Helping Your Anxious Child with Dr. Jill Ehrenreich-May & Dr. Donna Pincus
So many of us have seen increased fear and anxiety in our children during this pandemic, and we’re worried about how our own fear and anxiety might impact our kids.
Clinical psychologists and experts in child and adolescent anxiety, Dr. Jill Ehrenreich-May and Dr. Donna Pincus, join us to discuss how we can help our children through fear and anxiety as relates to the pandemic and beyond. They share advice on identifying the signs of anxiety in children and when to seek professional help in treating anxiety in children.
In this episode about fear and anxiety in children:
What does anxiety look like in kids, and how does it look different at different ages?
What are some signs that your child has reached concerning levels of fear or anxiety?
In many places, especially in the U.S., things are beginning to open up again. How do we go about talking to our kids about this in ways that will minimize their fear or anxiety?
What do we know about the potential long-term impact of the pandemic on children’s development and mental health?
How as a parent, can I know when my child needs additional help?
What Are Symptoms of Anxiety in Children?
Frequent complaints
Difficulty sleeping
Headaches
Tantrums
Seeking frequent reassurance about worries
Stomach aches
Irritability
Hopelessness
Bite-Sized Excerpts from this Episode
Helping Your Child Adjust to Changing COVID-19 Rules
What does anxiety look like in kids?
What is the difference between fear and anxiety?
Mindfulness for Anxious Parents
How can I tell if my child has anxiety?
What treatments are available for child anxiety?
Meet Our Guest Experts
Jill Ehrenreich-May, Ph.D.
Jill Ehrenreich-May, Ph.D. is Professor of Psychology and Pediatrics and Associate Department Chair for Graduate Studies in the Department of Psychology at the University of Miami. She received her Ph.D. from the University of Mississippi in 2002. Dr. Ehrenreich-May is the author of over 140 published works, including several treatment manuals, books, and peer-reviewed publications. Dr. Ehrenreich-May's currently funded research includes effectiveness trials regarding treatment of youth emotional distress in community settings. She is perhaps best known for her clinical trials research and evidence-based treatment manuals, including the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents. She currently has research funding from NIH and several foundation sources to support this work. Dr. Ehrenreich-May directs the Child and Adolescent Mood and Anxiety Treatment Program at the University of Miami, which provides evidence-based psychotherapy services to the local community. She is the current Member-at-Large for Science and Practice within the Society for Clinical Child and Adolescent Psychology (Division 53 of the American Psychological Association) and the incoming President-Elect of the Association for Behavioral and Cognitive Therapies (ABCT).
Donna Pincus, Ph.D.
Dr. Donna Pincus is a Professor of Psychological and Brain Sciences at Boston University and has been the Director of the Child and Adolescent Fear and Anxiety Treatment Program at the Center for Anxiety and Related Disorders at Boston University for the past 22 years. Dr. Pincus completed her Ph.D. in clinical psychology at Binghamton University in 1999 and completed her clinical internship and post-doctoral training at the University of Florida Health Sciences Center with a pediatric/child clinical specialty. Dr. Pincus has focused her clinical research career on the development of interventions for children with the most highly impairing and understudied anxiety disorders. Her research has investigated novel formats of cognitive behavioral treatment, including intensive treatments, as well as the impact of including parents in treatment with youth. She has been the recipient of numerous research grants from the National Institute of Mental Health, SAMSHA, PCORI, and local foundations. Dr. Pincus has published over 100 peer reviewed papers, chapters, and books. Dr. Pincus’ current research focuses on novel ways to implement evidence-based treatments for child anxiety in community settings, such as schools and pediatric primary care centers.
Dr. Pincus has also dedicated a significant part of her career to sharing accurate information about effective cognitive behavioral treatments for child anxiety disorders with the public. She has appeared on both local and national media networks, including NBC’s Today Show, Nick News, National Geographic Television, Women’s Lifetime Television Network, ABC News’ 20-20 Downtown, and Good Morning America. She published a book for parents, Growing Up Brave: Expert Strategies for Helping Your Child Overcome Fear, Stress, and Anxiety (Little, Brown, 2012), produced a popular relaxation CD for children called “I Can Relax: A Relaxation CD for Children”, as well as a children’s book on helping children cope with the death of a parent called “Samantha Jane’s Missing Smile”. Dr. Pincus regularly gives talks and workshops around the nation on child anxiety to parents and healthcare professionals. She recently won the Florence Halpern Award for Distinguished Professional Contributions to Clinical Psychology, awarded by Division 12 of the American Psychological Association.
Full Audio Transcript
[THEME MUSIC UNDER INTRO]
Dr. Amanda Zelechoski: Can you say... “This is Dr. Amanda Zelechoski.”
Child 1: Why do we have to?
Dr. Amanda Zelechoski: Just try it!
Child 1: I can't.
Dr. Amanda Zelechoski: Deep breath
Child 2: [Laughter] This is Dr. Amanda Zelechoski.
Child 3: [Yelling] Lindsay Malloy! Ah!
Dr. Lindsay Malloy: Wait, say Doctor Lindsay Malloy.
Child 3: [Yelling] Dr. Lindsay Malloy!
Dr. Lindsay Malloy: [Laughing] No, come back!
Child 4: This is Dr. Lindsay Malloy.
Child 2: Welcome to the [unintelligible] Parenting Podcast (laugher).
Dr. Amanda Zelechoski: [Laughter].
Dr. Lindsay Malloy: One more time.
Child 4: And then after that, can I have a candy?
Dr. Lindsay Malloy: [Laughing] No.
Child 4: Please, Mommy!
Dr. Lindsay Malloy: Okay, ready?
Child 4: The Pandemic Parenting Podcast!
Dr. Lindsay Malloy: Excellent!
[MUSIC ENDS]
Dr. Lindsay Malloy: Welcome to the Pandemic Parenting podcast. I'm Dr. Lindsay Malloy.
