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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 something I think a lot of families don't expect. The high achieving student who suddenly starts struggling. Sometimes this can be just the transition from high school or college and young adulthood, and the move from being a big fish in a small pool to being a minnow in the pack swimming in a vast ocean.
Matt (host):But a significant portion of the time, this is due to ADHD that has not yet been diagnosed. To frame our discussion, let's consider these facts: About 15,500,000 U. S. Adults are estimated to have ADHD, and about half of this cohort was diagnosed in adulthood. Adult diagnosis rates have risen as awareness of the condition improves.
Matt (host):And many adults with ADHD also have anxiety or mood conditions along with it. To help us unpack this phenomenon, we're joined by our good friend, Doctor. Gretchen Hoyle. Doctor. Hoyle is a pediatrician with twenty five years of experience and a special focus on youth 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. Hoyle, what's happening here?
Dr. Gretchen Hoyle:Doctor. Yeah. So this is one of those common things I see in older teens and college students. These are really bright kids. They're often straight A students in early school.
Dr. Gretchen Hoyle:They have basically been coasting on their raw intelligence for years. And then they hit high school and specifically like AP classes, and they're doing college level work and suddenly their system really breaks down.
Matt (host):And so it's certainly not that their intelligence somehow fell off a cliff. It's just that the demands changed.
Dr. Gretchen Hoyle:Exactly. I mean, in school, a lot of learning happens by listening in class, but higher level academics requires independent learning, reading, synthesizing, planning long term assignments. It takes a lot of executive function and some students simply hit the limit of what they can do without intentional structure.
Matt (host):Let's talk about what executive function is. Can you give us an explanation?
Dr. Gretchen Hoyle:Sure. So executive function is that ability to plan and to pay attention and attend to things that aren't necessarily inherently rewarding. And it's the type of, skills that folks with ADHD struggle with. So in this particular situation, if there's a mismatch there, these students, they absolutely have the intellectual ability to understand the material they're being presented with, but their brain systems need to organize and initiate and sustain attention. And those systems just aren't keeping up.
Dr. Gretchen Hoyle:And so that discrepancy is best described as ADHD.
Matt (host):So, diagnosis in, in older teenagers and college age students looks different at their age, right?
Dr. Gretchen Hoyle:That's right. We're not really using teacher Vanderbilt forms anymore. Instead, we rely on just sort of history, academic history, functional impairment, self report tools, the adult ADHD self report scale or the AS. And so what I wanted to do is try to explain that scale and read off the different items that are on that scale so that folks can understand what are the typical symptoms that we see for folks that were making a diagnosis of ADHD when they're when they're in their adult years or even sort of late teens and that type of thing. So the way that this works is that there are five different responses and they're scored zero to five.
Dr. Gretchen Hoyle:So like a lot of the questionnaires that we've talked about in the past, there's a numerical way to quantify what their symptoms are. So the, the options for just responding to each item are never, which is scored as a zero rarely, which is scored as a one sometimes, which is a two often, which is three and very often, which is a four. So here are the items. Number one, how often do you have trouble wrapping up the final details of a project once the challenging parts have been done? This is a really common thing where folks, can, they can get to the meat of the assignment, but then when they need to put on the finishing touches, they just don't have the stamina to get that done with their level of attention.
Dr. Gretchen Hoyle:The second one is how often do you have difficulty getting things in order when you have a task that requires organization? And this is where those later school years, high school and into college, where there's a lot of organization required that's beyond just being able to digest the material. And so that it really shows up in this age group. How often do you have difficulty remembering appointments or obligations? This has changed a little bit over the years because now everybody has smartphones.
Dr. Gretchen Hoyle:Usually they're putting their obligations and appointments into their smartphone and setting reminders, but there definitely are folks who forget to do that part. And so then they will wind up missing things and that can be a real challenge. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? So this is the procrastination one. And that one's on the questionnaire for young kids as well.
Dr. Gretchen Hoyle:But it's a core issue for folks with ADHD. And then there's some motor questions. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? So a lot of folks will have a lot of movement, like hands and feet, sometimes sort of bouncing leg, that kind of thing that they are using to help sort of regulate their attention to stay on task. How often do you feel overly active and compelled to do things like you're driven by a motor?
Dr. Gretchen Hoyle:So there's that driven by a motor question, which we think about a lot in young kids with lot of hyperactivity, but it appears in adults as well with with ADHD. And then question seven, how often do you make careless mistakes when you are working on a boring or difficult project? Well, that sounds pretty common for a lot of folks. How often do you have difficulty keeping your attention when you were doing repetitive work? Number nine, how often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly, which can be quite problematic from a social perspective and in employment and in school as well.
