level and then we also run through some of the evidence based treatments that we have and we know work so we're just a brief orientation to those so if you guys have questions about the slides as we go through you feel free to stop us and let us know we're also going to make sure we save at least fifteen really geared towards parents and the whole concept is it takes more of a preventative stance so what can you be doing for kids that may be trending more towards the anxiety symptoms that we'll be talking about but maybe don't necessarily people in treatment or don't have a diagnosis yet so it's very very user friendly lots of humor and funny anecdotes so i highly recommend it if you want to have a primary love we do she is a wonderful writer and it's actually a really easy read  attended why it's been so effective that what we do at treatment also some of the resources that would be available to you guys as parents to understand a reaction that severity of a reaction like you would for example if you were standing in the forest with a bear or a wild animal when you're taking a test for example if you're reaching that level of physiological arousal anxiety in that context then that's probably not so adaptive so part of what's so tricky diagnosing exactly disorders is trying to figure out when you cross that line from being adaptive to is different than having a panic attack so having a panic attack is having that really extreme fear and a lot of physiological symptoms associated with that maybe sometimes even similar or kids have described it to be similar to having a heart attack you know feeling really panic disorder however is then after having a panic attack or having multiple panic attacks actually fearing the panic itself and being afraid to go places because of that and being afraid that they're going to have a panic attack in the context of a certain situation which leads nicely into work which is often diagnosed a disorder which is having a fear of going someplace because of the feelings that you're going to get your body and being afraid that you're not going to be able to get away or get help so it's kind of very similar to what you would think of when you think of faster and faster and agoraphobia are often what are the same as far as how we think about them clinically  situations such as going into the elevator or getting embarrassed in public and so when we're really talking about an isolated panic attack or i always get possible bacon elevators when we're really diagnosing panic disorder we're seeing kids get panic attacks while sitting at home watching me feeling so that's where we start to see that thinking shift into something that's more of what we call disorder and i think the last two to stick i saw was i think eleven to twenty percent of adults will have a panic attack at some point in their life so panic attacks themselves are very certain activities specifically because they're afraid of being judged by other kids or by the teachers or other adults and so it's kids especially when you're thinking about kids with social anxiety term it's kind of a catch all but we like to think of it as those general pervasive worries that you get every day that might not be a defined bird confined to one  really interesting or funny because we obviously didn't but the family's falling saying my kids are worried about their safety it's cold how do they know they're protected and that would not be considered generalized anxiety so even though they were worried about an adult be able to keep themselves safe this was in response to a specific incident so if this kid is also worried about catching diseases or doing perfectly school or getting perfect grades six months after so in the fall after the bombing that's when we would start to be really concerned that this might be something more pervasive so it's really more generalized is out is set for life better it really is more of a catch all that there's o c d which interestingly is no longer classified as an anxiety disorder but exceptional worries that kids might get and the compulsion that they have to partake in in order to neutralize that worry that they're having so these might be kids that are excessively worried that the door isn't locked at night and that the compulsion is to go downstairs and check the door five or six times throughout the course of the night make sure that it's ok and as our people talk about a little bit later in the reinforce the cycle of there is that every time that they check that door they don't feel so much better and that's the piece that gets i think it's o c d i mean at that point we're really concerned about their own types of rule outs and differentials if we have all of those other social pieces to go along with them so contrary to an adult contrary to believe don't enjoy having done so it's an this this is the larger context in which they feel that that is where the treatment direction is going as well so instead of just treating the broader disorder treating the dimensional components of the disorder that it's more these things are wrong with my child when in fact the majority of these are all driven by the same type of thing and we're going to treat them in the same way so i think it's moving in a really parsimonious direction which is helpful to the public to help understand it a little bit  reasons for that are probably pretty varied does so it's not necessarily that we're seeing more anxiety this year as we were five years ago so some reasons are that our health literacy and access isn't proving and these are some of the reasons that it's also thought that some of the autism  rates are rising as rapidly as they are so we have better tools we have more people in the community who are assessing kids and we know what to call it a little bit more quickly than we used to be able to do that stigma is going down so if any  older side in the audience can remember what it probably felt like to mention to your friend back in the seventy's or eighty's that you had anxiety or sadness usually that was probably met with a pretty dismissive we all do what's the big deal what's the problem and you know talking to my parents generation it's just been so interesting to really think about the difference for better or for worse with how the community response to these types of things now so i think overall my personal opinion is it's a net positive that at least we're reducing that stigma a little bit of a lot of work to do what we do with that information as it comes up also academic expectations are higher than adverse so now especially with the public schools there's the pressures of its own and every type of study specially in the boston area and the northeast so colleges now the expectation as opposed to the thing to really be proud of achieving maybe in the first college grad in your family is not the silliest it deals with us before we have standardized tests of the was so there are a lot more expectations