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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 the Nimble Youth Podcast. I'm your host, Matt Butterman. Today, we're talking about one of the most challenging and confusing situations parents face. When a child's behavior becomes so disruptive that school is calling daily and sometimes hinting that your child might need to find a different classroom or a different school altogether. This episode is called When ADHD and Help!
Matt (host):My child is getting kicked out of school. And trust me, that title is not an exaggeration. This is a scenario we hear constantly in the messages we get and in Gretchen's clinic. We're joined as always by Doctor. Gretchen Hoyle, my partner pediatrician with twenty five years of experience and a special interest in pediatric and adolescent mental health.
Matt (host):Before we start, we remind you that this podcast is intended for informational purposes only and does not substitute for medical advice from a qualified mental health or medical provider. Please visit a healthcare professional with any questions about your child's mental health. So, Doctor. Boyle, thank you for being here again.
Dr. Gretchen Hoyle:Thanks, Matt. This is one of the most common and really heartbreaking situations I see in clinic. And the good news is once we understand what's actually going on underneath the behavior, these kids can get so much better.
Matt (host):So let's start where most parents enter your office with a child who is already having major behavioral challenges?
Dr. Gretchen Hoyle:Right. I mean, by the time they reach me, the behaviors usually aren't new, but they've escalated. And the type of behavior that I'm talking about is like aggression, meltdowns, outbursty behavior, bullying other kids, being super disruptive in the classroom. And this leads to problems with interacting with other kids. They're not really having play dates, and they're not getting invited to the birthday parties, and their behavior is really impairing their social function.
Dr. Gretchen Hoyle:And sometimes their school or their daycare has said, we're just not sure that we can keep your child. Or at the very least they're calling multiple times a week, wanting the parent to come pick up their child, which is super disruptive to daily life. And so by the time I'm seeing them, lot of times the parent is in a really tough spot.
Matt (host):And these, these are not what you call bad kids, right?
Dr. Gretchen Hoyle:Not at all. They're just overwhelmed. I mean, are kids whose nervous systems are going into overdrive and a huge proportion of them have either ADHD, anxiety, or both. And very often they overlap. And in many children, especially those with a history of trauma, what looks like bad behavior is really emotional dysregulation and hypervigilance.
Matt (host):Let's talk about that overlap because most people tend to think of ADHD as being one thing and anxiety as something totally separate.
Dr. Gretchen Hoyle:Right. Exactly. But in real kids, real life, they overlap like all the time. And the lines between them really blur. What I see over and over in this combination is I'll have a kid who has anxiety and that makes them feel really like rigid, which means that when things don't go their way in any even small way, they just become emotionally dysregulated.
Dr. Gretchen Hoyle:They can't handle that. And then their anxiety also just makes them really hypervigilant. They're constantly feeling like they're under threat. So they're constantly looking for things to not go their way. And that's just a real, like panic inducing situation for them.
Dr. Gretchen Hoyle:And so you'll have that, but then overlapped on that is ADHD. And that, like having ADHD and that sort of difficulty with executive functioning, really takes the brakes off of like their ability to control their behavior. So even if they would want to not act out, they just don't have the control over their impulses and they have really poor frustration tolerance and then they have real difficulties with transitions and unexpected things. And so those two things together, if they're anxious and impulsive, that's going to be a challenging.
Matt (host):Yes. And then that trauma complicates the picture even more, right?
Dr. Gretchen Hoyle:Yeah, absolutely. I mean, trauma changes developing brains. So kids who've lived through chronic stress or instability or loss or frightening experiences are often, they often present like they have ADHD and anxiety, even if the trauma is the root cause. And for these kids, I absolutely believe that we need to do trauma informed therapy and we have lots of other environmental things that we can do to help, but that all takes a lot of time and effort. But in the meantime, the child is spiraling at school and being sent home and being labeled as like dangerous or a bully or out of control.
