Podcast: Helping Adolescents With Anxiety

Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Hi folks. Good morning, good afternoon, or good evening to you, wherever you’re joining us from, whatever time it is there, whatever the weather looks like. Thank you so much for joining us for our chat today about anxiety in kids and adolescents.

I’m Jenn Kearney, I’m a digital communications manager for McLean Hospital, and I am joined by the very friendly Dr. Jason Krompinger as my cohost.

So before we kick things off, I wanted to share a little bit of good news. Anxiety is something that we all have. So if you have anxiety, your body’s doing the right thing.

The not so great news though is that if you have too much anxiety, it does have the potential to impact every part of your life, especially if you’re a young person. That includes physical health, emotional wellbeing, social habits, and more. So all of these reasons are why I’m really excited to have Jason with me today.

So we’re going to talk all about anxiety, its symptoms, the differences between different types of anxieties, how it can impact kids and teens, and if we have time, ways that we can address stigma around what’s a really common mental health disorder.

So before I start throwing all of these questions his way, if you are unfamiliar with him, Jason Krompinger, PhD, is a clinical psychologist and the director of psychological services and clinical research at McLean’s Obsessive Compulsive Disorder Institute. In his role at the OCD Institute, he serves as the director of the training program.

So he supervises students, post-doctoral fellows, and early career psychologists in the delivery of empirically-based interventions. So Jason, I am always so happy to see you, ‘cause you’re just such a friendly face and such a wealth of knowledge.

I want to get started by stopping talking and asking you first and foremost, what does anxiety in kids look like? I know we all have anxiety, but does it differ in teens, differ in adults? Like, what does that look like over a lifetime?

Jason: It can look lots of different ways. You know, I don’t want to give the impression right off the bat that it’s always going to look a particular way in either young kids or teens, or that it always looks some different way than it does for adults.

You know, for a lot of kids in, because as you said at the beginning, anxiety is so common and so fundamental to human experience. A lot of times it looks like, as you mentioned, a lot of discussion about anxiety or feeling nervous or feeling worried about stuff.

Those kinds of words will often get thrown around, avoidances of things that tend to be triggering to them, to be anxiety producing. That’s super common, of course, across the lifespan. But of course, you know, younger kids have different languages that they work with.

So it can look other ways too. You can have a kid that talks a lot about their belly hurting, for example, and it can just sort of give the impression that it’s a lot of this physiological stuff going on, oh, is there, do you have a stomach problem, do you have some sign of a medical issue, but in reality, that’s a manifestation of anxiety.

You’re just, like, lots of headaches and coming home from school, just kind of feeling tense. You know, kids, anxiety can look like tantrums, can be something like dissolving into tears, a lot of, kind of, sadness, a lot of like crying about things that you might not necessarily think were a problem for them. It can look like anger too and irritability.

So when we move into the teens, you know, I think in my, when I work with the teenage folks, a lot of teenagers kind of talk about it in a way that is very similar to how adults kind of talk about it.

They just can talk about it, especially these days, I think, it’s, there’s been a lot of good work in part because of webinars like what you do, Jenn, to decrease stigma around anxiety and mental health, generally speaking.

So I’m going to find that teenagers are better about just talking about their anxiety, using those exact words and talking about being keyed up, on edge, jittery, nervous, triggered, avoidant, whatever it is.

But in teens, you know, it can also look different ways. So you can have a lot of moodiness, like a lot of just irritability and that could absolutely be a function of anxiety, sort of anger, sadness, a kind of withdrawal, that kind of thing, spending a lot of time in their room. It can look that way, as well.

So, there are a number of ways it can manifest and you know, it’s always worth poking a little bit and kind of probing to see, could anxiety be playing a role here?

Jenn: With the full understanding that there are going to be differences in what anxiety appears like in kids and teens, what would be considered a quote, like, ‘normal’ level of anxiety?

And when would it be considered something that’s like a little bit more problematic than a toddler having a tantrum, for example?

Jason: Yeah. So it’s one of these things where I kind of, I like to shy away from getting people thinking about like anxiety as, there’s a certain, like the experience of anxiety, there’s a certain level that you cross where it becomes a problem.

We all experience anxiety, as you said, we all experience anxiety so differently. All kids experience anxiety so differently. We all, kind of, can learn to function alongside different levels of the experience of anxiety in different ways.

But I think it’s really, to answer your question, when is it a problem, it’s when it begins to just impair them functionally. So in a nutshell, when the anxiety actually gets in the way of kids doing the kinds of things that they want to be doing and that they need to be doing.

So going to school, hanging out with friends, going to birthday parties, trying out new things, trying new musical instruments, trying a sport.

You know, when, and not just like that kind of concrete stuff that like ‘functional impairment,’ it’s also just, if they can’t, they’re not happy, if they’re not enjoying their life, if they’re not, you know, if they seem to be just in their head all the time, worried about something.

Maybe they’re doing all those things that I just mentioned, but again, not sort of like meaningfully engaged. It doesn’t seem like they’re actually, you know, at a birthday party, for example, are they there and like talking to friends and having a good time and laughing, or are they kind of like in the corner or just sort of like, kind of otherwise detached from the group.

So it’s when those kinds of things happen, that kind of impairments that that’s when you start to think about, is this more of an anxiety disorder that needs to be addressed and it goes beyond sort of like the normative levels of anxiety.

Jenn: One of the things that I’ve heard from friends who are parents, having grown up myself, oftentimes, when your anxiety comes off as being a tantrum or utter refusal of something, a knee jerk reaction is kind of like, calm down, it’s fine.

Jason: It’s effective every time, just say it.

Jenn: I’m sure. How are adults sending kids the wrong messages about anxiety beyond just telling them to calm down and how can that actually impact their development?

Jason: Yeah. No, it’s a good question. Yeah, I think a lot of the role that we play as parents, or just significant roles in the kids’ life has to do with shaping their, I’m going to say relationship to anxiety, like how they sort of think about it.