in demand and we also know that social media is probably influenced again for better or for worse we see other kids talking about these things we may be concerned about what if i do express something on social media what if i  be family reinforcing the symptoms isn't necessarily new so this has been around for forever but we know that parents may have their own anxiety about kids futures that we may see parents as we're talking about for reinforcing certain things that may or may not be in the best interest of the kids in diety and i think what's also interesting is when you look at different siblings if we think about the whole genetic vulnerability piece we may have three different siblings all with pretty similar dynamic make up and for whatever reason here it's the same message to all three kids one of those kids may end up with anxiety the other to me not and i think it's pretty interesting to think about how we need to respond to certain kids depending on what they're bringing to the table so it's again i think that interview the environment and genetics that can really very alive in the family we also know parents can now log into portals they can see their kids report cards they have much more access i think than families used to so there's a little bit more pressure maybe a little bit more perception of pressure and i can't think of a single case i've seen or that our group has seen where it was just about school so it was about bombing at school or outs or germs that school or the street teacher at school or the bully at school or needing to be perfect on the test at school but we really need to help figure out what exactly it is about school that's making it to the bowl a lot of times we see families who have come in by the time they come in their home schooling their kids because school is so stressful that in order to actually get them moving through the grades they need to get through get to the  they need to be out of school studying so as much as possible we want our kids to be in the public setting for lots of different reasons so this is a really important piece that we always try and look at these are some of the common differentials that we might see a worry about having an attack at sense they can connect the dots why they don't want to go on the day that somebody told them they're bringing sandwich and they have an allergy and these are different things for us to think about because we can take that information to strategically meet a little bit of a safer place or at least let them nice and we need to also get a sense of where they're coming from are they trying to push the boundary is there some sort of conflict going on do they just not want to do this because they're afraid of having a panic attack and the only way they feel comfortable letting you know that is figure out how can i get out of it or how can i make it a little bit more bearable for tolerable so you can imagine if there is a way to get out of it so let's say the kid gets to go to the bathroom and is able to skip over the teachers but doesn't get one that's going to feel amazing so they got to we going to do we're going to try and rush through the test we might refuse to take the test all together we might be absent that day if we know that the tests are coming up ahead of time and we might ask for extra time or for extra help for extra time or extra help this might not necessarily be about think especially if this is something that's in the child's eye for already but just something that we might see so assuming that the child gets to do these things we rush through it and then the first one done we're going to get that really so absolutely ask for help whatever it is so that just felt so good i felt so reinforcing that i had just talked myself the only way to get through the test day is to rush through it or skip out of it if we do this every single week for a year you can imagine how anxiety surrounding whatever the presenting problem is i think that not just thinking about it as an avoidance model but thinking about some of the things they might be doing during those anxious times that aren't necessarily voiding but are things that they have to do to kind of neutralize that fear parents as they probably are but i think it's good to know about especially for parents who are involved with you know you're asking for so in a perfect world we would do a full semi structured diagnostic interview oftentimes it can take two to four hours we go through also has a really nice set of metric properties meaning if i were to give it to one hundred kids with o c d and the one hundred kids without all of their responses should look pretty different and that it would be consistent across kids so it's much more reliable in terms of sang let me just make up some questions and see what they say to them so that can be helpful but it's not certainly going to give us that objective numerical data that can give us some norms as to how those kids compared to other kids without that diagnosis to go through briefly what if your hierarchy is  also very well validated by three of us to use so both are great examples there's also the child behavior checklist and state worry questionnaire so there's lots of different questionnaires that have been here to support it i think when talking teachers and is needed and usually if you're doing a testing battery at school or in your report there will be some sort of software board carob or of anxiety symptoms especially if that's the question is is there a diety or not but just something to be aware of behaviors like maybe try and stay in this time or maybe i'll try and take five minutes to answer the first question as opposed to rushing for it ten seconds like they usually do and so we would i mean we spend probably two to four sessions on just the three component models so four hours be tried it fits the actual context of what's happening and look at this really the three component level is a tool for us to get to this and what we do is we teach kids ok so we have this reaction can change that reaction the test is going to make you nervous it's going to cause you to think these thoughts but it's this cycle right here it's the between the thoughts and behaviors or the actions that that's where we want to start to change things so often trying times it drives you to x through that part of the arrow so that the cycle that we want to break so we want to start saying ok i have this reaction i can think these thoughts but i wonder if there are some other things that i can do that are going to reinforce things i say that might be what we call brief behaviors or brewery missions depending on how the kids are down what the specific challenges are still for kids with test things id we could probably have five different things so it could be taking and casts could be taking part it could be taking a little spelling plays with mom in the kitchen so it can look like we're going to start the easiest