Dr. Amanda Zelechoski: And I'm Dr. Amanda Zelechoski. We are two psychologists, scholars, and moms, and together, we are the Co-founders of Pandemic Parenting.
Dr. Lindsay Malloy: We're here to share science-based research and help all who care for kids navigate this challenging time together.
Dr. Amanda Zelechoski: In this episode, we're discussing fear and anxiety in children of all ages. This might be our number one requested topic. So many of us have seen increased fear and anxiety in our children during this pandemic and were worried about how our own fear and anxiety might be impacting our kids and vice versa. But I think what was particularly great about this conversation is that much of the advice shared by our guest experts applies beyond the pandemic in lots of different contexts and that anxiety is one of the most common issues in kids. So I think the advice they shared will be really helpful.
Dr. Lindsay Malloy: Absolutely. So joining us for this conversation are Dr. Jill Ehrenreich-May and Dr. Donna Pincus, who are both clinical psychologists and experts in child and adolescent anxiety. You can learn more about their backgrounds on our website and in the show notes. I know I learned a lot from them, and I hope you get a lot out of the conversation too. Alright, let's get into it. Well, thank you so much for being here today with us to talk about child and youth, fear and anxiety. Really excited to have Jill and Donna with us in part because they are renowned experts in these areas but also because we've been working together now for just over a year on our project. That's all I guess, sort of broadly on how to talk to kids about COVID-19, how parents are talking to kids about COVID-19, and how that's affecting their adjustment. So that is something again we've been working on for over a year. We're really excited to get some findings out there, hopefully soon. But first, I guess let's start off by talking about fear and anxiety in kids and teens in general. If that's OK and then we can move on to talking more specifically about in the context of COVID-19. So, in general, what does anxiety look like in kids, and does it look different at different ages?
Dr. Donna Pincus: So, we know that anxiety is actually a very natural human emotion, and so we don't really want to take away all anxiety. And it's just as natural as being sad or being happy. And for many kids, though, you know, they experience anxiety, and some actually even like the feeling, or some recognize that having some anxiety can help you perform better on things. However, you know, I think that for many kids who experience anxiety that is out of bounds to the situation, it starts to interfere with them being able to do things that are fun, or if they do them, but they're not having fun when they're doing them. So I think it's an emotion that can become overwhelming, and it's hard at times to really articulate what they're feeling, and as a result, they may begin avoiding many things in life. And it's usually the very things that we'd expect at developmental stages that we would hope that kids would be involved in. Like young kids might avoid things like going on sleepovers or avoid going to camp because there may be bugs there or a boy getting a shot at the doctor's office. Whereas like older kids might avoid going back to school like they've all been gradually doing most recently because maybe there are things about school that are anxiety-provoking, so we do see a developmental progression. I think it's interesting to see across cultures even you see some very similar kinds of progressions of fear across developmental stages and many of the things we're afraid of; it's adaptive to be afraid of.
So like loud noises or strangers when you're little, it's not adaptive to just kind of hang, you know, go with anybody and then at different ages, it's adapted to be maybe afraid of you know situations I feel like, oh maybe, that there could be danger involved or other things. So things where you perceive a threat. So we know that gradually across the ages, gradually fears become a bit more abstract and they kind of follow cognitive development. So we do see a general progression in the types of fears that kids experience at different stages. So for example, young kids are more likely to have separation anxiety, but adolescents may be more likely to have something like panic disorder.
Dr. Amanda Zelechoski: Can we just unpack some of these terms like fear versus anxiety versus worry? Can you help us understand what each of those terms means? Because I think we mix them up a lot.
Dr. Jill Ehrenreich-May: So fear is really having to do with what's going on in here now. In the present moment, right? So I'm having a fear of something that I'm either imagining is happening right now, or I'm in the context of something happening right now. Anxiety is really characterized in a way by anticipation or worry about something that you know, oftentimes may be happening in the future, or they think might be happening in the future. We can care. We can kind of, you know, think about the timing of the stressor or the threat between the two. Anxiety tends to be a little more cognitive if you will, or you know it's really all about what you're thinking is going to happen when somebody is having a fear reaction in the moment, you know, their behavior can be very disregulated or can be very reactive to, again, what they feel like is a danger in the present moment.
Dr. Amanda Zelechoski: So thinking about that, then you know there's normal anxiety, like Donna was talking about, you know, there are things that it's healthy for us to feel anxious about. That's adaptive like you said. But I'm wondering what are some signs that our child might have reached, like concerning levels of fear or anxiety? So, where, where is that line?
Dr. Jill Ehrenreich-May: We really look at a couple of different aspects of someone's behavior because as Donna indicated, it is really normal to feel fearful and anxious during development. And you know, oftentimes you know the fears that children have, you know, early on, you know, are you know, somewhat transient and kind of pass over time to anxieties. Maybe a bit more stable. You know people who are kind of high warriors sort of tend to remain high warriors if you will over time, but the things that we look at are frequency. You know, how often is it happening? Is it happening every time you go to gymnastics? Or maybe just that one-time persistence, right? It's continuing to happen, you know, even beyond the point at which it would be kind of typical developmentally. Donna mentioned, for example, separation anxiety is really typical early in development, you know, but if it's persisting into older ages where it would normally have decreased, that would be something that we– to look at intensity, are they having like a huge reaction to these things or very small reaction that can be a little deceptive sometimes because some people who are anxious have a very internalizer experience. You don't sort of see it, obviously, but it's maybe having an impact in other ways in school and peer relationships and in terms of what they're willing to do, you know, versus avoid. And yeah, I mean I think those are the main things that we look at in terms of, you know, when we might be concerned enough to say, oh maybe I should, you know, talk to somebody about this or evaluate–
Dr. Lindsay Malloy: –it a little bit further.