Dr. Gretchen Hoyle:And we can't wait for the therapy to really take effect while the child is getting kicked out of school. That's the pragmatic answer to that.
Matt (host):Yeah. Yeah. So when a family comes in and says, Help! My child is about to get expelled. It's a crisis situation.
Matt (host):How do you actually figure out what's happening amongst all the drama basically?
Dr. Gretchen Hoyle:Right. So like with our other conditions that we've talked about, we start with measurement tools. This is objective data that helps us figure out, you know, what's actually happening with the child. I'll typically use the SCARED questionnaires, which is anxiety, anxiety like measurement tool. And I get a SCARED questionnaire from both the parent and the child.
Dr. Gretchen Hoyle:And the way that I do it in my clinic is I'll have the parent filling it out on the computer in the room, but then I'll be doing the interview with the child. And so it's not like they have to be able to read or necessarily completely understand all of the questions off a page. I'm going to say to them something like, Okay, I'm going to say a sentence to you and I want you to tell me whether it is not true, a little bit true, or very true for you. And they could give me the thumbs up, thumbs down, thumb sideways on that, or they can say it out loud, or they can point to it on the screen. There's lots of different ways that they can communicate their experience.
Dr. Gretchen Hoyle:But the sentences would be things like, I don't like to be with people I don't know well, or I worry about what's going to happen in the future. And then they'll tell me, and then that will give us a score. And those are lots of, there are different questions that then allow me to categorize their anxiety. It'll give me a total score for their overall anxiety, and then it'll give me sub scores on whether or not they're having panicky symptoms, so physical manifestations of anxiety, generalized anxiety, like just worrying about kind of the future and just sort of everything in their environment. Separation anxiety, super common in young children where they're having a lot of trouble separating from their parents or caregivers.
Dr. Gretchen Hoyle:Social anxiety, where they're really having a difficult time interacting with other people or school avoidance, and that's super true for a lot of kids who are having trouble in school. They will start having a lot of symptoms that are around trying to get out of school. And so between the parent and child version of that questionnaire, it gives me a lot of information. And then simultaneously, I'll do something called a Vanderbilt form. We've talked about in previous podcasts as well.
Dr. Gretchen Hoyle:And that is really just for the parent to do when I'm in the visit. And so that will tell me about the child's level of inattention, their hyperactivity, their impulsivity, their oppositional behavior. There are some questions on the Vanderbilt about anxiety and depression. They'll tell you about their school performance and their performance and functioning at home and in daily life. Now to make an official diagnosis of ADHD, we need typically a teacher Vanderbilt that goes along with the parent Vanderbilt to show that we have, we're having trouble in two different settings.
Dr. Gretchen Hoyle:But honestly, what is happening for a lot of these folks is that when I meet them in clinic, the parent already has an envelope that's sealed, that's coming from the teacher for me. And when I open it up, it's a, it's a teacher Vanderbilt. So teachers are getting very astute at knowing what's needed to really help that kid get better.
Matt (host):And so what you're doing on this initial visit is you're assembling a data picture on day one.
Dr. Gretchen Hoyle:Exactly. Yeah. And, and very often that picture just screams to me. Yeah, this child has both anxiety and ADHD and the two are feeding off each other.
Matt (host):So let's break that down in plain language. Why is this child melting down at school?
Dr. Gretchen Hoyle:Yeah. So, so the combination of ADHD and anxiety makes the world feel dangerous and unmanageable to them. The anxiety tends to make them really rigid as far as like not being able to go with the flow. Like things happen, which of course things happen all the time that we're not expecting, but for kids who had a lot of anxiety, that really triggers their panic and they blow up. It makes transitions really hard and terrifying for them.
Dr. Gretchen Hoyle:It makes them overreact to really small things in their environment, and it just keeps them hypervigilant or in fight or flight like all the time. And so that's a really uncomfortable place to be physically and emotionally and cognitively. That's a hard spot to be in. So if you're already in that place and you're having environmental stimuli that are making you feel more panicked, and if you have ADHD on top of it, now you do not have a way to control the impulse to act out. And so they wind up acting on their feelings and their emotions and their internal experience before they can really think about what the consequences of that are going to be, because they just want the executive functioning to be able to do that.