Yeah, so saying “calm down” or “don’t be nervous,” “don’t be anxious,” “stop worrying,” “stop thinking about that,” it’s often coming from a good place. I don’t mean to like disparage, I mean, anybody who’s here who’s used that for, I’m sure I’ve said that kind of thing. I do this.

Jenn: I’m sure that I’ve said it to adults, as well.

Jason: But that can be invalidating, you know, it’s like, meanwhile, the kid has the experience, whether you’re telling them to stop having it or not. I mean, that’s the idea. We all know that stopping, being instructed to stop thinking about things, isn’t so much a useful thing.

So I think that kind of further perpetuates this idea that these experiences that I’m having, this feeling that I’m having, are like a problem, or like a symptom or like something that I need to get rid, something I need to not have.

But also I think we can model problematic reactions to anxiety too. So oftentimes what can happen with kids with a lot of anxiety is that they want to avoid things.

They don’t want to do certain things, like maybe they don’t want to go to school, but maybe more often they don’t want to do other things in their life that they don’t necessarily have to do.

Where again, back to the, like, you know, doing the play date or doing the birthday party or doing the sports, like that sort of thing. And we can sort of unwittingly accommodate that and just say, “Well, if you don’t, if you’re too nervous to do that, then you don’t have to do it.”

Or if you don’t want to try that thing, maybe this happens with meal time, for example, like, oh, if you don’t want to try those different foods or, you know, have that, let’s find the thing that you’re going to eat and avoid any kind of discomfort that you might have around these other items.

We can, in doing that, if that becomes kind of a perpetual pattern and one that kind of results in the kid’s world becoming smaller and smaller and smaller, we’re kind of unwittingly sending this message that anxiety is like, what controls things. Anxiety is really running the show.

So we have to sort of organize our life around the anxiety, which is not what we want because we can’t really control it directly. And we don’t, as you know, and as I know, anxiety sometimes just comes on. And meanwhile, we have plenty of things that we’d like to do.

So when we accommodate the kids’ anxiety in that way, again, it kind of reinforces this message that we’re, sort of, like at the mercy of those kinds of feelings. And then as far as development goes, they’re sort of robbed of these really important experiences to have.

So one thing just to be watchful of, these kind of ways in which perhaps the accommodating, the anxiety has been accommodated. And just by the way, this is, just to be clear, incredibly normal for any parent to kind of engage in that sort of accommodating behavior around the anxiety.

The last thing we want is to see our kids anxious. It’s painful for us to sit with. So you come by it honestly as to why that impulse is kind of there to sort of protect them from the anxiety.

But again, in terms of the relationship with the anxiety that’s being created there, it’s like, again, that’s just an antagonistic kind of relationship with it. Like, okay, it’s this thing that I need to not have.

Jenn: One of the things that I’ve noticed, not being really far removed from being an adolescent is that one of the things that we try to do is mask our anxiety.

So can you provide some of the examples or some ways that adolescents are trying to make their anxiety more invisible?

Jason: Yeah, for sure. I think, so, I think one interesting thing that I’ve seen a lot these days, it’s kind of a little bit, it’s a little bit counterintuitive, but it’s when adolescents, they react to their anxiety by kind of being like a class clown in a way, just sort of like being sort of overly extroverted in sort of like a silly and just, you know, kind of like the life of the party kind of a thing.

In a way, that doesn’t necessarily fit with how they want to be, but it’s a way to sort of control other people’s perceptions of them and see, like, “See, I’m someone who’s fun and likable,” and acceptable and all that sort of stuff, I fit in, accept me, I’m cool, have me in your life.

And that’s, again, can often be just a function of anxiety where in reality it’s exhausting. They don’t really want to be behaving in that way, but they feel like they need to do that, again, as a means of controlling other people’s perceptions of them. So that is a really common way that it’s masked.

Or the other kind of, another variant, I was kind of hitting into this before when I was talking about teens, but it’s kind of the anger stuff, the sort of like the leave me alone.

Like, this persona, and again, I don’t want to generalize, but you can have adolescents develop this persona of like, “I hate the world” kind of a thing, you know, and it’s like, screw everybody, forget everybody, like, I’m kind of this person that is generally a misanthrope, kind of a thing. Like I just don’t, I’m not one who likes humans.

And that could maybe on some level be very well true, just because of the state of the world, but sometimes that could be just another way of, for them controlling their own anxiety, reality.

Like they would like to be more connected to other people and more part of the group, and sort of like have a community, but just have a lot of anxiety around it.

And this is like that persona maybe is more of a way to sort of relate to control that. It kind of provides an excuse to not have to sort of face that stuff.

Jenn: One of the things that struck me is anxiety as presenting yourself as being extra, as being really extroverted, where oftentimes we tend to think of people who are more anxious tend to be more withdrawn and isolated. That’s not to say that there aren’t a lot of folks who aren’t experiencing that.

One of the things I wanted to address is selective mutism. So we have received a few questions about it. First and foremost, is selective mutism and social anxiety the same thing? And how can a parent or a teacher tell if a child has either?

Jason: Social anxiety, let’s talk about that first. So that’s an anxiety disorder in which sort of core fear of it is negative evaluation from other people.

So the folks with social anxiety really struggle with social interactions in a variety of con, usually to meet criteria for social anxiety, you struggle with that kind of anxiety in multiple contexts.

So it could be in school, it could be at home, it could be in their place of worship, it could be in talking on the phone, it could be an email.

So there’s this kind of perpetual concern that, not only are they going to be evaluated poorly, people are going to think poorly of them, but the cost of that will be very dire. Like, so I’ll be sort of ostracized from the community, essentially.

Like not every kid is going to say everything I just said, but that’s kind of like what the basis of the fear is, people are going to make fun of me, I’m going to be embarrassed, all that kind of stuff.

So under the umbrella of social anxiety, there’s selective mutism. So it’s like, selective mutism is this condition in which, it’s kind of just what it sounds like, it’s often in younger kids, and it’s an unwillingness to speak in particular contexts.

So for example, in school, just not talking, and having it not get better over the course of a day, for example. It’s one thing if it starts off, the kid starts off kind of shy and just not saying a lot, and then eventually kind of warms up, but selective mutism is different than that, it’s just kind of, it’s persistent.