ones so it's like with anything when you're learning how to ride a bike we're not going to put you on the bike and send you down the hills the parents might but we probably know that both kids are going to be a little bit more successful if we try the training wheels birds so we want to start kids at a level where they actually feel excited about doing these practices and excited and good about themselves so for kids with school refusal lot of time to think this is where you know that it can really snowball if we have kids who haven't been to school in a year because they were having such extreme panic attacks that they had to be home school for a year we're not just going to send them and so if that's the ten you know the top of the higher we might start with well let's go to the school parking lot on the weekend and just sit in the park right now and see what that like so it's a really breaking down some been sufficient for the trials to show that the psoriasis the antidepressants are helpful for kids that doesn't mean they don't come without side effects we don't have a ton of data yet on long term what does that look like for kids who are that seven but we a hard time that might be when we would recommend having a psychiatry console to think about whether medication would be a good idea so these are basically the individual components of cognitive behavioral therapies still cycle that is really what we were just talking about so how many kids have anxiety a lot of times will actually calculate how many kids are in your school ok so we know that one in four kids has something that they're working on right now that's two hundred kids in your school that are also working on this besides you know so i think it can reduce the stigma a little bit in terms of remaining kids how many other other kids are in with other things and this is also when we would teach the three component model of the year cycle so really teaching them about what exactly this is how we're going to confront it oftentimes ask them to draw their anxieties and it's really silly you know whether it's the worry monster they actually have their draw on your face like that means something to them that's how they experience it oftentimes with the younger kids are really kids you know inside their body when they're when they're scared about something and that seems really resonate so i think that's really helpful with those younger kids and the younger the kids are the more behavioral it is the more it's just about reinforcement the more parent work that we do and if you think about where kids are in that three to five range parents are usually doing most of the things for them anyway so we might present to kids as we're a teacher mom some skills to help you when you're feeling really nervous and a lot of our work might be focused on we do a lot of parenting groups that are focused on up on me i know it's going to happen is one hundred percent going to happen i did it happen to that girl my cousin two years ago i know it's going to happen so we say ok let's test that let's actually figure that out if we were to go to school how many kids this year do you know of that got brought up on in the classroom so really starting to challenge that and break it down and this is where i think the lies in the ninety's really helpful because a lot of times kids i think in adults feel like anxiety is part of them and they don't have a choice over it so they might feel like i'm the worried kid i'm the shy kid i'm the kid they can't do anything right so when we start changing our language to be more reflective well actually you're really brave kid but sometimes things i gets in your way prevents you from doing things that you would like to do like go to soccer go to the movies we can think about it is something that we're stairs we spin and it's been easier to see if we can get butterflies in your stomach or get that just feeling and really what we're trying to do is we're trying to get kids used to feeling but not let it be what they're going to do with that feeling so just because you might feel a little bit anxious doesn't what would that be like and so usually we can get it down to enough of a level that kids can have some sort of and rewards are really important we have to retard the little ones may have tokens for the middle age kids privileges are great for adolescence  you tube video so anything we can do to get it down to more manageable level and really getting back to what their experience with it to be positive so if kids are kicking and screaming and saying absolutely i'm not doing it we're not going to do it and i always tell if i'm never going sleep but we can walk through a whole detailed story of what it's going to be like to pack a bag if you forgot your toothbrush you talk to how we call mom your friends parent has another spare with videos so really walking through all those worst case scenarios that when they get there there's water really doing the thing that it is that we're afraid of relaxation strategies there's also some controversy about when to teach this so my personal preference is actually to teach it after we've done it sputters because we run the risk of straw and they need to take a second to take some deep breaths before going back to breathing in the struggle that's ok because it's helping them do the thing that they were afraid of but sometimes we do run the risk of using relaxation as a practice and we just have to make sure that we don't get ourselves exercise there's been a lot more research recently that looks at a cumulative effects of exercise if we exercise regularly we have more indoor and it's possible wrong there unfortunately are not studies with kids yet at least for a depression i think obviously we see all sorts of obesity prevention take the studies take two diabetes types of studies out there so i think we know it's good i think it's a question what is it good for and when we use it and how do we implemented so i think this gets to be idea that i think we're both biased towards exercise being too old but there haven't been many large scale trials yet at least with kids to look at to do something to keep in mind so this is just a picture of this truck yeah yeah  might want to are subpar what are the thoughts about the reason that are all over the place and more and each to take away we might want to use those relaxations grounding to kind of get ourselves more settled if the racing thoughts are evaluated and related to maybe they're thinking always as effective for that reason just that it's like i don't know that it's true but i still can't help that feeling that's where exposures in the behavioral work really come into play because you can draw on their past experiences so for example say you have a kid that's really worried about the student is bad and you do an exposure where you know he is in his room heard twenty minutes by himself or whatever the response or whatever that period situation