School Attendance Problems: Characteristics and Psychosocial Intervention Approaches

December 15, 2022

Wendy Silverman, Ph.D., ABPP

Alfred A. Messer Professor in the Child Study Center and Professor of Psychology; Director, Yale Child Study Center Program for Anxiety Disorders

Meeting the Complexities of Adolescent Mental Health -- November 5th, 2022

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ID: 9306
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00:00I get to introduce our first
00:02speaker, who's Wendy Silverman,
00:03and I think it was a great coup
00:06for us to get her here today.
00:08She's a leading expert in pediatric
00:11anxiety and a professor in the
00:14Child Study Center. And I'm not a
00:18big fan of long introductions,
00:20but I I would just say that in terms of her
00:25clinic and clinical practice in anxiety,
00:30she's where I would send my
00:32daughter if she were to have
00:34such issues and and I think it's a
00:36great service that you provide.
00:38Thank you for talking today.
00:40OK, thank you Michael. Let me first
00:43share my screen before I get going.
00:58OK. Is that good?
01:02Looks good. OK.
01:03Thank you that that took about a 30
01:05minute practice yesterday with Katie.
01:07So thank you and thank you again
01:11for sharing your Saturday with us
01:13and thank you all of you and thanks
01:16Mike and Angie and the rest of the
01:19team for putting today this I think
01:21conference and one thing I've
01:24I always say you know they say
01:27that what is it that copying is
01:29the highest form of flattery so
01:32I want to mention that Mike has been
01:34a speaker at least two times at
01:37the anxiety conference that we have,
01:40this year it's going to be the
01:42first Thursday in May.
01:43And I'm just really thrilled that Mike
01:45is doing this and I'm participating
01:46in his and I think it's a really nice
01:48synergy and I just think it's shows
01:50I think something that you know I
01:53was really touched by Mike's story.
01:55I understood from his story why he.
01:59You know, it was helpful.
02:00And I think what Mike and I share, frankly,
02:03I know this is true of almost everybody.
02:06But I think Mike and I and the
02:08rest of his team, you know,
02:09really resonate to our how
02:11much we care about the kids.
02:13And I've been doing this now for,
02:15you know, for as long as you know,
02:17for such a long time.
02:18But it still is such a sad thing
02:22when I think about how we've made
02:24so much progress but yet there's
02:26still so many children who are
02:28suffering in the COVID pandemic
02:30just made that worse.
02:31And when it comes to
02:33school attendance problems,
02:34it also has worsened the situation.
02:38So what I'm going to be doing
02:40today in the time that I have
02:42is speak about this problem,
02:43this really big problem.
02:44And I'm speaking about it,
02:46as you will see,
02:48because it is something that
02:49intersects so much with anxiety and
02:52depression and other conditions.
02:54And so I would note that I do
02:57receive royalties from the
02:59interview schedule that I'm,
03:01that I've developed the Anxiety
03:03Disorders interview schedule.
03:07But this is what we
03:09don't want right now.
03:10Of course this is a slide
03:12before COVID when we actually
03:14were always in the chairs,
03:16but I think that we are now back
03:17in the chairs and so I think at
03:19the end of the day we would like
03:21to have as few empty chairs as
03:23possible rather than the opposite.
03:28And I just want to say,
03:30you know when it comes if you one
03:33looks at the research, because it
03:36is a little bit all over the place,
03:38but when I talk about what we know
03:41and everything, I'm I'm not going to.
03:42This is not a a big science talk,
03:45but I am speaking based on the science.
03:48It's informed by the science.
03:50And typically in the literature,
03:51when people are looking at these children,
03:54we usually mean kids who are missing 10
03:57to 20% or more of school days and that
04:01that translates to about 18 to 36 days,
04:04which is not little.
04:05I mean, think about yourself.
04:07If you missed that many days at work,
04:09I think your boss would be a
04:11little bit unhappy with you.
04:12And this is true as well, of children.
04:15Umm. Not surprisingly.
04:19It's true.
04:20This is true of all most
04:23problems that we have.
04:26And certainly was true even
04:28whether or not who's going to get
04:30COVID and and it is highest among
04:32there are disparities and you can
04:34see here just from the top down
04:36who, where it's highest among
04:38the minority students of color
04:41and you could see that there.
04:46Now there is a strong mental
04:49health component to this,
04:51which we're going to be emphasizing today.
04:53But I also want to say,
04:54and this is a quote from a child,
04:56because I know we shouldn't say good,
04:58I know we should say well,
05:00right, I don't, but, but,
05:02but how many children are waking
05:04up saying I don't feel good?