And a kid who otherwise talks plenty at home, for example, or, and of course that the condition is better explained because they don’t know the language or something along those lines.

So everybody with it, most kids with selective mutism have social anxiety, but not everybody who has social anxiety has selective mutism, so that’s kind of the relationship there. There’s usually a massive component of social anxiety that contributes to the mutism, but of course, social anxiety can look, as we just were talking about with lots of other ways too.

Jenn: Do you have any advice for students with selective mutism who are experiencing difficulty communicating with teachers and/or getting cold-called in school?

Jason: Getting cold-called. Oh, you mean in class, yeah.

Jenn: Yeah, the teacher, they’re not raising their hand, the teacher calls on them, everybody’s worst nightmare.

Jason: Got it, yeah, yeah, yeah. So it gets to some of the treatment stuff. So, for a lot of this stuff that we’re talking about, the indicated psychosocial intervention is cognitive behavioral therapy, which oftentimes involves a major exposure component.

Exposure just means you’re practicing facing your fears. But you do it in a very structured way where you’re working with the therapist, you are making a list of all the different things that are anxiety-producing and you kind of work on them systematically.

So with selective mutism, you know, ideally you are working with somebody who’s addressing that with you.

And, even more ideally, perhaps that therapist is in contact with teachers, with other people in that kid’s life, so that they’re aware that that’s what’s happening there, that it’s not just that the kid’s being a jerk and doesn’t want to participate in class, that there’s an anxiety component involved.

So that you can practice with, can we practice saying like a word or two? We start like as small as possible to practice getting used to that kind of step first, and then gradually kind of building our way up to more challenging kinds of exposures.

Jenn: One of the things that has popped up, more recently because of the pandemic, is just incessant screen use.

So whether it’s kids that are learning remotely, that’s the only way that they’re engaging with their peers, everybody’s on a phone constantly. Are there ways to tell if screen use is helping a kid’s anxiety?

Jason: Okay, no, sorry. Go ahead. It’s a joke, go ahead.

Jenn: Oh, good. So how can you tell if screen use is actually helping a kid’s anxiety or if it’s just another form of avoidance?

Jason: That’s a good question. It all comes down to function. So how is it actually working for them? And that applies, so what I’m going to say applies certainly to screen use, but applies to really any behavior that a kid is doing in response to their anxiety.

So what I mean by function is just, how does it work for them, what is it doing, and how does it sort of fit within the context of their life? So you could have a kid who uses, I’m just saying, like uses screens or uses a particular intervention as a means of navigating their anxiety.

And it helps put them in a position to tackle their homework, for example, or puts them in a better position to tackle a difficult conversation with a friend or talking to a teacher and that sort of thing.

If it actually works for them, meaning they engage in that behavior and it doesn’t get in their way, they don’t get stuck, they don’t rely on it, where, “Okay, well, if I don’t have that thing then I can’t do any of these other things.” Then it might be workable, it might be kind of fine, just see how it works.

But in other cases, if it’s something where, again, it’s kind of the opposite of what I just said, where it becomes a crutch where you absolutely need this thing to rely on in order to function, you need to control any kind of set up basically where the mindset is, “I need to control my anxiety first and then live my life,” is probably a problem.

Don’t let me say that, I mean, look at it for yourself, or look at your kids kind of behavior for yourself and see if that’s the case. But that general sort of arrangement, like that kind of algorithm, if then, like, again, if it’s like, “I can only live my life if this anxiety is eliminated in some case.”

If that’s what the function is of those kinds of behaviors, then it’s more likely to be problematic. But yeah, I like the question because it’s not a blanket thing, I don’t we can sit here and say all screen use is bad.

I mean, whether we like it or not, screens are a thing, and screens will continue to be a thing, and we will find a way to have screens in our lives and not necessarily all have anxiety disorders, we’ll find a way to co-exist with that. And I think paying attention to function is a way to do that.

Jenn: Speaking of function and screen use, do you have any advice for a parent who has a child that’s isolating in their bedroom and playing a lot of video games because of their anxiety and depression?

Jason: Yeah, totally very common kind of coping response, to sort of have video games, especially these days, kind of provide these universes to inhabit, where it’s like you don’t have to face, you don’t have to face what’s out there.

Of course, ultimately I’d love to see that kid in treatment, but as far as the parent role goes, I would have like, this might sound like, I don’t know if this sounds like simple, overly simple advice or not, but to have a conversation with your kid.

And I think it can be quick to, it can be easy to sort of like, again, interpret that kind of behavior as like, oh, they’re just like sort of lazy, or unmotivated, or all they want to do is play their video games all day.

And I think kids generally are sort of equipping themselves to respond to that, to sort of like have that fight.

Don’t come at it from that perspective, more just like, I wonder about how you’re feeling these days, and I wonder about what things are like for you, what kinds of things are you thinking about, what’s worrying you, what kinds of anxieties you have?

It’s okay to share with them, for sure, like I’m anxious for you, I’m anxious, it’s my own stuff, but I have anxiety. when I see that you haven’t left your room all day. Can we just talk about that?

And it’s less of an evaluative thing necessarily, like a punitive thing, and just more to open that conversation, working on that specific. And there might not be any necessary intervention in there per se, but opening up those lines of communication, I think is, you can’t do anything else without that.

So I’d start with that. Just exhibiting curiosity, genuine curiosity, and concern as well about their inner world, if that makes sense, just what goes on for them. A lot of kids just feel misunderstood so they, and just kind of coming across like, “I’m interested in understanding what’s going on.”

Jenn: I feel like this next question, you’re going to have a really similar answer for, but I would be remiss to not ask, any advice for helping kids manage anxiety around COVID?

Jason: Yeah, so certainly talking about it for sure, But this will apply to other anxieties too, and certainly COVID.

So a lot of the, if you just, this is quite intuitive, I think, but with the younger kids, the anxiety that’s there in part, is a function of just not having the information, you know what I mean? So like the first time my daughter wanted me to like, I think she did this, like check under her bed for monsters or check the closet or something like that.

