisions, make the best possible outcome for that kid. Right. And the other thing that the behavioral health care managers can do is they can help navigate the very challenging landscape of trying to find allied mental health providers. So this would be, like, therapists.
There is a lot of resistance in the insurance world Yep. To cover those kinds of services, and so it it often requires help. So it used to be, you know, a long time ago, I would be, okay. Well, you need to talk to your insurance and see who you can see for therapy. And, 90% of the time, probably, it just never really happened because, parents would run into insurance challenges or they, would be calling somebody who they, you know, couldn't get an appointment with or they're scheduling really far out, and that's those are still all challenges.
Right. But to have a professional advocating for doing that for you on your behalf makes a huge difference because they already kinda know what the landscape is and who sees which insurance and who's scheduling out in a month and who's scheduling out in six months. And all of those things, take a lot of the burden off of parents who are typically very busy and challenged with whatever's going on with their child and often don't have time during the work day Right. To be able to make these connections. And so the behavioral health care manager does that on their behalf, and then there's a whole bunch of bunch of other things that they do.
They do a lot of parent coaching with parents. They're able to talk to them during, you know, little individual individual times that they can find for a five or ten minute conversation about, okay. You know, here's a little checklist of things to be thinking about for your child with ADHD. Like, how is how are things going at their bedtime, and are they getting, you know, are they getting enough sleep? Are we setting up setting them up for success with that?
Do they have a clutter free environment to do their homework in? Right. These are all things that, of course, I, you know, can talk to them about too, but sometimes I run out of time because I have, you know, certain number of minutes that I'm allotted and, of course, you know, it's important to try to maximize that as much as possible, but having additional support, in the form of behavioral health care manager has been, you know, just, I think, really a game changer. And we've been doing that type of care for more than ten years. Yeah.
And just recently, it has become something that we can bill insurance for. Nice. Okay. So that has been helpful. That's very helpful.
I'm sure. Yeah. For the practice. Yeah. And I think that the I mean, I really think that the, that the systems are recognizing the fact that mental health is an important thing to be able to get a handle on.
And if for no other reason, if you don't do it, it can be very expensive. Right. The more expensive problems down the street. Correct. Exactly.
And so I think that people are starting to recognize that we need to take a more, like like, a holistic approach to mental health and try to get really, you know, try to try to, you know, get on top of it before it, you know, blows up into some really scary, problematic, long term thing. And that, I think, is really what we're, you know, trying to do. And so and so, and so collaborative care makes that, you know, much more possible and much more, like, you know, revenue positive, all the things that, you know, that we wish weren't part of medicine, but they are. And so, and so then the other part of of of collaborative care is the collaboration part comes in with the idea that you, as a general pediatrician, knowing that, you know, my general pediatric training, now given it was, like, in the nineties, so it was, like, you know, a whole long time ago. But at that time, we had pretty minimal, training in mental health.
They're they're getting more now for sure, but still, you know, there are definitely people who have subspecialized in mental health. So psychiatrists And then also also there are behavioral developmental pediatricians Uh-huh. Who do this kind of work and have subspecialty training in that. I see. And so we so anybody who's doing collaborative care has an engagement with one of those types of people who has additional specialized training so that I have a resource to go to that I can talk about my cases with so that I am sure that I'm doing, you know, managing correctly.
Right. Right. So, and that has been also a game changer, you know, super helpful. Right. Learn a lot from that, and and I think the the patients benefit from it a ton.
And so, and so I'm very excited about the new landscape with collaborative care, and and the other part of it, I think it's important to to understand as well is that, you know, the collaborative care model, at least in the way that it's set up in North Carolina, so the bit you know, you have a you have the patient sort of at the center of it, the primary care physician, there's behavioral health care manager, and then there's your sort of specialist person who's helping. But all of that information is being is is stuff that we are able to quantify within the electronic health record and sort of what we call a registry functionality. Right. And so it allows us to be able to see, okay. Well, this is what your score was on your questionnaire, numeric, like, representation of how how you were doing.
You can quantitatively evaluate the the efficacy of the treatment. Right? Correct. Exactly. And you can do that on an individual level, and you can also do it on a population level.
So then you can say, okay, this is our process for managing folks with these conditions. What percentage of them are getting better at this rate, you know, like, how what percentage of them have dropped their total score by fifty percent or have gotten to the therapeutic score that we're targeting, and and all of that is just quality measures that help us get better at doing this type of care. And so all of that stuff is, I think, extremely, you know, it just it's I think I think it really takes us to a new place as to how to manage this, and I just think it's really important because I think for a long time, we've been trying to be like, okay. Well, I'm just gonna dabble in this here, anecdotally do this and whatever, but now we put some really good framework around it that is evidence based and numerically quantified, and we have a more, you know, intact plan for addressing it because we know, like, as as time goes on that, the numbers that we are getting for pediatric mental health and adolescent mental health, we had a huge frame shift of of increases in the prevalence and incidence and prevalence of these conditions, you know, during and after the pandemic.
And that increase has, you know, has slowed down, but it hasn't gone back down. Like, so we just went to a new level, and we're staying at that level. Yeah. So we know that it's gonna continue to be, you know, a big part of what, you know, we're gonna be doing. If you're taking care of children, you know, in a in a medical setting, then this is something that is important.
Yeah. You have to be on top of this. Right. Right. Absolutely.