Dr. Gretchen Hoyle:And can they can't really access their coping strategies in the moment, and things really they will escalate. And then if these are kids who have trauma in the mix as well, for a lot of them, their brain learned to be hyper alert and the system goes into alarm mode so quickly for them and they react to perceived danger, even when there isn't any, and that they often feel awful about their behavior afterward, but they just aren't capable of controlling it in a moment.
Matt (host):That brings us to the million dollar question, kind of the chicken and egg situation. Should parents treat the ADHD first or the anxiety first?
Dr. Gretchen Hoyle:Right. And so this is where it gets interesting and complicated. Sometimes I'll just ask the parents, I'm like, okay, do you want this child to feel better first or act better first? And a lot of times, I think most of the time parents think that the kind thing to do is to say, well, we want them to feel better. There can be some challenges if you're treating the anxiety first, and it doesn't go quite the way we expect.
Dr. Gretchen Hoyle:So sometimes if we are treating the anxiety, we're lowering that, like for some of these kids, the only thing that is keeping their behavior and impulsivity in check is that they have some worry about getting in trouble. And so when we help bring that down a little bit, then their impulsivity actually gets a little bit worse. And then SSRIs, the medicines that we typically use to treat anxiety, so these are often thought of as antidepressants, but that's what we use most often to treat anxiety in kids. Although there are other options that don't have these same side effects, but for the standard ones, the SSRIs, they do have the potential to activate ADHD symptoms. And so some kids can, they might feel a little bit happier and better, but they can have trouble with being more impulsive.
Dr. Gretchen Hoyle:And so sometimes what they start to look like is there's kids who are kind of, we call happy hyper, where of course that's much better than being angry, but it's still disruptive. So we have to sort of consider that as we're coming up a treatment plan. If we treat the ADHD first, many kids feel like they're more like in control of their feelings and their internal experience, and they're more in control of being able to get things done that they're supposed to, and that often can lower their anxiety. But stimulants themselves physiologically are up regulating the nervous system, and so that can sometimes cause them to feel more anxious and can also cause them to have more rumination on things that they're worried about. And so it's a little bit of a back and forth between those two things.
Dr. Gretchen Hoyle:So if we think about it as a neurotransmitter model, kids with overlapping symptoms often have low activity of serotonin in their brain, and that is what is driving the anxiety. And then they also have low activity of dopamine, especially in the front part of the brain, And that causes them to have ADHD symptoms. So we really need to address both of those and we need them to be, and we want to have adequate levels of both of those, those neurotransmitter activities, but we also want them to be in balance with each other. And sometimes that is where the real nuance comes in is trying to keep them in balance with each other. So how do
Matt (host):you handle this in real life? What's the treatment plan?
Dr. Gretchen Hoyle:Right. So a lot of times with parents, I'll talk through all of these potential outcomes of treating one or the other first. Lately, I've been actually starting with really low doses of both. So I will put them on a really low dose of a stimulant and an SSRI, and then I will sort of alternate going up on those so we can see how they respond. It is a painstaking process, but it it's is, the thing that I've seen that allows the child and the family to be the most comfortable with medicine, because sometimes if we start a medicine and it makes, even if it makes one thing better, if it makes another thing worse, then that really lowers the confidence of the child and the family that things are going to be going okay.
Dr. Gretchen Hoyle:And so I've started doing it this way. And I think that for a lot of our kids, it's been helpful. Sometimes parents have very strong opinions on starting one or the other, and I am fine with that. So we can say, well, we're just going to start with the ADHD and then see you back in a week or two, and then potentially consider something else. And I also can tell most of the time when I'm having side effects, I think the logic is when you start two things at once and you have side effects, how are you going to know which one it is?