The first time she asked me, she was like three, it would’ve been weird for me to be like, “Well, you got to just deal with it, there could be monsters, I don’t know,” and I just walked out of the room. That’d be a strange way of responding to anxiety, even if it was technically an exposure.

No, I’d have to be like, no, let’s get some information here. I know you have these, like you hear these sounds, and this is what that sound is actually, this is the house doing, I don’t know, the heat coming out or something like that.

And well we look under the bed and we see, yes, your bed creeks when you move and those are what those sounds are, you’re getting information as a way to understand the world more and have less anxiety about it.

So with COVID, it’s the same thing, first of all, understanding what is it, what are you worried about specifically? And then it’s absolutely okay to have that conversation with your kid. Like, well, here are the reasons why, of course we don’t know for sure what happens, but here are the reasons why you are safe, we do X, Y, and Z.

We are careful in this particular way, perhaps you’ve gotten, depending on the kids, how old they are, perhaps they got the vaccine, this is how the vaccines work, this is what, as adults, this is what we do to navigate COVID.

And it’s really a low probability, you can do it in a language that fits with the kid, but the chances of something really bad happening are pretty low. So having that conversation, if you haven’t, that might be intuitive, it’s okay to have.

Now, the way anxiety disorders work is that, a kid can here that, and then there’ll be this like, that bit of uncertainty that’s leftover. It’s like, oh, how do you know for sure? And like, there’s this kind of ongoing sort of pull for asking again and again and again.

And that’s where again, we think about function. Now we’ve gone beyond just getting information, and now it’s about, I need to get rid of that uncertainty, which is not something you can really do with people.

So that’s when with your kid, you’re like, we’re not going to have this whole conversation day in and day out, let’s go do stuff. Like let’s go live life anyway, let’s make a list of things that we can do, even though we’ve got these worries about COVID and kind of just, in practice, getting into our lives a bit more. So that’s kind of a response you might have.

Jenn: Do you have any advice about how to start a conversation about anxiety with my kids? Whether or not it’s COVID-related, a lot of parents, I know you and I were talking before the session started, a lot of anxious kids grow up to be anxious parents who then raise anxious kids.

So it’s important for kids to understand healthy limits to being anxious, right? So how do we approach that conversation in general?

Jason: Yeah, I mean, it depends on the kid, of course, I can’t say that for everything, it just depends. But one thing that I think about, especially in the way that you framed it, Jenn, the anxiety that we had as kids is a gift.

And the reason why it’s a gift is because now we’re in a position as parents where we know what they’re talking about when they say anxiety. Imagine if we didn’t have anxiety at all, and then our kid comes to us and it’s like, I have anxiety. And we’re like, oh, tell me about that, I don’t know what that’s like. That’s a kind of a difficult position to be in.

So I think one way to start the conversation is to disclose your own experience. Talk about what it’s like for you and say, “I was really anxious today and here are the reasons why, and this is kind of what my brain was telling me, and this was kind of how I felt, and I wonder what it’s like for you.”

And you could explicitly do that, the kind of overture towards them. You don’t have to do that, but you could just start by just talking about your own. Not like as a lamentation, you know, just more as like a matter of fact kind of thing.

Like as a matter of fact kind of thing, this is a part of my experience. I think a lot of kids can potentially, or certainly have the perspective on their parents that they don’t have anxiety. Like, there’s my dad, or he’s never, I’ve never seen him anxious before in my life, but he probably has anxiety, he probably has something, at some point in his life.

And that can be really powerful, especially for that parent to disclose to their kids their own experience of it. So that’s one way to kind of initiate the conversation.

Jenn: Do you have any advice about ways to talk to my child’s teacher, coaches, after school facilitators, et cetera, about anxiety that they’re feeling, or is it something that we shouldn’t really bring attention to?

Jason: Certainly, I’m not going to say you shouldn’t bring attention to it. And at the same time, I don’t want to give the impression that if your kid has anxiety, you need to immediately tell everybody that they come into contact with either.

But I think it’s particularly those cases where the anxiety is, kind of like what we were talking about before, the anxiety is evident in some of these maybe unusual ways or in ways that can be misinterpreted as acting out, for example, or the acting out is a function of something other than the anxiety, to have that conversation with teachers or coaches or other people that the kid’s going to come into contact with.

In best case scenario, I don’t want to say best case scenario, but in certain scenarios, if your kid has anxiety to the point where they’re working with a therapist, I mentioned this before, it’s customary to just have the teachers be in contact with the therapist, have the coaches be in contact with therapists too, depending on if the kid is okay with that and you’re okay with that as a parent.

Just to kind of get on the same page is what’s going to be useful for the kid. I would actually, I would, before doing, no matter how old your kid is, I mean, if they’re very young, you might not have this conversation, but just like I would first have a conversation with your kid about, “Well, what do you think we should do?”

Just to know that you’re, just for them to know that you’re interested to kind of get their perspective on that specifically. I think that’s useful. And then as far as like how to talk about it with the teachers or kind of with the coaches, I think just naming it very directly.

I think so much of what we’re talking about is anti-stigma and increasing awareness of mental health, we don’t have to tiptoe on it. And, so, you know, he’ll show up in this way so know what’s going on for him is that he’s got anxiety, and these are ways that we’re talking about working on it.

Or even just inviting the teacher to brainstorm with you on how to address it in the classroom, teachers are more and more savvy around this stuff these days, and probably will have ideas already.

They have already had kids in the class that have had had similar kinds of struggles. They are the busiest, most dedicated people on the planet, and I feel like they are on average, pretty interested in understanding your kids.

So being direct and naming it, I think is a way to start. You don’t have to sort of code word it or anything like that.

Jenn: One of the things that I want to mention about classrooms is that sometimes if a student is that anxious, they just refuse to go to school altogether. So what are some ways that we can help students that are going through that cycle of school refusal because they are that anxious?

