Growing Up Brave

Hello, everyone and thank you for joining us for today's webinar about growing up brave. My name is Sarah Speltz and I'm an Assistant Director in the BU Alumni Relations Office. Today's webinar is sponsored by the BU Alumni Association and is offered as part of our Live to Learn alumni education program.

Many of our educational programs are held on campus, but we plan to offer more educational webinars because we want to connect with our alumni around the globe. And we have alumni joining us today from across the East Coast, including Massachusetts, New Hampshire, Connecticut, Rhode Island, and New York. So thank you everyone for joining us.

For each and every one of you out there, we really appreciate that you're taking time out of your day. Before I introduce today's speaker, we just have a few housekeeping notes. As you know by now, this webinar is being hosted on the Adobe Connect online meeting platform. If you experience any trouble with the audio or visual portions of this presentation, please contact Adobe Connect at 1-800-422-3623.

Today's presentation is being recorded and will be available online on our website. And our speaker today is eager to answer questions you have. You're welcome to submit them during the Q&A portion in the chat box that you'll see. We'll pull that back in a little while and you'll be able to type in your questions, and we hope to answer as many of them as possible. Now it's my pleasure to introduce our speaker for today. She's presenting from BU's Charles River campus here in Boston, Dr. Donna Pincus. Dr.

Pincus is an Associate Professor and the Director of Research for the Child and Adolescent Fear and Anxiety Treatment Program at the Center for Anxiety and Related Disorders at BU. Her primary research interests include the assessment and treatment of children's fears and anxieties, and she's especially interested in developing new treatments for young children with anxiety disorders. In 2012, she published Growing Up Brave: Expert Strategies for Helping Your Child Overcome Fear, Stress, and Anxiety. And she is the creator of the Child Anxiety Network, a website designed to provide thorough, user-friendly information about child anxiety. Dr. Pincus, thanks again for being with us today, and the floor is yours.

Thank you so much for that nice introduction, Sarah. I appreciate it. I would love to begin by just welcoming everyone and also to thank the colleagues and staff at our child program here at the Center for Anxiety.

And we have both an adult program and a child program here. And it's really state of the art treatment that is provided for children and adolescents as well as adults with these types of problems, and also state of the art research that's really advancing what we know works for helping people who are suffering from these types of problems. So for those of you who don't know where we're located, that iconic Citgo sign in Boston is usually one thing that we tell patients. We're in this white building like right practically underneath the Citgo sign. And one reason why Kenmore Square is a great place for us is that it's an excellent opportunity for us to do lots of different kinds of exposures, from the crowds that are present today for the Red Sox games, to being on subways. A lot of times there are situations that we can recreate that help actually patients to face the fears and the things that they're thinking about and things that they're worried about. So one helpful thing is that if others who are listening are concerned-- and I'm sure that many of you who are listening today are concerned about someone or have someone in your mind that you are thinking about that you might have some questions about, our center does provide referrals all around the country to different places that provide evidence-based treatments for anxiety and their related disorders. And so you should feel free to call us, especially since there's very few specialized treatment centers around the nation that really specialize only in these types of issues.

So we-- it probably is not necessary for me to describe the importance of this topic of anxiety, but we do know it's one of the most prevalent problems affecting children and adolescents and they can interfere significantly with functioning. And if we don't treat anxiety disorders, they tend to persist in kids. And they can worsen, and they can lead to other forms of problems, such as other psychopathology.

For example, a child who is very anxious might turn toward something like substance use or other kinds of unhealthy coping skills rather than healthy coping strategies. And maladaptive levels of anxiety can certainly interfere with your ability to enjoy everyday life. If you think about the last time you were anxious about something, maybe you were so anxious that you actually didn't do something that might have brought you a lot of joy. And many children-- and actually the majority of children-- who have anxiety either go unidentified-- so school teachers might misinterpret they're anxious behaviors.

Maybe they're getting up and asking for a drink of water or they're asking to go to the bathroom all the time. And maybe school teachers might think this is just maybe oppositional behavior, or parents might not quite know exactly what to make of some of the tantrums or avoidance strategies. Sometimes what's underlying these things is actually anxiety. So we certainly want to get at these things at the earliest stages. And it's very clear that this could also affect both children's and family's lives, especially for parents who might need to get to work. I know this past week, I've seen lots of parents struggling with the drop-offs of kids in new situations. Some kids just take a day or two to ease into things, whereas for other children, it becomes really difficult for them to enter new situations, to the point where they may be crying or having a lot of struggle.