Dr. Donna Pincus: Yeah, I absolutely agree with everything Jill said, and also anxiety can also be very physical too. Kids have somatic complaints. Just building on that, like you know, stomach aches, a headache. I feel nauseous. I'm not sure if I might be sick. There's always that possibility, you know, kind of questions like that, so it's not uncommon for kids to wind up at the school nurse's office when they have anxiety, and in fact, like they are really experiencing some physical sensations. It's just that they're not indicative of illness. It's more just the fight or flight system, so another market parents might look for like frequent complaints, frequent stomach aches, frequent headaches, difficulty sleeping, falling asleep, lots of worries on the mind, all those things and–
Dr. Jill Ehrenreich-May: –seeking reassurance too from parents and caregivers that you know we have kids who check a lot of times per day about whether or not this thing they're worrying about is going to happen and it becomes interfering to the parent or it becomes interfering to the teacher to get through the day.
Dr. Amanda Zelechoski: I think a lot about that, with– like you were talking about the cymatic pieces of it. Both of you like that with stomach aches, right? Like kids don't have the language, or sometimes they can't tell between what feels like butterflies or nervous feelings in my stomach versus a stomach ache because I ate too much candy, and they just know that they feel something. And so I do think that's why it's so confusing and kids a lot of times we'll say I have a stomach ache, but it's just what you or I might talk about is like oh I'm my stomach's in knots 'cause I'm so nervous, but I could tell the difference between that and an actual stomach ache and so yeah I would yeah, yeah.
Dr. Lindsay Malloy: Yeah, butterflies, butterflies. I think it was Donna who was talking about interfering, or was that you Jill, about interfering with the parent. And it just made me think like there are times when there are kids who don't really see their anxiety as a problem who might even like some aspects of it. But maybe it's the parent who is struggling with some of these things. Like do you see that in your research or practice? Yeah, that would be tough. You know to maybe try to convince them that it is a problem or that it is something worth seeking treatment for. I suppose it depends on their age, largely there.
Dr. Jill Ehrenreich-May: But they talk about when we're asking people about their symptoms. Something called the actor-observer phenomena, when we ask parents oftentimes what their child is experiencing, they're going to attribute it to the child. The child is having anxiety, they're having symptoms in their body, and a lot of times the child is going to attribute it to the situation, you know? I find that like you know school is prompting this or this other situation is making me feel this way, and so you know because of that and also because of factors related sometimes to the child age at cognitive development. You know, sometimes they just can't put words to the experience just yet. Especially our kids under 7. And that can lead to some of that difficulty that kids have and sort of really accurately identifying what they're experiencing related to anxiety.
Dr. Lindsay Malloy: So what about parents in terms of their own anxiety? How important is that in terms of possibly, you know, transmitting our fears or anxieties to our kids and whether our children develop significant fear or anxiety?
Dr. Donna Pincus: I think you know many behaviors that I like to use the word inadvertent because we don't mean to cause our children more anxiety. But you know if you inadvertently like to react in a way where maybe you're overreacting to a situation or your own anxiety about it is getting in the way kids feed off of. They watch us more than we recognize sometimes, I think. And then can get information, and they're watching us to get information about what is safe and what's not. What is a level of threat they should be paying attention to, and so remembering that modeling is one way that kids can acquire fears or different anxieties. And even you know behaviors like excessively reassuring someone has got your phone you know who you call if you have issues, right? And you know you're on the way to camp and suddenly the child starts to doubt whether or not they think they can do it, or even the behavior like answering a lot of worry questions like we did have one child one time who he's like, the policeman of the house. He would ask lots and lots of questions, and every time a parent answered the worry question it was just reinforced and the worried questions continued. It wasn't distressing at all for him, he says I just have lots of questions, but to his parents they found it to be very distressing to be constantly asked these questions so.
Dr. Amanda Zelechoski: Donna, are you inside my house like what is going on? I feel attacked. No, I'm just kidding but I think it's just interesting. I was thinking about what you're saying with the reassurance and parents providing that, but the kids not seeing it as problematic maybe. And when we think about, especially in this pandemic, there are many things we've had to remind our kids about. Or it is our anxiety, so we're saying, you know, don't forget to do this. Go wash your hands, don't forget you. And yeah, when there's uncertainty and we're settling some of our own anxiety, I see that kind of butting up against kids, reassurance seeking when we don't have answers either for the kinds of things they're seeking reassurance about, and so yeah, it's just something to be mindful of, like I haven't always realized until others have pointed it out. Like, do you realize how many times your child has asked this question again and again. Or you know what? You were just saying, modeling that like if I have another child who actually is pretty forgetful and I do need to tell him again and again to do things or the other kids hearing that and then like you said, I'm now I'm modeling this, you know, repetitive sort of checking.
Dr. Jill Ehrenreich-May: And when we do therapy with children who are having anxiety a lot of times we're working very directly with the parent to kind of monitor and pay attention to their own emotions when they see their child distressed. Either you know, and again during the pandemic it may be for a lot of very understandable reasons, but you know, when we're feeling anxious as parents, we're not going to be super logical. We're not gonna, you know or, you know, we're not going to be able to kind of think through, oh, it isn't very likely that they would experience, you know, a problem in this situation, you know, we just see that our child's upset and the more upset we become, the more likely it is that we're going to say, you know, what? Forget it. Right? Like I'm just we'll do this another day. We'll try this again some other time, and you know, like Donna was suggesting, it really just ends up kind of sending this message that that was probably a dangerous situation. Or that was probably something that we really did need to avoid and so paying really good attention to how you are feeling as a parent when these things are anxiety-provoking for your child you know is really quite crucial to you knowing getting them through effective therapy.
