Part 1: Anxiety & School – Identifying Anxiety and What To Do About It

 Kelcey Schmitz: We want to welcome you to our presentation today which is part of a series on anxiety and the return to school. My name is Kelcey Schmitz and I work for the University of Washington at the School Mental Health Assessment, Research and Training Center or SMART Center, as the School Mental Health, leads to the Northwest Mental Health Technology Transfer Center, our the center is located in Seattle. So, whether you are returning 100%, virtually, hybrid, or all in person, we do think you’ll find this session relevant to your situation. Our funder SAMHSA has asked that we provide this disclaimer that the views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies at the Center for Mental Health Services, the Substance Abuse and Mental Health Services Administration, or the US Department of Health and Human Services. The University of Washington SMART Center The Northwest MHTTC acknowledges that we learn, live and work on the ancestral lands of the Coast Salish people who walked here before us, and those who still walk here, we’re grateful to respectfully live and work as guests on these lands with the Coast Salish and Native people who call this home. We encourage you to learn about the ancestral lands you’re joining us from. On the next slide, I want to spend just a moment to tell you about the Mental Health Technology Transfer Center Network. It was funded by SAMHSA in late 2018. The MHTTC network includes 10 Regional Centers, a National American Indian and Alaska Native Center, and National Hispanic and Latino Center and a Network Coordinating Office. We know that many of you may be joining us from outside of our region, and we want to make sure that you know about the MHTTC where you are located. You can visit the MHTTC Network to find a center near you or to check in with other centers across the nation. So just briefly, I want to introduce those of you who are new to our center. The Northwest MHTTC supports the School Mental Health workforce in Alaska, Oregon, Washington, and Idaho, and on this slide, you can see a variety of ways that you can get in touch with us. You can see our website and email on how to reach us, a link to sign up for our newsletters, and social media accounts for a variety of ways that you can connect with us. We do send out monthly newsletters, as well as training and resource blasts. So, please sign up and be in the know about what we’re offering. So, at this point, I want to invite our guests to come on video. Dr. Kendra Read and Dr. Jennifer Blossom will be spending the rest of our time with us today. They’re going to present some amazing content and then have generously offered to answer any questions that you might have during our Q&A session. So again, at this point, I am going to turn it over and want to give a warm welcome to our guest presenters today. Thank you. Kendra Read: Thank you so much Kelcey for that warm introduction. So, appreciated. So as Kelcey mentioned, my name is Kendra Reed. I am a clinical psychologist and the director of anxiety programs at Seattle Children’s Hospital and Jennifer blossom is also a clinical the psychologist was recent with us at Seattle Children’s as a postdoctoral fellow and is embarking on her new academic career as a professor at the University of Maine. Alright, here we go. Here’s more about our introductions here. Both of we hold expertise in the assessment and treatment of anxiety and mood disorders, including OCD in youth. So that is what we are here to talk about with you all today. As our disclosure, we don’t have any conflicts of interest. We won’t be discussing any off-label product use, and we have no commercial support or sponsorship. This is not a co-sponsored talk, so nothing to disclose here. Our objectives during our presentation, today are to review how anxiety presents in educational settings, to discuss and learn more about the empirically supported strategies to address problematic anxiety in educational settings and to describe school-based approaches for anxiety that encourage and reinforce those empirically supported strategies of approach versus avoidance. We’ll get more into that shortly. Okay, so I like to start here with everybody. I am sure all of you have experienced anxiety and some form or another in your lives, because anxiety is a human emotion, we all have it. So, I’m going to describe anxiety to you all like I would to a family coming in to seek services with us because I think it’s really helpful to hear how we would describe it so that you can implement this in your work with families but what I want everybody to know, kids, adolescence, parents, and you all as educational providers is that anxiety is a normal, adaptive, and protective feeling. This is our body’s natural alarm system. It’s the system that says “Hey, watch out for danger, danger, danger, get out of here”, when something is a threat to our safety. So, it’s an important feeling that we have, it is a good thing and then often, in many cases, it can be kind of a performance boost for us. If I didn’t feel anxious at all about an upcoming test, I might not even crack the book for it. So, anxiety isn’t all bad and I like to start there with everyone because anxiety gets a really bad rap. We hear the word anxiety, we’re like, oh, no, must not feel that but in reality, anxiety, as I said, is a human emotion. We all have it, and it is often a really important one. Though anxiety can become problematic when it causes significant distress or interferes with the functioning of youth or their families. So when it grows, when that natural alarm system grows to be too big for the situation, and I use this example a lot with the families that I’ve worked with, but if we go back to that natural alarm system, I use this analogy of a smoke alarm or a fire alarm in somebody’s house. That is a useful tool. We want them installed in fact that it helps our homes be up to code and we need fire alarms and sometimes those fire alarms go off when there’s no fire, right? So, I tell this story of how in my old house, the smoke alarm would go off every time someone took a shower, which is true and was very problematic because we also have a husky. So it was very loud all of a sudden, and during the shower, the last thing you want to do is get out to like deal with the loud things that are happening but that’s kind of like what happens in the bodies of people who have problematic anxiety. Their body and their mind is going “fire, fire, fire! Oh, no!” but there’s no fire. There’s no smoke, right? There’s, no, there’s no true threat to their well-being. There is a perceived threat that is inaccurate, right? but we don’t want to, quote-unquote gets rid of anxiety, I’m not in the business of curing anxiety, because that would be problematic. That’d be like uninstalling all of the fire alarms in folks’ homes that would, houses would start to burn down. Those alarms are there for a reason. So, we don’t want to uninstall those alarms. We don’t want to take the batteries out but instead we want to recalibrate that alarm to take a second to say, wait for a minute, is there smoke? we need to stay in the situation to see if is it as bad or as problematic, as I am assuming in this moment. So, I’ve, we’ve also included here a table of some common fears and worries that crop up at several different developmental stages and these I think are important to note just to point out how anxiety is super common and pops up all the time and in fact, we see themes for, for youth throughout their developmental stages for when we typically see anxiety about this or that. All of that to say pre-school on, you can still meet the criteria for quote-unquote, anxiety disorder, or have problematic anxiety in the specific topics if kids are starting to pull away from their peers, in terms of the amount of distress and interference they are experiencing about these topics. So, the main takeaway point from this is anxiety is normal. We don’t want to get rid of it altogether. I always tell kids; that you’d end up at the hospital for a different reason. That would be bad, but our job is to help them stay in this situation to recalibrate that false alarm that’s going off. Say, wait a minute, is this as bad, is this, is there smoke? We’ll hand it off to you Jen. Jennifer Blossom: Great, thank you. So at this point, we’d like to welcome everybody to use the chat function and let us know from your perspective what you’ve seen in your students and kiddos, what anxiety looks like. So, if you wouldn’t mind taking a moment to enter the chat, different behaviors or different things that you’ve heard from your students, school avoidance, it looks like is the first thing off the bat that is something that Kendra and I see often stomach aches, I’m seeing a lot of withdrawal and isolation. Some tears, shutting down, sometimes aggression. We see anger, outbursts, and aggression that can come up as a way to avoid it. Covering face, crying, this is great. Thanks so much for jumping right in here and keeping them coming. So a lot of fear. Some I’m seeing sometimes that people are seeing self-harm or suicide ideation, suicidal ideation, the withdrawal that there’s a lot of reaching out to parents that kids are afraid to participate or they’re not answering questions, difficulty regulating. Something that we often see particularly in a school setting is kids going to the nurse excessively, and having difficulty paying attention. That’s a very common one. Sometimes looking for substance use or using substances as a way of avoiding anxious feelings, and sleep disruption. Somebody