But I'm coming today with a very hopeful message, and the hopeful message is that I'd say over the last 10 to 20 years, we've now developed many affective non-drug options for helping children and adolescents and adults overcome impairing levels of anxiety. And we know that about 75% to 80% of kids are actually diagnosis-free, if you can imagine that, even at our post-treatment points. So you can imagine if a child is seen for not only some cases, three months, and in other cases, the field has really gone toward developing treatments that are deliverable in, say, a period of eight days, where a child might come in for eight days in a row and really develop some new skills and new learning and a lot of practice, and then go home to their natural environments where they can then try to implement those new skills. So it's actually never too late for any of us to teach the children in our lives some new coping skills, and I would argue that all of us could use some of these skills. Truth be told, the skills that we teach adults for handling anxiety aren't that different than the skills we teach children for handling anxiety and for helping them feel more comfortable with their natural human emotions. So today, I will talk a bit about the nature of anxiety in children and adolescents, and what's normal and what's not. I think the very first task that we have is determining that.

Then I will talk about strategies for identifying anxiety, both at home and school. And then I'll tell you about what works, some of the treatment techniques we use here at our center, as well as some of the current research or innovative programs going on here at BU. And I know that most of you might be interested in where would you refer a child or an adult if they needed some help. So that's how I've divided up what I'll talk about today. So to begin with the nature of anxiety, I will start with a few excerpts from a very popular children's book.

And this is Wemberly Worried. Many of you may know a child that you think might be like Wemberly in your life. But he worried about everything.

Big things, little things, and things in between. Wemberly worried in the morning. She worried at night, and she worried throughout the day. You worry too much, said her mother. When you worry, I worry, said her father. Worry, worry, worry, said her grandmother. Too much worry. And if you notice, grandma's shirt says, go with the flow.

So she certainly wasn't succumbing to a lot of the anxiety. And actually a first grade classroom-- I took a picture of this when I was noting that one of the teachers actually used this book to talk to kids about what kinds of things was Wemberly worried about and what are they worried about. And it might be surprising to you that even young first graders could have something that would be on their minds. And I have you think to yourselves, what kinds of things do you think the children in your lives might worry about? Are these worries just normal worries, or do you think they're so excessive that they may interfere in life? And as we know, throughout development, we know that the content of the things we worry about tend to change over time. So to begin, we know that there's a range of things that we can all be afraid of. If you all think back to your own childhoods, whether it was a fear of spiders or a fear of the dark or fear of closed spaces, many of us can remember things that we might have been afraid of.

And in fact, there's lots of images that kids are exposed to in society-- whether it's from TV shows or media-- about characters feeling afraid or feeling worried. Whether it's cartoons or even in books, watching characters cope with fear is a common theme. And many children like even thinking about the idea of being scared and overcoming being scared. They even enjoy television shows like Fear Factor or other kinds of shows that might show someone actually facing their fears. And some children even enjoy the feeling, the adrenaline rush, that happens when you're watching a scary movie or going on that big roller coaster at the local amusement park. So in some ways, of all the human emotions that we feel, it seems that we are, in some ways, fascinated with this emotion of fear.

And as much as we take very-- we certainly accept the fact that many are happy sometimes or sad sometimes, sometimes when someone feels afraid, the first thing we want to tell them is to stop being afraid or to just relax, when oftentimes we know that fear is actually a very necessary emotion and its adaptive. Kids actually identify very much with these images of bravery and thinking about ways that they can become more resilient. And there's lots of books out there as well that might bring up these themes and movies. And talking about these things with your children and the kinds of characteristics that they enjoy about someone like Harry Potter or what aspects of his personality make him quite resilient even despite all the risk factors he's had in his life, kids sometimes like talking about this.

But we do know that fear and anxiety are actually quite natural human emotions. So if you think about the fight or flight system, it is like we are all very much already geared up to deal with danger and to be on the alert, and this can actually help our performance. If you think of the last time you had to give a talk or you had to run a race, sometimes having a bit of anxiety can actually improve your performance and improve your focus.

And these emotions tend to dissipate on their own, but for some children, these emotions kind of persist. So if we think about-- you might be thinking, well, how could it actually be adaptive for me to feel sweaty? And the last time I gave a talk, you might think, oh, my stomach was achey and I was nauseous and I was dizzy. And if you think about each of these different symptoms, if you think about how adaptive it might be if you were being chased by something for your whole body to suddenly be covered in sweat, if something truly were chasing you, how neat is it that our bodies actually gear us up to be covered with a film of wetness so that something couldn't quite grab us if it tried? Or for us to feel and experience nausea? If we were truly being chased by something, it wouldn't be adaptive for us to actually decide that it was time to grab a bite to eat.

Or dizziness, so you say, well how could that be adaptive? Well if you were truly being chased by something or you're in danger, it would be very good for your body to get all the blood to the legs or as much as possible to focus on escape. So that's why our heart races and that's why we have shortness of breath. And sometimes even in the first session of treatment with children, we actually teach them all of the reasons why each of these physical sensations are not something to be afraid of, but in fact are adaptive.

And anxiety's actually like a watch dog. It's quite protective. So if we look at children, you may be thinking about your own child. I present two contrasting scenarios here.