is and you draw upon that experience you know you go through each thing you know what happened to you what were your feelings what are your feelings now did the monster actually about and by drawing upon a very large compilation of experiences that they have fired through multiple exposures that sometimes is more salient that just this kind of thought of monsters are real well is there a way that we can get that attention from before bed maybe before the monsters come up so how can we ask if you're we have ten minutes of one time a long time whatever it is not because of the anxiety but just because you deserve it and because  if parents aren't there in that moment you could index card in their backpack remember to use your skills maybe they have breaks during the day so i think in the moment we don't we don't necessarily the parent there but in general parents are the ones that are also able to put we have lots of repeated practice and we also want to change i think what's important is keeping realistic expectations in terms of labs and we have those so all of us even as adults we may have worried thoughts throughout the week or throughout the year but it's what we do response to punish as well so you know telling them that i understand that you feel this way that must be really hard not dismissing it and a lot of times especially with teenagers you'd be surprised how far this goes that  validation like parents are actually hearing them out for once it doesn't mean that everybody in their bus is also not going through the same things they may have just as much on their plate as all of their peers but to really have someone take a step back and say wow i can't believe you have soccer practice you only really attending a very significant way to kids when they're doing something wrong and so you're just reinforcing even if it's in a negative way all of those negative behavior is by yelling and then engaging with them whereas you aren't necessarily paying as much attention to th they can be helpful it doesn't have to be the guidance counselor it but be the favorite gym teacher that gives the kid extra praise for jumping into the sport that he's really nervous about doing so those conversations i think are really helpful and just making sure the kids are getting a united time do you think we're going to get a tornado today teacher says don't know let's check out the weather let's see you can imagine the behaviors going to continue at home so the best way to really extinguish some of those anxious behaviors and make sure the kids are getting the united front is to really be in conversation with each other about how to do that to billy and having really concrete plans so this is where i think those rewards come into handy and again if kids are on accommodations this might be spelled out already but really having a good idea what does it mean to be brave does it mean that they are standing up in front of a class ring a book report or is that at the top of the hierarchy and i actually today we're just working on raising our hand and whispering the answer so it may look different meaning where kids are in their progress and finally just the self care is very important so as if you didn't already being a parent and a teacher is very very very hard work and takes a lot of effort so we just talked about basically all of the things that parents might feel like they should be doing more you might be having some negative judgments right better with those types of visuals as opposed to numbers so i think that's actually the most fun creative part of our jobs is trying to think about how can we shift this framework into something kids are going to understand so i think using things that kids like is also really helpful so if they don't like smiley faces but they really like the thermometer there's another one we have that's pictures of people carrying books and as it gets up the ladder there's more and more of the kids kind of stumbling after a while so whatever visual it is that works for them i think i think helps to be my first first few answers but i think your question gets at the idea that this is difficult stuff so it takes a while and we you know we tell kids and families when i can see change overnight it's going to be a learning process as they go so i think setting an expectation of ahead of time can also just help kids really understand that we're not expecting it but facts it's not like a band aid where we can just quickly figure out what's going on it's going to take a little bit of work and we'll get to have a harder time with d unfortunately insurance companies are which is why we're doing all this research to try and get them to reimburse for these types of things so that maybe one way around it i think having this talk about it schools is a big piece of it so if kids feel like they're the only ones coming in for this they may feel like they don't really need it but they still may be willing to come in if their best friend tried it and had good things to say so i think practicing even doing some relaxation exercises during the morning assembly just getting  helpful again i think with anything i mean nobody wants to be told that they're doing something wrong or that it looks like they're struggling with something that they other people are not necessarily seeing so i think joining with them and normalizing it from the beginning might be helpful there's a lot of of i'm so glad other creative people are starting to bring these things into the more mainstream just gets normalized it's something that we're we're seeing other places and we're not thinking about it as a disorder or something like  level of service that mean something that we built or maybe something we don't build for so follow up calls which teachers all sorts of things we would not bill for stuff it's a ten or fifteen minute how can we think about how to support this child with the work that we're both trying to patiently wait for him to say is the answer right that god is waiting for me so we can have clinicians come in and work with kids or pull them out of the classroom practice the answer come back again for an hour a week maybe once a month just to make sure that those skills are generalizing and that's really our primary goal so i think we would all feel terrible about our jobs if we stop kids getting better at the clinic but it was not generalizing to the community so it's really important to us to make sure that we're doing everything with the schools make sure that that's translating oftentimes how they had it coming into the school working with whereas you know for an older kid to social anxiety or something along those lines there is probably not as much that we would necessarily do with the school that wasn't coming up helpful to do an in service day on how that looks in the school and what we can do with that so i think often it starts with an individual child but we're very happy and open to do marginalised work to