Dr. Lindsay Malloy: It's so hard, though I've always been that parent who you know they tell you, oh, if your kid falls down when they're learning how to walk or whatever, you know, you should act calm because then they'll be calm about it. And I have always been and I still am to this day, even though they're like almost four and six, the [gasp] parents, like when something happens my husband even look at me like come on like you know we're adding so much to this and that checking back behavior that they do, I'm definitely not sending probably the best signals in that regard, so.
Dr. Donna Pincus: You have to forgive yourself too, 'cause it's natural, you know, to just, that mama bear comes out and we're hardwired maybe also to protect at all costs and you see a child gets hurt, so of course you kind of streak 'cause that's causing your alarm system to come back to me.
Dr. Lindsay Malloy: Yes, no. Thank you for that.
Dr. Amanda Zelechoski: I was just reading an article recently that was talking about how much parents have the tendency– like if you picture your kid on the playground, right? You know they're swinging from the jungle gym or whatever, and it's our instinct to say, “be careful”, you know, “hey, be careful” and the article was just talking about how like #1. You don't need to say that. That is to reassure yourself that you're I don't know about being a good parent 'cause you're reminding your kids to be careful. But it's more around building trust in them so it might be, I think, saying things like “hey, I trust that you're going to, you know, be careful out there” or “if it feels dangerous or scary, let me know.” But you're trying to empower your child to make those risk decisions instead of this constant reminder to be careful, you know? It was sort of reminding me of when we tell kids when they're really upset to calm down, you know? Like really does that work when somebody says that to you when you're upset, you know. No, I just don't know what that's about, like our need to constantly say be careful so.
Dr. Lindsay Malloy: And oh my gosh, I've done that. I just yeah I'm thinking of all the things that I need to work on as we're having this discussion. But it just reminded me that when my older child was about three and the younger one was one, he used to keep telling her no, don't do that. It's trained in us. And I was like maybe I am– maybe this isn't good, and I should tone it down a little bit when you've got the three-year-old saying that everything is dangerous. No, yeah, lesson, definitely learning.
Dr. Jill Ehrenreich-May: I think to a certain extent that you only have to give yourself a little bit of grace, right? You may be a person who is, you know, hyper-vigilant a little bit for what's going on with your child at the playground and you might not find that you always say the most empowering and effective thing in the moment. But you know, I think in reality, just noticing that you feel that way is kind of the first step, like noticing that you want to say be careful being mindful, you know, as a parent of what my emotion is telling me can also give us a cue to, you know, give them a little bit more autonomy and say, OK, that's a reminder to me that they need a little bit of space here and I'm gonna go whisper to myself here in the corner.
Dr. Lindsay Malloy: I love it. Great strategy, you know it like, and I know you both have multiple kids as well. We all have more than one child here and I think too just being mindful of the type of kid that you have and remembering that. So you know, maybe my younger one could use those reminders, but my older one doesn't really need them, and so if I'm giving those reminders with him and with his temperament, maybe that's just not necessary and it's going to overdo it and it's actually going to make him feel unnecessarily anxious so.
Dr. Amanda Zelechoski: Yeah, exactly. Well and it's making me think about this dynamic between the parents' anxiety perhaps, and the child's and how those can kind of go back and forth cyclically, like I was thinking about what you just said, Jill, you know that maybe you're a more hyper-vigilant parent, and I was listening to that thinking like I was a fearless kid. I was the one swinging all over the place like why now am I the parent on the playground saying, oh gosh, be careful, don't go so high, what are you doing? Like it made me so un-fun. So just sort of thinking about that and Donna I wanted to ask you like what are other things that we as parents do that actually makes our kids anxiety or fear maybe worse, like what are some of these other things we need to be mindful of like I was saying?
Dr. Donna Pincus: Well, I think communicating, you know, maybe making sure in those situations that you're talking about where you're like be careful, like maybe it's remembering hey, do– is what I'm saying helpful or am I maybe taking away from just immersing in the experience? Like, how likely is it really that there's going to be something really bad happening? Maybe using some of the techniques we teach them? Just keeping them for a moment and just being more mindful of even as a psychologist or researcher, we code behaviors, code, art utterances and sometimes you become more aware of like oh what am I saying and– but without being too critical, you know, of yourself also, but then you know also engaging kids, sometimes letting them hear that you know we're not perfect either. And we can have moments where we are sad. We can have moments where we're feeling scared. And maybe just actually saying them out loud like yeah, I'm feeling a little worried about this right now, but I know what I can do, number one. I know this and I'm like you know like they can hear you talk it through maybe for yourself, and that's kind of the self talk we want them to be able to engage in so maybe it is not necessarily hiding our emotions or having to expect ourselves to be these perfect people, because who is that, you know, there's not one parent, even with all the skills that we know as child psychologists, there's no way that I would say, you know, like I feel perfect at every utterance I make as a parent, and so we don't want our kids to think they have to you know that they have to build up that so. And maybe it's also remembering to have fun with your kids and to not worry so much. I mean, just letting go a little bit more.
[AD BREAK]
Dr. Amanda Zelechoski: At Pandemic Parenting, we're committed to sharing our expertise and research in ways that are immediately accessible and useful to families. As part of our efforts to sustain and expand this work, Lindsay and I are also available for virtual speaking engagements at your business organization, PTO, and we want to help you and those who you work with grow with and raise your children with, have the chance to do so in an environment that fosters and supports your mental health. Some of the topics we enjoy speaking on include parenting during the pandemic, the impact of trauma on children and families, children development, the mental health impact of COVID-19 on employees, and more. If you or your organization are interested in potentially collaborating, please reach out to us for availability and pricing through the request to speaker form on our website at www.pandemic-parent.org.