One is Zack, who's 10 years old, and Anna, who's a fourth grader. Zack is constantly worried and keyed up. His parents say he's the policeman of the house. He's always complaining of physical sensations that come on when he's worried. He can't fall asleep. And in fact, his mom said that even when he was on vacation, he worried about whether it would rain and what would they do then? And what would they do if somebody got sick? And even if mom answered all of his questions, he still had more questions. And his friends think he's too uptight, and he's starting to lose friends because of this.

And his parents just say, stop being the policeman of the house. Just let go and relax, but this is hard for him to do. And I contrast that with Anna, who's a fourth grader who sometimes gets scared when she watches scary movies on TV. She's had friends break her art projects. Sometimes she has a bad day. She gets worried about math tests. She often worries that her mother won't let her watch her favorite shows. But, in fact, she has a good circle of friends and is generally happy.

Now while both of these children are facing some anxiety or that emotion, you could see very clearly here where for Zack, it's starting to interfere in his life and it's actually quite distressing for him. So for Zack, it's very important that we would notice a red flag here, that this is maybe interfering with his social development and maybe interfering with his ability to have fun in life. So this is some of the key things that we look for, interference and distress. And we have to remember that we don't want to get rid of all fear because fear is a natural emotion, and we want to teach children how it can actually be enjoyable at some times to feel that feeling and to know that our bodies are geared up and working and ready to protect us. But too much fear or anxiety can interfere, and these are the ways that you may have noticed even in the children in your lives, that it interferes.

First of all, children might decide, I'm just not going to go to ballet school, or I'm not going to join soccer because I want to avoid things because it causes me anxiety. Maybe it impacts their friendships. For teenagers, right when they're supposed to be getting some more independence developmentally, anxiety can sometimes cause adolescence to gear back and decide that they want to cling to adults and may increase your depression. And in fact, if we don't treat these types of problems early on, especially when they're red flags and they're starting to interfere, they can lead to other problems. So kids often say when we've seen them after this problem has persisted that they've started to engage in substance use or maybe have started to think about suicide in the most extreme cases. So as I use these terms fears, phobias, and anxiety, and I think they're used pretty interchangeably, but they actually mean different things. And when I talk about fears, I talk about this very natural emotion, very intrinsic to development. And in fact, this is something you can think of we all have, even as babies.

It's very natural to feel separation anxiety or to feel some stranger anxiety, for example. But a phobia is an exaggerated fear. So it's persistent. It's disturbing. And it results in a lot of maladaptive or avoidant behavior. And anxiety is actually more general. It's a bit distinguished from fear. It's seen to be like a future-oriented emotion.

You're not quite sure what you're afraid of, whereas in the case of a phobia, usually it's quite circumscribed or specific. But it's like this general unease and wariness about the future or apprehension. So we can see-- I think it's neat that if we look through development, you see certain fears rise at very predictable times in development.

And actually, we see this even cross-culturally. So for infants and toddlers, having a fear of loud noises or strangers or separation is very common. In preschoolers, we have things like fears of the dark or monsters. As soon as you have the cognitive capacity to think about things that aren't there, you start to become afraid of things that you can have as imaginary objects. And as you enter school age or older children start to have more abstract fears like about world peace or about their school performance or about death or family member's well-being. So we see this very predictable and also even cross-culturally, very similar kinds of progression and fears.

And they seem to be related to childhood-- to cognitive development. And if you ask most children, normal children, healthily developing children between the ages of two and 14, they can say that they have at least one specific fear, 90% of them do. So this tells us that this is actually quite normal and just tends to go away with time, some of them as well. So my good colleague, Dr.

David Barlow, talks a lot and has studied a lot about why fears arise. And he has a theory that in fact we have to look at not only biological factors-- so we know that anxiety tends to run in families. We may be biologically prepared to be fearful at an early age. But we also have environmental factors, like inadvertent reinforcement or modeling from siblings or parents, parents who are maybe actually anxious themselves and without knowing it are maybe modeling that for children. And then we also may have other kinds of vulnerabilities, for example, having an inhibited temperament or having very early experiences with low levels of control over the environment. And what's important here is that in fact it's not just one of these things that might contribute to our showing or displaying an anxiety disorder in our lives, but the synergistic effect of many of these coming together at a given point in time that might then show itself as an anxiety disorder.

So if we think about most other forms of psychopathology are more prevalent in boys than girls during young childhood and school age. But for fears, by age six, anxiety disorders are twice as prevalent in girls than boys. And it could be that parents are more likely to label the behaviors of girls as more fearful and maybe boys as more oppositional, for example. But this also could be due to-- so this could be due to a report bias or it actually could be due to some vulnerability that females have to anxiety, and we know that women are twice as likely as men to suffer from anxiety or depression as adults. So something's certainly happening in this early stages, and I always think about what we could be doing for our young girls to try to prevent this.