mentioned, seeing that kids are on their phones a lot and that’s particularly common, right? because if we’re focused on our phones and looking down at the screen in front of us, then that doesn’t mean we do not have to interact with those around us or face things that might be anxiety-provoking in our immediate environment. Great. Excellent. Thank you so much for sharing. So, you’re mentioning a lot of the things that you’ll see on the slide here are things that you’ve just mentioned. So in particular, one of the things as we were preparing for this talk to think about how is anxiety manifesting. How is avoidance manifesting now that a lot of schools or a lot of classes are remote, so kids are meeting via, zoom or some other video conferencing platforms and one of the things that we’re thinking of is that there are in some capacity, it’s maybe easier to fully avoid participation in school. So, school avoidance is definitely a common problem. The hallmark of anxiety, just as Kendra was describing, initially, the hallmark of anxiety is that our bodies react when there’s a the situation in which we were worried about an immediate threat or danger and the automatic response to that is avoidance. Right? If there is a fire in my house, I want to get out of the house. That’s how I stay safe. The problem is that when that the alarm system is going off for things like talking in class or asking teacher for help, then avoidance becomes really problematic because you’re avoiding situations that allow you to participate in the classroom or learn what you need to do or get the help that you need and so oftentimes, what we see is avoidance when kids are physically in school, it might include going to the nurse’s office frequently, a lot of, you were mentioning stomach aches, others might have complaints like headaches. Avoidance might be asking to leave the classroom for a short period of time, excessive bathroom use, either due to semantic distress or because that’s an opportunity to leave classroom. When thinking about the class meetings via zoom, this avoidance can be not joining the zoom session or joining, but not responding verbally to questions, not participating verbally, using the chat function instead, or using the chat function and only responding to the teacher, so not responding so that all students can see. This might also be, you know, avoiding using (and we’ll talk about this on the next slide) but avoiding using the zoom camera function, there might be a lot of missed class or participation due to aches and pains or complaints about illnesses and oftentimes when we think about this from an anxiety perspective, is that when there’s additional medical workup, there’s additional testing that there’s not an underlying organic or medical cause for these semantic complaints. So, frequent stomach aches without an underlying medical etiology are commonly associated with anxiety and in some ways, this is because of cultural differences and emotional expression. So, just describing anxiety as more of a somatic experience is more common, particularly in Latinx cultures and so this is something that we might see more commonly there’s a there can be a lot of distress related to sleep, or eating difficulties. So, students may be less likely to eat while at school. This might not be something we’re seeing when we’re all on zoom based, but definitely something that’s pretty common when we’re in the brick-and-mortar schools. Additionally, excessive reassurance seeking is something that’s pretty common and this is something that we see with students in the classroom happens very frequently with parents but certainly with teachers and other school personnel as well and this is you know, the kind of thinking about your typical student that is on top of classwork but still asking very frequently about due dates are making sure they’re getting the rules just right are they fully understand the expectations for a specific test or project, and that they’re asking excessively and possibly even repeatedly asking the same question. As Kendra was just describing, when there’s an alarm going off when there’s an alarm system going off in your head or your body, it can be really hard to focus, right? If I was standing here trying to talk to you all and there was a smoke alarm going on, behind me, trying to keep track of what I’m supposed to be saying and which side we’re on would be really hard. So oftentimes, anxiety can look like in-attention and this can impact school performance and in some ways appear more commonly like symptoms of ADHD, but it’s actually, anxiety that’s getting in the way because it’s really hard to focus when you’re feeling anxious. So school avoidance, this is something that I saw very commonly in the chat. So, this can include excessive tardiness up to an including chronic absenteeism, particularly when thinking about Zoom meetings. I started to talk about this on the last slide, but showing up late to Zoom meetings are not showing up at all showing up and not turning the camera on and I do want to pause here for a moment and just make note of that they’re very valid reasons which some students are not comfortable turning a camera on, it might be unsafe for them to share information about their school environment, or their housing environment, or where they’re living and that might drive, drive them to keep the camera turned off and in som cases, it might be because o anxiety and worry around ho they look or where even though you know, they’ll see, they’ll say something about that they’ll say something silly or wrong o people will laugh at them. think you know, there’s on the thing that I’ve thought pull up here is when if you all were on camera right now there would be little panels of ove 300 people showing up on the screen and when students are joining as part of a classroom there might be 20 or so 30 or s students showing up on the screen but in, in somebody’s somebody’s mind who has anxiety they’re thinking about it. Like what’s happening right now, I’m the only camera on screens that means everyone’s looking at m and that can really drive a lo of avoidance. I also saw a lot in the chat, that there’ angry outbursts, or there’ difficulty regulating emotions Sometimes, what can happen I somebody feels really anxious about completing a specific task, and they refuse t complete the task, or if they get upset or dysregulated, cr or yell, they’re sent, they’re sent out of the room or they’re asked to leave the area so that doesn’t disrupt other students and what happens over time is that kids learn. If get really upset or I yell and say that I’m not going to do it then I don’t have to do that thing that feels really hard an it makes me scared and anxious So over time, those angry outbursts can actually be driven by anxiety even though the might on the face look more oppositional or quiet Sure and I just wanted to note, there was one question in the Q&A that I felt was really relevant to this moment of noting that some school districts are only having students use their names in the the video function of zoom and not have their video on and there’s concern that students might be zoning out or not connecting, if that’s happening all the time and from my perspective, I think that’s certainly possible. I think it’s hard for us to really know there’s a lot of uncertainty for us and I also want to reflect on how you, we have, you know, roughly 315 participants joining right now and so much engagement, even though I can’t see any of you, so hard to know, for sure. I think there’s a lot of uncertainty and there might be, as Jen pointed out, there might be some good reasons for students to have their videos off. In terms of an equity perspective, both in terms of like Internet bandwidth and the home environment and safety concerns around that and it does certainly allow youth who are anxious about being seen on zoom to avoid the situation. So, I have sort of mixed feelings about it from that perspective. Thanks for jumping in there. So, what we know about the causes and factors that maintain anxiety, it’s complex, there’s not one cause or likely one general issue that goes on when a child experiences problematic anxiety. Did you know that kids can be genetically predisposed to anxiety? So oftentimes, anxiety runs in families, so there might be an anxious parent or an anxious grandparent, and then we’re more likely to see anxiety in kids and the ways that that’s expressed come up and up in a couple of different ways. So, there are temperamental factors, kids who experience behavioral inhibition, they are less likely to engage with novel situations, they’re more cautious and careful in novel situations and this is, these are temperamental factors that we can actually observe as young as children as young as a few months old, that you can start to see these characteristics. They tend to just be more careful and cautious. This is not the kid who’s running out at recess on the first day of school, the new school just checking out all the gym equipment. This is maybe the the kid who’s kind of carefully following their other classmates and looking around to kind of get a lay of the land before jumping into anything and we also know that anxiety can be learned through observing others in the child’s environment. So, we think a lot about social learning about anxiety and in particular thinking about the ways that adults and other kids might model anxious behaviors for kids. So, watching as somebody appears overly cautious or if their – kids might be – observing their parent’s avoidance in certain situations, and that they learn that over time. There’s also a big factor of kids might be getting reinforced for avoiding. So, there might be inadvertent situations where well-meaning adults, teachers, parents, and other adults are trying to help a child feel better and be able to manage a situation and they’re actually reinforcing the anxiety. So, one of the ways that we think about this calmly coming up is that is excessive reassurance provision. So, “You’ll be okay. You’ll be okay. There’s nothing to worry about.”