Nimble Youth

SummaryIn this episode of the Nimble Youth Podcast, host Matt Butterman continues the discussion on dyslexia with Dr. Gretchen Hoyle, focusing on actionable strategies for parents after a diagnosis. The conversation emphasizes that simply increasing reading practice is not sufficient; instead, it is crucial to address the underlying decoding pathways in a child's brain. Dr. Hoyle uses a swimming metaphor to illustrate that practicing with incorrect techniques can reinforce ineffective pathways, akin to running on a sprained ankle. The episode introduces the concept of structured literacy, particularly the Orton-Gillingham method, which is designed to explicitly teach reading through a systematic approach that includes explicit instruction, sequential learning, cumulative reinforcement, and multisensory engagement.Dr. Hoyle elaborates on the four key principles of the Orton-Gillingham method, explaining how each principle supports children with dyslexia in building a strong foundation for reading. The discussion also touches on the challenges faced in public schools regarding the implementation of structured literacy programs due to funding and resource limitations. The episode concludes with insights on the importance of collaborative care in managing dyslexia, emphasizing that with the right support and instruction, children can thrive despite their challenges.TakeawaysEffort alone doesn't fix the underlying problem.Structured literacy explicitly teaches how language works.The Orton-Gillingham method is effective for dyslexia.Children with dyslexia need granular instruction.Multisensory approaches strengthen neural connections.Sound bites"Effort alone doesn't fix the underlying problem.""Structured literacy explicitly teaches how language works.""Engaging the whole brain is crucial."

Episode 34: Dyslexia, Part OneSummaryIn this episode of the Nimble Youth Podcast, host Matt Butterman and pediatrician Dr. Gretchen Hoyle delve into the complexities of dyslexia, a learning disability that affects many children but is often misunderstood. Dr. Hoyle provides a comprehensive definition of dyslexia, emphasizing that it is not related to intelligence or effort but rather a difference in how the brain processes written language. She explains that dyslexia manifests in various ways at different ages, from preschool through high school, highlighting the emotional and behavioral challenges children face as they struggle with reading and writing tasks.The conversation also touches on the overlap between dyslexia and ADHD, as both can present similar symptoms, making diagnosis challenging. Dr. Hoyle discusses the importance of formal evaluations and the role of family history in understanding dyslexia. She shares insights on how parents can recognize signs of dyslexia in their children and the significance of early intervention. The episode sets the stage for a follow-up discussion on effective management strategies and educational support for children diagnosed with dyslexia.TakeawaysDyslexia is an unexpected difficulty with reading.It's not about intelligence or effort; it's about brain processing.Dyslexia often runs in families, indicating a genetic component.Sound bites"Dyslexia is an unexpected difficulty with reading.""It's not clicking for the kid.""We ask the kids to read nonsense words."Chapters00:00 Introduction to Dyslexia01:03 Defining Dyslexia03:09 Signs of Dyslexia in Early Childhood08:18 Behavioral Challenges and Emotional Responses10:02 Family History and Genetic Links12:12 Diagnostic Approaches and Testing15:28 Overlap Between Dyslexia and ADHD17:31 Formal Diagnosis of Dyslexia

SummaryIn this episode of the Nimble Youth Podcast, therapist and author Katie K. May discusses the complexities of parenting highly emotional teenagers. She shares insights from her book, 'You're On Fire, It's Fine,' emphasizing the importance of understanding teen emotions, the concept of 'fire-feelers,' and the necessity of radical acceptance. The conversation explores common parental challenges, the impact of validation, and the significance of natural consequences over punitive measures. Katie provides practical strategies for preventing emotional escalation and rebuilding trust with teens, ultimately offering hope for meaningful change in the parent-teen relationship. Note: In the interview, host misidentifies the title of the book, which is "You're On Fire, It's Fine."TakeawaysParents often lack the skills to support emotional teens.Understanding behaviors as solutions, not just problems, is crucial.Fire-feelers experience emotions intensely and need different approaches.Counterproductive responses can invalidate a teen's feelings.Radical acceptance helps parents cope with their reality.Acceptance does not mean approval of all behaviors.Recognizing early signs of emotional escalation is key.Natural consequences teach valuable lessons more than punishment.Self-destructive behaviors are often coping mechanisms for pain.Emotional dysregulation can improve with time and effort.Sound bites"Emotions can be like a wildfire.""Parents go first.""You're On Fire, You're Okay"Chapters00:00 Navigating the Emotional Landscape of Teens02:01 Understanding Parental Challenges04:39 The Concept of Fire-Feelers06:25 Counterproductive Responses from Parents08:29 Radical Acceptance in Parenting10:16 The Importance of Acceptance vs. Approval12:33 Preventing Emotional Escalation14:38 Teaching Lessons vs. Natural Consequences16:22 Understanding Self-Destructive Behaviors20:21 The Hope of Change22:05 The Role of Environment in Emotional Dysregulation24:46 The Power of Validation26:48 Embracing Good Enough Parenting28:00 Rebuilding Trust and Connection30:40 Final Thoughts for Parents

SummaryIn this episode of the Nimble Youth Podcast, host Matt Butterman and pediatric mental health expert Dr. Gretchen Hoyle delve into the complexities of ADHD and anxiety in children and teens. They discuss the prevalence of these overlapping conditions, the effects of medications on each other, and the importance of addressing both issues simultaneously. The conversation highlights the risks of untreated ADHD and anxiety, the challenges parents face in seeking treatment, and the need for a balanced approach to medication. Ultimately, the episode aims to provide hope and guidance for parents navigating these difficult topics.TakeawaysAbout 40% of kids with ADHD also have anxiety.Treating ADHD without addressing anxiety can worsen anxiety symptoms.SSRIs can sometimes activate ADHD symptoms in children.Monotherapy may not be effective for kids with both ADHD and anxiety.Parents often find it easier to treat ADHD than anxiety.There is a stigma around using medication for anxiety in children.Managing anxiety is crucial; you can't just grit through it.Untreated ADHD can lead to significant academic and social issues.There is a higher risk of substance abuse with untreated ADHD.Early intervention can significantly improve outcomes for children. TitlesNavigating ADHD and Anxiety in YouthThe Interplay of ADHD and Anxiety MedicationsSound bites"Sometimes SSRIs can activate ADHD symptoms.""Monotherapy doesn't always work for ADHD and anxiety.""Hopeful takeaways for parents feeling overwhelmed."Chapters00:00 Understanding ADHD and Anxiety Overlap02:08 The Impact of Medications on ADHD and Anxiety07:58 Monotherapy vs. Combination Therapy09:39 Parental Perspectives on Treating ADHD and Anxiety17:35 Risks of Untreated ADHD and Anxiety