05:06Do I have to go to school today?
05:09Can I stay home?
05:10I don't feel good, Mommy.
05:11My stomach hurts.
05:13My stomach hurts.
05:14And this is a big and this is a very high
05:21co-occurring problem
05:23and some studies the rates have been as
05:26high as 25% when people have looked
05:28at the rates of somatic complaints.
05:30Now mind you, these are not fake
05:33somatic problems.
05:33Children actually do have these.
05:37These are not made believe.
05:39Sometimes they could be ways to get out,
05:41but many times,
05:43because anxiety and depression
05:44are related to somatic complaints,
05:47they all kind of intersect altogether.
05:50So I want to make it clear I'm not, these
05:51kids are not necessarily faking it,
05:53but certainly having mental health disorders
05:56exacerbates somatic complaints and vice versa.
05:58And then if you're not feeling well,
06:00you don't want to go to school.
06:03You can't.
06:03And I shouldn't say you don't want to,
06:04you feel like you're unable to go to school.
06:11Now this is a study from a decade
06:14ago that I was involved with when
06:17and this is a sample from Norway.
06:23But the findings are generalizable,
06:25I know based on my own
06:28other work in United States.
06:30And what's and, and it's important
06:32to note that these are adolescents.
06:34And it's also important to note,
06:36That these rates were
06:38as high as that mental health
06:40conditions are as high as 90% in
06:43kids with school absentee problems.
06:47And what I want you to see is that.
06:51OK, what I want you to see is that.
06:55I'm sorry, just.
06:58I'm sorry, I have to go back.
07:01What I want you to see is, I'm sorry,
07:04I'm kind of covering up my slide with
07:08with you guys but it's OK right now,
07:11I'm good. But you can see though is
07:13if you compare the absent in this blue,
07:16the not absent is green.
07:18Clearly the blue is highest, OK.
07:21And most of these,
07:24I'm I'm not sure off the top of my head which
07:25of these are statistically significant,
07:27but I think most of them are significant.
07:31And, more importantly,
07:32is what you see in the adolescents is that
07:37depression is the highest and followed by
07:40some other problems like ADHD,
07:43but also specifically our talk
07:45is you see generalized anxiety,
07:47social, panic.
07:48And I think what I want to emphasize is #1,
07:51how much higher the mental health
07:54conditions are with adolescents
07:56who are having school absenteeism.
07:58But also these are adolescents.
08:00And something I want you guys
08:02to understand is that because I
08:04know today we're supposed to be
08:06focusing a bit on adolescence,
08:07anxiety is a gateway problem.
08:10It's a gateway
08:11disorder, it's not carved in stone.
08:14I mean, don't.
08:15It's not like,
08:16but it typically is the case that
08:18anxiety is preceding depression
08:20and there is some developmental
08:22trajectory in what we see with anxiety.
08:25So,
08:25for example,
08:26it's not surprising to me at all that
08:28separation anxiety is among the lowest
08:31here because these are adolescents.
08:33If these were a sample of younger children,
08:36believe me,
08:37separation anxiety would be
08:39higher than the generalized.
08:41What happens as children get older,
08:44they typically go from separation anxiety
08:48then it goes exactly what you see here,
08:51the social anxiety
08:54to generalized anxiety,
08:56panic is usually a bit higher.
08:57I'm surprised it's not higher but still.
08:59And then you then have a depressive disorder.
09:03So this really mirrors what we see
09:06in school attendance problems,
09:08which means typically it's typically
09:09going to get worse and worse because
09:12you're going to have more co-occurring
09:14problems and depression is you know
09:16it's I personally prefer to treat
09:18anxiety before I get before it
09:20turns into a depressive disorder.
09:22So I think that's a very.
09:25I like that study that I was involved with.
09:27I think it it really shed light
09:29on some important developmental
09:30issues with with adolescents.
09:34Now you might ask hm if this is such a problem
09:38if it's really if it's real important,
09:41if it's real important, how come these kids
09:44are not getting help? And there was
09:46actually a and and there there was actually
09:48a study and what's really interesting
09:50is why parents were reluctant
09:52to get help and look at that stigma.
09:55OK this is from seven years ago. Stigma
09:57like and and and it's it's kind of like
09:59as we said we expect kids to go to
10:02school so for parents to bring their.
10:04To bring their child to the
10:05attention of someone, hey,
10:06my child doesn't want to go
10:08go to school.
10:09They they're feeling shame and
10:10makes them feel like they don't
10:11know how to manage their child.