. Oftentimes, that’s really communicating the feeling of anxiety that kids are learning that they can’t handle it and that they really need that help from other others in their environment. We also know that for kids with anxious brains, that alarm system again, as Kendra was saying, it’s really sensitive. So, that means that it’s really picking up on potentially nuanced or minute indicators in the environment that suggest that there might be something threatening. So, I’m walking into a room of 50 people and I hear one person laugh, and I, I’m automatically thinking, “They must be laughing at me. My shirt is so stupid. I can’t believe that, that I decided to wear this today.”. You know, they’re walking, they’re walking through on the bus to go home from school and somebody starts whispering to a neighbor. They must be whispering about me, anxious brains are really detail-oriented. It’s a strength and it can mean that if they’re really detail oriented, they’re picking up on things that could possibly be threatening, especially at school that comes up frequently walking in, you’re often in large groups of people. Sometimes you’re meeting new people you’re changing classrooms. Each class may have a different group of students. At the start of school, you’re thinking about where we all are right now, students are just trying to get up to speed on what different teachers expect. In particular now, in the a learning environment that we’re all managing, figuring out how to manage expectations and what is needed. There’s a lot of information to process and anxious, anxious feelings to really pick up on the things that suggest that there might be something dangerous or threatening. We also know so in addition to attending to those things, we also know that there’s a higher likelihood of misinterpreting things as threatening. So, you know, walking, walking past someone in the hallway or if you’re in a zoom meeting, and look at perceiving that maybe the teacher frowned for a moment and kind of a subtle shift in facial expression, that somebody with anxiety is more likely to interpret that negatively and personalize it. So that you know, the teachers disappointed in something that I did, or oh, they thought what I said, was silly or wrong. So, there are a number of things that come up in terms of processing information in the environment that can cause anxiety and then, in addition, thinking about environmental and life stressors, and that’s certainly something that is relevant for all of us in the current situation and when we think about this as a causal factor for anxiety, we distinguish it from traumatic experiences. So, experience of a specific trauma is considered something separate from anxiety and the treatment looks a little bit different from anxiety and what we know about most anxiety disorders and kids who experience some kind of problematic anxiety are many of them do not actually have a specific traumatic event related to that, their experience of anxiety. Oftentimes, what happens is that there’s a constellation of factors right, they might be predisposed to this experiencing anxiety because of genetics that they got from their parents and then if they exhibit some behavioral inhibition, they’re more cautious in new situations and then they’re reinforced for that the cautious approach in those situations but over time, this becomes problematic, and can lead to problematic anxiety. Great. So when we think about how this plays out, and how over time, these factors can contribute to the cycle of avoidance, so that it continues and becomes truly impairing. So looking at the picture on the the left hand of the screen, the cycle of avoidance, what we think about using that information to figure out how we can intervene and help move the child to the cycle of approach which is the right-hand, right-hand side of the screen. So the goal is to use this information about how we understand that anxiety is learned and maintained over time to figure out what can we do and what can well-meaning adults in the child’s life do to help them address problematic anxiety. So, if we start with the example of the cycle of avoidance, what oftentimes happens is that child the child may encounter a situation and they notice, anxious feeling. So, they start to notice that their heart rates increasing, they might notice a kind of tightness, they notice that their shortening of breath, and they, they have this naturally occurring experience of anxiety and what the body and the brain is telling you to do at that moment is avoid, is to leave the situation. So, the child experiences that anxiety, anxious emotions and physical experience, and then they avoid and what happens after they avoid is that somebody, some well-meaning adults again notice what’s happening, noticing a child having a hard time and jumps in and says “Oh, are you okay? Hey, what’s going on come here” what you know, comfort to them, you’re not feeling well. I want to make you feel better, completely understandable he jumps into say, Oh, you know “what’s going on? tell me what’s going on?” and the child then experiences anxiety reduction, right anxiety goes away. And what they’ve learned because of that is that if I feel anxious, I can’t handle it, what I need to do is a void and when I void, then I get comforted for that I get reinforced for avoiding and when this pattern plays out over time, and what happens that anxiety symptoms start to creep in earlier and earlier, the avoidance becomes more and more problematic. If this is something that the child was experiencing, walking into a specific class, this can begin to escalate to the point of you know, it’s the fifth period and The fifth period really hard for me, and then avoiding fifth period and then more and more relief that they experienced by avoiding the fifth period might try out to help I don’t even go to the school then I never have the risk of attending the fifth period. This is how anxiety and avoidance can play out over time and become really impairing. So with that in mind, we take that information and we figure out okay, so what do we need to do to help the child, approach the situation and learn the goal? As Kendra said we don’t want to get rid of anxiety, anxiety is really helpful. What we want them to do is learn that they can handle and they can tolerate anxiety. Over time in some of these situations are not objectively life-threatening or risk of injury, that they are better able to handle it and over time, their anxiety in those situations might decrease but we really want to focus on tolerating that initial fear and being able to function even when feeling those anxious feelings. So, when we work to help kids overcome anxiety, overcome problematic anxiety. We want them to actually practice doing the thing that makes them anxious and oftentimes, this can seem surprising or counterintuitive, when we’re talking with people about how we think about anxiety but if you think about it, this is, you know, this is a common, a common colloquialism that we hear, right? Face your fear. The idea is, that we want you to practice experiencing this so that you can learn you’ve got this, you can do it and that means we typically take gradual steps. So, we want to think about what’s the thing that makes the child really anxious and then we want them to bring on that anxiety. So, take a step toward that situation. So, can you think about a child who’s really scared about getting shots. It might be that first, we’re going to ask you to look at pictures of a needle and then you’re going to work, work towards watching a video of somebody getting a shot up to an including getting a practice shot and until you notice you know what, oh, I noticed I feel a little anxious, but I can do it. I can do what I need to do. So that I can go to the doctor when I need to so that I can get the vaccines when I need to. When we work on the cycle approach, we bring on that anxiety. We encourage the child we validate this is hard, but we know you can do it, we ask them to face that fear, and then instead of providing comfort, instead of providing comfort after the child has left a situation or has avoided the situation, we jump in and provide lots of reinforcement, and praise about brave behavior. Right. So, “this was so hard for you, and you still walked into that classroom, I’m so proud” and what, what the child learns in that situation, is that they’re actually able to handle more than they thought they could, or if the worst possible situation that they thought was going to happen happened that they were still able to handle it and do it and over time by reinforcing that bravery, we see less and less impairment, related to anxiety and potentially over time, reduced anxiety in those situations. So, from here I really wanted to go over what we know are the evidence-based interventions for anxiety, problematic anxiety, or anxiety disorders. So, because I think what we want to do is take the components that we know work from evidence-based therapy and talk about how we can apply those to educational settings. So, we know that the evidence based intervention for anxiety the most helpful thing is cognitive behavioral