SummaryIn this episode of Nimble Youth, host Matt Butterman speaks with Jamie Hrobar, a mother of two autistic children and a woman in recovery from alcoholism. They discuss the challenges of parenting children on the autism spectrum, the impact of addiction on family life, and the importance of community support. Jamie shares her journey through early diagnoses, the struggles with severe autism, and the fight for necessary services. She emphasizes the need for advocacy, understanding, and the power of hope in navigating these challenges.TakeawaysParenting a child with autism is incredibly challenging.Both of Jamie's children have taught her invaluable life lessons.Early diagnosis can significantly impact the support a child receives.The reality of severe autism includes significant behavioral challenges.Addiction can complicate parenting, but recovery is possible.Finding a higher power can provide strength in difficult times.Navigating the system for autism services is often a battle.Building a community of support is crucial for families.New parents should educate themselves about their child's rights.Resources for families with severe autism are critically lacking.TitlesNavigating the Challenges of Autism ParentingThe Journey of a Mother in RecoverySound bites"I see you and I understand.""You are not alone.""We need more resources."Chapters00:00 Navigating Autism and Family Life06:03 Early Diagnosis and Its Impact12:28 Struggles with Addiction and Recovery18:49 Finding a Higher Power in Recovery25:40 Navigating the Autism Service System32:17 Practical Steps for New Parents36:14 Building Community and Sharing Stories40:12 Messages of Hope for Parents45:37 Advocating for Better Resources

SummaryIn this episode of the Nimble Youth Podcast, hosts Matthew Butterman and Dr. Gretchen Hoyle discuss the complex interplay between ADHD and anxiety in children, particularly when disruptive behaviors lead to school challenges. They explore the symptoms, the impact of trauma, and the importance of accurate diagnosis and treatment. The conversation emphasizes the need for a comprehensive approach that includes medication, therapy, and sleep hygiene to support children's mental health effectively.TakeawaysUnderstanding the overlap between ADHD and anxiety is crucial.Children with disruptive behaviors are often overwhelmed, not bad.Emotional dysregulation can stem from trauma, not just ADHD or anxiety.Measurement tools like questionnaires help in diagnosing conditions.Treatment plans may require balancing medications for ADHD and anxiety.Sleep hygiene is essential for mental health and medication effectiveness.Parents should limit children's access to phones at night.Early intervention can lead to significant improvements in behavior.Support from healthcare professionals is vital for families in crisis.It's important to recognize that struggling children need support, not blame.TitlesNavigating ADHD and Anxiety in ChildrenUnderstanding Disruptive Behaviors in KidsSound bites"These are not what you call bad kids, right?""Medicine to me is gonna be on the table.""It means that their brain needs support."Chapters00:00 Understanding Disruptive Behaviors in Children05:44 The Overlap of ADHD and Anxiety11:02 Navigating Treatment Options16:54 The Importance of Sleep in Mental Health19:01 Hope and Support for Families

Nimble Youth – Episode 29 Show Notes“Calming Teenage Anxiety: Practical Steps Parents Can Use Today”Guest: Sophia Vale Galano, LCSW, author of Calming Teenage AnxietyEpisode OverviewIn Episode 29 of Nimble Youth, host Matt Butterman sits down with Sophia Vale Galano, LCSW—therapist, educator, speaker, and author of Calming Teenage Anxiety. Sophia’s clinical career has spanned public high schools, inpatient psychiatric units, residential programs, and private practice. She brings a rare combination of clinical expertise, real-world experience, and practical clarity to one of the most urgent challenges parents face today: teen anxiety.In this episode, Sophia walks us through:Why teen anxiety is risingHow parents often accidentally shut down communicationHow to tell normal developmental stress from true clinical anxietyWhen—and how—to seek outside helpWhat to do when teens refuse therapyThe single daily practice parents can start tonightHer holistic approach: movement, creativity, nature, and environmentWhy listening trumps solutions, and curiosity trumps controlThis is one of the most actionable episodes we’ve aired—packed with specific scripts, strategies and reminders designed to help parents move from panic to partnership.About Our Guest: Sophia Vale Galano, LCSWSophia Vale Galano is a licensed clinical social worker and the author of Calming Teenage Anxiety: A Parent’s Guide to Helping Your Teen Cope With Worry. Born in Los Angeles and raised in London, she holds a Master’s in Social Work from NYU.Her background spans:Counseling teens in public and independent schoolsProviding group therapy and case management in psychiatric settingsServing as a primary therapist for young adult males in long-term substance use treatmentSupervising social work associatesPracticing master-level ReikiWorking as a yoga instructorIntegrating art, movement, and nontraditional therapeutic modalitiesShe also consults for Hollywood Health & Society and volunteers with animal rescue organizations.Key Themes & Insights1. Why Teen Anxiety Is RisingSophia identifies two overlapping drivers:Classic developmental factors:PubertyHormonal shiftsCognitive changesIdentity formationModern amplifiers:Social mediaTechnology and screen saturationReduced in-person connectionCultural pressures around achievementThe result: more anxiety, earlier in life, and often harder for parents to interpret.2. The Trust Break: Why Parents’ “Solutions” Shut Teens DownParents often jump immediately to:“Have you tried meditating?”“Go outside.”“You’ll be fine.”…all well-intended but often perceived by teens as invalidation.What teens actually need first: To feel heard, seen, and understood. Not fixed.3. Why Setting Matters: Conversations Work Better Without Eye ContactSophia encourages parents and clinicians to switch the setting:Talk in the carGo for a walkSit side-by-side instead of face-to-faceDo something together (cooking, errands)Teens often open up when the pressure to “perform” disappears.4. Is It Real Anxiety or Just Teenage Stress?Sophia recommends observing two dimensions:Frequency How often is the anxiety occurring? Once a year? Weekly? Daily?Severity Does the teen…push through the discomfort?have panic attacks?avoid school?stop socializing?withdraw from activities they once enjoyed?The combination of frequency + severity helps determine when outside support is needed.5. When Parents Should Seek Outside HelpConsider professional support when:The teen’s functioning is significantly impactedAnxiety leads to avoidanceEmotional regulation is deterioratingStruggles persist despite supportive conversationsThe teen asks for helpSophia adds: any time a teen expresses willingness to talk to someone, seize the moment.6. Highly Sensitive Kids: What Parents Should KnowBeing sensitive does not mean a teen is destined for anxiety.Key protective factors include:Coping skillsEmotional literacySupportive relationshipsRegulation strategiesHealthy modeling from adultsSophia encourages parents to meet sensitivity with attunement, not fear.7. The Home Environment and Anxiety: Why Parents Must Do Their Own WorkSometimes a teen’s anxiety is shaped by the overall emotional tone of the household.Parents can help by:Managing their own stressSeeking therapy or supportModeling boundariesPracticing self-careNormalizing help-seekingTeenagers learn more from what they see than what they’re told.8. Three Repeatable Moves for ParentsSophia offers three concrete steps parents can start today:1. Respond with curiosity, not solutions Use open-ended questions:“Tell me more about that.”“What was that like for you?”“How did you get through it?”2. Keep the door open Even a 30-second conversation is progress.3. Collaborate instead of rescuing Work with the teen, not for the teen.9. What If Your Teen Refuses Therapy?Sophia cautions against forcing therapy unless safety requires it.Instead:Ensure the parent has their own supportAvoid enabling patterns (e.g., rescuing from academic consequences)Offer choices: therapist style, format, specialtiesRevisit conversations over timeNormalize therapy as one option—not the only optionSupport must feel collaborative, not imposed.10. The Lightning Round: Quick TakeawaysAre phones the main driver of anxiety? No — it’s multifactorial.Is labeling anxiety helpful? It depends — labeling can empower or enable.Do school accommodations risk over-accommodating? Sometimes.Can sleep/exercise reduce anxiety in two weeks? Often yes, but it depends.11. What Parents Can Try TonightSophia recommends starting with:The “Open Dialogue” chapter from her book — a guide to asking questions that create trust, connection, and emotional safety.It’s the foundation for every other technique.Resources MentionedCalming Teenage Anxiety by Sophia Vale GalanoAvailable via Amazon, Penguin Random House, Barnes & Noble, and independent bookstores.Sophia’s website: sophiagalano.comClosingIf this conversation resonated with you or someone you love, please:Subscribe to the Nimble Youth PodcastRate and review on Apple PodcastsShare the episode with parents, educators, and caregivers who may benefitYour support helps other families discover our work.