Are there kinds of coping skills that we're not teaching our young girls that we should be? So many factors that I think are important for parents and grandparents and those teachers and others that are really wanting to help children with anxiety is remembering not to model some of this anxious behavior. And although protection feels very innately right for most parents, overprotection can backfire and actually cause a child to almost rob them of opportunities to get involved in new learning. So think about lots of the coping skills we develop. Sometimes we have to develop those coping skills by facing situations that might cause us some anxiety. So to say that your child's never going to go on a sleep over or never going to go to an afterschool activity or a birthday party alone might then rob them of that opportunity of actually developing some new skills.

The other thing that can also increase anxiety for children is over reassurance. So even though you want to say, don't worry, you'll be fine. You're going to have a great day in school and don't worry, you can always call me on my cell. And remember, you can always call grandma on her cell. And if you overdo it a bit, sometimes children start to question whether or not they're safe. Other things like having high control, parents controlling everything children do, that we know that can cause a lot of increased anxiety.

So giving your child some psychological autonomy within reason and of course as certainly going along with their developmental phase is certainly important. So you want to give some good structure, but also help encourage approach of new experiences. And I think that's a big theme that we teach to children, but we also teach in all of the parent components that we have in treatment. So here's an example of parents maybe overdoing it. I don't worry about anything. My mom does all the worrying for me.

Or in this case, get back to your seat, Mom. I can handle this. So clearly the child's not going to learn how to catch or how to play the game if mom's swooping in. And of course, this is not to say that all parents do this, but just being mindful of when is it a good idea to step in and being more mindful of when is it a good idea to step back.

So these are some of the things I think we just discussed that might maintain anxiety disorders in children. And now I'd like to talk about how would you identify anxiety in the children in your worlds? So one way is to look at whether they're not doing developmentally appropriate activities. Is everyone else able to separate and go to birthday parties, but your child is not able to do that? Do they have so many physical complaints in the morning, like stomachaches or headaches, that it's maybe interfering with their ability to eat lunch or their ability to separate from you in the morning? Are they worrying a lot or expressing a lot of worry about peer interactions or school performance? And another good key thing to think about is noticing whether your child is-- maybe they're doing things, but they're engaging in activities with distress rather than happiness. And we don't want that to happen at all as well.

How is this interfering with relationships with the family? So I tried to divide this up for you in terms of physical symptoms, some of the things we tend to see-- chest pain, restlessness. Of course, you have to rule out any medical problems that might be happening, but we also want to think about whether a child has repetitive thoughts or is constantly keyed up, some of those psychological symptoms, as well as other behaviors. So again, avoidance is a key behavior you should look for, a refusal to participate in activities. But sometimes, it is-- I do some work in the schools helping bring anxiety treatments to schools, and one thing that school nurses say is that oftentimes many children come there with stomachaches where she knows that it's not a medical issue, but it's more of anxiety. So school nurses tend to be over-utilized in some ways and oftentimes teachers might make accommodations for kids with anxiety by letting them leave the classroom when in all of the research that we know has been done in this area, it's more important to teach a child how to stay rather than how to leave the classroom. Other behaviors you might see are irritability or tantrums, especially if you're a young child, say, not wanting to go to try a new activity. And that can actually be one subtle form, or maybe not so subtle form, of avoidance.

And we know that these anxiety problems can occur at any time in life, so I want to make sure that's clear. But certain disorders are more likely to emerge at particular developmental periods. So for example, we don't tend to see panic disorder emerging in the very youngest children, but in fact, it tends to come up around adolescence, whereas separation anxiety disorder is more prevalent, say, in five or six year olds or younger children.

So I wanted to show you, at least in the DSM V, a list of the possible or the different categories of anxiety. And so these are things like separation anxiety disorder, specific phobias, and that is people could be afraid of really any object or situation, from fears of thunderstorms to fears of the dark to fears of getting a shot at the doctor's office. These are some examples. We've had fears of costumed characters that we've treated here at our center.

And actually Rhett the Terrier from BU has come and helped us with actually helping one child enter new situations and be able to go to Disney World when she was too afraid of costumed characters. So we are able to actually have children facing their fears, but specific phobias are another thing that we treat. Generalized anxiety disorders, really worries, kids who can't turn off worries and are very keyed up all the time.

Social anxiety disorder is also another disorder we treat here and we tend to see this a bit more in adolescence, but again this can be really situations like giving a talk to just having a hard time talking or making friends and engaging with other people. And finally, panic disorder and agoraphobia occur when you are actually afraid not of a particular situation necessarily, but of the physical sensations, like shortness of breath or heart racing. And those symptoms themselves become very alarming to you. And in parentheses below, you see I've listed school refusal, obsessive compulsive disorder, selective mutism. These are all related to anxiety disorders, but not necessarily now in the DSM V are not categorized as anxiety disorders. But if you think about, there are lots of reasons why a child might refuse school. One might be separation anxiety. They may also have a specific phobia of something in the school.

We have kids that are avoiding skill school due to generalized anxiety. They have just lots of worries and they can't shut the worries down. Also, school is a social situation, so some might refuse school due to that reason.