10:13So stigma is actually one of the
10:15biggest barriers to why parents do
10:18not seek help and then also lack
10:20of school resources is up there.
10:22There also is a belief which frankly
10:26it's not completely farfetched.
10:29That, that, that that it may not help and,
10:32and and and one of the main themes of
10:35today for me today is that we still do
10:38need improved and better treatments.
10:40And then there's also that idea
10:42that on one hand help,
10:43it will be ineffective and the
10:45other hand it's temporary.
10:46Although I can let you know for sure
10:49that sure if you get a child younger,
10:51an acute case of school absenteeism,
10:54the chances of them getting back
10:57to school is significantly higher
10:59than in adolescence,
11:00and this is something that's been
11:02documented for like 1/2 a century already,
11:04that the older kids are
11:06more difficult and challenging
11:08to get them back, what we call chronic,
11:10you know, the chronic
11:12absenteeism that's been happening for for,
11:16you know, throughout childhood.
11:21Now this is also kind of cool I think.
11:23So I wanted to share this with you
11:26because usually the first thing that
11:29happens is once it's recognized
11:31that there is a problem,
11:33typically what happens a lot is
11:35schools when they do get involved,
11:37they do some type of accommodation
11:40and we actually just published
11:43this article and we publish this
11:45article because it was actually,
11:46it was peer reviewed,
11:48but it was part of a I think it's
11:52yeah European Journal because
11:53it was part of a special issue
11:55that and you could see the Spanish
11:58headquarters of Spanish at the in
12:00the title because it was it was
12:01as I said it was invited by some
12:03people I know who are running this
12:06journal and I thought and since it's
12:08international #1 there is
12:10an international, a side point, there is
12:13now an international organization to
12:16help kids with with this problem.
12:18I actually because I've been
12:20doing this work for a long time
12:22with my work on anxiety,
12:23I actually was one of the founders
12:26of this international organization
12:27and so part of these articles
12:31appeared related to this organization.
12:33I just wanted to explain like why is
12:36this Spanish in that article so, but anyway.
12:39Back to the study,
12:41because it was a school and
12:44education journal.
12:45We meet, we looked, we don't have,
12:47we didn't have the
12:49anxiety program that I run.
12:52We
12:52had a sample of over 500 kids and over
12:573/4 were in kindergarten through 6th grade.
13:01And this is the problem with the study,
13:03but it still is I think,
13:04really revealing.
13:05So we looked at kids who had
13:08either a presence or an absence
13:10of an IEP or 504 plan.
13:12We didn't have anything more than that.
13:14And this is a limitation,
13:15but still bear with me.
13:17Look at what we found and then we have.
13:19And so this is this is clinic anxious kids,
13:22not kids who came for school
13:24refusal.
13:24It's just kids clinic anxious and
13:27we just look to look to see who had
13:30this IEP or 504 and who didn't.
13:32We always give these measures and
13:34we looked specifically at the social
13:36anxiety subscale of major
13:38anxiety measure and we also looked
13:40at the school subscale of a major
13:43scale called the Child Anxiety Impact
13:46and what was really interesting
13:49is that we found that the presence of
13:52the plan was significantly greater.
13:58Was associated with significantly greater
14:00anxiety related school impairment.
14:02That is if you had a plan among our kids,
14:05you had higher anxiety impairment using
14:08that impairment scale that I talked about.
14:12And if you had the plan,
14:13it did not reduce the influence of
14:18social anxiety on anxiety related impairment.
14:22So it was great anxiety impairment
14:25and it didn't reduce the influence.
14:27So what the implications for us is
14:30that at least when people are putting
14:33in these that it suggests and it's
14:36just a suggestion that perhaps
14:38because school based
14:41accommodations for socially anxious
14:43kids were not helpful in terms
14:45of reducing their impairment.
14:47It also didn't reduce the impairment
14:49of social anxiety on school
14:53related activities.
14:54Now I have to emphasize there are only
14:56about two or three other studies that
14:57have ever looked at least that I know
14:59of at least that weeks when we searched.
15:01And so the couple of other
15:04studies are consistent.
15:05Now again this is a limited study.
15:07We didn't do a close accommodation.
15:10But I can tell you just because
15:13we run an anxiety clinic,
15:15most of the kids who come to our
15:17anxiety clinic and have these plans,
15:19it typically is related to
15:22the anxiety problem.
15:23So again,
15:24we didn't systematically look at it,
15:26but I know from talking to many of these
15:29families, it could be things like,
15:30OK, they don't want to give it,
15:32it's hard for them to give
15:34a verbal presentation.
15:35So they don't need to do a
15:37verbal presentation presentation.
