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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 podcast. I'm your host, Matt Butterman. And today we're continuing a really important series on depression in kids and teens. If you've been listening, know, we're breaking this topic down by age because depression doesn't look the same in a seven year old as it does in a 17 year old. Today, we're focusing on middle school, that tricky, high change, emotionally intense stage that so many parents struggle to understand.
Matt (host):And I'm really glad to welcome back Doctor. Gretchen Hoyle, pediatrician with over twenty five years of experience. She spent the last decade focusing more and more on pediatric mental health. Before we start, I 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.
Matt (host):Doctor. Voigle, welcome.
Dr. Gretchen Hoyle:Thanks, Matt. I'm really glad to be talking about this age group. Middle school is really a pivotal time for most kids.
Matt (host):Yeah, it really is. So, let's start there. Why is middle school such an important age when we're talking about depression? Right.
Dr. Gretchen Hoyle:So, middle school is really the perfect storm, right? So, you have puberty starting, major changes in brain development. I always say to people, you know, the brain goes through puberty too. It's not just the body. So increasing academic expectations play a big role.
Dr. Gretchen Hoyle:Like when kids move into middle school, they're expected to be able to just keep up with more. There's a higher expectation of executive functioning. And more and more I see middle school kids who are taking, you know, high school level work. And so that tends to put some pressure on them. Then suddenly the peer relationships can carry a lot more emotional weight.
Dr. Gretchen Hoyle:And what I see clinically is that middle school is often the first time depression becomes clearly diagnosable. Before this kids may have more anxiety or emotional sensitivity, but then during middle school, those symptoms can deepen into depression. And a lot of what parents see is just sort of getting written off as, you know, as puberty hormones, they got attitude, when really there's something more serious going on. And so it's important for us to know what to decide.
Matt (host):Right. But how common is depression in middle schoolers compared to younger kids or their older teen counterparts?
Dr. Gretchen Hoyle:Right. So here's sort of the way that this stacks up. So to back up to elementary school, it was like one to two percent would make a diagnosis. By middle school, it's like three to five percent. And then it just climbs quickly as kids get older, set by high school rates by late adolescence, like fifteen to twenty percent.
Dr. Gretchen Hoyle:So it's pretty substantial. Middle school is often where depression first becomes visible and impairing. It's not just moodiness. It's a real shift into like difficulty function.
Matt (host):Yeah. And so, what does depression really look like in middle schoolers? Because it's not always just being glum or just sadness. Right?
Dr. Gretchen Hoyle:Right. Exactly. A lot of parents expect depression to look like crying or saying, I feel sad, but that's not what I usually see. The biggest thing is irritability. It's just that persistent, like irritability, grouchy.
Dr. Gretchen Hoyle:And, know, I think we all expect that from our kids, but when it's a persistent thing, it's, and it seems to be impairing their ability to function and it just, is sort of relentless. Then I do sort of now, I think it's time for us to take notice withdrawing from things that they used to enjoy. So a lot of times in middle school kids will sort of shift around their interests, you know, that they used to enjoy. They may not want to do anymore. They may pick one or they don't like doing music lessons, whatever it is that they there's, they're just, you know, they're changing.
Dr. Gretchen Hoyle:And so they should definitely have some freedom with that. But if they're really just withdrawing from everything, even things that they used to enjoy, then that's kind of a red flag. Loss of motivation. So just cannot get it together to get stuff done. And of course in middle school, the stuff is typically some combination of academic, you know, assignments and then some expectation at home, as far as like maintaining their room or their clothes or their, you know, chore kind of things.
Dr. Gretchen Hoyle:And with kids who just have no motivation to do that, that's concerning. And then if that's happening, of course, for long enough, then you're going to see, you know, academic performance go down. So you start to see the grades go down. Sometimes that's the first thing that parents really gets their like attention in that they can see the grades dropping in whatever the parent portal is that they're using for school. So even though they're all, they may have, it may have occurred to them.
Dr. Gretchen Hoyle:My kid seems a lot more irritable than they used to, but maybe that's just puberty. But then when you see that their grades are going down, you have sort of think to yourself that's time to sort of intervene. They often will have increased conflict at home. A lot of this conflict is about, is about the declining grades and the lack of motivation and this just sort of withdrawal and stuff as parents are trying to, you know, get their child to kind of right that ship and get back engaged. And a lot of times kids will just say things like, I don't care.
Dr. Gretchen Hoyle:I just don't want to do that. I don't care. I don't care what you say. I don't care what I'm supposed to do. I don't care about the future.