And some develop panic attacks in school. So I wanted to demonstrate that just because a child has school refusal, it is really important that you get a really good assessment of what's happening in order to know what is this due to? Why is this child having these troubles? So we usually, when we do a good assessment, we do a very thorough-- get a thorough verbal account by both the child's perspective and the parents perspective of what they're afraid of. We also assess how much the problems are interfering and distressing. And we give some various different kinds of measures, all very psychometrically sound, good measures that are not going to be too taxing on the families, but help us to glean a lot of good information about how to help. We always want to rule out any other medical causes of anxiety symptoms, like asthma, if you're experiencing shortness of breath due to certain reasons, or substance use, some of these other problems. So we get a really thorough history from children and from their parents.

And we also assess for trauma. We want to rule out any other reasons why a child might have, for example, hypervigilance or avoidance. So I can't emphasize enough how important it is as a very first step, if you're concerned about a child in your life, how to make sure you're getting a very thorough assessment of why the child is experiencing anxiety. That always leads to a good treatment. So the next part of my talk is about how to help. I'm sure many of you are interested in some hands-on strategies on what kinds of techniques could you use to help children and families with anxiety. And one of these is-- really, the gold standard-- it's called cognitive behavioral treatments. And the cognitive part refers to how we learn to change our thoughts.

Many times, we go into situations, and we may have thoughts that are not true at all, thoughts such as, oh, I think I'm not going to do well at this, or if I get up there, everyone's going to laugh at me. And those are just guesses. We teach kids that those are not actually necessarily facts. So we teach them some cognitive skills to teach them how to change thoughts or get rid of thoughts that maybe are not accurate and may be just feeding that anxiety cycle. We also teach them some different kinds of behaviors that they can adapt, rather than just avoidance. And we have to teach them why avoidance is bad. So the cognitive behavioral treatments overall are seen as the very gold standard treatment you would want to ask for your child. So if you're asking for or talking to a provider, you want to use those terms.

Medications are also used at times, although sometimes medications are necessary to-- especially in more severe cases-- to help a child even enter new situations, and then eventually the medications can be oftentimes weaned off. But many people do not want young children or adolescents on medications, as the brains are still developing, and so oftentimes we would recommend first a course of cognitive behavioral treatment to see whether a child could respond to that first before going toward medications. But for some, a combination of cognitive behavioral treatment and medications are important as well.

So it's really-- we make those decisions after a good, thorough assessment. And overall, our treatment goals are to help reduce the frequency of this anxiety response to also not only lessen anxiety, but also increase the positive activities that could reinforce the child's strengths and also help the child learn new ways of coping with stress and new ways of coping with negative emotions. And the very first step in this, and I think one part that actually helps everyone feel quite a bit more relaxed, so to speak, is just learning about what anxiety is and understanding that it is a natural emotion. And it's not necessary to shoo it away every time it comes up, but in fact just being able to acknowledge that, hey, there is anxiety coming up. I'm sure that's because my body is geared up to fight, and it might think that there's actually truly danger here. And these are real feelings that kids have, but these are not harmful.

So just because your heart is racing doesn't mean you're going to have a heart attack. Many times kids get alarmed by these feelings. Sometimes we'll actually draw out an outline of the body and to show how each physical symptom is all part of helping protect us in case of danger. And we also teach children how to break down anxiety into what you feel, what you think, and what you do.

And I think anything is easier to deal with if you can break it down into certain parts. So you might want to have your treatment address each of these different components. So what we do is we teach children different ways to think, so changing maladaptive thoughts into more adaptive ones, and we use really kid friendly terms here.

Also, teaching them how to not be afraid of what you feel, and actually how to bring on some of these feelings. We even have kids running in place and breathing through like a straw and doing things to actually bring on feelings that might cause them anxiety, just to show them how our bodies actually bring these feelings down pretty quickly. And so our treatments also help us to deal with the do part, which is the behaviors. So we teach them how to approach new situations, and we call this exposures. So again, sometimes we'll use a sheet that looks somewhat like this with thoughts, physical sensations, and behavior. And we can even have your child fill out in these circles, so to speak, the thoughts they're having, the physical sensations they're experiencing, and some of the behaviors that they may be doing.

And we show how these three actually feed each other and can actually get someone into a position where they feel quite alarmed. And also, how do we break that cycle? So how do we teach skills that can actually cause children to feel a lot better? So as I just described, you might do some detective thinking. How do you know if your thoughts are realistic? And kids love the idea of being a detective about their thoughts. And we teach them how to deal with their worry thoughts. We also teach them what the chances of this happening? I had one child who would run home thinking, what if someone's going to try to chase me? But it never happened before, and she lived in a very safe neighborhood.