15:38They can do a written presentation.
15:40On certain days,
15:41if they want to come later to skip a
15:44certain subject that's hard for them,
15:46that could be an accommodation.
15:47So again,
15:48these accommodations,
15:49they're extremely well intended
15:51and we participate a lot in them.
15:53But I think there's a lot more
15:55that needs to be done to determine
15:57whether or not they're helping and
16:00benefiting the way we hope they are.
16:04Now you might ask,
16:05why wouldn't they help though?
16:07I mean,
16:08you just said descriptively
16:09they're not helping.
16:10But what could be the reason?
16:12I mean, they're well-intentioned.
16:13What could be so bad if a child has
16:16social anxiety and it's really,
16:18really,
16:18really hard to get them to do a
16:21presentation in school and if the
16:23only way to get them to go to school
16:26is to say you don't need to do
16:28the verbal presentation,
16:30you can just write a written report.
16:32What is wrong with that?
16:34And true they are coming to school
16:36but what I am suggesting,
16:38it's not helping their anxiety.
16:42But I want to say a little bit more now
16:46about the importance of understanding
16:49that one size does not fit all when it
16:54comes to anxiety school attendance problems.
16:57And so although the CBT kind of
17:00approach is the strongest evidence,
17:03frankly.
17:04CBT,
17:05it's not helping everybody
17:07and even with anxiety
17:10you have about
17:1240% of kids who are not benefiting from
17:15CBT and they and they do need more and so
17:18but it certainly is the best that we have,
17:21but we need more and so I
17:24I want to just emphasize
17:27when it comes to school attendance
17:30because I think sometimes people
17:32are too quick to do a, a straight,
17:35if they're going to do an evidence
17:37based thing and they know CBT
17:39is the strongest evidence base,
17:40they're very quick to then set up
17:42a hierarchy that I talked about.
17:45OK, Saturday go to the school
17:47and nobody is there.
17:49And then like let's gradually,
17:52you know in the morning let's
17:54pack our bag and then the next
17:56morning let's walk through the school
17:58stop and then the next morning and you
18:01know and then we'll have mom there with you.
18:03I mean you know the whole
18:04shebang.
18:05And you know, so it's kind of like a one
18:08size fits all hierarchy to some extent.
18:11But I think what's important is that
18:14each child is different and this is
18:17a model from many years ago that
18:22that I developed with a graduate
18:24student who's now a distinguished professor,
18:26Chris Kearney.
18:27And some of you have followed
18:30this literature.
18:30I'll show you one of his
18:32books in a slide soon.
18:33But Chris,
18:33when he was a graduate student,
18:35and this is my, he was one of my
18:37first graduate students.
18:38This is when I was at SUNY Albany,
18:39and I was there in the 1980s,
18:42and we developed a functional
18:45model of school avoidance,
18:47and we talked about how kids may
18:51be staying home
18:53to approach positive experiences.
18:55Or they may be staying away from school
18:59to avoid negative experiences and events.
19:03So for example and this is you know
19:06for those of you who are understand
19:09functional analysis of behavior analysis,
19:11it's coming from a functional or
19:14behavior analytic perspective.
19:16And so in fact Chris and I developed
19:19something called the the School Refusal
19:21Assessment Scale and Chris, as I said
19:24is now a distinguished professor
19:25and he has moved much more than I have.
19:28I've kind of focused, continue to
19:30focus more on anxiety because just
19:32recently I just saw he had a
19:33an editorial in the in the main child
19:37psychiatry journal and he's and I
19:40recommend his work a great deal but anyway.
19:42But back to the more basic model
19:45function due to approach. So what
19:47happens when they stay home?
19:48Well remember I showed you the
19:50child staying in bed?
19:51Well the child stays home
19:53with mom and moms and dads.
19:56I don't want to just focus
19:58talk about moms dads and moms.
20:00They mean well.
20:00But I have everything I'm saying to
20:02you now I'm not making up and
20:04this is not at all about blaming anybody.
20:07It is hard to have a child not going
20:10to school and it's hard for us
20:13not to know what to do with these,
20:15with our children and sometimes we, you know,
20:20kind of fall into some routines and it.
20:22And as I said, it's the protection trap.
20:24So I've seen children who get to spend time
20:27with their parents by being able to go to
20:29work with their parents, or I've seen kids.
20:32The thing about the pizza,
20:33I didn't make that up.
20:35When the parents went to work,
20:36they made sure,
20:37they made sure that pizza was
20:38being delivered. Again,
20:39I am not making this up.
20:41They get to stay home and do what they want
20:44on their computer.