Dr. Gretchen Hoyle:I mean, a lot of times they're saying stuff, it's hard for kids to conceptualize how what they're doing in middle school is going to set the tone for high school. And then that's going to go to college. I mean, I know that it sounds like a record record to them on parents day of these kinds things, but the, for kids who are really just sort of repeatedly like, I don't care about that. Then that's something I probably ought to try to get a handle on because they often, that's often what they're saying when in reality, if they could be more like specific about it is I'm, I feel sad. I feel depressed.
Dr. Gretchen Hoyle:And that's why I don't care. But a lot of times it's the behavior that's telling the story.
Matt (host):But is this different from depression in the younger elementary age kid?
Dr. Gretchen Hoyle:Right. So younger kids typically show depression more by, you know, their outward behavior. And they also have a ton of physical symptoms like stomach aches and cleanness and regression and stuff. Middle schoolers will internalize more. They for sure have physical symptoms as well.
Dr. Gretchen Hoyle:So see a lot of kids, you know, in this age group who have recurrent belly pain or headaches, or sort of these episodes of sort of, I think it's like autonomic dysregulation where they often feel faint or dizzy when they get anxious. And then that can lead into sort of reducing their activity. And then their symptoms look more like depression. So there's a lot of like overlap with these conditions. In middle school, they internalize things a lot more than they did when they were in elementary school.
Dr. Gretchen Hoyle:They are more aware of peer comparison, which is, you know, kind of a nightmare if you're growing up at the time that we're in right now, where there's just so many opportunities for comparison. Like it's just never ending exposure to comparing yourself to other people on social media and stuff. And it's part of why we wrote that out up until later, but that's a, that's, you know, an ongoing, I think conversation for parents, kids in this age group, they tend to be much more sensitive to social rejection. That's part of the problem with social media is that their brains are pretty squishy. And so when they feel rejected, it's pretty, it's a pretty deep cut as opposed to like an adult where you're like, that's, you know, hurts my feelings, but I'll get over it, you know, but for sort of middle school age kids, that's a much harder thing to do.
Dr. Gretchen Hoyle:And they're just more really capable of negative self talk. This is a big thing too. They will just be super unkind to themselves internally. And so their distress is like quieter, but then often like deeper than what you're seeing in elementary age kids.
Matt (host):And so I'll ask the counterpart to the last question I asked, which is, how does middle school depression differ from what you would see in high schoolers?
Dr. Gretchen Hoyle:Right. Yeah. So high schoolers, you know, they're, and you know, when we think of high school, they're in puberty, but they're pretty far into puberty and they're really having more like, and I think that we're feeling like it's probably mid twenties before people reach their full, like frontal lobe development. But at the very least people in high school are going to have more insight and autonomy than they do in the most. And so they may have better ability to recognize that they're feeling sad and that there is something sort of pervasively problematic for them.
Dr. Gretchen Hoyle:And so they're able, a little bit more able to self like refer or direct themselves in for help. Middle schoolers are kind of in between. They're emotionally complex. I mean, they're more emotionally complex than younger kids, but they still rely heavily on adults to notice what's going on with them and intervene. And that's made screening and observation really important at this stage.
Matt (host):Yeah. So we've often talked before about anxiety and depression being comorbid or overlapping. Does that still apply here a lot?
Dr. Gretchen Hoyle:Yes, for sure. So this is for sure true. Like the younger you are, the more likely the anxiety is going to be the predominant thing. And it's certainly going to be the way that the thing that gets presented first. So, you know, that anxiety can often, you know, they'll have a lot of perfectionistic sort of thinking and they're sensitive and things sort of throw them off.
Dr. Gretchen Hoyle:And so if you're having chronic worrying about school and friendships and family and performance, and that can really, you know, wear people down over time and emotionally eventually could lead into depression. And that's why we're typically well assessed for both anxiety and depression simultaneously.
Matt (host):Yeah. So how do you actually assess a depression in a middle schooler?
Dr. Gretchen Hoyle:Sure. So we use the structured tools that we've talked about in previous podcasts. So for the anxiety, we often use a tool called the scared questionnaire where you have a parent and child version of that. And so it's important to get the child version and the parent version. It's interesting that around middle school, like a lot times in elementary school, the parents score on the questionnaire is higher than the child's score.