Jason: The first thing to do is understand why they’re anxious. So what is it exactly that is anxiety-provoking? Is it social anxiety, is it fear, is it perfectionism about their schoolwork, is it a fear of falling apart or having a panic attack, or fear of soiling their pants when they go to school?

Something like that, it could be so many things. So don’t skip over that stuff. Just like, what exactly is it that’s going on?

Because when it’s gotten to the point where school refusal is happening, I think, like I was saying before you asked me about, well, what’s the point where it’s kind of, the anxiety is no longer normative, that’s when we’re wanting to work on it to address it in a therapy setting.

That’s what the therapist is going to want to know. And what is exactly, what’s kind of being feared here. And then an exposure can be created, or a set of exposures can be created to begin to gradually address it.

This is where IEPs can be created, and again, schools can be collaborated with to understand, okay, what’s going to work best as far as gradually getting the kids to be able to attend school.

And I think perhaps one silver lining of the pandemic has been that there’s remote options these days. So perhaps there’s something to be figured out as far as we started Zoom, and kind of come in or whatever.

I don’t want to go too far down that path ‘cause every school is going to be different. But again, starting with understanding what the nature of the anxiety is. That’s going to give you the grist to develop a plan that’s going to make the most sense.

So if a kid is worried about social anxiety, then you’re going to have a therapist who’s working on how the person’s thinking and appraising people’s interactions with, kids’ interactions with people and doing perhaps exposures.

Not in school, but around outside of school, around other people to sort of get more comfortable interacting with people and kind of reacting to them, et cetera, before thinking about getting them actually back into the classroom. So I’d start with that.

Jenn: We got a really thoughtful question from a teacher who’s asking, how can we help parents understand that their child may need professional help for their anxiety?

Jason: Yeah, that’s a really good question. Teachers, I think that you have a lot of authority here just given or kind of scientific authority is the way I might put it, because you have a wealth of data.

You have a lot of kids that you’ve probably worked with. Even if you haven’t been teaching that long, I imagine you’ve interacted with a lot of kids and you’ve seen the kinds of kids that are more impaired, and you’ve seen the kids that, you’ve seen kind of dysfunctional impairment that I’ve really been talking about.

You’ve kind of seen how that manifests. Like they might have gotten themselves to the classroom, but perhaps you’ve seen that they, a kid can’t turn in an assignment or has to spend an extra hour getting things just right before they turn it in.

And you know that’s not, you’ve got that kind of a bell curve in your head, and you’re like, okay, that’s not part of like the normal, that’s more on the end. I think, again, in the spirit of stigma reduction and mental health awareness to call that out specifically with the data to back it up, that’s going to be the best way to do it.

Just saying the kids seem anxious, he needs help is probably that might not necessarily go over super well. But just to say specifically, these are the things that I’m seeing that could create these concerns in me and kind of present that to the family and I’d imagine, you know, oftentimes they would understand.

But even if not, you’ve got the evidence to back you up and ideally, if the family then is able to connect their child with services, then all that data is incredibly useful for the treatment team to have as well.

Jenn: Do you have any advice for when homework becomes a trigger of anxiety for students? So like homework then becomes not just an assignment, but a list of things that has to get done before anything else can happen in their life.

Jason: Oh, really? Yeah, yeah, yeah. Part of the question is, I think, is the answer in there a little bit. So first of all, homework’s going to be trigger, it just is. I’m sorry.

Like, you know, irrespective of your kid, homework is going to be stressful, tests are going to be stressful, studies are going to be stressful, and that’s just kind of, that’s part of life. So that’s not a problem in and of itself.

But yeah, like the way you just put it, Jenn, if it becomes, if there’s a lot of inflexibility around the homework, if there’s a lot of rules, where it’s like a no, the whole house has to stop, or at least the kids’ life has to stop until this gets done.

So ultimately what you’re going to be doing or what the treatment team will be doing is promoting this idea of flexibility. A really kind of a core antidote to anxiety ends up being flexibility because anxiety is very rule-focused.

We were saying before, just like what you just said, if this, then this. Like, if I have anxiety, then I can’t do this. If I have homework, then I can’t live my life. So the antidote is more flexibility.

It’s like, well, can I take a break? Okay, can I take 15 minutes? Can I put something aside for a bit, does this is really need to get done right now, if not, can I practice letting it be?

And that will be uncomfortable, but maybe that’s the exposure to work on. That’s where you’re going to get to.

But before you get to that, again, kids need to feel understood, and they have to understand that you’re not promoting that because you don’t care about their grade, that you don’t care about them doing well.

Or that you think they need to lower their standards or something like that, or like that their ambitions are misguided, or something along those lines. Like you get it, they want to do well. That’s what’s kind of driving that.

But the message is more like, the way that you’re doing it is running into the ground. Like, that’s just seems, it’s burning you out. That’s the message that you want to send.

So that’s why, again, I’m getting more into sort of like the treatment end of things that a therapist might be saying, but we’re not trying to make people worse students by being more flexible around their homework.

We’re actually just trying to make them better students where again, there’s more freedom around those kinds of stressors.

Jenn: How can we determine whether we could let our teen handle their own anxiety, or when we should step in as a parent to be supportive and encouraging?

Jason: Yeah. Always being supportive and encouraging is always a good approach, but I think, again, communication, having that conversation and sharing observations, but not having this...

So being open about, what is it you’re seeing, what your concerns are, but really not so much being an we’re-gonna-fix-it mode, if that makes sense, like just immediately going into, like, I see this and this is what I think we should do.

Just more like, again, I see this, and this is something that appears to be challenging to you. I don’t know for sure, but that’s what it looks like just kind of opens the door and just knows that like, I’m here to talk about it.

And kids are going to be much more amenable to any kind of intervention if they are the ones that feel like they have some sort of autonomy here and some sort of like say, especially teens, you know what I’m talking about, say over how things go.

So again, open the doors of communication, make that connection with your kids. But I think that when we jump to the fixing it, that can be invalidating sometimes, it’s just sort of like, “Oh, I’m just a ball in, she just thinks I’m a ball of anxiety and I can’t make my own choices, and she just needs to like walk me through everything.”