20:45Hey, if you're adolescent,
20:47who likes to get up at 6:30/7 AM?
20:49You get to sleep in.
20:51So there is that function of school with
20:54attendance problems and looking at the scale.
20:57But even if not looking at the scale,
20:59trying to understand what is the
21:01child doing when they are home is
21:04really important because it's that
21:06staying home that keeps that approach
21:09approach toward home strong.
21:13Similarly, and it's not either
21:14or by the way. It's not it.
21:16I said it's and/or. Some kids,
21:18the function is mainly approach,
21:20for some kids it's avoidance.
21:23And these things,
21:24these avoidances as you can see they kind of
21:27do map on, frankly, to our anxiety disorders.
21:29For the younger kids,
21:31I'm not,
21:32I'm avoiding going to school because
21:35if I go to school I'm away from my mom.
21:39I'm terrified about being away from my mom.
21:42I'm afraid to go to school.
21:45I don't want to go to school because
21:47I'm going to have to give be called
21:49on and I'm going to like maybe vomit.
21:52Now I've seen a lot of kids
21:53who come to our
21:55anxiety clinic and they have a big anxiety,
21:58big concern about and I actually,
22:00we actually, now it's coming back to me.
22:02Chris Kearney and I actually published
22:04in the 80s a case study of a child
22:07who had bowel movement concerns.
22:09I mean this child was convinced
22:10that if he went to school,
22:12he would have a bowel movement
22:14in the class.
22:16And then when we did more assessment
22:18it had to do of course with,
22:20well yes because when I have
22:21to be with other kids,
22:22my stomach really hurts and I can't
22:25control my stomach and I'm
22:27afraid I'm going to have an accident.
22:30So again,
22:31this is for some of them and
22:33then for some of them,
22:34it's some of these other
22:35things that you could see here.
22:36So these could be avoidant reasons for
22:39avoidance and why it's so important
22:41to pay attention to the function.
22:44Besides,
22:44when thinking about how to attend
22:47to these kids.
22:55And so I kind of and so if
22:57you think about it from this approach
23:00there are then, instead of the straight
23:02CBT approach that I talked about which
23:05is sort of like the standard approach.
23:07If you think about it this way there
23:10are some then you know modules or
23:12treatment plans that are a little bit
23:15different than your typical exposures of the
23:19typical CBT exposure and you could see.
23:22And a lot of them,
23:23if you look at the ones this has to do with
23:26For these reasons that have to do with,
23:29you could see a lot of these frankly
23:32have to do with teaching parents some
23:35contingency management and appropriate use
23:37of rewards and and this type of thing.
23:40And again I I know I sound.
23:44And again,
23:44I don't make this these things up.
23:47I it, it is.
23:50If I if I could.
23:51And again, these are extremely,
23:53extremely well-intentioned parents
23:54and I think they are and I and
23:58I think they actually.
23:59And so they're not being
24:02dishonest in any shape or form.
24:05It it's just that it's you get into
24:07a pattern that's really long standing
24:09and it gets really hard to like, you
24:12know, recognize that pattern until you
24:14see somebody outside of your little
24:16bubble who can point out these patterns
24:18because I've seen so many times when
24:21we suggest to parents some of these things.
24:24It is.
24:24It is.
24:25If I had, if I could, if I had a
24:28nickel for the number of times I've
24:30heard "oh we've tried that,
24:32it doesn't work."
24:32If I had a nickel for that,
24:34I probably wouldn't be doing
24:35this on a Saturday morning.
24:37No, I'm joking because we're not getting
24:40paid anything, but it was a good,
24:41funny joke for a moment.
24:42So anyway, so.
24:44Yeah.
24:44And I mean and I remember
24:47an example when I was in Miami
24:50when a parent. The child would
24:52not get out of the room.
24:55The child would
24:57lock himself in the room on the
24:59days he had to go to school.
25:01And the parents, what they tried to
25:03do and they came to us and they go "we
25:05don't know why this is not working,
25:07you told us to do,
25:08we're doing rewards
25:09It's not working.
25:11We're doing exactly what you told us to do.
25:14We're putting the Bunny.
25:15We bought a Bunny. He wanted a Bunny.
25:18Carlos wanted a Bunny.
25:20We bought a Bunny.
25:22The Bunny is right outside the door.
25:25And our plan is to gradually get
25:27the Bunny further and further
25:29away from the door and eventually
25:31bring it to the school."
25:32But we've had to explain, well,
25:34"no, it can't be done before,
25:37it needs to be done after.
25:38It has to be a consequence."