[END AD BREAK]
Dr. Amanda Zelechoski: So I just had one follow-up question before we changed gears. I guess related to some of the examples you're giving so you know just in how sometimes, what we're seeing in our kids is anxiety, but we don't know that it's that in the ways that it's showing up. So you talked about stomach aches, for example, but I was kind of also thinking about the other extremes like Lindsay and I work a lot in juvenile justice spaces where you know we see lots of disruptive behaviors from kids. Really serious behaviors, and so I was wondering if you could talk about how you know what are some other examples of behavior like really disruptive behaviors. Your kids might be showing that are actually anxiety underneath them, even though that's not what you would guess is going on.
Dr. Jill Ehrenreich-May: I mean, the first thing that comes to mind when you say that is irritability.
There's actually been research during the pandemic that, like irritability, has been kind of skyrocketing, especially during quarantine periods, you know, kind of makes sense. Everybody sort of stuck in places together. If you think about when you are experiencing a lot of worry, as an adult, you know, at least for me, you know, if I'm worried about some, some tasks that I'm doing and then somebody else you know, kind of drops in and asks me something sometimes. Something kind of innocuous like I might snap at them, or I might sort of, you know, say something in a way that really wasn't the nicest way that I could have possibly said. So this is mostly my problem that I'm talking about.
Dr. Amanda Zelechoski: I'm with you.
Dr. Jill Ehrenreich-May: But I think that there are a lot of our kids who you know, especially in the middle school years where they're expressing being in some ways some of the chronic worry or sleep problems related to their chronic worry that they're having in terms of being kind of irritable and more difficult in the way that they're managing things, they may seem a little hopeless or kind of like they, you know, don't know if they can, if they can manage things you know, and so might start showing.
Kind of what looks a little bit more like depression-type symptoms over time, so sometimes we see some of those things happening. I think that there is a lot of overlap between, you know, some of the disruptive behaviors and some of the more internalizing or anxiety-related behaviors that we see in younger kids sometimes too. But you know it can vary in terms of how much you know that's making the problems worse. But we certainly see kids at times behaving in a very what they call oppositional way when they're anxious about something that can really confuse parents 'cause like suddenly somebody is just refusing to go somewhere or do something or follow a direction and it's actually, because they're they're feeling very anxious about it. It makes it really confusing in terms of what to do as a parent then too, 'cause you might be like feeling for them like I see that they're nervous, but they're also like being.
Dr. Lindsay Malloy: You've just described my three-year-old to a T. Really, really right now.
Dr. Jill Ehrenreich-May: We normally see– yeah, yeah.
Dr. Amanda Zelechoski: Yeah, and like most teenagers like you're saying, I just think about how you know parents will sometimes experience that exactly as you said oppositional or–
Dr. Lindsay Malloy: I respect that.
Dr. Amanda Zelechoski: Like this kid just bit my head off. All I did was ask you to pick up your socks, so you know or get ready we have to leave for school. And we don't realize that there's, they're just sort of tormented underneath with whatever it is they're worried about, but it's not coming out that way, so it's hard for us to have empathy 'cause it's like, whoa, what is your problem?
Dr. Jill Ehrenreich-May: There still have to be limits, right? You know, you say without limits in those circumstances, even if it is coming from, you know anxiety relatedness. Right, yeah?
Dr. Donna Pincus: Yeah, we've seen more tantrums too, and young kids. So tantrums are another example of a behavior that could be anxiety even though initially it might seem like someone just being oppositional. But you know, if you think about a tantrum if done at the right time, we could actually help you avoid something. So I had one example of a parent I saw just as I had taken my own child to a dance class and the parent really wanted her daughter to engage in the ballet class, and you know the child started, you know, was really resistant to do it. And the parents said, you know, come on, we paid for this. Your dad is working an extra job to get money for this. Like all kinds of things to you know filter into it other things than it turned into bribing and I was just sort of like silently observing in my head, but then, and we've all been there like you want your kid to do something, and they're not doing it. How frustrating that can be? Then eventually it's like well, you know, what I did buy you some amazing chocolate chip muffins and they're in the car. If you do it you'll get that returned to bribing, and then at the very end, it was like the daughter had a tantrum and she was just very frustrated and I saw that week after week tantrums, right beforehand, and I think that that was functioning too you know, for as avoidance of the situation. So here I think tantrums can have very many different functions, and we see that sometimes. It can be even though it seems like oppositionality could be.
Dr. Amanda Zelechoski: Yeah, which then gets reinforced. But Donna, it sounds like you're saying that bribery is not a good parenting tool? I'm gonna need to unpack.
Dr. Donna Pincus: You use it sometimes. Not a lot. I think to reward. So the well-timed reward, if we could say.
Dr. Jill Ehrenreich-May: Especially if they're not doing it already, right? Like you want to, you want to increase a behavior you want to see more of.
Dr. Donna Pincus: You're right, right and praise good parenting tools. It depends on how we think about you know rewards and not necessarily like if you do this, I'll give you the cupcake, but not if you don't, you know, like it's something where you're exerting control, and I think the difference with rewards the child is really in control. Then they kind of know that it's up to them to engage in the behavior, then they'll get the reward. But if you're then making sure that you're completely in control of that I'm not giving it to you, then suddenly it may just foster more anxiety.
Dr. Amanda Zelechoski: I guess, yeah, and that's like it reminds me of that persistent kind of school refusal cycle then where it's what you're describing. Sort of, the tantrum or whatever the problem behavior is. It's just getting reinforced because you have a child who's super anxious about going to school. So they go there, and they act out so that the parent gets called and has to pick them up and they've achieved, you know, sort of the goal, but we're missing what's actually going on because it's like, Oh well, this is just a child who's acting out at school like yeah, so then it gets reinforced.
Dr. Donna Pincus: Yeah, or kids who just skip class, they kind of go to the bathroom, they wind up going somewhere else, and the teachers are labeling them as oppositional or like defiant in some way.
That, but yeah, maybe in June I've experienced this in our clinical work for sure like they're just avoiding math class because they have panic in that and no one could see no or know that just by looking at them all they see is a behavior of avoidance. But really what you– that is like a struggle that they're going through and they–
Dr. Amanda Zelechoski: That's right.