Absolutely. So, in conclusion, we've talked a lot about continuing care for ADHD and and what the the clinical practice, what types of of, treatments are available and and how the the clinical practice and particularly this collaborative care model Mhmm. Plays a role. Is there how do parents sort of navigate what is a very complex condition, and is there anything that the parents can do to sort of help their children through ADHD? Yeah.
So they're so, honestly, you know, parents have an enormous role, caregivers, whoever that may be, even the child. And sort of there are there are lots and lots of different, like, resources for this. So, certainly, Russell Barkley's writings that we had we'll, post, he has really, really good, books that have tips for parents on what are appropriate expectations. Right? Like, what should you be able to expect from your child with ADHD so that you can sort of, as a parent, frame your expectations so that they're appropriate for that child so that you're not frustrated and they're not frustrated kind of on an ongoing Right?
So that is a really big thing that parents struggle with, and and I think it also sort of highlights the idea that, you know, generally comparing one child to another is not super helpful. But, but for kids with ADHD, you know, if your other like, some friend has a child who's the same age and they're they have a different behavior or how they're doing with, you know, their executive functioning or whatever it is that they're trying to recognize the fact that your child has challenges that may make that a later developmental thing for them Mhmm. Is helpful. So the parents who who have kids who have the best, you know, who who do the best with ADHD are parents who are understanding who are knowledgeable about ADHD, and they're willing to learn as much as they can. Knowledge is empowerment.
Knowledge is empowerment for sure, and they're also, you know, willing to recognize that, that their child is an individual and and unique and that that when they hit certain developmental milestones, it may be different than it is for other kids. Okay? So that is an important thing. And then there's all the other strategies that our behavioral health care managers often will go over with parents and I will try to do as well, but, you know, there is a lot about setting up your home environment, you know, for success for your child. And so the idea of, you know, trying to have things as to the degree that it's possible, as predictable as possible, having a routine that really helps kids with ADHD because, it just helps them know what to expect.
And that's true for all kids, but for kids with ADHD particularly, I do wanna sort of make a plug for sleep because I think that in addition to, like, the struggles that folks are having with mental health stuff, I think that a lot of people, kids of all ages, are really struggling with sleep. Yeah. And, and Jonathan Haight, I think, hits on this a lot in the anxious generation, and I think it's a lot of the phone stuff. Yeah. It's it's all these digital distractions.
Right. And so if there is one thing I could say to parents with young ish children or even older children is that, there is just zero reason for your child to have access to their phone at night. Right. Right. And and that is I I have said that before in the office in front of a 13 or 14 year old, and I have never been glared at so hard.
Right? I mean, like, it is it's really off putting because you're like, oh, gosh. That really struck a nerve. But but I know that that kid is, like, not sleeping, and they are not functioning very well in school, and their grades are reflecting that, and the medicine is not gonna work all that grade. Whatever we do, it's not gonna work if they're not sleeping.
Yeah. And so, I am a big proponent of that, and, you know, kids hate it when I say that, but there's really, you know, sort of that old adage that, you know, nothing nothing good ever happens after midnight. Well, that's true, you know, even if you're in your own room or whatever. Like, you probably they they need to be asleep, and and and the the I think it's important to recognize that there there is an entire industrial complex that is geared towards capturing your child's attention through their phone. The information industrial complex.
Yeah. Exactly. And they have zero qualms about whether your child is doing well in school or is emotionally regulated Right. Or is headed towards, you know, they don't care. Right?
There's just zero interest in that at all. They are it's a financial for them. They're paid to figure out how to capture your child's attention and keep it for as long as possible. And if that means through the night and interfering with their sleep, that is all the better for them. Yeah.
Exactly. And so I think that we just need to not I think it's that's one of the things I would say, and this is something that, like, you know, my my children are older now, but I know that I did not, you know, like, have a handle on this at the ages that they were when they, you know, had phones and stuff. And so that is, if I could redo it, that'd be the biggest thing that I would do is that is to make sure that, you know, that is not gonna interfere with their sleep. That just needs to be the rule for everybody Yeah. Because it's just there's and and I think kids are like, oh, I use it as my alarm clock.
Well, you know, alarm clocks are, you know, 11 or $12. You can set you can set your well, you or you can set your phone alarm and, you know, it'll work. And well, they'll say that they want their phone Oh, I see. Because because that's the only way that they can get it. Yeah.
But that is and, you know, not to, you know, sort of dissuade every all that, but I really think that that is, that is not a good enough reason. It is not a compelling reason to have one. And and that's typically the argument. And so parents will be like, oh, yeah. You need you're using as your alarm.
I'm like, you need to get them another alarm or just get them up. I mean, I don't know. Whatever it is, but, like, them having their phone at night, I swear, is just not that's just not a good thing. It's not a good thing. So those are a few little, like, tips, and we can get into more of that.
But those are, all things that, you know, I think can be helpful for kids with ADHD. All kids, but particularly that group. Excellent. Well, thank you, doctor Hoyle, for this intense and and, you know, wide ranging discussion on on ADHD, in the in our next and the the final episode of our three part series on ADHD. We'll continue talking with doctor Hoyle, and, we'll take a look at the variety or you might wanna say that the panoply of medications available to treat ADHD.
Thank you for joining us today. We're excited to have you along on this journey as we explore, the complexities of parenting in the modern world. Be sure to subscribe to our website, www.nimbleyouthpodcast.com. That way you won't miss an episode. Again, we'll also be posting links there to some of the the research studies and books that, we've discussed in each episode.
So we'll see you next time on Nimble Youth. Until then, take care and remember raising a mentally nimble child is not just about preparing them for the world, it's about helping them thrive in it. See you next time.