25:40And and the and the whole Bunny
25:43thing is just wasn't really a
25:45realistic reward anyway because
25:47there wasn't any chance that well,
25:50you know, getting the Bunny to school.
25:51But this is an example though
25:54of the common misconception
25:56of thinking of and kind of conflating
25:59bribery with reinforcement.
26:01So anyway, so a lot of this has
26:03to do with the appropriate use
26:05of rewards and monitoring and
26:07limits and parents limits and
26:09not doing parent accommodation.
26:11That's what a lot of what you
26:12see on this slide is about.
26:17And Umm. And here are some kind of like,
26:21again, these modules are
26:23borrowed from CBT principles,
26:25but you could see how they're
26:28more focused and structured on the
26:30particular problem, being away from Mom,
26:32so dealing with separation,
26:34you know, etc.
26:37I'll let you look at that for a moment.
26:45So and so Chris Kearney,
26:48he's has several books now but
26:50this is one of his early ones where
26:53he developed some of the ideas that
26:55that I talked about that we that
26:57we worked on back in the 80s, as I
26:59said, that he's continued to work on
27:01and actually Anne Marie Albano is
27:03actually a co-author of the Anxiety
27:06Disorders Interview Schedule that
27:08I acknowledged in the beginning.
27:10So you might want to check
27:13out some more of this work.
27:15And so this is my last
27:18slide about key strategies.
27:20First to recognize good,
27:22recognize good attendance,
27:24engage students and parents
27:25because of the stigma that parents
27:28have about all of this stuff,
27:29monitoring and keeping track of it,
27:32providing and, I used and here
27:34it's personalized more better
27:35it's doing this personalized
27:38kind of functional approach.
27:39And then you know the talk about, think
27:42about barriers because there are
27:44many barriers that come up which I
27:46don't have time to talk about,
27:47but these are some key strategies right here.
27:54So in summary, mental health and
27:56physical health are key factors.
27:58I hope I showed you how they
28:01intersect. There's much heterogeneity.
28:03A great deal of heterogeneity and that's
28:06why functional assessment is helpful.
28:08School accommodations are rarely studied,
28:10but the couple of studies,
28:12including the one I just showed you,
28:14have questionable utility.
28:15But we need to study this more.
28:17CBT is the strongest evidence.
28:19Parent involvement can be helpful,
28:22but don't fill the kitchen
28:23sink at the parents.
28:24Focus on reducing the accommodation.
28:27And then I ended again with this notion of
28:30the heterogeneity and the importance of not
28:34thinking about a one size fits all.
28:36But I also want to say this slide makes,
28:38this presentation makes it look easy.
28:41It's not easy in fact, partly
28:43why, I give kudos to Chris
28:45Kearney who continued this work.
28:47I got I kind of got more interested
28:49in the anxiety business and not
28:51just on the school attendance
28:53problem business because it is such
28:55a challenging challenging problem.
28:56But I hope some of this today is helpful.
28:59So, thank you.
29:04Wendy, thank
29:05thank you for an excellent talk.
29:08I guess I'll be I'll be sort
29:10of asking some of the questions
29:12and I guess the first question
29:14we had which was very similar to
29:16the one I had in terms of the
29:20kind of the research study
29:21on the 504 plans is
29:28Um, essentially are the 504 plans
29:34or AKA the school accommodations not
29:37showing benefit to the kids because
29:40they're not well implemented or
29:42targeted or more that we don't really
29:44know what to do to help the kids.
29:48You know, it's a good,
29:49I mean look this study again.
29:52It came out because we were asked.
29:55I mean, I mean I'm being frank.
29:56Like I don't know if we would have
29:58done this study if we were not
30:00specifically targeted by the editors
30:02and the point of
30:04this special issue was about social
30:06anxiety in school and academics.
30:09I mean because frankly
30:11we only had what we had.
30:15We only had presence or absence.
30:18This is the limitation but we thought
30:21that's just look so and I think what
30:24we found is revealing nevertheless.
30:26I mean I still think it's revealing
30:28what we found but we don't know what
30:30exactly the accommodations were we
30:32don't have that information nor do we
30:34know how well they were implemented.
30:36So I cannot speak to that and and
30:38this is an extremely you know I
30:40can't emphasize enough the caveat
30:42to this study but I can tell you
30:45there were only two other studies
30:47I believe and they also found
30:49the questionable benefit of the
30:52kinds of accommodations where kids
30:55are being asked to stay away from
30:58things because they're anxious.
31:02So, so I guess I should give a shout
31:05out to Nicole who asked the question.
31:07The next question kind of, it will
31:10be off of Lisette's question.