Nimble Youth Podcast — Episode 28 Show NotesAutism, Then and Now: Patrick’s Story and the Power of CommunityHost: Matt Butterman Guest: Dr. Gretchen Hoyle, MD — Pediatrician with 25 years of clinical practiceSeries: Growing Up with Mental Health Conditions🎧 Episode OverviewIn Episode 28 of Nimble Youth, we launch a new series exploring the lives of people who grew up with mental health or developmental differences — and how family, community, and changing knowledge shaped their journeys.We begin with autism, seen through the life of Patrick, Dr. Gretchen Hoyle’s cousin, who was born in 1972, long before “autism spectrum disorder” entered everyday language.Patrick’s story unfolds in a time when:Autism was rarely diagnosedThere were no IEPs, formal supports, or online communitiesKids who struggled socially were often labeled “odd,” “quirky,” or “in their own world”Through this deeply personal narrative, Matt and Dr. Hoyle explore:What autism looked like in the 1970s and ’80sHow family love created an early form of “community” before diagnostic language existedHow much more we understand now — and what hasn’t changed🧩 Patrick’s Story: Autism Before We Had the WordsDr. Hoyle describes growing up in a close-knit family of nine cousins, all within a few years of each other. Patrick, two years younger than her, quickly stood out as:Exceptionally brightCarried an almanac everywhereMemorized capitals, populations, imports, weather patterns of countries few adults knewSocially and physically differentStruggled with coordination in group gamesNeeded accommodations for things like Easter egg hunts (the “Patrick egg” hidden in plain sight)Took language literally, missed inside jokes and social nuanceEven without a label, his cousins created a kind of protective community around him — choosing teams thoughtfully, saving the visible egg, involving him in play.Years later, as Dr. Hoyle went through psychology, medical school, and pediatrics, she recognized what hadn’t been named at the time: Patrick was on the autism spectrum.🔍 Autism vs. “Just Neurodivergent”: What We Look ForMatt asks: What distinguishes autism from someone who’s just quirky or neurodivergent?Dr. Hoyle highlights key features often present in autism:Communication differencesLiteral interpretation of languageDifficulty with nuance, jokes, or implied meaningSocial interaction challengesTrouble reading others’ moods or facial expressionsDifficulty initiating and sustaining conversations with unfamiliar peopleSafer and more regulated with “their people” (like cousins or known peers)Narrow or intense interestsDeep, specialized focus (e.g., the almanac, birding later in life)Topics not typically shared by age peersShe notes that:What used to be called Asperger’s syndrome would likely have fit PatrickToday, this is folded into Autism Spectrum Disorder (ASD) with varying levels of support needsWe now know much more about sensory sensitivities, stress processing, and strengths in autistic individuals than we did in the 1970s🎓 Patrick’s Adulthood: Strengths, Challenges, and CommunityPatrick:Did well academicallyAttended college in a community for students with similar challengesCompleted a Master’s in Library Science (very on-brand for his love of information and systems)But adult life brought:Strain in employmentDifficulties with friendships and relationshipsIncreasing challenges with day-to-day interactionHe eventually moved back in with his mother and stepfather after a hard period, especially around the post-pandemic years.In 2023, after a family reunion and a special celebration of their ancestral family home in Old Salem (Winston-Salem), Patrick was killed in a car crash following an argument during a drive back from the event.His death remains a profound grief and a powerful touchstone in Dr. Hoyle’s work.💡 How Patrick’s Legacy Shapes Clinical Work TodayIn clinic, Dr. Hoyle says Patrick is “with her” every day when she meets:A bright child who is socially isolatedA teen who feels different but can’t say whyA parent who quietly says, “I don’t know how to help my child make friends.She sees:The craving for communityThe tension between strengths and vulnerabilitiesThe risk of anxiety, depression, and loneliness layered on top of autistic traitShe also underscores the hopeful piece: We now know so much more about:Teaching social communication skillsSupporting executive functioningHelping neurodivergent kids thrive in school, work, and relationshipsBut she also warns that:Kids today have fewer in-person interactionsMore time on screens means less practice reading faces and body languageThis is especially concerning for neurodivergent kids, who need live practice to build those social pathways👨‍👩‍👧 Six Takeaways for Parents (Patrick’s Legacy in Practice)Matt and Dr. Hoyle close with six key reminders for parents who see parts of Patrick’s story in their child:Explore differences with curiosity, not fear. If your child seems “different” socially, talk to your pediatrician. Early assessment and support can make a big difference.Autism is not a tragedy — isolation can be. Community, acceptance, and connection are deeply protective. Being alone with difference is what hurts most.Be open to the community your child needs, not just the one you imagined. Your child’s “people” may not look like what you pictured — and that’s okay.Recognize and celebrate strengths. Neurodivergent kids often see the world differently, and that’s where innovation, creativity, and new ideas come from.Remember vulnerability alongside strengths.