Dr. Gretchen Hoyle:But for the most part, the most common side effects, like with the stimulants are trouble with their appetite. And so that's why I usually can attribute that to the stimulant. If they're feeling more nausea or dizzy or that kind of thing, I usually think more of that's the SSRI. Headaches are tough because those could be either one. And so it's kind of like, when is the headache?
Dr. Gretchen Hoyle:Is it when we are expecting the ADHD medicine to be wearing off or is it more kind of all through the day, which makes me wonder if it might be the SSRI. And so there's lots of like nuances to how to figure this out, but there's a huge factor that I really always talk about with parents when we're in this conversation. That's like, that's about sleep.
Matt (host):Yeah. Because sleep affects everything. It really does. All aspects of their mental health.
Dr. Gretchen Hoyle:Absolutely. So sleep, I almost think of it as a third medication or a third modality that we're using to help improve things for them. So getting good sleep is super helpful in improving their behavior and their mood regulation and their attention. And getting good sleep is critical for the medications to work well that we're giving them and is very helpful for impulse control. So when a child isn't sleeping well, it becomes nearly impossible to get their medicines balanced.
Dr. Gretchen Hoyle:And then I think I will take the time, the opportunity to give my usual public service announcement, which is my very, like, this is an unpopular, opinion with the kids that I take care of, but there is no reason, no good reason for your child to have access to their phone at night.
Matt (host):So many times, but it keeps, it keeps needing to be said. Think I what we're going to do is come out with a merch line. We'll have a, a pictograph. We'll have a cell phone with a circle around it and a slash.
Dr. Gretchen Hoyle:Right. Cell phone with a little, yeah, a little nighttime scene and be like, Nope, Nope.
Matt (host):Right. Right.
Dr. Gretchen Hoyle:So yeah, it is. That's a, that's a big thing. And of course that's not typically happening for my really young kids because they don't have a cell phone yet, but as kids get older and we can talk a lot about like just overall screen exposure during the day. But, and I think that there's a lot of conversation with that. We want to try to mitigate that.
Dr. Gretchen Hoyle:It definitely causes a lot of dopamine secretion in the brain and that can make it hard to get the medicines to work and all the other behavioral stuff. But I can say without equivocation that access at night is just not a good thing. So if I don't have nothing else, I would really encourage parents to recognize that and have that child's like tablet or phone or whatever electronics they have access to during the day, unavailable at night, preferably charging in the parents' room, that kind of thing.
Matt (host):So it's a complicated situation, but your message is as always one of hope, right?
Dr. Gretchen Hoyle:Right, right. Absolutely. It is amazing how much better these kids can get when we get the right combination of things going. We need a good diagnosis. We need a solid diagnosis.
Dr. Gretchen Hoyle:We want to use objective tools to get to that diagnosis. And then we want to balance the medications very carefully, and then really support them with additional therapies and sleep hygiene. And I know that probably listening to this, folks will be like, well, are we always having to do so much medicine? And I get that, but I would say that when people, when kids are quote unquote on fire, like getting kicked out of school or they're really having serious functional impairment, then I do, medicine to me is going to be on the table. Yeah.
Dr. Gretchen Hoyle:So, and, but I would say that getting with these, these types of families and working with them, it's really one of the most rewarding things that I do because it's amazing how much better kids can get when we get them on the right stuff.
Matt (host):Yeah. You're, you're kind of like a fireman. You're, you're putting out the, the blaze, right?
Dr. Gretchen Hoyle:Right.
Matt (host):Right. Well, Doctor. Hoyle, thank you again. I think this episode is going to help a lot of families feel more understood and give them a roadmap for what to do next.
Dr. Gretchen Hoyle:Thanks, Matt. And thanks to all the parents listening. And if your child is struggling, it doesn't mean that you've done anything wrong. It means that their brain needs support and we have the tools for that to work.
Matt (host):Absolutely. This has been the Nimble Youth Podcast. We'll see you next time.