Dr. Donna Pincus: –don't have to verbalize to anyone so.
Dr. Amanda Zelechoski: Or lazy. Sometimes they're labeled as lazy, right? Blowing it off doesn't care, apathetic, and it's like sometimes apathy, I think, is another one that can mask anxiety actually going on.
Dr. Lindsay Malloy: I love the examples of the dance class, and I know that must be so hard for you to sit there like knowing all these potential strategies and not being able to jump in. But I'm wondering if we can talk about the clinical work and research that you both have been doing during the last year and how COVID has impacted kids and families in terms of anxiety and fear and what, you know, what are the big fears and anxieties that you're seeing in kids and parents, right?
Dr. Jill Ehrenreich-May: Now you know we've been seeing a lot of everything. Let me just start by saying that I think that we are seeing more fear, more anxiety, more worry, more sadness, more irritability, you know, it is across the board more, and I think that’s kind of like the bottom line of it.
To a certain extent, I think it is related to fit. It can be quite variable. We certainly have kids who have family members who have health risks or they themselves have health risks. And they're, you know, quite worried about being in spaces that you know, all of us have concerns about, you know in terms of possibly, you know, infecting themselves or infecting a family member. Increasingly, what we see a lot of is the challenges related to the extended periods of social distancing and you know the consequences if you think about it we're talking all about avoidance and how you know that is the action that you want to take when you're feeling fearful and anxious and into a certain extent, we've all been in mass avoiding and escaping for the last year plus. So for people who were already anxious, this, you know– Let's say I was socially anxious, you know, about being around other people. Well, this was like just a dream, you know, that I got to be away from, you know, people and all the things that were difficult for me for a really long time. So now trying to think about how to reintegrate, particularly for people who struggled, you know with it before, or have struggled with it during it. We're seeing quite a lot of that in the representation of the kids that we’re working with.
Dr. Donna Pincus: Yeah, I think for kids who were afraid of, you know, needles before now that we're seeing a resurgence of kids who are coming in like they're afraid of getting a vaccine. So even being 16 or something where they have avoided this effectively or you know, got only the necessary shots and now realizing they have to face it again. Or kids who were afraid of germs. For a while there, then, during the situation where they were like then being told like everywhere, there could be a germ that's dangerous to you. It could be floating in the air and you don't know where it is and you can't see it. It's like, you know this general alarm where I think those kids felt more anxious, and interestingly, some of the things that he that I think that you know we might have seen too that many kids like, you know, experience like just, you know, intense, you know, just feelings of anxiety because you know they were isolated and some kids felt like a little bit better like they felt like, wow, this pandemic allowed me to not have to go to school and that's what I was most excited about, you know, it allowed me to do and that's why I didn't like school because like you know what? There's some things about school that were difficult? Or maybe you know, I'm afraid of a particular teacher and I didn't like a particular class and now look at this. Everybody online I can even put up my hoodie and not have to talk during breakout rooms, which is what I hear many of the teenagers just do not talk during breakout rooms and that there's it's possible to avoid in all sorts of ways that weren't possible before.
Dr. Amanda Zelechoski: Well, and when I think about alright, so these are all sort of legitimate things you're describing that you know people were anxious about or conditioned to be anxious about, you know, throughout the pandemic, and now you know we're starting to get a lot of questions from parents around as people get vaccinated as we start to get back to whatever normal is going to look like on the other side of this you know how do we unconditioned all these things? We've conditioned our kids and ourselves to be afraid of or avoidant of, and I think related to that, you know, I've been seeing some headlines around in areas where you know the vaccination rate is pretty high, while people are still having irrational fear about, you know, getting back to life, and it's like how is that irrational when we've told you for over a year to be afraid of these things. So I just wondered your thoughts about– kind of as life returns again in whatever form, what are those anxieties going to look like, and how can we help parents and kids with those?
Dr. Jill Ehrenreich-May: If you are seeing or knowing that your child is very reluctant about going into spaces that you have deemed safe or you believe are safe, or they're vocalizing a lot of anxiety about those kinds of situations, I would say first to start with empathy and understanding, right? It's completely understandable why people might be feeling this way during this time. It's understandable you know why this might seem overwhelming to you, allowing just first the conversation to happen that I you know, I see you, I understand, I think, can lead to, right. What can we do that will feel reasonably safe as a starting point? You know, I’m a big believer in exposure therapy and you know, I think that sometimes you have to negotiate a little bit where you start, right? Maybe the child doesn't feel comfortable yet to be in a grocery store. Or to be, you know, in an enclosed movie theater or something along those lines, but might feel comfortable to go to a park with one friend and maybe eventually sitting, you know, in a library for one minute or two minutes and then coming back out. So what we want to do is kind of think about what are like baby steps along the way that will help us get back to again within a sort of a reasonable, safe space. A more normalized level of social interaction.
Dr. Donna Pincus: Yeah, it's hard 'cause we've been out of practice, and I also think there's some things that are going to be new situations that kids are navigating, and I have three kids and they're all in either middle school or high school. And you know, now, learning that when they go back to the lunch room it's gonna look very different than what it used to be. You talked at lunch and you had to navigate the social scene. Well, now there's rows of, at least in our school, chairs at least three feet apart, you get an assigned seat, you eat facing [inaudible], you don't know if you're going to be placed next to a friend, you can't choose where you sit. So there's like a little bit less control in that way. It’s harder to read people's facial expressions 'cause the kids are all masked, so there's some differences in what they're navigating in terms of their social interactions. So I think it's changed the, you know, the things that they're having based on a daily basis might be a little different. So we might see types of anxieties that we haven't necessarily seen before.