So again, just sort of letting it more, letting it be that you’ll get to the intervention stuff when the kind of kid comes to you with that question or with that request.

Jenn: For any students that might be tuning in, do you have any advice for them when they experience anxiety around their future plans, whether it’s college, career or beyond that?

Jason: Very abnormal, totally.

Jenn: I’m an adult and I’m still anxious about that, so you’re not alone.

Jason: Maybe they could help me with that, no, for sure. So again, there’s nothing, kind of like we’ were talking about homework, nothing more normal than having those kinds of concerns. I’d say, start with that first of all.

Pay attention to your response to that whole narrative. Sometimes, the response can be one of like, okay, well, thus I need to, it gets back to the rigidity stuff. Like I need to really lock down, and I need to study eight hours a day, and I need to sort of, if I’m not studying, I’m flooring over my options for the future and I’m getting into the best school.

And if that response works, if you’re happy doing things that way, if you’re living the life that you want to live doing things that way, you feel like you’re able to move towards what’s important and meaningful to you, then cool, do it.

But if there’s something about that, that is too, it’s too tight, it’s too rigid. You’re not seeing your friends, like you’re not playing your video games, you’re not doing the other things that you’re getting enjoyment out of, and it’s all for that, that’s not sustainable, it just isn’t.

And so one thing to do is don’t look at, is to shift in perspective where, instead of looking at those other extracurricular things as, meaning…

I’m not talking about extracurricular activities, not that all kids are pushing themselves to do all of those, I just mean more like the guilty pleasure kind of stuff, or the kind of chilling out and the socializing, look at those, not necessarily as breaks, but more as vital.

That’s how we recharge, those are the things that we need to do to help us replenish our resources to do the hard work. And that’s how you’re really going to, I think, that’s more sustainable, that’s kind of approach that you’re going to take that’s going to benefit you the most later in life.

It actually helps you get what it is that you want. So just kind of be curious about how you respond to that. Like, I want to have a good future narrative.

Jenn: One of the things that I know we’ve discussed, not explicitly, but there’s kind of an undercurrent of stigma that’s gone through this conversation around people are anxious to talk about their anxiety, they’re afraid of being judged or embarrassed, stigma still exists, try as we might, it’s still out there.

How can teachers or counselors approach the topic of anxiety with either parents or students that grew up with that cultural stigma around getting help is not okay.

Jason: Yeah, totally. I think that if we, it’s kind one of those things where the more we talk about it, the more we can kind of talk it into existence.

So if it’s something where, for example, in a classroom or in the context of the school we advertise, I’m just kind of making this up, kind of, like we advertise an afterschool group for those who struggle with anxiety, something like that.

Or we are increasingly sort of, if a teacher is talking to a classroom and as, I’m trying to think of exactly what this context would be. So we were talking before about coaches. So maybe a teacher is like talking to the class and saying, “Well, you might talk to your coach.”

The teacher might be talking about some topic and referencing, “Oh, you probably have coaches or other people in your life to talk to about whatever the topic is.” Even just throw in or your therapist, or that, you know what I mean?

Like just sort of like having it be like, oh yeah, it could be that there are people here with therapists too. Those things that kind of feel a little bit small, but I think those are the little ways that we kind of break all this down, and would just, more openly acknowledging that this is something that not only exists, but it’s something that’s more than okay.

Guidance counselors do the key work, and I think making it more and more clear that seeking out help, not just for where am I going to go to school, that kind of thing, but just more like, I’m having difficulty managing my feelings, having them playing more of a role in classrooms, coming in, speaking to students, again, advertising more like having office hours for people just to kind of come in who are struggling.

Those are the kinds of things that if we can build into the system more, I think we can further reduce the stigma.

Jenn: How can teachers, coaches, et cetera, talk to parents if they believe that the parents need for success and perfection is actually negatively impacting the child?

Jason: The parents need? Yeah, yeah, yeah. I think it’s the same, it’s a similar thing that I was saying before about just presenting the information, like what it is exactly that you’re seeing in the kid, and comparing that to past experiences that you’ve had, and being matter of fact about it.

So, and validate, I think one way to really help to create less defensiveness is when I think we acknowledge that other people come by their behavior and perspectives, honestly, it’s a result of their own experiences they’ve had.

So if, for example, if you have a kid that you’re working with, that you know the nature of the family, the nature of the culture perhaps, is that there’s not a lot of conversation about mental health and it’s kind of, it’s very much seen as a thing that we don’t talk about, showing that you have some competence around that, some cultural competency.

And like I understand, this is something where historically, that folks in that background have not kind of can discuss and I totally get it. But again, here are some concrete ways in which I see that impacting your kid.

And I think when you come at it from that sort of objective or perspective, that’s when it’s going to be more likely to be received.

Jenn: What can I do if my child continues to tell me that everything is okay, but their behavior is basically the opposite. They’re unmotivated, they’re unengaged, and I feel like I’m at my wit’s end?

Jason: Yeah, totally. So, first of all, as a parent, you can still set limits, you know what I mean?

So it depends on what unmotivated and engaged looks like, but if they’re living in your house, you may have rules around living in your house where it’s like, okay, there’s got to be a certain amount of time spent on doing certain chores, contributing to the household in certain ways, making an appearance at dinner, that sort of thing.

So having a sort of set of expectations is absolutely okay. A kid having anxiety doesn’t preclude them from having those kinds of limits held to them.

Another, just key aspect of all this, I don’t know if we’ve mentioned yet, setting limits, sitting with your kid’s anxiety without intervening, like I was saying before, that’s hard to do, that’s... You yourself as a parent are having to deal with the emotions of that and the anxiety around that, and the catastrophic thinking around that.

So again, in the spirit of reducing stigma and increasing access to mental, or just the awareness of mental health, finding support for yourself. There are tons of wonderful family therapists out there who will work with family members of kids who are really in a difficult spot like that.

So having a community of your own, I think can help. Without that community, I think parents can get just really, really anxious and really sort of like not, impulsive isn’t the right word, but just sort of like quick to just intervene in some way, or just get really kind of upset with their kid and a way that’s going to just sort of make things worse.