Dr. Gretchen Hoyle:How often do you misplace or have difficulty finding things at home or at school? At eleven, how often are you distracted by activity or noise around you? So this comes into play in a classroom setting, even for older kids and college students. Number 12. How often do you leave your seat in meetings or classroom situations in which you're supposed to remain seated?
Dr. Gretchen Hoyle:That still happens for some people. They just feel the need that they need to get up and walk around. How often do you feel restless or fidgety? How often do you have difficulty unwinding and relaxing when you have time to yourself? How often do you find yourself talking too much when you're in a social situation?
Dr. Gretchen Hoyle:And then number 16, when you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them themselves? Number 17, how often do you have difficulty waiting your turn in situations where turn taking is required? And number 18, how often do you interrupt other people when they are busy? So they can respond zero to four, zero, never, rarely, sometimes often, very often. And we'll score that.
Dr. Gretchen Hoyle:And then there are norms as to what percentile folks will fall on within the, there are normed averages in which we can see where, where a individual scores on, on that percentile. And a lot of times what happens is the folks who have, who meet criteria for ADHD, they'll score at the ninety ninth percentile most.
Matt (host):Right. Yeah. Test IQ along with, with that, with that scale as well. Is that ever ordered?
Dr. Gretchen Hoyle:Right. So IQ testing comes into play for folks most typically earlier when we did like the neuro cognitive testing or psychoeducational testing. For folks who have gotten to this level, typically they're, they are at least of average IQ, if not above. And so we know that they are capable because if you've sailed through elementary, middle school, and the first part of high school on your intellect, then that's not the issue. It's more like once you're starting to hit a wall, it's because you're just not able to really organize and digest the material effectively because of the executive function systems that are just not working at the level that you're intellect.
Matt (host):Makes total sense. So, and, and this is not rare at all, especially these days, right?
Dr. Gretchen Hoyle:Yeah, it's not rare at all. I mean, we now know that about half of adults diagnosed with ADHD were actually got their diagnosis in adulthood, not in childhood. And so, when a college student walks in thinking, how did nobody notice this? It's a really common thing to not really pick up on it until they're much older.
Matt (host):Oh, let's address the elephant in the room, I guess, or the controversial part which is medication and how do you how do you go about determining whether medication is needed?
Dr. Gretchen Hoyle:Right. So this does make people uncomfortable. I think a lot
Matt (host):of times people are like, oh, you're
Dr. Gretchen Hoyle:just using medicine as like a performance enhancing substance. And you're like, yep. I mean, because really what's happening is that when I prescribe stimulants for these kinds of students, I'm really not giving them something that they don't have. I'm just helping them access what they do have. And these students who understand the material, but the executive functioning barrier is keeping them from being able to engage with it.
Dr. Gretchen Hoyle:And in college, especially I will use like short acting stimulants a lot because the way that their schedule is in college, it's not like high school where you go, you know, at eight in the morning and you're there till 02:30. I mean, you're like, you have like a 09:00 class and then like a 01:00 class, and then you're going to do other things in between. And then a lot of times they're studying later in the evening. And so I'll often use short acting for that purpose so that they're not on the medicine all day if they're doing different things throughout the day. And then I find that like for some students and some, the combination of that student and the material, they don't need medicine all the time because it, whatever it is that they're, they're studying, that they're really interested in, their brain is creating its own dopamine.
Dr. Gretchen Hoyle:It's inherently and intrinsically rewarding to them and they don't really need to be on medicine. But there's a lot of things in college, like there are in all levels of school, where it's someone else's agenda, right? So a lot of school and a lot of life is someone else's agenda. And so you have to be able to attend to things that aren't necessarily inherently rewarding for you. This can be a really helpful tool to do that.
Dr. Gretchen Hoyle:And so, when I think about it, college is a pivotal time as far as like being able to get to a place where you can sort of launch your career, whatever that may be. And there are going to be certain classes within your discipline that may or may not be all that engaging for you, you still need to get through them. And it does make a big difference, as to whether you're able to do that successfully or not. And I think that parents and kids and just people in general are investing a lot of time and money into this. And so, we want to put them on the best possible footing that we can so that they can get the most out of those years.
Matt (host):Yeah. That make, I mean, that makes a lot of sense. And I, from personal experience, I can tell you that sometimes you need some, some rocket fuel to sort of get you through those, those hoops that you have to jump through. Right. Stimulants can, can be that, that boost that you need, if, if you are, if you have ADHD.