Dr. Amanda Zelechoski: Yeah, I was talking with somebody recently who was sharing the example of, you know her daughter is in middle school, and it's been completely remote learning and so you know like you were talking about kids have their cameras off, you're not really seeing everybody as much, and so she went back for some sort of orientation something, and she came home and said, mom, these boys from last year they're like men. They have facial hair. They, I mean, it was like puberty happened to her peers while she's been home on a zoom screen, and it was really distressing to her, you know, I was in school with boys a year ago, and now they are men, and I just thought wow, like how different?
Dr. Donna Pincus: Yeah, the passage of time is just kind of, you know, we may be felt we're all doing something similar during that time, but we didn't get the snippets of being able to see anyone to see those changes over time, yeah?
Dr. Jill Ehrenreich-May: Just to add a slightly different perspective because I'm in Florida and my children have been back in school since October of 2020, but I think that one thing that I have noticed is weird is–, I have been really impressed with how resilient and how able to kind of take on these new routines. Our kids have been, my kids are way better and more compliant with things like mask usage, social distancing, and other things. We were at a park, and my daughter was riding a bike with me, and I said, you know, you don't have to wear mask while you're biking like it's OK 'cause you're like moving and she's like, no, there's are a lot of people around so you know I think it's more appropriate for me to keep my mask on.
Dr. Amanda Zelechoski: 100%.
Dr. Jill Ehrenreich-May: I'm like OK, seven-year-old. The kids are so much better at this than the grown-ups.
Dr. Donna Pincus: My daughter today had saxophone well, she plays saxophone in the band. Well now, band is outside with bell covers on everything, and you're in a tent playing outside where like there's a whole neighborhood there and built. All the 6th graders out there playing in the band, so that's like a different level where you might feel a little self-conscious about playing there. That's a new situation we haven't had to navigate before.
Dr. Lindsay Malloy: Yeah, but I do love thinking about and just pointing out how resilient they can be and arguably more adaptable than we are in many ways? But I just was thinking too about, and this might sound kind of irrational, but I'm talking to anxiety experts, so that's fine, right? But I sometimes feel this way, and I hear from other parents too about the long term effects of this, which obviously we don't know yet, but that's what a lot of people want to know about, like what, how have we changed the course of development for our kids. Kids by, for example, making them suspicious of other people like I definitely feel that when I'm out. I'm like I have young kids so I have to really remind them OK, stay back, stay 6 feet back, you know. And things like that. And I know a lot of parents who are talking about what you know what that means long term. And I liked that. I can't remember which one of you used the word, sort of unconditioning our kids to these things, but I get the sense that what you're saying is that this is possible, that we can get them back to normal. Whatever normal might look like that. We haven't sort of caused them to forever be suspicious of other people, for example.
Dr. Jill Ehrenreich-May: Yeah, I think that we have to remember that a lot of things are developmentally going to happen in similar ways as they would have happened before. Maybe things were a little delayed. Maybe you know your kindergartner didn't start in person kindergarten, you know, at the time that you had expected, and they're still going to have to go through transitions related to separating from you there and getting used to the structure and getting used to you know again in these odd circumstances, but they will get used to it, you know, it just maybe a little bit longer or a little bit delayed and I agree with you completely Lindsay, it is weird out there right? It feels weird. It feels odd anytime anybody does something unexpected. Just wait, you know, surrender we all have kind of, you know, conditioned ourselves almost to have panic-like responses.
Dr. Lindsay Malloy: Like the vigilance, like the constant vigilance of the environment, yeah?
Dr. Jill Ehrenreich-May: Yes, there's constant vigilance. It's gonna take a while, you know, for that to lessen, but you know that should lessen as feelings of safety increase, right? So and for some people, that's going to take even longer because they are very kind of hyper-vigilant or worried by nature and it's going to take them a longer time to sort of sense that their safety. But you as a parent can reinforce that right, you can say alright, I think it's safe because of acts or you know, I see that this is happening, you know, and so we're going to move over there, you know, whatever. It might be so that you can make the world that feels pretty unpredictable still a little bit more predictable.
Dr. Donna Pincus: They also just did mismatch that now we have adults that are vaccinated, but kids aren't those might not be wearing masks now 'cause we just, I mean in all different states. I know it's a little bit different in terms of the rules, but you know now adults don't need to make more masks outside, but then kids aren't yet protected. So where do you– how do you say you're not sending a consistent message, at least before it was like we are masked. And my four-year-old niece said, oh yeah, we wear masks 'cause there's a germ, and we got to keep ourselves protected from this germ. And oh OK. Yeah, you're right. I wear the germ. I wear that mask to protect you from the germ. You do the same thing for me, but now it's like, wait why is she not caring about it? She's not worried. Why are you not wearing a mask? And so we can, I think, in different territory now we're having to explain things that might be harder to understand, and we've all been learning together throughout that.
Dr. Lindsay Malloy: Yeah, well, you could come to Canada where the vaccine rollout is so slow that you know we're all still wearing masks, so yeah, well, I got a funny story. Like when you brought up the fear of needles that's resurfacing. That's so fascinating, 'cause I wouldn't have necessarily predicted that, but I guess, yeah, kids and teens are hearing about shots all the time now, like, but hearing about vaccines, my kids were so excited about the vaccine for like a year because I kept telling them about these people, these amazing scientists who were creating this vaccine that was going to get us out of this situation. The virus, you know, we would get back to normal, actually, and then they found out that a vaccine was a shot which they didn't realize before so they were all excited about it, and then they're like hold on wait a second, what like, it's a shot? Oh no, I'm not interested in that. They're quite scared of them so maybe by then they could get like a kid version, that's an–
Dr. Amanda Zelechoski: It's gummy. A delicious syrup. It's like a fruit.
Dr. Lindsay Malloy: –argument or something they gotta get working on that. Exactly, exactly.
Dr. Donna Pincus: Although one of my grad students to do your dissertation is on an online like using talent health, treating kids for fears of shots, actually, so it's pretty cool where she's mailing them little packets and doing gradual exposures she's going to, you know, do that with the kids and like a one-session treatment.