Dr. Gretchen Hoyle:And sometimes I think it's just, it may not totally understand the question, not really be able to like articulate it. You know, there's like a, you know, you ask them something and they'll say, well, that's a no for me, but then the parent score is a little bit higher because they can recognize it more somewhere around middle school that tends to shift. So the kid's score tends to be higher, mostly because they're sort of hiding what's going on. The parent are not, maybe not aware of the anxiety that they're feeling. So these questions on the scared questionnaire, things like, or the items are like, you know, I don't like to be with people that I don't know well, well, that not true, little bit true or very true for you?
Dr. Gretchen Hoyle:Or, you know, I follow my mom or dad wherever they go. And is that not true, a little bit true or very true for you? So some of those are things that parents can see and sometimes it's not. And so that's what's happening with the scary questionnaire in this age group. For depression, we usually use a questionnaire called the short mood and feelings questionnaire or the SMFQ.
Dr. Gretchen Hoyle:And that one has 13 questions that ask about mood, enjoyment, energy, self worth, and loneliness. And we talked more in-depth about those exact questions in the previous episode on elementary school. And so it's potentially helpful to listen to that one as well. Even if you have a middle schooler, because a lot of times folks will benefit from thinking about what their kid was like as an elementary schooler, to be able to sort of understand kind of how persistent these symptoms have been. But more in-depth in that, but starting to range around age 12, we will also often add the PHQ as an assessment for depression.
Dr. Gretchen Hoyle:And this is the one that lines up closely with the diagnostic criteria for depression. So around age 12, we feel like that's a reasonable thing to start asking. Over the last two weeks, Have you been feeling down, depressed, or hopeless? And you can say not at all, several days, more than half the days, nearly every day. And then we'll ask things like little interest or pleasure in doing not at all, several days, more than half the days, nearly every day.
Dr. Gretchen Hoyle:So we have nine questions like that. And then you get a score and we can tell whether or not that score is sort of outside the normal range. And then we can track it over time as we're making different, as we're doing different interventions to see if we can get improvement in their symptoms. Right. Well, includes this question about suicidal ideation.
Dr. Gretchen Hoyle:And so that is where it's really important, you know, for us to go ahead and ask about that. So the ninth question on that is like over the past two weeks, have you felt like you would be better off dead or hurting yourself in some way? And so that's, again, it's a not at all, several days, more than half the days. And so that can be a real insight into what's happening with kids. Now these, that question is positive more often than people would think.
Dr. Gretchen Hoyle:Okay. So a lot of times kids will tell me that that's at least several days. Sometimes it's every day, but, but what's often happening is that when I dig deeper, so what, if that question is true, then it will trigger some additional questions and we'll potentially at some point do a podcast more about like suicide risk assessment, but, it will ask more about, well, can you tell me more about that? Can you tell me about whether or not you have intention to do this? Have you made a plan?
Dr. Gretchen Hoyle:Can you share that with me? Those kinds of things. And most of the time, as it turns out what their experience is something called passive suicidal ideation, which is that it will occasionally come into their head that it would be easier if that things would be easier if they weren't around, or maybe other people would be better off if they weren't around, but it's something that's typically transient and that they feel like they have control over it. So they're not ruminating over it. They're like, oh, I shouldn't think about that.
Dr. Gretchen Hoyle:They're able to sort of push it out. But it's when kids are saying, you know what, that's a really persistent thing for me. I'm having a hard time with that. And that's typically indicates that we need to, go to a different level of care.
Matt (host):You've mentioned measurement based care here before. Can you explain what that means in this case?
Dr. Gretchen Hoyle:Right. So a measurement based treatment to target the idea that we're going to use standardized questionnaires, like the ones that we've talked about, get a score on those helps with diagnosis, but then also we're going to then intervene with different management tools. Typically this is going to be a medication and or therapy. And then we're going to recheck those question responses later on to see if the symptoms have gotten better. So what we're hoping is that the symptom scores are going go down and that would imply that the child's improving as far
Matt (host):as their depression goes. So where does ADHD fit into all of this?
Dr. Gretchen Hoyle:Yeah. ADHD is always in the background and all of these things that we're thinking about. And so that doesn't mean that every kid with depression has ADHD or every kid with anxiety has ADHD. There are definitely kids who don't have that, but I will find that middle school is when there's sort of the biggest jump in the expectation for executive function. So going from fifth grade to sixth grade, like typically in elementary school, you know, you're going to be with the same teacher or maybe you're going to switch classes once and have a team of teachers, you know, that you're going back and forth with the two, but that sort of controlled.