Nimble Youth Podcast — Episode 27 Show Notes“Adolescence”: Why a British Crime Drama About a 13-Year-Old Boy Is Resonating WorldwideHost: Matt Butterman Guest: Dr. Gretchen Hoyle, MD — Pediatrician with 25 years of clinical practice Series: Nimble Youth: Conversations in Pediatric Mental Health📺 Episode OverviewIn Episode 27, Matt and Dr. Gretchen Hoyle dive into the British Netflix sensation Adolescence, a four-episode psychological crime drama that has captured global attention and sparked urgent conversations about boys, mental health, peer dynamics, and the pressures of early adolescence.Premiering on March 13, 2025, Adolescence quickly became a phenomenon:66 million views in its first two weeks141 million+ views by month threeMetacritic score: 91/100Called by critics “as close to TV perfection as the medium gets”The series tells the story of Jamie Miller, a 13-year-old boy arrested for murdering a classmate. Told in single-take, real-time episodes, the show captures the intensity of early adolescent psychology—bullying, online shame, emerging masculinity, family strain, and the vulnerability of identity at age 13.Matt and Dr. Hoyle discuss why the show has resonated so profoundly, what it reveals about youth culture today, and how clinicians, educators, parents, and advocates can use it as a tool for conversation and prevention.🎞️ What Makes Adolescence So Impactful?Dr. Hoyle unpacks the factors driving its global reach:Authenticity of teen experience: Not glamorized. Not sanitized. Honest about pain, invisibility, and peer cruelty.Single-take cinematography: Long, uninterrupted scenes heighten tension and mirror the relentless emotional world of adolescents.Universal themes: Despite its British setting, the show resonates across cultures facing similar challenges—smartphone immersion, online radicalization, peer exclusion, and rising teen isolation.A rare depiction of boys' inner worlds: Especially around entitlement, masculine scripts, manosphere content, and resentment-based peer cultures.🧠 Five Key Themes the Show Gets (Uncomfortably) Right1. Peer Culture & Social Media PressureJamie’s journey is fueled by:Viral humiliationDigital micro-bullyingOnline shame loopsConstant comparisonPressure to perform socially 24/7Clinically: Ages 11–15 are where Matt and Dr. Hoyle see the highest sensitivity to peer feedback and online ecosystems.2. Masculinity, Entitlement & Manosphere InfluencesThe show portrays how boys can be pulled toward:Misogynistic online communities“Incel” identity narrativesResentment-based belongingAnger as a coping mechanismReferenced thinkers:Jonathan Haidt – The Anxious GenerationRichard Reeves – Of Boys and MenScott Galloway on boys’ struggle for identity and meaning3. Family System Strain & Parenting FatigueJamie’s parents are overwhelmed—working, caregiving, juggling screens, and blindsided by their son’s online world.Clinically: This mirrors what pediatricians see every day — exhausted families, fragmented attention, and hidden digital lives.4. Early Adolescent Identity (Ages 13–15)Dr. Hoyle emphasizes:Puberty + cognitive shiftPeer world overtaking family worldBrain restructuringHeightened vulnerabilityAge 13 is a documented inflection point for increases in clinic visits for anxiety, depression, social issues, and crisis events.5. School & Community ResponseThe show reveals:How institutions react after the crisisHow little we see of the “before”The need for early intervention, not just emergency responseTakeaway: Schools, parents, and communities need better prevention strategies long before a child reaches a breaking point.🧰 Turning Media Into Action: What Parents & Educators Can DoFor ParentsAfter your teen watches the show, ask:“Which character did you identify with?”“What moment scared you the most—or felt familiar?”“Has Jamie’s sense of invisibility ever happened to you?”“What would you do if you saw someone being excluded online?”Also:Discuss screen habits when upset or boredEncourage intentional offline coping and embodied experiencesFor Educators & School CounselorsConsider:A 90-minute workshop or advisory sessionA short clip (5–10 minutes) with content warningsBreakout groups on peer pressure, masculinity, online behaviorWhole-group discussion on intervention pointsClear debrief: safety, confidentiality, and help-seeking normsFor Therapists & Youth AdvocatesUse themes like:IdentityBelongingExclusionTurning pointsAlternative routes to purpose and leadership that don’t rely on anger or misogynyGuiding question: “What have been the turning points in your story?”⚠️ Content ConsiderationsStrong language (British “potty mouth”)Intense themesThe murder itself is not shown, but implications are heavyNot recommended for all teens without guidance or discussion👂 Listener Questions Addressed in This Episode1. “My son says the peer pressure in the show isn’t realistic. How do I keep the conversation open?”Dr. Hoyle’s advice:Validate his experience: “It’s good you haven’t seen this.”Pivot to...