Dr. Lindsay Malloy: What is this?
Dr. Amanda Zelechoski: Yeah, I'm glad you brought up treatment on it because that's exactly what I wanted to ask next is, you know, we've been talking about kids who can be very adaptable and resilient, and they can– But there are also kids really really struggling right now, and so I'm just wondering if you both can sort of speak to like how as a parent can I tell if it's time to get help for my child and if it is, you know what kinds of treatments are out there, like just give me a little insight into, you know, we can fix this or how I can tell if I need to take steps like that?
Dr. Donna Pincus: Well, usually we start with some of the things we started the conversation with. Like we talked about interference in developmentally appropriate activities. To stress like doing your kids doing something but they don't look like they're having fun doing it. Everyone else is outside at the bonfire but and having fun roasting marshmallows and rings but your child isn't having fun or looks like they're just marking time before they leave. Thus, complains of the frequent headaches, the frequent stomach aches, the avoidance of situations, maybe some tantrum, maybe irritability or sadness. I mean, these are all like constellations of different feelings that kids feel and sometimes very intense ways where you can tell when your child is just not enjoying the things that most kids seem to be enjoying.
So those are some markers, and, thankfully there are, you know, I'd say over the last few decades, there's been a surge in research on anxiety and kids, and we know now much more than we ever knew before about non-drug options for anxiety. And so I think that's a very hopeful message, and the term that parents might be looking for is cognitive-behavioral treatments. Those are treatments where we're, you know, helping teach kids some skills and parents some skills for really targeting, like changing kids thoughts, especially thoughts that are only negative or that only really lead to us feeling more anxious. They also target feelings and just as Jill mentioned, like those baby steps that you want to enter new situations. And our treatments help parents to know how do I structure those baby steps? When do I give rewards? How or– high fives as they go through it? How fast is too fast to go through? How much do I push? All those kinds of questions are usually addressed in treatment, and then we also kind of teach them how to recognize these feelings in their body. Also understanding what they are, even just understanding what anxiety is, why some of it is helpful and exactly what's happening, and in a very simple, easy to understand way.
And we'll describe that to kids, sometimes even drawing it out for them exactly what the fight or flight system looks like, and some kids actually say, you know what? After session one, I already feel a little better just knowing what this is, knowing that I'm not different than other kids. So you know, there are ways that we can make it more palatable or fun where you don't feel like you're in therapy. So I think those are just a summary of, you know, some of the skills-based treatments that I think parents could look for. And the nice thing is that kids tend to respond pretty quickly.
Dr. Lindsay Malloy: Before we, before we move on to Jill, I just had to write down the marking time before it looks like they're marking time before they leave? That's a great phrase, and I felt like it just described me at every party. But I was meant to like marking time before I leave, that's excellent. Thank you.
Dr. Jill Ehrenreich-May: Okay. I feel like that's my number one here. All right? Yeah, I think that Donna summarized it beautifully, and so I don't have a ton to add. I will say that I think that it's really important as parents to be careful consumers of what kind of therapy approaches that you're looking for. And Donna rightly said, you know, you know, make sure you're looking for something that might look like cognitive behavior therapy. There are other things like acceptance and commitment therapy or other sort of behavior modification approaches that are similar to that, and so it does come in some other different labels or forms, but you know it's not like every psychologist really or every therapist or every counselor is really clear all the time on the type of model of therapy that they use. So I think it's really important that parents ask questions about the science behind the work that somebody is providing, because you know the therapies for anxiety are like one of like the really big good news stories in psychology. You know they work well, they work fast, they produce a pretty substantial response for a lot of kids now. Not every kid, but for really for most kids. And so if you're not getting that kind of effective skills package of some sort from your clinician. It might be time to kind of think about who else could do that for you.
Dr. Lindsay Malloy: That's a great point.
Dr. Amanda Zelechoski: Let's see, like great reminders.
Dr. Lindsay Malloy: Absolutely careful consumers. I like that, and I think that will be helpful to parents.
And I think this whole discussion will be extremely helpful to parents. We're so happy and grateful that you joined us today to talk about vaccine anxiety in kids and teens as we, and especially as we start to, you know, open things back up in a lot of places and we hear again from so many parents who are experiencing challenges with this. So we just want to thank you so much for your time and joining us.
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Dr. Lindsay Malloy: Thank you for joining us for this episode of the Pandemic Parenting Podcast. Make sure to hit, follow or subscribe on Apple Podcasts, Spotify, or whichever platform you're listening on to be notified of future episodes. We'd also love to connect with you on social media. Look for our blue and yellow logo when you search Pandemic Parenting on Twitter, Facebook, Instagram, LinkedIn, or YouTube, and you'll find us or follow the links in the show notes.
Dr. Amanda Zelechoski: Let us know what you think of this episode by leaving a review on Apple Podcasts. Your five-star review helps us move up the charts to reach even more parents and caregivers. If you have a specific question or topic you'd like us to address in a future episode, let us know. You can email info@pandemic-parent.org and mention “podcasts” in the subject line.
Dr. Lindsay Malloy: And this podcast isn't all we do by the way. Pandemic Parenting is a 501(c)3 nonprofit providing free science-based resources for parents and all who care for children while navigating the COVID-19 pandemic. To learn more about our organization and access our extensive library of webinars, videos, blogs, and more, visit www.pandemic-parent.org.
Dr. Amanda Zelechoski: Lastly, this show wouldn't be possible without supporters like you. Lindsay and I donate our time to this podcast, but we do have an incredible team working behind the scenes to make this all happen. If you'd like to support the show beyond leaving your five-star review, visit www.pandemic-parent.org/support and donate today.
Dr. Lindsay Malloy: Thanks for listening, and we hope you can join us next time.
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