September 11, 2024
Cindy Lopez: Welcome. My name is Cindy Lopez, the host of this CHC podcast, Voices of Compassion. We hope you find a little courage, feel connected and experience compassion every time you listen.
In this episode, we talk with CHC experts, Dr. Emily Hsu, psychologist, and Julia Terman, doctoral intern at Stanford Children’s Hospital and CHC. They talk about accommodating anxiety and what it means for both parents and children. We explore what accommodation looks like, how parents might unknowingly reinforce their child’s fears by altering routines or providing excessive reassurance. We also talk about typical examples of accommodation, like allowing a child to avoid anxiety inducing situations – and contrast these with more productive responses that encourage resilience. Hear about how you can be a supportive parent or caregiver while still helping your child face their fears, fostering independence and confidence. Tune in to learn how to strike the balance between empathy and empowerment.
Welcome, Dr. Hsu and Julia. I’d love it if you could take a minute to tell our listeners a little more about yourselves and why this is such a valuable topic to discuss.
Julia Terman: Well, thank you so much for having us. I’m really excited to be here. My name is Julia Terman, and I’m a clinical psychology intern at Stanford Children’s Hospital and Children’s Health Council. For the last five years, I’ve been doing clinical treatment and assessment with kids and families experiencing a wide range of challenges, but I’ve really developed a focus on anxiety and OCD. And I’ve also been doing research on cognitive behavioral therapy, which is an approach that’s really helpful when it comes to the topic we’re talking about today, and so this topic is really important to me because in this work, I’ve noticed that parents and caregivers are usually really concerned about their kids and how to respond when children are struggling with anxiety. And they typically have tried everything in their toolbox and feel at a loss, and often I think the most loving and caring way for them to respond instinctively sometimes isn’t necessarily the most helpful when it comes to long-term coping. So I think there’s a lot of power in helping parents learn a framework for understanding their child’s anxiety and learning how to respond in a different way.
Emily Hsu, PhD: Hi everyone. My name is Dr. Emily Hsu. I’m a licensed clinical psychologist. I’m an adult psychologist, and I also am bilingual, and I use English and Spanish in my clinical work. I’m really excited to talk about this topic about anxiety because I do get a lot of questions asked, particularly for newer parents, and this typically occurs where they’re not sure when to intervene or to let the child kind of work it out. And so, I typically find that to be the case when it comes to my child appears anxious, should I let them, you know, work it out or should I do something else? And so I do think that this is a topic that we could ask across the lifespan because we all experience emotions. So I’m really excited to talk about this.
Cindy Lopez: Thank you both Dr. Hsu and Julia for being with us today. Let’s talk first about what anxiety is. Can you describe that?
Emily Hsu, PhD: I think there’s a lot of different ways to describe anxiety. Anxiety can be a thought or multiple thoughts. It can be a feeling in your body. It can be both of that. How I start to know that I’m feeling anxious, for me, it starts physically. I feel almost like I can’t breathe, or something’s like sitting on my chest. It almost feels like what I describe it as acid reflux. And then from noticing that feeling, then I feel compelled to do something. Um, like I want to either say something or I just want to do something. And typically I’ve experienced that wanting to do something to decrease this terrible feeling that I’m having in my chest. I also think that anxiety can be thoughts and that it can be worries, which we know worries can be helpful. It’s just how the worries either paralyze you or enable you to make a decision that you need to make, depending on if it’s one that needs to be made now. So I think anxiety is a lot of different things.
Cindy Lopez: Thank you, Dr. Hsu for describing it that way, because I mean, even personally, like I have some of those kinds of feelings. I’m like, is this anxiety? Yes, this is anxiety. And wanting to do something, like, I don’t want to feel this way anymore. So I think for our listeners who are likely parents and our caregivers or educators, it’s kind of normal for them as the caregiver to want to make the child feel better. So is that what we’re talking about when we say we’re accommodating anxiety?
Julia Terman: So I think in a sense, yes, but it’s a little more specific than that. Accommodating is something parents do in an attempt to help their child feel better, but I can define a little more specifically what we mean when we say accommodating. And you’ll see that it doesn’t actually always work out that way, and it usually doesn’t. So in psychology, when we use the term accommodation, we’re talking about a change that a parent makes to help a child avoid something that makes them anxious. Accommodating would be removing whatever the threat is. So that might mean taking the child out of a situation that makes them anxious or allowing them to avoid doing something altogether or removing something else from their environment.
So it makes sense why parents would do this because if you have a child who’s really anxious, let’s say they’re crying, they’re really distressed, you’ll often see that anxiety drops almost immediately after you accommodate, after you remove the, you know, so called threat. So this is why this often feels like the most supportive way to respond when your child’s struggling, but this often ends up backfiring because it teaches your child that they can’t cope with the scary thing. And yeah, they might take away the message that the only reason they felt better is because they avoided the scary thing, and then the fear gets bigger and bigger.