🎧 Nimble Youth PodcastEpisode 26: The Vanderbilt Form Explained – A Teacher’s Guide to ADHD DiagnosisHost: Matt Butterman Guest: Dr. Gretchen Hoyle, MD – Pediatrician, 25+ years clinical experience Length: ~35 minutes🧠 Episode OverviewTeachers play a critical role in helping pediatricians diagnose and manage ADHD — and one of the most important tools in that process is the Vanderbilt ADHD Diagnostic Rating Scale. In this episode, Dr. Gretchen Hoyle breaks down how the Vanderbilt form works, what the scores mean, and why honest, detailed teacher feedback is essential for accurate diagnosis and effective treatment.This conversation is designed especially for teachers, but it’s also a must-listen for parents who want to better understand how medical and educational perspectives come together to support children with attention and focus challenges.📝 Key Topics CoveredWhat the Vanderbilt ADHD Diagnostic Form measures — and how it’s used by pediatriciansUnderstanding symptom scores vs. performance scoresWhy functional impact matters more than just “active” behaviorWhat to do when Vanderbilt scores don’t match classroom narrativesHow to handle parent-teacher communication and avoid frictionThe importance of honest scoring (“often” and “very often” matter!)How follow-up Vanderbilt forms guide treatment effectivenessSetting therapeutic goals — aiming for a total score around 18Recognizing when a learning difference may coexist with ADHD💡 Key Takeaways for TeachersThe Vanderbilt is a communication tool, not a test — your input directly shapes a child’s care plan.Honesty matters: If a behavior stands out compared to peers, mark it as “often” or “very often.”Performance scores are as vital as symptom scores — they show real classroom impact.Comments count: Short anecdotes and observations help contextualize scores.Submit forms directly to the physician’s office when possible — this helps protect your relationship with families and ensures smoother communication.Follow-up forms help track medication effects, side effects, and academic progress.If symptoms improve but academics don’t, a learning difference may also be at play.📊 For ParentsParents should know that the Vanderbilt form is not a judgment of their child — it’s a structured communication bridge between teachers and healthcare providers. If your child’s teacher is asked to complete one, it’s part of a process to better understand your child’s learning and behavior patterns so that interventions can be timely and effective.🧩 Practical Insight from Dr. Hoyle“The Vanderbilt that I get from teachers is a communication tool. It’s a way to tell me what’s happening in the classroom. It’s not a test for the teacher or the child — it’s honest data that helps me help that student.” — Dr. Gretchen Hoyle📎 Resources MentionedInitial Vanderbilt ADHD Diagnostic Teacher Rating Scale (fillable PDF)Follow-Up Vanderbilt Form (Links available at NimbleYouthPodcast.com)🔗 Share This EpisodeIf you’re a teacher, please share this episode with your colleagues or administrators. If you’re a parent, consider sharing it with your child’s teacher — it could make a real difference in how your child’s needs are understood and supported.

🎧 Episode 25: Growing Up with Type 1 DiabetesGuest: Dr. Gretchen Hoyle, Pediatrician Host: Matt Butterman Duration: ~35 minutesEpisode OverviewIn this heartfelt and deeply personal episode, host Matt Butterman and pediatrician Dr. Gretchen Hoyle explore the realities of growing up with Type 1 diabetes — from teenage independence and risk-taking to resilience, technology, and hope for the future.The conversation begins with a powerful moment: Matt shares his experience receiving a 50-year medal for living with Type 1 diabetes at the American Academy of Pediatrics Conference. That milestone sparks a rich dialogue about what it means to thrive — not just survive — with a chronic condition through adolescence and into adulthood.Together, Matt and Dr. Hoyle offer insight, humor, and perspective for families navigating the challenges of Type 1 diabetes in teens, including the emotional toll and the breakthroughs that make long, healthy lives possible.Key Themes & Takeaways🩸 The Adolescent TransitionTeenagers with Type 1 diabetes face unique challenges balancing independence, identity, and daily medical management.What may look like “rebellion” is often exhaustion from the relentless self-monitoring and decision-making diabetes demands.Dr. Hoyle notes that while technology like CGMs and insulin pumps have transformed care, adolescence still brings an intense desire to be “normal.”⚖️ Risk, Resilience, and ResponsibilityPuberty brings insulin resistance, peer pressure, and risk-taking — and diabetes complicates it all.Some teens push boundaries with alcohol, late nights, or skipped checks, while parents struggle between micromanaging and letting go.Dr. Hoyle advises parents to move from “manager” to “coach,” staying nearby as a steady, non-controlling presence — “on the banks of the river, not steering the boat.”🏃‍♂️ Finding Balance Through ActivityMatt shares how cycling became his outlet — helping regulate blood sugar, build discipline, and create community.Sports and physical activity can be empowering for teens with diabetes, improving both glucose stability and mental health.Having role models — like other athletes with Type 1 — helps normalize the condition and inspire perseverance.💬 The Emotional Side: Burnout, Anxiety, and CommunityLiving with diabetes can take a heavy mental toll. Burnout, frustration, and depression are common, especially for teens.Dr. Hoyle emphasizes screening for emotional well-being and helping kids find supportive communities — online or in person — where they can connect with others who “get it.”Type 1 can accelerate emotional maturity: many teens with chronic conditions become empathetic, resilient, and socially attuned beyond their years.🌄 Hope and LongevityMatt reflects on how far diabetes care has come — from manual injections and paper logs to automated closed-loop systems.Receiving the 50-year medal is a testament that teens diagnosed today can live long, thriving, limitless lives.As Matt says, “A diagnosis of Type 1 doesn’t define your child’s life — there really are no limits.”Quotable Moments“It’s proof that you can live, thrive — not just survive — with Type 1 diabetes.” — Matt Butterman“Parents need to be the banks of the river, not the ones steering the current.” — Dr. Gretchen HoyleResources MentionedChildren with Diabetes – support, education, and community resourcesJDRF – advocacy and research for Type 1 diabetesTeam Novo Nordisk – professional athletes living with diabetesListen & Subscribe🎧 Nimble Youth is available on Apple Podcasts, Spotify, and all major podcast platforms. Follow us on Facebook and Instagram for updates and parent resources.Visit nimbleyouthpodcast.com for more episodes and show notes.uyD57NUKKDskWdkiYDRD