Matt (host):But people, I guess parents often worry about Adderall being used recreationally on campuses. So how is that, how do you address that?
Dr. Gretchen Hoyle:Right. So this is, yeah, this is called diversion. I mean, you're doing, using it for a purpose that it was not intended for. And so we definitely take misuse seriously. These are controlled substances.
Dr. Gretchen Hoyle:So it's a federal crime to be diverting these. And so it is really important when I tell, when I, when I have patients where they have a diagnosis and, and where I'm going to be sending them medicines to take them for them to take with them to college, I make sure that they have a safe place to keep that locked up so that it doesn't end up in the hands of someone else. The research on Adderall use, like that's the, one of the more common, like, especially short acting medicines that we use, but the research shows that when college students use stimulants without prescriptions, it's mostly to study for academic reasons and studying and focus. And it's not really used as a, for euphoria or to, partying or chasing a high. Now that doesn't make it safe or legal, but it does tell me that there's an unmet need.
Dr. Gretchen Hoyle:If folks are using these medicines without prescription, but they're using them to study, it does sort of say to me, well, if a student is seeking medication to function academically, there's a good chance that they might benefit from an evaluation for ADHD and see if that's actually present. And, and then we can do this in a more appropriate fashion. There are lots of ways for folks in college to engage in substance use that is not related to this. And so while I know that there are some episodes of misuse of this substance, the majority of the time when it's being sold or trafficked in some way on a college campus, it's for the purpose of studying. And that just makes you feel like, well, probably ought to figure out why that's necessary for that person.
Matt (host):Yeah. Yeah. So I suppose the, the $1 solution or depending on where you buy it, maybe the $5 solution is a strong cup of coffee. And I know that was how I got through college as a young adult with undiagnosed ADHD. And so, that's what a lot of students do.
Matt (host):They don't have access to these maybe more appropriate stimulants, right?
Dr. Gretchen Hoyle:Sure. Yeah. So humans have used stimulants to study forever and actually that mechanism of action for caffeine is very similar to what happens with, with the medications that we use. Coffee is a stimulant. The difference is that a prescribed medication is a little more targeted and we can monitor it.
Dr. Gretchen Hoyle:It's more medically supervised, but for sure it has a similar approach to basically just making more dopamine available as an app so that you can maintain your attention in the frontal lobe and stuff. And so that's, that's really what's happening. And so that is just, I think that, that I think we all, prior to widespread use of these medicines, we're finding ways to do that. This, like it's going to be like monitored by a provider and that is potentially a better way. I mean, I do think that there's a lot of folks using other sources like these energy drinks and those are super problematic, I feel like for a lot of people.
Dr. Gretchen Hoyle:And there's just other, there are ways to access those functions that are, I think safer. I get the logic of people are like, well, this is cheating somehow. But I would also say that like, it's, it, if you have somebody who has the intellectual ability to understand the material, well, let me put it the other way. If the person is not able to understand the intellectual material, then the stimulus is not going to help all that much. Right?
Dr. Gretchen Hoyle:Okay. So, it's kind of like extra time on tests. That accommodation is not going to make a huge difference if you don't understand the material. So if you, we're, what we're really trying to do is, is give people access to be able to work at the highest level that they can, knowing that like, time goes on, the executive functioning gets better and better, and that are really like our frontal lobes. There's a little bit of discrepancy between males and females.
Dr. Gretchen Hoyle:And, but like we realized that probably it's not till our mid to even maybe late twenties that all of those executive function circuits are working at their very best. And so, but college happens earlier than that. And that's your typically for most people,
Matt (host):that is
Dr. Gretchen Hoyle:your immersion in the highest level of intellectual cognitive function. That's being driven by someone else. Hopefully all of us are gonna be lifelong learners and we're gonna read and, and engage in things that, but those things are typically gonna be things that are of interest to us. Right.
Matt (host):I don't know how many pots of coffee I had to drink to get through James Joyce's novel Ulysses when I was in college, but it was, it was numerous pots.
Dr. Gretchen Hoyle:And Right.
Matt (host):And I'm a, I'm a coffee fan. I'm a brewed coffee fan. I have to say. Right. But here's a worthless, but still an interesting aside about how cups of coffee became known as cups of Joe.
Matt (host):I'd always heard it was because of a, there was a US Navy captain named Joseph who had banned alcohol consumption on a ship. So he replaced alcohol with, the ergogenic and alertness benefits of coffee. But apparently now the most widely accepted theory is a linguistic evolution, Java and Mocha, interestingly enough, were both common terms for coffee. People used to combine them and call it, they call it coffee Jamoque, which is a cool, it's a cool name. I have to start using that.