31:12I have one part of it and then I'll.
31:16But can just say Mike, I mean Nicole,
31:17it's a really, really good question.
31:18And again I don't want to go too
31:20far from the data, but I do think
31:23the fact that we even found this,
31:25I just think it's really interesting and
31:27I also have to say besides the data,
31:30it does fit a lot with
31:32my, you know, many decades of experience
31:35that and also what we know in
31:38on what on the importance of not
31:41encouraging avoidant behavior.
31:42So I would basically say any
31:46school based accommodation where
31:48it's encouraging avoidance
31:50behavior is it's the complete
31:54antithesis to what we
31:56want to do with these children.
31:58So I do want to stand by that
32:00even though I'm giving this research caveat.
32:03It fits so much with what we know
32:05about the importance of exposure.
32:08I guess Lizette's question is "how
32:13can we inspire parents to practice
32:16patient monitoring techniques when
32:18using rewards? As a special education
32:20teacher who writes and follows IE plans,
32:22I think this is the the missing link."
32:25I will add as a sort of second part
32:27to that question at a much more basic
32:30level which is are there any good
32:32kind of generic 504 accommodation
32:35plans for schools in terms of,
32:38to follow in terms of kids with the
32:41school refusal or chronic absenteeism?
32:45Michael, in terms of your question
32:47I frankly I do believe that
32:50people in your audience might have
32:52a better answer to that because
32:54I'm not like in the trenches there
32:56to know what that might be.
32:58So I'm going to have to and I'm
33:01and so I and I would love to
33:03hear from others frankly if they are
33:06aware of plans that are specific
33:08to this that are not encouraging
33:10avoiding behavior. I know I don't
33:13know the answer and in terms of.
33:15So the first question is "how do we get
33:17parents to do reinforcement type of work?"
33:19Is that what the question
33:20using rewards or how do we,
33:22I think Lizette's question is "how
33:24do we inspire parents to practice
33:27patient monitoring when using rewards?"
33:29I think the larger question is how
33:31do we get the parents to do at
33:34home the evidence based practices
33:35when they're working at the school?
33:38I mean there are some really good,
33:42evidence based books out there.
33:44I mean I mean I personally
33:46I do like Alan Casden's book.
33:48I don't know what other people think
33:50but I like Casden who was a professor
33:52here at Yale you know had has
33:55a book on on these principles. The
33:58classic book from I think from probably
34:02from 1/2 a century ago frankly
34:04I mean is Gerald Patterson's book
34:07about you know about training
34:09parents so there are.
34:11I'm sorry I can't give you a, I
34:13wish. These are good questions,
34:15but I think you know all in terms
34:18of giving parents some tools.
34:20But then I think it's really,
34:21I mean frankly, Lizette, it's Lizette, right?
34:26Lizette I I have to tell you,
34:28I mean I gave a presentation,
34:30it's a little bit of, I gave a
34:33presentation a couple of days ago
34:35here with the Child Study Center.
34:37And I told and I emphasize that
34:40what I am now focusing on
34:44in my last Hooray, so to speak,
34:47is, because I am so frustrated
34:50by what you're describing
34:52and how much there is
34:54all these problems and I don't
34:56know if what I'm going to be,
34:57what I'm going to say is going
34:58to be the panacea,
35:00but I'm working on a science based
35:04parent digital intervention
35:09based on the work we have done.
35:11We're going to be developing,
35:16we're already working on this,
35:17we're developing videos, we're developing
35:20exercises and we're developing
35:22a way for parents to access this
35:25information by their telephone,
35:27by their computer, by their, by WhatsApp.
35:30And we're going to be providing,
35:33in the pocket of parents, the
35:37main tools to help improve
35:40sustainability and duration because I
35:44I don't know if this is going to work,
35:46but I think the problem I think
35:48it's I think part of the problem
35:51with all the current technology
35:52if it's not science based,
35:54there's too much stuff being thrown at
35:57people and I can only tell you that
35:59this is one thing I'm working on.
36:01Because I think face to
36:03face meetings can only go so far
36:06with many families.
36:11I'm sorry I'm getting harassed
36:14at the bottom by my dog who's
36:16barking at us to take her out.
36:19So I missed some of your answer.
36:23I guess the next question comes from
36:26Anonymous and it was a question
36:29of "how would you, how did you address
36:31the child who was refusing to go
36:33to school because of bowel concerns?"