Dr. Gretchen Hoyle:It's almost like there's an adult there that's sort of, sort of escorting you through the day, the way that a parent might. Whereas in middle school, the most typical model is that kids will have a different teacher for each subject. And they're supposed to manage kind of all of that, like figuring out like what, like how to get, I mean, just physically get to the classroom and then figure out like what the nuances are about that teacher and what their assignments are and keep up with multiple different streams of work that have to be happening. And it's also often tell me that the big jump in middle school is that, you know, if you're in elementary school, your teacher is assigning homework and she may have this much math or some significant amount of math, and maybe it'll go a little light on the language arts. But if you're in middle school and you got two completely different teachers, maybe really high levels of both of those things on the same day or in the same week, and that can feel really stressful for kids when it feels like, you know, they're having to manage that.
Dr. Gretchen Hoyle:Now, these are life skills, you know, cause like most of us, you're not going to, going to have an adult, like following us around every day, you know, sort of paving the way for things to go smoothly, but it is a big step up. So, you know, for a lot of times for kids, if they have ADHD and the executive functioning is not really where it, you know, where it would be with their peers. If your, you know, cognitive abilities are, you know, age grade and age appropriate, then you really do need to be in, you know like that level of work. But if your executive functioning doesn't really allow that, then that can be pretty challenging and stressful and emotional. And a lot of kids just kind of like will conk out on that, kind of give up a little bit.
Dr. Gretchen Hoyle:And then sometimes they don't really, you know, this isn't really figured out until you get a report card or, and then you can kind of see that things are not going as well. And a lot of times too, in middle school, because you have multiple different adults involved. I think a lot of times parents feel like that their kid can get to the end of the term and be doing really poorly, but they haven't heard from the teachers. That's just not the way things work in middle school. A lot of times in elementary school, if you're kind of tanking, then a lot of times they'll reach out, but that's just not really all that doable in middle school.
Dr. Gretchen Hoyle:You have so many kids, you know, that each teacher has that they'd have to be on the phone all the time, especially time off course. And so the kid is kind of responsible for making sure that they're keeping up with everything. And that can be really challenging for kids with ADHD, and then it can exacerbate symptoms of anxiety and depression if they're just not really capable of doing And so that is where things, you know, can sometimes start to
Matt (host):tank in middle school. Yeah. Let's talk about treatments. Therapy is normally part of the plan, right?
Dr. Gretchen Hoyle:Right. I mean, for, was only for depression. I mean, that's an ideal scenario is that we've got some therapy involved. And again, and, and so we had talked about the four P's in the previous, like podcasts about elementary age, but there are like predisposing factors, which are often biological for a depression. So And when I think about those, I think about this for family history and sort of your, how you're wired up as to whether or not you're predisposed to have trouble with depression.
Dr. Gretchen Hoyle:And then there's precipitating factors and those are typically contextual for like, what's going on in that child's life. So, you know, loss or grief or bullying or things that are happening that tend to, you know, like often like happen around the same time that you're starting to have these symptoms. So there's almost like a two hit hypothesis, like you had some predisposition and then you had something happen that sort of brought it out. And so we can often get a lot of help from therapists by being able to process some of those precipitating factors, especially if it's things like my parents are suffering or like grandpa died. I mean, are things that are very common precipitating events for kids.
Dr. Gretchen Hoyle:They happen for a lot of them, but they can, you know, be like sort of kick kids into sort of a depression depending on, you know, what else is going on for them. And so then we think about those as predisposing and precipitating, and the perpetuating factors are things that are sort of ongoing things that make it hard to pull out of a depression. If you're having chronic family stress or maybe chronic illness or something else is going on, that makes it harder to turn things around. And so a lot of times having a third party adult, so therapists were like care manager person involved can be really helpful in helping address some of those things so that we can take the load off a little bit. And then there are the protective factors.
Dr. Gretchen Hoyle:So that's the fourth P and that's the other direction, which is things that can help mitigate the factors that are, that are pushing towards depression. So, and so the therapy can work with lots of those things. It can try to increase the strengths and try to mitigate weaknesses or the things that are precipitating troubles. And that can be extremely helpful. And these kids are at an age where, you know, they're often able to articulate what's going on with them.
Dr. Gretchen Hoyle:Do you find that girls are a little bit able, better able to do that than boys? It just sorta depends. And of course there's pubertal factors that are involved in that as well. Girls tend to, you know, aunt goes through puberty too. Girls do that a little bit earlier.