Matt (host):Apparently Jamoke was eventually shortened to Joe by the 1940s. There you go. Perfect. Yeah. So that's great.
Matt (host):Returning to something more useful. What's the big takeaway from what we've discussed today?
Dr. Gretchen Hoyle:Right. So if a bright student suddenly struggles, don't assume that they've stopped trying. And, and it's hard to predict kind of when they're going to hit a wall, but there's tons of kids out there who are just pretty intellectually very capable and they can absorb by osmosis when they're in class, when they're young and they get all the way through. And then they sort of got it out during middle school. And we talked about like where there is a bit of a threshold there, where you have to be more organized and keep up with different teachers and all that, but they're able to do that.
Dr. Gretchen Hoyle:And so, and I will say that for the most part in early education, early and in middle school education, if you're sitting down at the end of the year and your EOG is like, you're killing it, then they are really not going to bother you all that much. Right. So if you're really smart and you're able to do that stuff and just get it in by osmosis, even if you're not turning everything in or doing all the crossing all the Ts and dotting all the Is, that school has bigger fish to fry than that. But once you get into like these, higher level classes, a lot, the most common scenario is that they get into AP classes and that used to be a junior year high school kind of thing. And now like they're taking APs like freshmen.
Dr. Gretchen Hoyle:And so they're just hitting a wall. Like it's not, it's just more than their brains can keep organized, especially in high school when they've got like all these other things that they're trying to do. I mean, our previous podcast with Nicole Beale, who talks very eloquently about how that threshold of expectation just keeps going up. And so we'll see that in that age group. Then, then we'll have kids who can sail through that and then they get to college and they'll get to some college level classes and then they'll hit their wall.
Dr. Gretchen Hoyle:So it just depends. A lot of times what we're needing to do is bridge that executive functioning gap and we can get there a lot of times with pretty low doses of medicine for very short periods of time, but it makes a huge difference in the outcome. And so that is one of the things that I feel comfortable in doing that because it does make a huge difference. And when you're,
Matt (host):you know, some of these schools are 6 figures a year.
Dr. Gretchen Hoyle:So, yeah, that's a different thing from what it was generation ago. And so like, it's, I think it's, I think it's, it makes sense to try to get the most out of that time when you're
Dr. Gretchen Hoyle:there because it's limited and there's because it's wasted for sure.
Dr. Gretchen Hoyle:Yeah. Yeah. Nope. That's right.
Matt (host):So, what we've talked about today, the populations that we've, we spoke about today, students in their late, later teens and young adult years, this is exactly the kind of population that you will, one of the populations that your new behavior medicine practice pediatric behavioral, health practice called MindBridge Behavioral Health will serve. Right? So tell us a little bit about your plans there.
Dr. Gretchen Hoyle:That's correct. So I've been in general pediatrics practice for twenty five years, and I am wanting to shift my focus into just doing behavioral health. There's a huge need for it and I have really enjoyed it and I want to be able to have my own space to do it. And that is a little less noisy and frenetic and less screaming involved than there is in a general pediatrics class. And so, and so we're going take all of these strategies that we've talked about, on the Nimble Youth Podcast.
Dr. Gretchen Hoyle:And we've been using those, in real world general pediatrics now for years. But we're going to focus on that. And so that practice, that new practice is going to be opening in the 2026. We have a website that is up. And if you want to have more information, it's mindbridgebehavioralhealth.com.
Dr. Gretchen Hoyle:And there's just lots of good information there as to how we're going to structure this. But I think that in general, like pediatrics in general has, has a real responsibility to meet the needs of young people, meaning children, adolescents, and even young adults. And the need in this current generation is shifting towards mental health.
Matt (host):And so that's what we're going to do. There's really a great need in our local society and society writ large, I suppose. So we'll, and we'll have more information on Mind Bridges Behavioral Health, coming up very soon. And we'll have links certainly at the Nimble Youth podcast website as well. Until then, my thanks again to Doctor.
Matt (host):Hoyle for offering her perspective and insight on this unique concern for young people today. And thank you to our listeners for joining us, whether on the audio podcasts found on all major podcast platforms or via our video broadcast on YouTube. We remind you to please rate our content and offer comments or questions at our website, which, again, is podcast. Helps us to provide you with the content you wanna see and listen to. And please, also follow us on social media, Facebook and Instagram, especially at Nimble Youth Podcast.
Matt (host):Until next time, please take care of yourselves and the young people in your lives. Bye for now.