🎧 Episode 24: “Sandpaper Moments, Part 2 — Helping Kids Build Grit by Getting Comfortable with Discomfort”Guest: Martha Metzler, Author and Counselor Host: Matt Butterman Length: ~35 minutes Series: Nimble Youth Podcast🌿 Episode OverviewIn this follow-up to one of the season’s most powerful conversations, author and counselor Martha Metzler returns to Nimble Youth to expand on her “Sandpaper Moments” philosophy — the idea that both parents and kids grow through the rough, gritty experiences that shape character and resilience.Host Matt Butterman and Martha explore how real health isn’t about eliminating discomfort but learning to move through it with curiosity, self-awareness, and grace. Together, they discuss how parents can support their children’s growth without rescuing them — and how learning to sit with discomfort, rather than avoid it, builds emotional grit and true confidence.💡 Key Themes & Takeaways1. Getting Comfortable with Being UncomfortableTrue resilience is not the absence of struggle — it’s learning to respond to it with purpose.When parents fear or “rescue” their children from discomfort, they unintentionally send the message that their child can’t handle it.The goal is to shepherd, not shield — guiding kids toward problem-solving and self-trust.“Health isn’t about a life without discomfort. Peace comes when we learn to get comfortable with our discomfort.” — Martha Metzler2. Be the Banks, Not the RiverBorrowing from the Needtobreathe song “Banks,” Martha reminds parents:“Hold them close, but don’t hold them back.”The child is the river — full of individuality and direction. Parents are the banks — offering boundaries, safety, and gentle guidance without steering every turn.Practical ways to build confidence:Let your child order their own food.Have them call a friend instead of texting.Encourage face-to-face interactions at home.These small acts help kids face social anxiety and develop self-agency in manageable doses.3. Modeling Discomfort and Coping in Real TimeKids learn more from what we do than what we say.Martha shares how naming her own anxiety out loud (“My stomach feels tight, I’m going to take a few deep breaths”) helps her children see that anxiety isn’t something to fear — it’s something to move through.Parents who model healthy emotional regulation teach kids:Anxiety is part of life, not a failure.You can respond with purpose instead of panic.4. Blocking Out the Arena: Parenting Beyond Public OpinionParenting in the age of social media means everyone’s watching — or at least, it feels that way.Martha encourages families to “block out the arena” — to stop letting the imagined audience shape how they respond to their child’s struggles.Focus instead on authentic connection, not performance or perception.Remember: Shame is the biggest roadblock to true transformation and peace.5. Responding Instead of ReactingWhen fear or anxiety strikes, pause and ask:What’s making me feel scared right now?Am I reacting to my child’s discomfort or my own unresolved story?Whose discomfort am I trying to fix — mine or theirs?How could this be an opportunity for growth rather than rescue?These reflective questions (also available in the episode handout) help parents move from panic to presence.6. Parents, Work on Your Own StoryUnhealed stories often drive controlling or fearful parenting.Parents who explore their own emotional patterns model courage and authenticity.As Martha says, “We’re not broken, we’re patterned.”Healing your story helps your child write their own — without being burdened by your fears or unfinished chapters.7. Your Child’s Discomfort Is Their ClassroomStruggles are opportunities for learning and growth — not reflections of parental failure.Let your child’s voice emerge, even if it means sitting in silence or letting them disagree.Resist the urge to assume what they feel; instead, ask and listen.“Your child’s discomfort is their classroom — it’s where they learn who they are and what they’re capable of.” — Martha Metzler🧭 For Parents: Reflection PromptsMartha shares these questions to use when fear or frustration arises:What am I afraid of right now?What part of my story might this be touching?What does support — not rescuing — look like here?What can this struggle teach my child about who they are?How can I respond with curiosity rather than control?👉 You can download the full Parent Reflection Handout for this episode at: www.nimbleyouthpodcast.com/resources📚 Mentioned ResourcesSandpaper Moments by Martha MetzlerInternal Family Systems (IFS) Therapy framework“Banks” — song by Needtobreathe🎙️ Listen & Connect 📘 Learn more about Martha Metzler: marthametzler.com 📱 Follow us on social media: @nimbleyouthpodcast

🎧 Episode 23: “Disconnected: Understanding NEET Youth and the Struggle to Launch”Guest: Dr. Gretchen Hoyle, MD, Pediatrician Host: Matt Butterman Length: ~35 minutes Series: Nimble Youth Podcast🌐 Episode OverviewIn this episode of Nimble Youth, host Matt Butterman and returning guest Dr. Gretchen Hoyle explore a growing phenomenon among young people known as NEETs — youth not in education, employment, or training. Often highly online, socially withdrawn, and anxious about adulthood, these young adults represent a rising and concerning pattern in pediatric and mental health care.Dr. Hoyle draws on her 25 years of clinical practice to describe who these young people are, why this trend has accelerated since the pandemic, and how families and providers can help them reengage with the embodied, real-world experiences that support mental well-being.💡 Key Themes & Takeaways1. What Is “NEET”?Definition: Young adults (typically 18–24) not currently engaged in education, employment, or training.Prevalence: Around 13% of young adults in the U.S. fell into this category in 2022, peaking at 15% during the pandemic.Origins: Many NEET youth experienced disrupted schooling during COVID-19—and for some, relief from social anxiety or bullying made returning to in-person environments even harder.2. The Digital PullThese young adults are often deeply immersed in online worlds, maintaining virtual friendships while disconnecting from face-to-face interactions.Sleep disruption is common, with reversed day-night cycles and declining motivation to engage offline.This lifestyle can reinforce anxiety and depression, making re-entry into the real world increasingly daunting.3. Who’s Most at Risk?Dr. Hoyle identifies several vulnerable subgroups:Neurodivergent youth, especially on the autism spectrum.LGBTQ+ and gender-expansive teens, facing added social pressures.Rural or lower-income youth with limited opportunities and support.Youth in insular cultural or religious communities, who may have fewer external peer networks.4. Pathways Back to ConnectionCollaborative care is key — involving medical providers, behavioral health managers, and families.Mental health support often starts with addressing underlying anxiety or depression through therapy, medication, or both.Behavioral health coaches help break large, intimidating goals into small, achievable steps to reduce overwhelm and build confidence.Progress is nonlinear — even small wins matter and deserve recognition.5. Community Resources & Next StepsCommunity colleges, Job Corps, AmeriCorps, and local workforce boards offer bridges back to education and employment.Parents can help by shifting from pressure to partnership—asking, “What’s one small step you can take?” rather than “Why aren’t you doing this?”Early intervention is best: start by consulting your pediatrician or family doctor to assess for mental health concerns.🧭 For Parents: Key TakeawaysThis pattern is increasingly common — you’re not alone.Avoid panic. Change is possible through gradual re-engagement and support.Seek professional help early to identify anxiety, depression, or neurodevelopmental challenges.Celebrate small steps and maintain connection without control.📘 Mentioned ResourcesJob Corps – www.jobcorps.govAmeriCorps – www.americorps.govLocal Workforce Development Boards (search by state)The Anxious Generation by Jonathan Haidt (for context on digital influence and youth development)🩺 Expert Insight“Embodied experience is the best way for our brains to learn, to feel comfortable and happy, and to avoid symptoms of anxiety and depression.” — Dr. Gretchen Hoyle🎙️ Listen & Connect🔗 Full episode available at Nimble Youth Podcast Website 📱 Follow us on Facebook & Instagram: @nimbleyouthpodcast