But she worried about it almost all of this circle, let's say all of the pie, whereas the real chances of it happening, she decided, were just a tiny speck. So we try to help kids to change the amount they're worrying about something to be more in line with the real chances of it happening. So interoceptive exposure is a fancy term that really is reflective of a series of exercises that we help children to do to try to teach them not to fear these physical sensations that are brought on by the fear response. And we conduct these exercises right here in session. So I'm jogging in place with my patients, bringing on the very feelings that maybe they were avoiding before.

But we show them how anxiety naturally comes down, and they get to see how their heart kind of slows down a bit and kind of comes down naturally. And we oftentimes do this in the case of kids who have panic disorder. But one current theme is that we know that anxiety oftentimes causes us to avoid things, and that makes fears grow. So the more we can stop avoiding, the more we can help fears to go away. So I have pictures here just showing the different fears we have treated here at our center, from fears of pigeons, to fears of heights, to public speaking, to panic or claustrophobia, to fears of dogs.

And we actually take patients out and help them to face these things, not forcing them at all into these situations, but helping them to know and actually guide us in when they're ready for that next step. And what we build is actually a ladder, so to speak, and we call it a bravery ladder with children. And we make a series of situations that they may enter, from petting a small dog, for example, to petting a little bit larger dog, to having a dog maybe jump up onto your knees, and gradually facing a fear like a fear of dogs. Now we have to also remember there's many forms of avoidance, so making sure that we help children and parents to know what are subtle forms of avoidance, where a child might say, oh, I'm just going to stay home, or I'm not going to do anything new. I'm not going to try something new.

I had one child who decided that they were so afraid of heights that they only wanted to pick a college based on which college didn't have any elevators. So you can see that's a very more evident form of avoidance, but that's going to actually change very much in limiting that child's choices of where they go to school. So you'd want to really help them as well. Other things that cause avoidance are things like safety behaviors. Taking things like a water bottle with you everywhere, not just because you want to stay hydrated, but because it has some sort of superstitious value for you, or thinking you need some kind of lucky charm with you. So we oftentimes will take away some of these safety behaviors in conjunction with the patient's agreement to try to help them to take some ownership of their success, that it was not due to the lucky charm or the water bottle, but it was due to the fact that your body is geared up to protect you, and you've learned some skills that can really help. So here are some examples of avoidance.

I'm not coming down for dinner. Didn't you read my blog? Is there someplace I can sign up for a do not call on me list? We may all have been there at some point, where we just did not really want to be called on. And, as I described earlier, you might help a child or family create what's called a bravery ladder. And you break down the fears into smaller steps, and we try to arrange them from the least challenging to the most challenging, with the top of the ladder being the most challenging.

And we try to teach children that there are many things you can do. Even if your heart's racing, you can still do it. And they start to see that just because they feel anxious doesn't mean that they can't approach new things in life. And in fact, the anxiety tends to go down the more we start trying new things.

It's often helpful, at least initially, to build in some small rewards. I like to use non-materialistic rewards, things like time with parents, going out for ice cream together, maybe having the child be able to pick the dinner for dinner time. Things like this can really go a long way. High fives, a lot of praise can really go a long way in helping a child to get that motivation necessary to face fears. And so these are the things I'm talking about in terms of specific parenting techniques you might use to support a child who's anxious-- modeling non-avoidant coping behavior. The next time you have a problem, let your child see how you're working it through. Use very specific praise of brave behaviors. Give the child control or choices around age appropriate decisions.

Help them to use some coping skills to manage high emotions. And remind them that anxiety is a natural emotion and actually can sometimes even help. So if you always think for a moment about something you were once afraid to do, but then you did, you might think about how your life changed, about how your life might have opened up and the value that facing your fears might have and maybe talking about that with your child if it's something that you think might help. So whether its getting on that water slide, or finally traveling, or running a race, or singing, thinking about ways that not only children's lives or all of our lives might be happier if we confronted some things that we are afraid of. And so sometimes we use the analogy of riding a wave, like actually entering a situation, you watch your anxiety peak. Then you watch the crest of the wave come down as you stay in the situation, rather than getting up and leaving. Other strategies that we do use with children are things like mindfulness strategies that have become more popular recently in teaching kids how to be in the here and now, how to not think already a week ahead of time what should I be doing then, and what happens if this happens, but actually trying to learn how to be more present and aware of all of our senses, say, right at that moment.

So if you're in math class, really being present in math class, for example. Or if you're washing the dishes, being present then. And sometimes technology, I know, can distract us from our mindfulness, but even giving kids some breaks from technology and not using their phones when they come home right away to be able to see-- to actually have a break and to take a walk as a family and notice all their senses, notice the things they see or are thinking about or hear or smell. Those things can help kids to become much more in the present. So think about the things you might see if you're more present-focused rather than distracted.

And we tend to see a whole lot more detail in the things around us, and some might argue that you actually have more enjoyment in life rather than being so future-oriented. Sometimes we will teach children relaxation training, different kinds of ways that they can relax to help themselves fall asleep. We do encourage them not to use relaxation when they're doing an exposure. And that means like we really want them to feel anxiety and not think that they just need to relax to bring it down and just shoo it away. So this is one way that the things that we're teaching are maybe contrary to what you might think.