therapy and cognitive behavioral therapy has, it looks at the common connection between thoughts, feelings and behaviors. So for example, if you hear you’re going to an amusement park and you think I love roller coasters, you’re going to feel really excited, and you’re going to ride them, and then all that’s gonna feed back to next a time where you’re like, loved it. It was so much fun. Can’t wait to do it again but if you hear you’re going to an amusement park and you think I’m going to die on a roller coaster, you’re probably going to feel anxious, probably try to avoid it, sit on the fence, and not go at all. I’m sick, I can’t go, right and all that’s going to feed back to the next time you hear you have to go to an amusement park, you’re like, the the only reason I lived is that I never stepped foot on those grounds, even though everybody else probably lived or you probably wouldn’t be revisiting that amusement park, right? So, we really want to help people tackle changing the cycle in that thoughts, feelings behavior cycle in two places. That and that is thoughts and behaviors. A lot of times, people come into our offices because they have problematic feelings. They feel really anxious and that’s the problem but we actually don’t target that directly because our whole point is that I actually that’s a really normal feeling, right? but so we want to change how we think about situations that are kind of bringing about that feeling of anxiety, and we want to change our behavioral spots what we do in those situations in order to reduce problematic anxiety over the long run, and that changing the behavior part is exactly what Jen was talking about that facing your fear part and that in CBT is called exposure or facing your fears and exposures that we know are the most a critical piece of treating anxiety disorders, it’s the most the important thing you can do. It’s helped kids of kids approach anxiety-provoking situations, rather than avoid them so that they can have new learning experiences and realize this isn’t as bad as I thought it was going to be and or I am much more capable of handling this than I’ve ever given myself credit for or the anxiety has given me credit for. So that’s, that is the most evidence-based treatment and the most important a component within that treatment. So, as we move on, we’ll be talking about how you do exposures in a school setting. I do want to take a very quick note to say, a lot of times, historically, treatments for anxiety have focused a lot on relaxation strategies and more recently, our field has moved away from focusing on using relaxation strategies for several reasons. One, and kind of, you know, really importantly to me is that it’s really a contradictory message to send kids, you know, we’re starting off by saying anxiety is totally normal but calm your body down, you’re starting to feel anxious, take those deep breaths, right? So, that’s a really confusing message and it starts to build and reinforce this fear of this, those somatic symptoms that start to build when kids feel anxious. So, we want to avoid that contradictory message and instead, help them build mindfulness of the situation. You know, mindfulness not being synonymous directly with relaxation, but just building awareness without judgment of like, oh, there’s my stomach again. Oh, I’m doing that thing where my hands are shaking because I’m feeling nervous. So, awareness without judgment of those feelings of anxiety without feeling like they have a responsibility to tamp it down to bring it down. Kendra Read: The other really the important thing to note is that relaxation strategies have been shown to not contribute to two outcomes for problematic anxiety. So, these strategies are not helping kids in the long run, so we no longer focus on them and I think that’s really important to note because I hear from a lot of schools, where that is the primary focus of their anxiety intervention in the school setting and I would rather than move more toward focusing on how we do exposure in this situation. Jennifer Blossom: So, the other a piece about empirically supported treatments for anxiety in school settings are around or I mean, not necessarily schools, but empirically supported interventions for anxiety are the medication side. So, there are medications that we know are helpful to youth experiencing problematic anxiety, primarily SSRIs, or Selective Serotonin Reuptake Inhibitors. It’s not recommended that anxiety or that medication is the primary or the only line of treatment for anxiety and we do know that youth with CBT and medic who’ve received both CBT and medication together, respond to the best intervention. So, oftentimes families will start with CBT and then consider medications if they’re not responding as we’d like because anxiety is just too high for them to benefit from treatment and then when we bring meds on board, they seem to get a boost so they’re able to engage more in the treatment and benefits. So, that’s just something to note is that kids the research show that kids who get that combined treatment does the best and kids who get just medications or just therapy, do about even not statistically different. All that’s better than a placebo pill and all that’s way better than nothing. Kendra Read: So, how do we support students with anxiety? and at the risk of sounding like a broken record here, I just want to emphasize that the best practices to consider in a school setting are those that encourage approach instead of avoidance. So, I think what becomes really, really hard about this is that it means that you will experience anxiety. As we do exposures. We help families bring on the anxiety. If we are not experiencing anxiety, anxiety during an exposure. We’ve picked the wrong exposure. We need to have that alarm kind of going off. So it can have a moment to say, wait a minute, so my alarm is going off. Is there smoke, right? Is there something bad that’s happening? What is the other evidence in the situation? Rather than just evacuating, right? So, it’s hard to watch kids experience anxiety, it feels like we’re doing something wrong. It goes against our instincts as parents, as educators, as compassionate people. It’s hard for Jen and I still, even though we do this as a job. So, I think it’s just really important to note that, this can feel uncomfortable for everybody. If I go back to the cycle that Jen was talking about, you’ll notice that as adults come in, or peers come into rescue youth who are experiencing anxiety, everybody’s anxiety goes down. So, we are also reinforced for kids avoiding and we want to watch out for that trap because we really need for them to have those new learning opportunities in situations where they experiencing anxiety. Jennifer Blossom: Kendra, I want to just jump in here because I noticed a question that popped up in the question and answer I think, is particularly relevant when we think about encouraging approach and encouraging exposure and facing your fears. There was a question that came in asked about how anxiety intersects with racial microaggressions or experiences racism and thinking about how In those situations the alarm is picking up on a real threat to somebody’s well-being or invalidating them and how oftentimes when people are experiencing that they’re faced with invalidation. They’re told that it’s not a real threat. So I’m curious how you see that intersecting with the decisions to pursue exposure, what other options there might be? Absolutely. So, I think as I read that question, I think one thing that I want to think about there is that we are not telling kids whether or not the threat is real and I think that’s where people tend to fall into that the trap of gaslighting, right? because in for gaslighting somebody is like, oh, this is a threat, this is a problem and other people are dismissive of it and say, “No, it’s not what are you talking about.” right? and when it comes to anxiety for you, we are not weighing in on whether something is threatening or not. Our job is to better help them be able to examine the evidence themselves. and sometimes we do come to the conclusion jointly that actually, this is a dangerous situation. There is a real threat here, in which case, there’s a different intervention that needs to happen in order to, to ensure one’s safety, right, but I think that is really key. We do not want to fall into the trap of weighing in and saying, This is no big deal. Just get over it. That is problematic if there is a true threat and it is very problematic, even if there is not a true threat, right, because it’s also super invalidating for people who are like, actually, this is really hard for me, right? So either way, that’s problematic for us to say, this is no big deal. This isn’t a problem. We want to – our goal is to help them evaluate the situation and really pull in more evidence. Kendra Read: One of the things that Jen noted earlier is that youth and actually people with problematic anxiety tends to interpret the information around them in ways that are either extra picking up on threatening situations or misinterpreting things, so we just want to be careful and for into – for when we think about racial microaggressions, this may not be misinterpretations and often are not misinterpretations. So, we want to be really fair and saying, in laying out the evidence for what’s, what’s happening. So, we can be really clear and not be having conversations where we’ve already arrived at a decision and we’re just teaching you, that’s where, or dismissive in some way. Anything you would add to that, Jen? Jennifer Blossom: I think, to the point that you’re