Cindy Lopez: So I’ve been in education for a kabillion years and worked with kids. And when I see them struggling, my impulse is to reach out and help them, right. So, how can parents help if it’s not about accommodating, and maybe we can talk a little bit about what accommodating is?
Emily Hsu, PhD: I think a lot of parents have this mentality of, you know, we want our children to experience life in a way that is positive, typically, right? Anything that we’ve had to experience, whether it’s anxiety, a negative emotion, or negative experience—typically parents want their children to not have to experience that. I think the whole fix that attitude that parents might have I think is something that is very understandable because we want our children to be okay, right? And I also do encourage not only parents, caregivers, but just anyone in general who tends to have that, I want to fix it, or maybe that’s the thought they’re having, to really take pause and be mindful and maybe curious, if that’s the word, of why do I want to fix it? And what exactly is it that I’m trying to fix? And kind of zoom out before you intervene, and think about what’s my goal, especially when you see a child looking anxious because sometimes we don’t always know if a child is anxious, like we might observe some behaviors, some facial expressions that seem like anxiety, but it might not be, but after identifying it, it is anxiety. I think it’s one of those kinds of things where at the end of the day, and this might help us understand like why accommodating can be helpful short-term, but why it can be problematic long-term, is recognizing that the goal when it comes to helping our children manage their emotions is just that. We want to teach them – and this is what we do as therapists, as educators, as caregivers – we want our children and ourselves to learn how to manage anxiety versus eliminate it. And this is where accommodation can be problematic because, well, accommodations are helpful, right? We’re accommodating. Are we then teaching the child that this threat is something that you can’t tolerate? And then it also runs the risk of, “Oh, well, if Mom takes away, if Dad takes away, if Grandmother takes it away, then that means that this is actually truly scary.” And so that’s where accommodating, which is typically when we’re changing something, that’s what I think of an accommodation as. We’re changing or we’re adding something because accommodation can be changing or adding, that can be problematic long-term.
Cindy Lopez: Interesting, just thinking about part of what is communicated when parents step in and accommodate or support, whatever that looks like, that it backfires. So talk about that a little more. Why doesn’t it help?
Julia Terman: In the moment, it does help the child feel better because there’s this really specific thing, right, that’s making them anxious. Let’s say whether it’s spiders or a certain social situation. And so, of course, when you take it away, they’re going to feel relief, but the reason it backfires is that the accommodation reinforces this idea that they can’t make it through the scary situation. And what helps us learn to cope with anxiety is learning that we can get through it, and I think we all experience worries about different situations in our lives, but something that makes it extra hard to cope with those situations is when we don’t trust that we can make it through and that we can do it and that can make anxiety a lot worse.
Cindy Lopez: So let’s dive into accommodating. What are some examples you might be able to share with us?
Emily Hsu, PhD: I think they’ve been in the terms of school refusal, which is something that I personally feel has increased with the COVID-19 pandemic where children didn’t have to go in person to school because we had to keep them safe. And one family that I’m working with,this child was bullied, and there was a fear because this person had to go to school with the person that bullied them. And of course, there’s a real threat, right? And it was one of those kinds of things where the child stopped going, but then the parents felt so bad that that was a result of this, these terrible incidences. And, started being like, oh, if you’re stressed, you know, like you, you don’t need to go to school like, and this started happening after any appointments, any kind of appointments, like she would only go to one appointment, but the child said that she didn’t want to go to any appointments or leave the home. And mom was like, that’s okay. I don’t want you to be stressed, that’s an accommodation, that feels great, right. You don’t have to go to an appointment. And so did she meet her goal of her child not being stressed? Probably, but then we see the problem where the child is no longer going to school, or the child is learning, okay, I don’t need to go to school because it’s too stressful for me, or if I’m feeling certain feelings that feel like anxiety or just discomfort or stress, I don’t need to do anything. I don’t need to leave the house. And so this is where it can start to backfire, where parents have good intentions. You know, like I’m of the mind where I assume good intentions of my parents, but as we see, I mean, the mother’s goal was for her daughter not to be stressed, and she had also felt really bad that she had not noticed the anxiety that ensued after she was pulled. So there was guilt that was involved, right, but that is an example that I can think of where the mother accommodated, but also it first started off as the mom really wanted to be attuned. And in trying to be attuned, she started not asking leading questions, but being like, oh, I don’t want you to be stressed, you know, kind of put words on for experiences. And then that led to accommodating. And so it was kind of like this one thing led to another, and then this child hadn’t gone to school in a year, slowly, slowly.