But having the community can sort of protect against that. So support groups is another kind of great way to be connected to a community.

So addressing, I think your own, this might be an unsatisfying kind of answer like, and part of it, other than like setting the limits, kind of addressing your own anxieties and knowing that you’re not alone, I think can be a useful way to ultimately get to a situation where the kid is able to be helped.

Jenn: One of the things about growing up is that substance use is a discussion, it’s something that happens in teens. I think we would be remiss to say that it doesn’t happen.

Do you know if substances, whether it’s marijuana, alcohol, even caffeine, if they impact anxiety levels in teens and young adults?

Jason: Yeah, I mean, gosh, there’s so many other people at McLean who are better at answering this question than I am, but certainly they play a role in it.

And typically is the case with adolescents, is that this is the, if we’re talking about behaviors and how they function, those are the kinds of behaviors, the substance abuse, the alcohol use that are the go-to behavior, can be go-to behaviors as a way of controlling the anxiety.

So like that’s going to be the way in which I navigate my experience with anxiety or get rid of my experience of anxiety is via the substances.

And the problem is that, of course that people are precluded, the kids are then precluded from learning that, hey, I can actually deal with my anxiety without those substances. And of course, the substances themselves can, physiological dependence can increase on those substances creating really a real problem.

So I think in those kinds of situations, what’s called a dual diagnosis intervention is most indicated there where you’ve got, there are various programs here at McLean and elsewhere that address both anxiety and mood disorders, which really, at the heart of it, and also the substance abuse issues as well.

The first part of your question though, I’m feel like I’m pretty, was it impact on development or something like that?

Jenn: Just impacting anxiety levels. You did a nice job.

Jason: So it’s like the substances can control the anxiety in the short-term sense, but in the long-term, there’s a perpetuation of the disorder.

Jenn: So since we’ve highlighted a way, that’s really not that healthy to cope with anxiety, what are some healthy ways that we can cope with anxiety, whether it’s our kids’, our own, or even both?

Jason: Yeah, totally. So don’t overlook the basics. I think that’s one thing where, just looking at things, this is a little bit outside of the psychology world per se, but looking at your sleep.

It’s not really outside of the psychology world there are plenty of psychologists that look at sleep, but pay attention to your sleep cycles, your sleep habits, do you have a consistent bedtime, do you have a consistent wake time, are you getting exercise, are you eating reasonably well?

These are the things that a PCP will be on top of, but those are important, it turns out. The closest thing that we have to an all-purpose intervention for anxiety is exercise. Believe it or not, it’s more often, the vast majority of the time exercise is something that is useful for anxiety.

But beyond that, so eat, sleep, exercise, social connections, and increasing those social connections with people as a way of managing anxiety, many people use spirituality as a way of managing anxiety too, that could absolutely be.

So those are some kind of key domains, just to take a look at it in case the, it’s the one place I think to start, if you have a lot of anxiety, plays a huge role in your life, just to kind of ask some questions, that well, am I at least attending to those kinds of basics, which can be a challenge in and of themselves.

But beyond that, I think it’s the question of, when you are, it’s not the case that anything that reduces your anxiety is inherently problematic, or is like a problem behavior or something that’s perpetuating an anxiety disorder.

If you find things that you do in your life, that they may reduce the anxiety, but they also move you towards what’s meaningful to you, they help you get into your life more, more engaged in what’s in front of you and they work.

And when I say work, it means like they don’t get you stuck. You don’t get dependent on them, you’re kind of in this situation where they fit within the context of your life, I think is a phrase that I already used before. Those are good things.

It’s hard for me to give you a list because it’s so different for different people. There’s one kid who can use the video games as a way of avoiding the world, but there’s another kid that uses them as a good coping strategy where it’s sort of like, you know, I need my power of…

I don’t know if kids play World of Warcraft anymore, that’s like it’s old at this point, it’s Fortnite I guess more now, I do my hour of that, and I’ve had my social time, ‘cause you know, some friends and all that sort of stuff maybe, or I have my immersion time in that.

And then I’m done with that, and I brush my teeth and I go to bed, or I go do something else, that’s what I mean by sort of fit in the context of your life. So look for that thing that seems to fit in that way.

Jenn: I know a lot of what we’ve talked about so far has been addressing anxiety outside of a clinician’s office, ways for parents to support. But when should a parent consider bringing their kid to a licensed mental health provider for anxiety?

Jason: Yeah, again, it’s when, the functional impairment is the word that we use. So where they are not doing the kinds of things that they would want to be doing or that they need to be doing.

So when the kid starts refusing going to school altogether, or, with selective mutism, like we were saying before, not talking at all in school, refusing to go to do various things outside of school, extracurricular activities, seeing friends, like I was saying before, just is not even…

When doing these kinds of things is more talking a lot about worries constantly throughout the course of the day, in a way where it’s like the whole household is almost like on hold until the anxiety is kind of taken care of and then we can all live our lives kind of a thing.

When it is impacting the flow of life in that way, I think that’s when it’s good to start thinking about mental health intervention.

Jenn: So what are some of the best therapies for anxiety related issues in kids and teens, and are there differences in the treatment if you were seeking it as an adult?

Jason: Yeah, so some good words to be listening for if you’re investigating a therapist to help with anxiety be it any kind of anxiety: childhood anxiety, adolescent anxiety, or in adults, cognitive behavioral therapy, which is kind of a really broad term these days.

And it covers lots of different things, but therapists who talk about being cognitive behavioral therapists or who do something called acceptance and commitment therapy, which is part of cognitive behavioral therapy, exposure therapy, those are all kind of, mindfulness based interventions, mindfulness based cognitive interventions, cognitive therapy, those are all kind of the words that you’re listening for because those are the interventions with the most evidence for them.

So they all involve this idea of looking at the various components of the anxious experience. So we have anxious thoughts, when we’re anxious, the catastrophic kinds of thinking, we have anxious feelings, of course, and we anxious behaviors, anxious things that we do.