making one of the things that we think about when approaching a situation that kiddo or family is describing as anxiety provoking, just kind of a decision tree that we work through and initially you ask is the fear realistic? So when I think about the question that was asked, and the consequences of racism? The answer to that would be yes. Right? The fear is realistic in that situation and when that situation arises, then we work on figuring out if is this something that the kiddo should know how to manage. If there are specific things that we want them to know how to manage, then we want to give them the skills to do that. So, that’s kind of our initial decision point there and I think that that’s where we want to be thoughtful of experience of racism, there’s the very real reason why that would be immediately threatening to somebody. So that’s, that’s the lens through which we would approach it. Yeah, totally agree. Totally agree. All right. So, in terms of what teachers can do, truthfully, we want teachers to work with students and families as issues come up to encourage this idea of the approach instead of avoidance. I think Jen and I have both read a lot of different, you know, IEP or 504 plans that have clauses in it that end up accidentally reinforcing avoidance and then our feedback is, is around how to turn this piece around so that we’re actually moving toward the feared situation and learning more adaptive responses, rather than encouraging avoidance, just in order to reduce that experience of anxiety and in many ways, we use a school-to-home note, which I’ll show you in a second. I’m sure many of you have used variations of these notes for different behavioral concerns that have come up in classrooms and the application of this to anxiety is not really so different but as you work with youth with anxiety, I really think about how to be supportive and what it actually means to be supportive to somebody with anxiety and that means approaching situations with this an important combination of both validation and confidence. It’s the “I know it’s hard and I know you can do it.” combination. Oftentimes, we see people fall into traps where they’re just, you know, holding on to one of those two pieces of that equation. So either just validating like this is so hard and kind of getting stuck in the admiration of the difficulty, or holding on to the confidence piece of like, buck up, kid, come on, you can do it, this is no big deal, and both of those alone are problematic and in terms of moving anxiety intervention forward, so we really need the combination of both of those to build a supportive environment. Kendra Read: So just, you know, as I mentioned, this is an example of a school to home note, as we apply it to anxiety and I would imagine, you know, I kind of took the framework from this directly from our ADHD disruptive behaviors clinic, which shows you just how similar the behavioral approaches can be. So essentially, we just want to set a behavioral goal with a family around anxiety, obviously this example is for a younger child. If you look at the smiley faces and all of that, we want to set like a really specific, observable, time-limited, you know, smart goal around an anxious anxiety or brave behavior. So for this child, this example child, their goals are around, walking into class independently, whispering to the teacher three times throughout the day, and raising their hands during specials and then we want to make sure that we’re giving them opportunities to reach these goals, tracking their progress and then finding having some way of coordinating that information back to parents so that they can or other caregivers, so they can really reward and reinforce their youth progress toward more brave versus avoidant behaviors in the school setting. Jennifer Blossom: Kenda, if you could just go back to the last slide there is relevant to one of the questions that came in asking about what age you can use these principles with kids and, as noted, Kendra noted here with the smiley faces, this is a school-to-home note that’s really designed for, you know, kiddo as young as in kindergarten, what we know is that you can employ these strategies, you can use these approaches with kids as young as three, you know, oftentimes, we’re then talking more to the adults in the kid’s life. So, talking to the teachers, talking to the parents or other caregivers, that these skills and these strategies still work well, even with really young kids and that oftentimes, if we can catch them that early, we’re just setting them up for better success so that we can really leverage the strengths of that of those brains that are wired more towards anxiety and help them meet their goals. Absolutely, thanks, Jen and I would say that actually our anxiety programs go down to age two at Seattle Children’s, and all the way up through age 18 and beyond. I mean, not at Children’s but these principles are universal, regardless of age and there are just some adaptations in terms of exactly how you would apply this for different age groups. So as Jen mentioned, for kids, I would say roughly seven and younger, I’d be working much more with parents than with kids directly. That’s really different than those than you know, it’s a different kind of story or opportunity for those of you in school settings. So we can talk more about that in the question and answer period if you would like. Kendra Read: Okay, as I mentioned, in terms of supporting youth with anxiety in school settings, we tend to see some common pitfalls, of tending more toward accommodation versus approach in anxiety-provoking situations in formalized 504/IEP plans and I -accommodation is this good word, bad word. In a school setting, it tends to have a really positive connotation. In the anxiety world, it has a really negative connotation. So, accommodation means essentially, you know, being complicit with a child’s anxiety and helping them avoid anxiety-provoking situations. So when Jen and I talk about accommodating anxiety, we’re thinking of, you know, parents who will never ever go out on a date night because their child doesn’t want to be alone or will never eat at the same table as their kid because their child can’t handle it, different things like that. So just want to note that we use that word really differently across our different settings but in general, it has it all goes back to that approach versus avoidance difference. So, a lot of problematic pitfalls that we run into are things like these contra-indicated accommodations, like extra time, not calling on a student or allowing, directly allowing avoidance of certain specific activities. Extra time is a really tricky one and I know, we have a lot of conversations about this all the time, it comes from a good place of wanting youth who may be distracted by their anxiety to have more time to, you know, manage that, when in reality, what tends to happen when we give you extra time, when we give youth with anxiety extra time is that they tend to spend that time worrying or engaging in more anxious behaviors more avoidance, so it ends up not being a helpful intervention in the end. My internet connection is a little unstable. So, apologies if I’m breaking up. As I mentioned, things like relaxation strategies, strategies, and journaling are not bad things to do, but they’re also not helpful. So we would not want those to be considered the primary interventions for anxiety in any setting and really, it also comes down to really requiring this partnership from all parties, from teachers, specialists, and caregivers, so that there is a clear plan for what we’re working on and how we’re going to be approaching this in a situation that is supportive to the child, so involving that combination of confidence and validation. The “I know it’s hard, and I know you can do it, and here’s what we’re going to work on” and I think sometimes we’ve, you know, heard from school-based personnel who feel kind of reticent to approach exposures in their setting thing like, “Well, I’m not a therapist, maybe I shouldn’t be doing this.” but in reality, we all have ownership and agency in this in this behavior change and this change in problem problematic anxiety, even if you’re not a quote-unquote therapist or psychologist, we need youth to practice exposures in all settings in order for this to generalize to all settings. So, it’s really important that these things are practiced in the school setting as well. Okay, Jen, come back on for our Q&A. Jennifer Blossom: So, we have been working with a lot of people internally at Seattle Children’s, as Kendra mentioned, I was there. The working remotely, as I’m sure many of you are just over a month ago, as well as many, many people throughout the greater WWAMI region and there’s been a few common questions that have come up that we opted to highlight here and I’m also aware that there have been a number of questions that may have been coming in over the Q&A section. So, thank you so much for sending those in, please feel free to continue sending those. So, my thought is that we’ll just jump right into the question and answer questions that are coming in. So I think one, one question in which I’m seeing kind of a few iterations are going back to this idea of the 504 plan and how we develop a 504 plan that acknowledges and integrates the evidence-based recommendations for anxiety and one of the ways that I think about that is really getting concrete on some of the goals in the school setting and instead of providing, providing kind of a blanket statement, like more time to finish something is figuring out where the child currently, what