That, oh, if you're anxious, let's go to a clinic that teaches you how to relax. And in fact, yeah, this might be one very minor component we teach to kids, but it's really not the major part of what helps them get better. What's I think most critical, one of the best ingredients, at least our research has shown, is actually facing fears and going through the exposures and trying new things and having parents model and reinforce those things. I have here in a series of slides some other skills we teach, social skills training if a child needs that.

We use stickers or rewards-- that's what contingency management is-- and other kinds of techniques as well. And in fact, we also want to help parents have children get good sleep. We know good sleep predicts good emotion regulations. So doing things like creating a good bedtime ritual, getting out of bed if you can't fall asleep within 15 minutes. You really want your bed to just be associated with sleep and not anxiety. And then we gently have kids go back and try again when they're feeling a bit more relaxed, and actually really praise them for brave behaviors. But getting good sleep and a good routine is necessary as well.

So just as an end before I take some questions, I just want to describe that we do have a lot of research and programs going on here at BU at our Center for Anxiety and Related Disorders in our child program. And one big project we have is ways to bring treatments to youth in community settings and in schools. And I currently am running a grant where I'm bringing many of the skills I'm talking to you about to school settings, public school settings, where kids might not have access to evidence-based treatments otherwise.

We're also working with folks at Boston Medical Center to bring treatments for anxiety and depression and other childhood problems to primary care settings. And we are also developing many intensive formats of treatment. We even have a camp here at BU where we help kids with what's called selective mutism, kids who won't speak up in front of others. And the effects on parents and families, I thought it was really captured by this quote. This one parent said, there are no words to express our gratitude After watching her suffer for almost three years, it's nothing short of miraculous to have her living the life of an average 12 year old after a week of treatment. Know that we couldn't be happier with the results of our visit to Boston. This was a child who was treated in our clinic. So in conclusion, we have definitely made much progress in advancing our knowledge of how to treat anxiety in youth and adults, and we are continuing to do this through the current research programs that we have going on here at BU and across the country.

But we still need new ways to develop some novel treatments that could be integrated into everyday settings that kids naturally go to-- so school programs, after care, places that children would naturally go. And we also are currently researching ways to boost outcomes for the kids who don't respond right away to regular treatments. How can we make our treatments better? So this was a good image here.

This child was-- pretreatment, she thought that anxiety was like a dragon, and it was way bigger than her, as you see. And at post-treatment, you could see she became way bigger than this anxiety dragon, which is always a good sign. I thought from a child's perspective was neat to see. And another child said, well, Dr. Pincus, this is how I felt beforehand.

I felt like I was saying boo and no, no to everything in my life. And after I'm done learning skills, I actually feel like I'm saying yes, yes. And this is in the eyes-- from eyes of a young preschooler who could describe it this way. So for anybody who needed some more help or wanted some advice, the Center for Anxiety and Related Disorders here at BU. I have our phone number up here and ways to look at some of the programs we have on our website. And we're located right here in Boston on the Charles River campus.

And I invite you to explore some of our adult and our child programs, and see if there's something here that could benefit you. Many people kind of fly up from different parts of the country even to benefit from some of our programs, especially the more intensive ones that could be done in just a week's time. And we also have, again, a very good referral service for those who are needing help. And so I thank you very much, and thank you again for your patience in the beginning of the webinar with the logistical issues.

But I think we did well and I was able to get a lot of good information to you in a short period of time. So thank you very much for your attention. Thank you, Dr. Pincus. I really appreciate all of the information, and thank you everyone for your patience with the technical difficulties, which I think I am the one who caused them, so I'm so sorry for the inconvenience. But you'll see there's a chat box at the bottom and you can type in questions.

So I will read through those and I'll read them out loud for Dr. Pincus. But go ahead and type in any questions you have, and we'll try to get to as many of them as possible. And please know we're going to focus on the questions that apply to the largest number of people, of course. Let's see. We have lots of things coming in here.

People are typing. All right. And of course they're not showing up because today's the day of technical difficulties.

There we go. Thank you. Is there a website with a schedule of upcoming classes? Classes at the center, I'm assuming. Dr. Pincus? Well let's see. Well we have a number of upcoming programs, for example, like our camps and other things. In terms of upcoming-- I don't know if they're talking about upcoming trainings.

If you called our center or went to our website, you would see a lot of the upcoming trainings that we have, whether it was trainings for therapists or trainings for the community. We oftentimes will give talks in the community. So maybe this person's also writing about-- so I will give talks at schools or other places as well to educate the public about these types of problems that kids face and also how we can better help them. Thank you.

And I'm not sure I will be able to pronounce this word. Anxiety co-morbid with Asperger's, is that approached differently? Oh, that's a very good question. So the question is about anxiety.