Episode 22: ACEs – Invisible WoundsGuest: Dr. Gretchen Hoyle, PediatricianPost-traumatic stress disorder (PTSD) in children and adolescents is often overlooked, yet it can profoundly shape mental, emotional, and even physical health for years to come. In this episode of Nimble Youth, host Matt Butterman is joined by pediatrician Dr. Gretchen Hoyle to explore the hidden scars of trauma and the role of Adverse Childhood Experiences (ACEs) in long-term well-being.Children and teens experience trauma differently than adults, and their symptoms don’t always look like what we might expect. From sleep disturbances, regression, and clinginess in young children to nightmares, flashbacks, and hyperarousal in older kids, PTSD can show up in many ways. Left unrecognized, these symptoms can evolve into lifelong struggles.Dr. Hoyle explains how clinicians use tools like the ACEs questionnaire to measure early life stressors and the PCL-5 to evaluate the impact of trauma on current functioning. Together, these screening tools guide effective diagnosis and treatment, while also shedding light on how trauma literally reshapes the brain and body.Listeners will learn about:The four key symptom clusters of PTSD in youth: intrusion, avoidance, negative mood/thinking, and hyperarousal.How ACEs like abuse, neglect, domestic violence, or parental substance use increase risks of both mental and physical illness across a lifetime.Evidence-based treatments such as trauma-focused cognitive behavioral therapy (TF-CBT), play therapy for younger children, and emerging modalities like EMDR, narrative therapy, and even neuroplasticity-driven approaches.The importance of trauma-informed care in schools and pediatric practices—shifting from punitive responses to understanding behaviors as possible trauma reactions.The protective role of resilience built through safe, stable, and nurturing relationships.As Dr. Hoyle emphasizes, early intervention makes a difference. Even when trauma is discovered later in adolescence, healing is possible with the right support.Resources Mentioned:National Child Traumatic Stress NetworkACEs AwareThe Deepest Well by Dr. Nadine Burke HarrisThe Body Keeps the Score by Dr. Bessel van der Kolk👉 Follow Nimble Youth Podcast on Facebook and Instagram for updates, resources, and upcoming episodes.

🎙️ Episode 21: Parenting with Purpose Through “Sandpaper Moments”Guest: Martha B. Metzler, Therapist & Author of Sandpaper MomentsHost: Matt ButtermanEvery parent knows the rough edges — those moments of tension, anxiety, or overwhelm when raising kids. Therapist and author Martha B. Metzler calls these “sandpaper moments,” and in her new book of the same name, she explores how parents can respond with purpose instead of fear.In this episode, Martha and host Matt Butterman discuss how parents can use the “sandpaper” analogy to guide their responses to their children’s anxiety, giving kids both a visual and a tool to manage big feelings without being overcome by them. Together, they explore practical coping skills that help children — and parents — reset, regulate, and move toward resilience.Martha shares tangible techniques such as grounding exercises, breathwork, sensory tools like gratitude bracelets, and the powerful role of nature in calming the nervous system. She also emphasizes the importance of shifting identity: recognizing that while we experience anxiety, it does not define who we are.With warmth and hope, Martha reminds us that parenting with purpose means showing up daily, embracing both grit and grace, and modeling for our children how to navigate the rough patches of life without fear.🔑 Key Takeaways“Sandpaper moments” smooth our edges: Parenting isn’t about eliminating every challenge but learning to respond with purpose and intention.Coping skills matter: Grounding exercises (5–4–3–2–1), breathwork, gratitude, and tactile tools like beaded bracelets help kids regulate anxiety.Nature heals: Stepping outside, breathing fresh air, and moving the body can reset the brain in ways screens never will.Avoidance ≠ coping: Numbing with phones, iPads, or Netflix doesn’t build resilience — purposeful response does.Anxiety is part of life, not your identity: With discipline and practice, kids and adults can learn to manage anxiety so it doesn’t get bigger than they are.Grit + grace = growth: True resilience comes from both naming hard feelings and trusting your ability to move through them.📌 Resources & LinksMartha B. Metzler – www.marthametzler.comMartha’s new book: Sandpaper Moments — available locally in North Carolina and on AmazonFollow Martha on Instagram: @marthametzlerExplore more episodes and resources: www.nimbleyouthpodcast.com💡 If this episode resonates with you, share it with a fellow parent navigating their own “sandpaper moments.” Growth often comes through the rough spots — let’s embrace them together.

🎙️ Episode 20: School Shootings and Their Associated TraumaGuest: Nicole Beale, M.Ed., High School Counselor Host: Matt ButtermanSchool shootings have become an all-too-frequent reality in the U.S., leaving behind not only immediate victims but also a ripple effect of collective trauma among students, parents, and educators. In this sobering episode, host Matt Butterman and public high school counselor Nicole Beale discuss how schools are navigating the psychological toll of this violence, the preparedness measures educators are trained in, and the ways that desensitization has quietly reshaped the student experience.Nicole provides frontline insight into how students are coping — or in some cases, becoming numb — in the face of repeated tragedies. She also outlines the safety protocols schools employ, from lockdown drills to random metal detector days, and highlights the importance of school resource officers in fostering both safety and trust.This episode is not about policy debates, but about the lived mental health realities for students who are growing up in an environment where safety cannot be taken for granted. Parents will gain perspective on what schools are actively doing to prepare and protect, as well as how the proximity of violence — whether near or far — affects students differently.🔑 Key TakeawaysCollective trauma is real: Repeated exposure to school shootings, even from afar, affects students’ mental health and sense of safety.Desensitization is increasing: Unlike past decades, many students barely register distant shootings unless they directly affect their community.Preparedness matters: Lockdown drills, safety plans, and staff training are routine parts of the modern student experience.Mixed reactions to security measures: Tools like random metal detector screenings can either reassure or heighten anxiety depending on a student’s background and community.Trusted adults make the difference: Having clear safety plans and strong connections with educators and school resource officers reduces student anxiety and builds resilience.📌 Resources & LinksNPR coverage of the Annunciation Catholic School shooting in Minneapolis (referenced in episode)National Association of School Psychologists – Resources on School Safety & Crisis ResponseEverytown for Gun Safety – Facts and Research on School Shootings🎧 Listen to this episode and explore past episodes at: www.nimbleyouthpodcast.com💡 If this conversation resonates with you, please share the episode with other parents, educators, or community members who care about student well-being.