are they currently able to do, and where do we want them to be? and then how do we find those steps to get them towards that ultimate goal? So, how can we phrase something that allows them to take steps towards participating in the class? You know, being able to complete that assignment when they’re asked to, in particular, think about a a child who might have difficulty speaking in the classroom, one of the questions that came in was relevant to whether we can apply these principles to selective mutism and the answer is certainly yes, Kendra and I do this a lot. Kendra has a specialty clinic that specifically works with families and helping kids learn how to speak in settings that they feel uncomfortable doing so. So, thinking about a 504 plan in particular with a selective mutism kind of focus, if you have a child who is completely nonverbal, who is not able to speak out in the classroom, oftentimes what happens is we find that teachers are jumping in or providing answers for them. Other students might recognize again, well-meaning compassionate people jumping in providing answers for them, what we want to do is help, help encourage the child to start to be able to answer the question themselves. So, a 504 plan might say something like – initially might say something like respond to nonverbal. So, being able to shake your head yes or no, that’s still providing some kind of information in engaging in some kind of communication. If there’s the complete absence of communication, then it might be being able to whisper an answer to the teacher. So we can think about what is the steps and how can we integrate them into the 504 plan? So that we’re getting the student and supporting them to be able to answer a question in the middle class when, when other students’ peers are there. I would just add that, you know, I know that 504 plans often we can’t change them as quickly as we would like to change behavioral goals. So, sometimes I encourage schools to phrase a 504 accommodation or an IEP the goal, you know, honestly, IEP s with their, like the goal framework kind of lends themselves a little bit more to this idea but the idea that we’re going to gradually be approaching and, you know, moving from totally not speaking to respond, you know, 80% of the time to the teacher in at least a voiced response. So, you know, if you put your hand on your throat, you feel your hand vibrating, right, and we just state in the plan that we’ll be identifying weekly goals. The teacher will be providing, enough opportunities for the child to reach their goal, and we’ll be providing support for the child to try again and just kind of discuss what the communication plan from school to home looks like because that can – that looks different for every school that I’ve worked with, depending on what’s feasible. There’s no one exact the right way to do it and that gives us a little bit more flexibility to work on those successive shaping steps of moving from, you know, just, you know, shaking our head, no, to mouthing no, to then whispering, to then talking. So, the exposures in school said that’s one example. Kendra Read: There are exposures in school settings that can look so many different ways. It just really depends on the different situation. So sometimes we are, you know, as the adults in the situation, setting up some social opportunities, for one child to talk to another, sometimes it’s like, okay, just so you know, I’m going to call on you during this part of the day or sometimes I – a lot of kids have, are so anxious about making any mistake or they redo and redo and redo their work or they, you know that, or there work has to be perfectly neat. So, then we have them turn in work that they finished with their non-dominant hand or they definitely made a mistake in there on purpose and they’re going to turn it in and see what is so bad about this, what is the worst thing that happens when I turn in a mistake? So there are all sorts of different exposures that you do in a school setting and it just so depends on the specific fears that the child is endorsing. Okay, so let’s, there was a the question at the top about PTSD and anxiety, and whether or not they can co-occur or would not be concurrently diagnosed, and absolutely PTSD and anxiety disorders can co-occur 100% they can be diagnosed at the same time, we just want to be careful that we’re not to double counting the same symptoms and we want to be clear that not every anxiety disorder, you know, anxiety disorders don’t come about because someone definitely experienced a traumatic event. Right. You know, fear of spiders doesn’t mean they’ve definitely experienced a horrible situation with spiders, for example, or for selective mutism. This is one of the big ones, where there’s this myth that they’ve experienced a traumatic event and that’s why they’re not speaking. Not true, but for PTSD, you know, that is like one of the only DSM diagnoses where we know exactly that there was an event that precipitated the onset of this disorder. So, it is common for youth who have are just get like anxious. Pre-traumatic events say they have social anxiety. A traumatic event happens they get in a really bad car accident and they can’t get back in the car anymore. They have true PTSD related to the car accident, and they have social anxiety. So these two things were not double counting, but they are happening at the same time. Okay, Jen, I’ll let you pick one. Jennifer Blossom: So, I’m seeing a lot of questions and just getting some clarification around skill building and why we are recommending against using strategies like relaxation or journaling and so in particular, just thinking about why and Kendra talks about relaxation in terms of the message that sends or the threat of the physical experience of anxiety and the general idea is that we want kids to have that physical experience of anxiety and know that does not automatically mean that the worst is going to happen or that they’re not able to handle those feelings. There are many situations we’re experiencing that physical anxieties, really helpful. In the beginning, Kendra was talking about, you know, if you’re preparing, if you have a test on Friday, and I have no anxiety about that, then I’m probably outside playing with my dogs not sitting – in front of a book trying to understand the material, right? In some ways, anxiety is really helpful and adaptive. What can become problematic is when anxiety is so high about the test that I can’t even think about opening the book, because I’m so worried that I’m not going to be able, to learn what I need to learn. So, we really want to help, help kids and help students figure out that I can notice that I’m experiencing some of that anxiety but I can still do the things I need to do. I feel anxious about the test but I’m still able to sit down and focus on the material and study the way that I need to. When we tell them, “Oh you notice that your heart is racing or you notice that your muscles feel tense. Let’s take a moment and sit back and spend some time breathing.”. What we’re doing is we’re sending the the message that bad anxiety is really something to be worried about or scary that they aren’t able to handle those feelings and then what happens is when they walk into class to take that test and they’re feeling those same feelings, they think they can’t handle it. So, we want them to do is practice handling and practice tolerating. When I think about a strategy, like journaling, one of the things that I think about is that, you know, anxious brains again, they do a really good job of thinking. They’re constantly thinking, they’re constantly coming up with the what ifs, what if, what if, that’s what gets in the way of sleep, that’s what gets in the way of paying attention in class. So, if we ask somebody to write down all of those thoughts, and those what-ifs, we’re not necessarily giving them the skills or the strategies to still be able to do what they need to do and in In some cases, we may be letting those what-ifs allow for avoidance because now they’re writing about those what ifs instead of doing that thing, that’s hard and this is something Kendra and I have just recently started talking about kind of how can we rephrase and reframe thinking about exposure and practice based on your fear as a coping skill. I think that’s one of the things that can get lost or is confusing is that when we think about facing your fears that we’re ignoring that, that is still is learning a coping skill because what I’m learning is that when I feel anxious, I can still do what I need to do. When I feel anxious, I can still pick up that book and sit down and read the first paragraph when I feel anxious, I can still open my computer to start writing that essay. That’s coping skill and the way that you build that coping skills by taking those smaller steps until you’re able to do that thing that’s really hard. What would you add to that? Kendra Read: I would just want to add about there’s this piece that we call expectancy violations. We also want kids to have those learning experiences, to see that the thing that I expect to happen, really doesn’t always happen or even if it does, it’s not as bad as my the brain is assuming it is. This is the coping skill and I think a lot of people get wrapped up in the toolbox, and I need to give kids all these other things to do when they feel anxious but the thing we need them to do is to practice staying in the situation, and quote-unquote, riding the wave. So, I’m seeing some other questions about like, what do we do in situations? Like when a kid is anxious, what do I do? and really, when that