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 …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
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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
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A high, prolonged cortisol level can mess with a lot of stuff. It’s even been seen to decrease the volume of your hippocampus, the area responsible
for learning and memory, and a reduced hippocampus
is more often seen in people with depression than those without. So all this is to say that the extra stress is probably not doing your brain or your body any favors. And humans are historically
bad at making decisions when they don’t know
what’s going to happen? So, what can you do to
reduce the allostatic load? Reduce stress. Eating well, exercising, and maintaining a regular sleep schedule cannot be overlooked. Exercising alone can
reduce stress hormones, even with just a 20-minute walk. And a different way of
thinking could also help us: an idea called model-free learning. It’s trial and error. Instead of basing your risk assessment on similar examples from the past or envisioning future scenarios, you just take it one step at a time. This way, you reassess and
update your estimate of what’s happening and how to prepare. We’re dealing with a new virus, constantly changing policies, and likely a completely different schedule and maybe even environment. Our brain is on high alert at all times to identify potential threats. This means that even if you’re spending most of your time laying around, your brain isn’t, so try not to beat yourself up for feeling tired or fuzzy, or unmotivated. You just don’t need anything
else to stress about. Now that you know all of this, how are you feeling? Alex: To be honest, I
do still feel the same. Fran: I think I’m feeling a
bit better after watching it. Victoria: It’s
my body is exhausted from feeling things and being under stress all day, all the time. Graham: Whenever I feel
that allostatic load starting to weigh down on me, you know, I can put a
name on it, a face on it, and it makes it a lot
easier to deal with it.