🎙 Episode 19: Building Stability — Supporting Students Through Transitions and StressGuests:Nicole Beale, M.Ed., High School CounselorDr. Gretchen Hoyle, MD, Pediatrician Host: Matt Butterman Duration: ~50 minutesOverview: When students face instability at home, frequent school moves, or life transitions, the impact often shows up in the classroom. How can schools, families, and healthcare providers work together to meet both academic and emotional needs?In this episode, host Matt Butterman talks with counselor Nicole Beale and pediatrician Dr. Gretchen Hoyle about how instability affects teens — and how stability, connection, and communication can make all the difference. Together, they unpack the challenges of absenteeism, home life stress, and the overwhelming demands families face, while offering practical, compassionate solutions that schools and parents can implement right away.Topics Covered:Why frequent school moves often correlate with academic strugglesHow schools identify at-risk students early — and the role of trusted adult connectionsMeeting basic needs: food security, transportation, and access to resourcesHow pediatricians support students through collaborative care and family educationThe importance of helping parents and grandparents navigate new school technology systems (like Infinite Campus)Healthy communication between schools, families, and healthcare providers — and how to avoid frustration cyclesWhy remembering that school is about more than academics (socialization, development, and meeting basic needs) mattersKey Quotes:“The biggest difference we can make is removing barriers and connecting students to trusted adults.” – Nicole Beale “Healthy communication means asking questions before anger takes over — and giving each other grace.” – Nicole Beale “We have to remember: for some students, school is not just about academics. It’s also where they get fed, clothed, and feel safe.” – Dr. Gretchen HoyleResources & Links:Nimble Youth Podcast Episodes & Show NotesSalisbury Pediatrics Collaborative Care Program (local model mentioned in discussion)Learn more about Maslow’s Hierarchy of Needs as referenced in the episode📢 Share This Episode: Know a parent, educator, or healthcare provider working with teens? Share this important conversation with them.🔗 Visit: www.nimbleyouthpodcast.com for full show notes and past episodes.

🎙 Episode 18: Always More — Anxiety in High-Achieving TeensGuest: Nicole Beale, M.Ed., High School Counselor Host: Matt Butterman Duration: ~45 minutesOverview: Today’s high school students are taking more AP courses, joining more extracurriculars, and aiming higher than ever — but it’s taking a toll. In this episode, we explore the hidden cost of high achievement and the anxiety that often lurks behind perfect GPAs and packed résumés.Matt Butterman speaks with veteran public high school counselor Nicole Beale about the growing mental health strain on ambitious teens and the pressures they face from school systems, colleges, and well-intentioned parents. Nicole shares compassionate, real-world insights from her 25 years supporting students and her own perspective as a parent of a high-achieving teen.Topics Covered:The culture of perfectionism and how it drives academic overloadWhy AP course loads have skyrocketed — and what’s fueling the trendThe unintended consequences of class rank, college admissions metrics, and school report cardsHow snowplow parenting and peer comparison amplify anxietySigns that anxiety is becoming unhealthy — and when it’s time to intervenePractical strategies for families: setting limits, quitting wisely, and restoring balanceWhat gives Nicole hope: increasing mental health support in schools, more compassionate teaching practices, and resilient teens finding their own pathsKey Quotes:“It’s a pressure cooker, not because kids are too sensitive — it’s because the system rewards overload.” “Sometimes, the most successful college students are the ones who had the courage to get off the train.” “A B is good enough. Your physical and mental health are more important than a perfect GPA.”Resources & Links:The Race to Nowhere (Documentary referenced in the episode)More on AP and college admission trends: collegeboard.orgFor mental health support: Speak with your school counselor, pediatrician, or a licensed therapist📢 Share This Episode: Know a student, parent, or educator who needs to hear this? Share the episode or leave us a review to help others find Nimble Youth.🔗 Visit: www.nimbleyouthpodcast.com for full show notes and past episodes.

🎙️ Episode 17: “When Tantrums Go Too Far: Understanding Disruptive Mood Dysregulation Disorder (DMDD)” Host: Matt Butterman Guest: Dr. Gretchen Hoyle, MD, Pediatrician Duration: ~35 minutesEpisode Summary: Chronic irritability, frequent temper outbursts, and emotional volatility—these behaviors may go far beyond typical childhood tantrums. In this episode, host Matt Butterman is joined by pediatrician Dr. Gretchen Hoyle to unpack Disruptive Mood Dysregulation Disorder (DMDD), a relatively new but critical diagnosis that helps explain persistent mood and behavior challenges in some children and adolescents.Dr. Hoyle explains what sets DMDD apart from ordinary moodiness and how it's different from disorders like bipolar disorder. She explores potential causes, including genetics, trauma, and neurodevelopmental factors, and discusses evidence-based treatment approaches ranging from cognitive behavioral therapy (CBT) and parent management training to medications such as atypical antipsychotics in severe cases. The episode also emphasizes the importance of early diagnosis, school accommodations (like 504 plans), and the effectiveness of collaborative care models in managing this complex disorder.Key Topics Covered:What defines DMDD and how it differs from bipolar disorderRisk factors, including trauma, stress, and neurological dysregulationWhy emotional regulation is at the core of DMDDTreatment strategies: CBT, parent training, medication, and trauma-informed careHow schools and families can collaborate through 504 plans and support systemsThe role of pediatricians and behavioral health teams in identifying and managing DMDDThree Takeaway Facts:DMDD affects approximately 2–5% of children and adolescents, with symptoms typically appearing before age 10.Unlike bipolar disorder, DMDD is chronic and non-episodic, characterized by persistent irritability and frequent behavioral outbursts.With early intervention and a multi-pronged approach, many children with DMDD experience significant improvements over time.Resources & Links:NIMH: Disruptive Mood Dysregulation Disorder OverviewAACAP: Facts for Families on DMDDVisit our website for full episode archives and additional resources: www.nimbleyouthpodcast.comAbout Our Guest: Dr. Gretchen Hoyle is a board-certified pediatrician with over 25 years of clinical experience, specializing in pediatric mental and behavioral health. She is a regular guest on Nimble Youth and a passionate advocate for early intervention and integrated care.

This episode explores how to help kids with anxiety and OCD by changing not their behavior—but the parent’s. Our conversation centers around Dr. Eli Lebowitz's book, Breaking Free of Child Anxiety and OCD.