happens for me, like all day long, I just want to – I sit with them and I say, okay, so you’re experiencing anxiety, what’s happening in your body right now? How are you feeling it? What’s your number? and so I want them to practice rating on a scale from say, zero to 10, how anxious they feel. So, that’s one way that they can build some mindfulness of saying like, okay, I’m at like a seven right now and I’m noticing that my stomach really hurts and that’s like, okay, so what are you thinking at this moment? I’m thinking, I’m totally going to fail this presentation, I’m going to bomb it, everybody’s gonna laugh, etc, etc. And say like, okay, well what is happening in this situation is anybody laughing? Like, well, I can’t hear that anybody’s laughing. So maybe they’re not. Maybe they are in their own homes, but nobody’s mics are on everybody’s automatically muted. So, if I don’t know, if they’re laughing, how will it ever change my life? So, just some thinking through some different situations like that to think through that expectancy violation, violating what we expect – the anxious anticipation of what’s going to happen. Okay. Jennifer Blossom: I see, I think we, I hope we answered some of the questions about the Final Four Planner IEP is about how we can approach it. I see some questions about like homeschooling and one on one the school supports, and how do we help families understand this and man, is it hard, you know, I just want to validate that like, as much as we do this for a job, we don’t convince every family that this is the important way to go and we really try to, to bring them in and discuss how, you know, you know, one of the other programs run at Children’s as a school avoidance program, which is not running this fall because most schools are remote. So, there’s no brick-and-mortar school to avoid for most of our students, but what I tend to see is that the families that pull out into homeschooling because of anxiety, those kids tend to have really escalating very problematic anxiety, very interfering anxiety that continues for years. So it does become a really big problem and so I just want to describe that the trajectory that I see for them before they make that decision and be very clear that homeschooling online homeschool, That like we’re all pigeonholed into that right now because of COVID or most of us are, so we’re not making that decision because of anxiety but when we do make that decision because anxiety is contraindicated. It is problematic in terms of changing this cycle. So it’s very, very much not recommended. ] Kendra Read: Jen, do you have a the question you wanna? Jennifer Blossom: Yeah, I was just searching through the Q&A and I see a lot of questions and thinking about how we can adapt some of these recommendations and approaches, particularly for older students. So, thinking about high school students, and thinking about it, there were some comments about the student kind of report card can be more challenging with a high school student and I think, you know, in some ways, really just kind of working, working with the student and figuring out kind of what’s going on for them at school and at home. I think one of the things that we know that comes up commonly when working with families is that oftentimes parents are not necessarily as attuned to some of the things that may be coming up at school for their kiddos, Kendra and I have worked with families where, you know, after kind of years of school difficulty and some anxious avoidance in high school, that’s when the parent found out about kind of what was going on. So I think, really making sure to work as a team. In some capacity, I think something that can happen developmentally when working with younger kids that there’s a tendency to exclude them completely as if they can’t understand these principles. When, as Kendra says two and three-year-olds, even if they’re not coming in for the treatment the session, they get the idea that was brave, awesome job, right? So we can still be working with them directly and integrating these strategies with really young kids and in the same way when you’re working with high school students, just as you would reach out to parents for, other types of concerns, if you were seeing chronic absenteeism or if there was a lot of missed work but bringing parents in to support high school students are a really helpful and a great opportunity too as much alignment as we can get with practicing some of these strategies both in and outside of school, I think can be really helpful and effective and when we think about some of the types of anxiety that we see, more commonly, social anxiety is much more common in adolescence. By very definition, adolescence is a time period where we are more prone to peer evaluation and judgments and that’s an opportunity that’s ripe for the onset of social anxiety and fears, and really coming up with creative ways to practice bringing on that anxiety, like answering a question, just wrong, purposefully making a mistake or having a long pause in the middle of a presentation. Wearing a t-shirt to a zoom meeting with a huge stain across the front, you know, thinking about ways that you can help bring that on because one of the things I know from working with lots and lots of teams with social anxiety is that it’s really hard for them to be in these situations and they really want those peer relationships and connections. So, figuring out how we can work with their own goals and use their own motivation to help them take those steps, towards doing the things that they want to do. What would you add to that Kendra? Kendra Read: You know, I’m not sure that there’s a whole lot more I would add to that, Jen. You know, one of the things that I’m noticing a lot of the questions are just like, yes, but how do we do exposures? Yeah, how does what does it look like? and so I just wanted to give a couple of more examples for different kinds of areas that kids are anxious, about and how we can do that in a school setting. So, we’ve talked a little bit about how to set up, you know, brave talking exposures for selective mutism. So, really, it’s setting a goal for Okay, so today we’re going to whisper three times and so I’m going to give three opportunities for you to whisper with me one on one, or I’m going to get five opportunities and your goal is to do three out of five. So, I’m going to come by your desk and say, what was the answer to number four? and you’re going to tell me to practice whispering to me the answer to number four. A lot of times as Jen was noting, we need some kid involvement in some youth involvement in setting this goal. We need them to know what the goal is, so that they can practice reaching it and they can, we can give them some forced choice of like, okay, so it sounds like from your parents that, you know, we’re going to work on, you know, saying hi to a peer. So do you want to practice that? This time of day or this time of day? Do you want to do that with you know, you sit next to Johnny and Susie, do you want to practice with Johnny or Susie first and I’ll be listening. So just some, some different examples like that. Practicing making mistakes, practicing, turning in imperfect work. I think I’ve said those already. Jen, do you have any other specific exposure examples? I don’t want to overcomplicate really what exposure is it really is simple. So like I’m telling a kid, okay, let’s go do some trivia with some people down the hall. Here’s a list of trivia questions I’m going to give them I want you to get two of those wrong and then we just go do it. It’s really as simple as that. Jennifer Blossom: Yeah, I think one of the things that come to mind, particularly when we think about the context of COVID-19, is that everyone is managing a lot of uncertainty right now and not being able to tolerate uncertainty is a hallmark of anxiety, right? Anxious brains want to plan they want to know they want to be able to anticipate what’s going to come up, that’s where worry comes from. Worry is a maladaptive coping strategy that if I think about something enough, or if I think about all the possible outcomes, then I’ll be prepared to handle them. So, when we think about the current situation, in particular for kids, maybe who didn’t have, didn’t have much anxiety before wasn’t really getting in the way but right now with COVID and everything and that there’s been a lot of back and forth, of not knowing what to expect for school and as they get used to the startup school still having, you know, trying to navigate what’s going to be expected in terms of grades or things like that is really opening up opportunities to practice tolerating uncertainty. So in going with the example that Kendra had just had, of asking them to go answer questions that they’re not going to know what the questions are in advance and being prepared to answer questions that they’re unexpected for, or having, you know, coming up with a plan that’s not shared and advanced so that they can they can tolerate being in a situation where they weren’t able to think about and plan for really thinking about what are ways that we can think about some of the uncertainty that is typical of everyday life, COVID-19 is causing a lot of stress and a a lot of realistic anxiety for people, particularly when we think about the disproportionality of COVID risk and consequences of COVID we know that there are going to be significant mental health concerns for particularly communities of color. So we want to think about, what are the things happening right now? How can we, again, assess, understand the full context for this kiddo? What are things