36:37Well, I think our paper, as I said
36:41I'd forgotten about that paper
36:43that we published like in the in the
36:4780s but if I, but if I recall
36:50correctly but even now I'll just say
36:53you know a lot of times those kids
36:56have it has social evaluation
36:59concerns so, you know, so what we did
37:02was, we I honestly don't remember
37:05the paper but I'm going to tell you
37:07what I would do now is I would be
37:09focusing on what the person,
37:11the child is eating before school
37:12and try to like make sure that
37:14there isn't something in their
37:16stomach and in their diet that could
37:18give them those those feelings.
37:20A lot of these children have what
37:22we call anxiety sensitivity,
37:24which is another construct that's really
37:26important to understanding anxiety.
37:28And if you're interested,
37:29I have a scale that I developed called
37:33the Childhood Anxiety Sensitivity Index.
37:35And what this is, anxiety
37:37sensitivity is we all get anxious,
37:40but some of us have feelings in our body.
37:44Like, I have to have a bowel movement
37:46or I'm going to have a heart attack.
37:48And some kids particularly
37:50have these feelings of,
37:53these sensations.
37:54So one thing is to 1st see if the child
37:58has those sensations and work on.
38:01And,
38:01through
38:03exposure and through cognitive work,
38:05working on that and also then doing
38:09the exposure with going to school
38:11and having them feel more comfortable
38:13because what was triggering this was
38:15the social evaluative situations.
38:18So doing kinds of like gradual exposure
38:21with social evaluative situations at
38:23the same time targeting the feeling,
38:26you know maybe in the office. Work with
38:29those sensations in their body. Sometimes,
38:31some kids, when kids have these
38:33kind of physical sensations,
38:35I don't go right away to
38:41meditation or mindfulness.
38:42But we actually have public papers
38:44on mindfulness because for kids
38:47who do have somatic symptoms,
38:49we have found that mindfulness,
38:51which is a measure, which is kind
38:53of like a next wave of cognitive,
38:55can be helpful.
38:55So I mean it's kind of like a
38:57combination of a few things of,
38:59of getting people to understand
39:01those feelings in their body,
39:02getting kids to maybe attend to and not
39:04to attend to it through mindfulness,
39:07relaxation, and then doing exposure
39:09with social evaluative situations.
39:11I don't know if that helps.
39:12Does that answer the question Anonymous?
39:15Yeah, I don't, they can't
39:16they can't answer back, so.
39:20I hope that answers the question.
39:24I think we're going to wrap up in a minute.
39:26I'm going to tie up the last couple
39:29questions and I guess I just want to
39:31thank you for coming and talking to us.
39:34Liz made a comment which I think is good
39:40"I struggle with parents who push for
39:43those avoidance accommodations and who are
39:45not on board with any interventions
39:48that make the child feel uncomfortable."
39:50And I guess if it's alright,
39:51I'm going to answer it.
39:52I would say that, I don't want
39:54to speak too much for Wendy,
39:55but I think we all really struggle with
39:58that and that's a major factor in treatment.
40:02Some of the questions in the talk really
40:05highlight part of the reason why this is
40:07such a vexing problem for the kids and is just the
40:10And that a lot of, that this
40:12involves you know the treatment of
40:15chronic absenteeism not only involves
40:17a school but involves the parents and
40:20mental health professionals working
40:22together and that the really probably
40:24the plan for this in terms of the
40:26interventions in the 504 plans and
40:29the accommodations probably involves
40:31a lot more coordinated, specialized
40:33services than are typically available
40:35to the schools and I think it's
40:37a big crux of the issue.
40:39Exactly and in fact,
40:40That's exactly that.
40:41Chris has written like a book on
40:43like a multi tiered approach which is
40:45exactly what you're speaking about.
40:47So I'm certain that type of multi tier
40:51approach is needed because it's
40:53it takes a village to help
40:55deal with this problem for sure.
40:58And so we're going to take a 10 minute break.
41:00But Christina put in the chat,
41:03"the largest challenge for me is that
41:05the educational system is not set
41:07up for providing clinical support.
41:09The schedule, the structure
41:10and focus is education."
41:12And I would say that the mental health
41:15system, at least for children is
41:17not well set up to provide support
41:19into the schools and in the homes
41:21in general and that it's really
41:23modeled after adult mental health and
41:26involves an office based practice.
41:27So I think that that's a big
41:29crux of the issue.
41:30And I think part of the reason for
41:32this forum and thinking about these
41:34issues and starting to open up the
41:36dialogue between the Child Study
41:38Center Center and the school mental
41:40health personnel is that yeah,
41:42we could be doing a lot better job
41:44than we are with everything we all
41:46know and just getting together
41:47and thinking about it.
41:51Thanks everyone for listening.