Dr. Gretchen Hoyle:And so sometimes that's a factor, but they're, they're old enough to reflect to some degree on what their thinking is and whether or not their thoughts really make sense and whether or not some of their thoughts can be like, how do we can work with those thoughts, especially negative thoughts, especially negative self talk, those kinds of things that therapists can really help kids with that. But they're also, you know, young enough that, well, first of all, you can get them good to go to therapy because, you know, they are still dependent on the parent typically to get around and do things. So it's, it's, you know, as I'm in high school that can get harder. If a kid really doesn't want to go to therapy in high school, it is hard to get them to go because they are off doing other things. They often, you know, have the, you know, the freedom to do that.
Dr. Gretchen Hoyle:And so it's just more of a challenge. And so if, you know, for middle schoolers, we can get them to go. And once they go, typically it's, you know, they find it to be super helpful. Just getting over that hump of actually getting there. And so that's a little easier with middle school aged kids.
Dr. Gretchen Hoyle:And then they are just able to, they're in that sort of, you know, sort of in between time where they do have some level of insight, but they also are still to some, to a large extent being managed by the adults in their lives. And so there are ways to get them to therapy and that can be really helpful. Then there's also, also medication. And so, you know, I, like I say this every time, but if I could work up in a world where nobody needed medicine, I would love that. Cause it would mean that there wasn't, nobody was depressed or anxious or had ADHD or whatever within that world.
Dr. Gretchen Hoyle:And so, we're kind of back to our typical SSRI medicines. So these are selective serotonin reuptake inhibitor medicines. So the most common ones of those are fluoxetine, which is Prozac, which is Lexapro and sertraline, which is Zola. Choosing between those medicines that will often ask if the child's been on anything before and whether or not that was a good or bad fit. Ask them about family history.
Dr. Gretchen Hoyle:That can be extremely, extremely helpful whether or not they've got other symptoms. You know, there's a little bit of nuance about picking an SSRI for somebody who has ADHD and just like what our side effects have been on other medicines. And then the like practical considerations, like whether or not they can swaddle a pill or as, or do we need to do liquid instead? And then like everything, insurance gets to say, right? So the insurance is going have a formulary that's going to say what is covered.
Dr. Gretchen Hoyle:And then I need to typically pick from those so that we can make sure that they can actually get the medicine. To some extent too, I have to be aware of what is available in the community. So this is less of an issue with SSRIs as far as like shortages of certain medicines. The big issue with ADHD, that's careful monitoring is really essential. We want to see them pretty frequently while we're trying to improve at the beginning.
Dr. Gretchen Hoyle:And then once we get on the right path, we can spread that out some. But it is really important to, you know, to get to where we're improving symptoms. We may not get to what we would necessarily consider to be therapeutic scores on every one of those questionnaires. And that's going be an ongoing thing, but improvement is important and it really does make a big difference in there.
Matt (host):To our normal concluding question, if parents could take one thing away from this episode, what would that be?
Dr. Gretchen Hoyle:Right. So like a lot of these concerns that depression in middle schoolers is real and it's pretty common and it is very treatable. And the earlier we get started, the better that can really change the child's trajectory. And this isn't about, you know, parenting problems or a kid who, is a, just like, just like we use medicines to treat conditions like asthma and diabetes. And just in the same way that, you know, other organs in the body can have trouble.
Dr. Gretchen Hoyle:And we treat that with medicine. The brain can have trouble and we treat that with medicine. And so I realized that there are lots of reasons that folks are concerned about that. And I totally understand that. And so I think it's important for us to be able to have that conversation, raise about side effects for how long they're going to be on the medicine, that type of thing.
Dr. Gretchen Hoyle:Those are common questions. And I think that when we frame it from the perspective of you're really only in middle school for a really short period of time. For most people, for most adults, we ask them like, what was the toughest time growing up? It's usually that, right? Yeah.
Dr. Gretchen Hoyle:Right. And so we, you know, we know that you're, there's going to be some, you know, bumps and bruises along the way for sure. But if a child is really having pretty profound difficulty, then it's worth intervening and trying to right that ship because it does have an impact on, you know, what's to follow.
Matt (host):Such a tough time, two or three years, but it seems like a decade, but both, you know living through it and then as a parent of a
Dr. Gretchen Hoyle:As a parent, tell you true.
Matt (host):For sure. Thank you again Doctor. Hoyle. Next up in the series we'll be talking about depression in high school age teens where risk and independence continue to increase. Thank you to our listeners for joining us today, whether on the audio podcasts, which is found on all major podcast platforms or via our video broadcast on YouTube.
Matt (host):I need you to please rate our content and offer comments and questions at our website podcast. We wanna hear from you and your desires for material. Also, please follow us on social media, Facebook and Instagram, especially at nimble youth podcast. Till next time, please take care of yourselves and the young people in your lives. Bye for now.