that are coming up? What are the objective risks that they might be facing? and then what are ways that this anxiety might be creeping in that it’s getting in the way of them being able to do the things that they are able to do right now that they are able to participate in staples that are going to keep them connected to some of those, those social supports? and how can we leverage some of the strengths that they might have currently, certainly, Zoom meetings, Zoom parties, and Zoom classrooms are not the ideal setting for many people, but there are ways that we can still encourage that participation and get creative with getting kids involved. So I think, you know, the uncertainty piece is one that I think comes up a lot. In particular, I think again, we think of that as the – perhaps more commonly with older kids, but certainly right now with COVID, because it’s just a prime situation for us all to be thinking about it. So, think of just different creative ways that you can help kids experience situations that they’re not able to prepare for. I’m curious Kendra, have some other ideas that you might have about thinking in a new school context or particularly in the online school context? What are ways to introduce uncertainty that would allow students to be able to better tolerate that? Well, I think there are just a lot of natural opportunities that come up that we can capitalize on. Sometimes I set up like more contrived situations of like, okay, we’re going to do exposure and you’re not going to know what it is or sometime this weekend, your parents are going to change their plans. You don’t know when you don’t know how you don’t know what it is. So different things like that and their job is to tolerate that meaning to keep their behavior within you know, appropriately behavioral bounds, they can still experience anxiety and frustration and so I would just note like, there are so many natural opportunities coming up for us to tolerate uncertainty every day with COVID and remote learning, and will we have Internet connection? and will this work and, and all the other things happening around us like, the wildfires, like there’s so much uncertainty, and so much we don’t know and, and just sitting in that place of like, what if we don’t know? What if there’s no answer? and that feels really anxiety-provoking, but we just need to sit in that place. So I see a lot of questions like, but what do I do during the exposure? What do I say to them? and I really, especially when they’re starting to get really anxious, and I really just say I want them to check in with them just repeatedly to say like, hey, what number you at, what do you – what are you doing? I know this is hard, but I know you can do this. So just keep going back to that supportive statement of I know this is how I think you can do it. I know you can stick with this situation, and then point out all the little ways that they are already doing it. Like, life is uncertain, and you survived every moment of uncertainty up until today. So, is there any evidence that you’re not going to survive the uncertainty hereafter? No, we have no evidence that that’s true. Might we have evidence that the opposite is true? So the truth is, we all survive uncertainty every minute of the day. I don’t know what, I don’t know actually what’s going to happen in the next hour of my life. I have some things that might, you know, help me predict that but I don’t actually know. So I think just pointing out all these little successes that they may not be giving themselves credit for during the exposure of like, you’re still here, you’re doing it like we’re just going to ride this wave. You don’t have to do anything to make this feeling come down. You are not responsible for that. It just will. It is what it is. So we just need to stay in this situation. So I really want everybody to release themselves and have the responsibility to make themselves calm down, but it’s nobody’s responsibility. It’s just what goes up will come down and we’re just going to ride that wave. If you think about it like you’re in the ocean and like the waves are coming and you’re trying to push them back, like calm down waves, like they’re just gonna knock you over, right? So instead if we ride that wave, and we accepted remindful of it, and we’re like, okay, like, how hard is this? What number is this? Okay, this is a really big wave, oh, I’m going up really high. Wow I’m going really fast into the shore, right? We just want to observe what’s happening. We’re more likely to experience improvement and greater success in the situation than if we’re like, must calm down, got to force this down. So, I really want to let go of that sentence. Kendra Read: I’m jumping around a lot, but I’m feeling the Jen, what did you want to add? pressure of time. So, I just want to note that there are some Jennifer Blossom: Yeah, so I think just to kind of end and questions in there around partnering with PCPs and other medical professionals. I want to say that Jen, and I do have an ongoing connection with PAL or the Physician Access Line here in the Northwest and we are creating and together  we call laboratory Nat Young Bluth in into connection for primary care for anxiety and OCD. So that is forthcoming for those of you who are school nurses, I just want your job to be is to help to connect some of the somatic feelings that address some of the questions that come up with how to help how we’re experiencing anxiety and being a part of the goal setting with others around like may- be their goal is to not check in at the nurse so much, which me annoys that they’re avoiding the classroom, potentially avoiding the thing that’s anxiety-provoking, and potentially trying to just exit altogether. That’s less so happens in the times of COVID but just in terms of like what we typically see. support when kids are in the thick of the anxiety, while anxious brains do a really good the job of being detail-oriented, those details tend towards the threat. So, sitting with them and commenting on what they are doing while they’re feeling anxious is really a way an effective way to be supportive of students and help get them engaged in exposure situations. So, if you notice that they are feeling anxious, or they share with you that they’re feeling anxious, commenting on what they’re able to do in that moment, finding what it, finding, even if it’s a small step, something that they are doing at that moment that is helping them be effective in whatever the strategy is. So, thinking back about participating in a zoom class, if a student went from not participating at all to using the chat, jump on that, that’s the first step towards talking in class and joining via video and joining the class. So, an an effective strategy is really focused on what they’re doing well because at that moment, it’s hard for them to see it and that’s going to be a really rewarding opportunity for you and for them to be able to continue taking these steps towards facing their fears. This has been really great. I’ve so appreciated all the questions that you’ve raised. Kendra, and I love doing these types of presentations and as she’s noted multiple times, it’s a bit of a different situation not seeing any faces, but we’ve really appreciated the engagement and so looking forward to working with you and meeting with you again, in just a few weeks, and with that, I’ll turn it, Kelcey. Kelcey Schmitz: All right, thank you. A huge thanks to Kendra and to Jen for their presentation today. I know for me, personally and professionally, I couldn’t take notes fast enough and for those of you who have participated today, just a reminder that we will have the recording up for you who like me will probably be watching this and sharing it with other people who need to see this. On the next slide, it’s just a a reminder of how you can get in touch with us. We have many opportunities for you to participate in live webinars, we have many recorded School Mental Health webinars that you can check out. We have a newsletter, that we send out monthly newsletters and event blast to you. So, we just highly encourage you to connect with us, especially if you’re in our Northwest region but you’re also welcome outside of our region, as well as reaching out to your local regional center to get more support and then our last slide is to thank you and a a reminder that part two, managing anxiety during COVID-19 will happen on October 20. So we hope that you will register for that. I will say this, this session sold out so if you haven’t registered already for session two, it might be a good opportunity for you to take care of that now. We know we still have lots of questions in the Q&A and we will carry those forward to future events that we have with Kendra and Jen. So, huge thanks to Kendra and Jen. Huge thanks to our Northwest School Mental Health team that is been working behind the scenes to help with the chat and the Q&A and just keep this webinar running smoothly with that, we will officially end the webinar but keep the room open for just a few moments. So, you can take down those links and complete the evaluation but at this time, I want to thank everyone and we will end the webinar.As found on YouTubeFUNNELIFY is a new, first-of-its-kind, groundbreaking app ➯➱ ➫ ➪➬ which finally allows you to deliver separately auto-generated mobile pages with unheard before lighting speed. Plus it skyrockets ➯➱ ➫ ➪➬ After using the Funnelify product, you will recognize a great increase in your leads and sales. This product shows methods to boost your traffic without using any shortcuts. The best thing is that you can build unlimited …