Is it co-morbid with Asperger's disorder was a term we used in the DSM IV, but now it's seen as part of the autism spectrum disorders. And we will-- we have oftentimes treated patients who've had anxiety and also have had those types of symptoms of Asperger's disorder. And sometimes what's helped is keeping the-- depending on the child, and I know that there's a range of how functional-- oftentimes the children that I've treated have benefited from just a bit more concrete skills and doing a lot more of the behavioral part, really focusing on practicing rather than as much of the cognitive skills. So I think it does depend on how verbal the child is and how insightful they are into their own problems. But even with children who are much less verbal, I've been able to-- many of our clinicians here have treated patients where they had both of those issues going on at the same time. And it is not uncommon to see children with many other-- to have anxiety and also have some other co-morbid problems. So anxiety oftentimes doesn't come just in a neat package by itself.

There's also other things going on, and this doesn't mean that we can't treat them. You might just need to tailor your treatments to those patients. OK, the next question is if you've seen any significant differences in anxiety disorders among different socioeconomic or ethnic groups? There's lots of research going on about some-- I think we have to look at the context, about what's happening. As the research shows, that it's not just SES, for example, that might cause differences in anxiety or prevalence, but it's actually what that brings, so the risk factors that, say, being in a lower SES environment.

Poverty might also bring low nutrition, which also brings a lot of other stressors and maybe violent neighborhoods, which might bring on anxiety or certain types of anxiety or trauma, for example, that we might see more prevalent in families that are in those neighborhoods, for example. So we just need to be always cognizant of the cultural background and be sensitive in the ways that we're delivering our treatments. And also conscious when we're teaching parents certain skills, knowing whether the skills that we're teaching would maybe be in line with one's cultural beliefs. And how can you deliver skills in a way that will feel acceptable to people of many backgrounds? We have a question about in addition to Growing Up Brave, is there anything you've put in print for therapists working with adolescents with anxiety? Yes, absolutely. So I've written a treatment manual for adolescents with panic disorder and that is called Mastery of Anxiety and Panic for Adolescents. And so you can find this-- this is available on Amazon and all that, but you can find this-- there's also a workbook that I wrote so that not only would the therapists be able to help adolescents with anxiety, but adolescents would also have their own workbook. And it's called Riding the Wave, much in line with the analogy I talked about, just that we are talking about staying in a situation and letting the anxiety come down.

And this is the Riding the Wave workbook that I published with some colleagues here at Boston University and that we use in our eight day treatment program of kids who have panic and anxiety. And could you please repeat the title of your book for those who are interested in checking it out? Yes, I wrote a book called Growing Up Brave: Expert Strategies for Helping Your Child Overcome Fear, Stress, and Anxiety. And that was published by Little Brown. And so oftentimes we'll bring this-- well just I was motivated to write the book because I was giving so many talks where folks in the audience were saying that it would be helpful to have this information in a user-friendly way. I also see there was a question about the book that I was reading from at the very beginning of the webinar. That was a children's book and so I'm not sure if that was also another question as well. I was quoting from and it was called Wemberly Worried. You're right.

I do think that is the question, yeah. You're right. Thank you. And we have maybe time for one more question if anyone has one, otherwise we'll share some information about our next webinar. Oh, is there anything specific you would recommend to help a student who has social anxiety and refuses to participate in class? Yes.

So for a child who has social anxiety, I would recommend probably first having them practice maybe in smaller groups, and maybe this could be done in the school setting. I know sometimes schools might have, say, peer leaders, where they do-- some schools call it a chip and chat. So they bring their lunch and they go to a smaller social circle where they might first try to have lunch while they're talking. And maybe it's facilitated by a social worker or a teacher or someone who's just having lunch with them in a small group, where they are then they to practice some skills, like making eye contact and figuring out how to keep a conversation flowing.

So those are some social skills. So we might first need to determine whether that student really had some deficits in their social skills and whether we needed to boost those first, but then having them practice it maybe in smaller groups. And then maybe having the teacher really reinforce the child or adolescent as they start to maybe participate in class a bit more. Maybe they'll participate if you break up the class into smaller working groups then, and then gradually can participate if the group is a little bit larger. So it's almost like creating a bravery ladder and implementing it in school with maybe the top part might be them actually raising their hand in class, and then getting a ton of praise from that teacher about their participation and from parents and maybe keeping a log of it.

But part of it is motivating the child to even want to do that, so might start with some core skills. Thank you very much. Dr. Pincus, we're so grateful for you taking time today to share this information with everyone. And thank you alumni, all of you Terriers out there for spending a little bit of time with BU this afternoon. We hope you'll join us for other webinars, including our next one, which is on October 18th at noon. We have a BU alumnus named John Hupalo, a nationally recognized expert in education loan finance who will present Plan and Finance Your Family's College Dreams.

So we hope we'll see you back there. Thank you, everyone. Thank you again, Dr. Pincus. And I hope you all have a great day. Yes, thank you so much.