So cognitive behavioral therapy is generally centered around addressing each of those components.

So how do we respond to our thoughts that we have? How do we sit with our experience kind of better the experience of anxiety? How do we kind of get more comfortable with it, so to speak, and how do we respond to it behaviorally in a way that’s more helpful and adaptive?

So if you’re working with providers that are talking like that, as far as what they’re going to do with your kid, then you’re on a good path. It’s not really, fundamentally, it’s not different across the, as far as like the principles that play across the lifespan. It’s just the language is different.

How it’s presented might be different. My work with kids, is that my, when I first started doing this work, I worked mostly with kids. And the first thing we would do is name the, we’d give it a name, the anxiety, Mr. Worry, or something like that.

You might not do that as much with adults, but you can, if you want, I don’t care, some people want to name their anxiety so it’s good. So it can be vary, in terms of like the specific language.

And with kids, it will, I think the other thing that’s important, although again, this applies across the lifespan, you’re doing a lot more work with parents, especially the very young kids, as far as how they’re responding to the kid’s anxiety, and what kinds of behaviors they’re reinforcing, what kinds of behaviors they don’t want to reinforce.

But as people get older, even though I work a lot with adults now, and we do a lot of work with the families, the loved ones, and social supports, how to respond to them too. So it all applies.

Jenn: I want to talk a little bit about treatment refusal, because that is something that certainly kids provide a lot of pushback.

So how do you approach your child if they’re refusing therapy when they do actually need it? And part of it is because they’ve had previously not great experiences in therapy.

Jason: Yeah, yeah. That’s what you’d say. Like, yeah, I totally get it, I totally get why. And to be able to sort of articulate their perspectives, why they’re... When you have somebody who’s refusing treatment, you want to ensure that they get that you get it.

So if you are able to, again, articulate in no uncertain terms, okay, this is where you’re coming from, and this is why you’re refusing. You’re going to make a lot more headway with that compared to like, I don’t care, I’m don’t want to listen to you, you’re going to therapy.

That’s not going to work. That’s not going to work so much. And then finding a therapist who is willing to be flexible too. There’s some therapists out there that will say, “This is how I do the work. And if the person’s not willing, then they can come when they’re ready.”

And that’s fine, I get people who have that perspective, but in these cases, it’s not going to be helpful, like you’re saying.

So there are other therapists who are very behaviorally based and know everything that I was just talking about as far as the cognitive behavioral interventions, but they’re also willing to say, yeah, at the beginning, the work is going to be more, we’re just chatting and getting to know the kid.

And it might not really look like a lot of active intervention per se. So, finding somebody who’s more kind of willing to sort of have that runway is going to be useful or important for them as well.

And even having a test, a brief five or 10 minute conversation with that therapist is something that is going to, it’s going to be important.

Jenn: Do you find that those same concepts that apply for an adult who needs care and refuses treatment?

I mean, one thing I want to consider is like 18 and 19 year olds in the U.S., still technically considered teenagers, also considered adults who can make some of their own medical decisions.

Jason: Yeah, for sure. Yeah, absolutely. So it’s similar, I think as soon as you start being really insistent on telling somebody what they have to do, that’s when they’re going to sort of dig their heels in and say, well, here are the reasons why I’m not going to do it.

So, continuing to pound away at that is not going to be useful in any way, just feels like people’s autonomy is getting taken away. So yeah, to ensure, yes, I think that that response is applicable in those cases too.

Jenn: I think we have time for one more question. So do you have any advice on strategies that kids and teens can use while outside of the home, whether it’s at soccer practice, or school, that can help ground them and keep them from getting into a spiral of anxiety?

Jason: Yeah, it’s going to differ by kid, and it’s going to differ as far as how you’re using this, but one, okay, just to be, to answer your question to be very concrete, anxiety is often so much about doing stuff in your head, like puzzling things through and figuring things out to make things okay, and then you can move on.

So getting out of that, and one concrete way to get out of that is a simple mindfulness practice of engaging in your five senses. What I like about is it’s kind of portable and you can use it in those kinds of contexts you just described, but you know, literally, what am I seeing right now, what am I hearing, what am I, you know, the five senses.

Engaging in those five senses and practicing shifting into those and paying attention to them when those experiences arise, instead of going right into the, I’m going to get wrapped up in my catastrophic thinking, whatever the case might be, is a good practice.

Now that’s not a light switch and just doing it, me saying that and having somebody try that, isn’t going to be just a way to turn off the anxiety, and just make everything great, but it’s a practice. It’s a skill that one can get better at over time. Again, like you say, specifically as a means of grounding.

Jenn: I’m going to sneak in one more question. I know I said I wasn’t going to, but any resources?

Jason: Liar.

Jenn: Yeah, you know me. Any resources, last words of wisdom that you would recommend to folks tuning in who want to learn more about anxiety in these populations?

Jason: Yeah, so just some organizations to be connected to. So the Anxiety and Depression Association of America, the Association of Behavioral and Cognitive Therapies, those are two, even I think the APA has some good information on their website.

This is just good, as far as if you’re looking for sources of reputable information around intervention, around kids, those are the organizations you really want to sort of get your information from.

So if you’re on your Googling and you’re doing Google searches, those are the kinds of places that you want to be, where what’s being said is really the cutting edge as far as the latest research and the latest understanding of what’s going to be most helpful for patients.

Jenn: Amazing. I always love talking to you because you just have, not only do you have an answer for every single question, which is mind boggling to me, but you also answer it in just such an empathetic and rapid fire way that I feel like I’m having a conversation with myself sometimes, and it just makes me so happy.

And it also didn’t hurt that we matched today, so that also is an added bonus.

Jason: Oh yeah, it looks really good. Yeah, man.

Jenn: For all of those reasons, and a hundred thousand more, thank you so much for joining me to talk all about anxiety in kids and teens. This has been a really fabulous session, and anybody tuning in, this actually concludes the session.

So thanks so much for joining us, until next time, be nice to one another, but be nice to yourself too. Thank you again Jason, and have a great day everybody.

Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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