Cindy Lopez: Wow. Julia, do you want to share any examples that you can think of?
Julia Terman: Well, I think first what you’re speaking to is sort of like this snowball effect, right, which we often see with accommodation where it starts with something that seems pretty small, and then before you know it your accommodations have led to some pretty big changes in your child’s life where they’re not engaging in the things in their life that they used to, whether it’s school, whether it’s activities, whether it’s hanging out with friends, whether it’s sleeping in their own bed.
So, yeah, accommodation can really snowball, and before you know it, you’re making so many changes to a child’s life that they’re not living the same life anymore, but other examples, I think, you know, with the school refusal, I think leaving the house, anxiety about leaving the house, whether it’s related to social anxiety. So the child’s worried about how they’re going to be perceived by others. So accommodation for that might involve allowing the child to not leave the house. Other situations could be, if a child has a phobia or a really big fear of something specific that they might have to face if they go into a certain kind of setting, then a parent might let them not go into that setting. So let’s say a child has a phobia of spiders. I already gave that example, but it’s a classic one. Maybe the parent will say, “Oh, you don’t have to come on the picnic with the family this weekend, you know, because you’re really scared there might be spiders around.” And you can see how something as small as a fear of spiders, all of a sudden could start taking over a child’s life because now they’re not going outside. And there’s a lot of examples that are also medically related. So, a lot of kids have a lot of anxiety around needles and getting shots and blood. And so a lot of times anxiety accommodations can start impacting kids’ medical care because they won’t be getting the care they need.
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Cindy Lopez: So we’ve talked about the accommodating and how that’s probably not the best response. So, what could a more productive response or some more productive responses or strategies be for parents or caregivers to use?
Julia Terman: The important thing is to be empathetic and warm and validating to your child. You want to show them that you hear them, that you’re really sorry that they’re feeling this way and that you feel bad that they’re feeling this way, right. And you can do that and also help them face the thing that they’re anxious about. And so I think that’s the key is being supportive and also helping them face the fear. And this can be sort of one small step at a time. And the technical term we use for this is exposure. And that’s this idea of taking baby steps in facing whatever that fear is.
Emily Hsu, PhD: Yeah, I would agree. I mean, I think, you know, you can’t promise a child that their fears, are unrealistic, right? I happen to be afraid of spiders, and I think it’s one of those things where, I know logically that it’s a fear, right? And that they can’t hurt me, but it’s one of those things about anxiety, right? It doesn’t make sense sometimes. I love how Julia mentioned exposure because we want to—in therapy and also like as parents and caregivers, educators—open our children’s worlds to experiencing everything, right? And not just the good, but also the not so great, you know, provided that it’s safe. And so I think it’s one of those things where we want to express like realistic expectations because you can’t promise the child that their fears are unrealistic, that they’re not going to fail a test, but what we can do is like Julia was saying, we can respect their feelings and we do that through validation because it’s important to understand that validation, like, when we say, you know, it makes sense that you’re worried about going to the doctor, doesn’t mean that we agree. Validation does not mean agreement, but it’s a way of joining your child and being attuned and being like, yeah, I can see why you’re scared, which for me, I feel is very like empathetic, like Julie had mentioned and powerful and so you can say, yeah, like, I know you’re scared, you know, that’s okay.
Again, it’s okay to be scared, and I’m here, you know, like, what would be helpful? How can we cope ahead if we do do exposures, it could be graded exposures, which is starting off at something that is a little bit anxiety provoking. I would say 10, that’s an emergency, five is like middle of anxiety, zero is I’m totally fine, there’s no anxiety. I will start off with like a six. There’s something that’s mildly anxious, and we do this right with children because typically the goal is independence, you gradually fade. And that’s where when it comes to accommodations, they can be helpful. If you’re fading the accommodations, right, like we don’t, when we accommodate add more or stay the same, right, like with individualized education plans or 504 plans, there’s accommodations, therapy is not meant to be here forever, but it’s help to give you tools to work with, you know, what’s going on.
Cindy Lopez: As I hear both of you talk and thinking like, you know, different causes for anxiety mean different types of responses, and that some interventions might not feel good. As a parent or caregiver or educator, like, you know, this is not working because it’s escalating, the worry is getting bigger, like help. So what do you say in that situation?
Emily Hsu, PhD: If I’m going to do some sort of exposure, even with my family members, we’re doing an exposure, right? I just call it what it is. I’m going to prep them for the exposure and also get their consent and depending on the type of treatment I’m doing, because anxiety treatment can look different even though they are related and similar. I’m going to tell, like, for example, in my group that I led at Kaiser Permanente with obsessive compulsive disorder, I would prep them and say, we’re going to be doing this exposure for about 30-45 minutes. And we would do it as a group, right, because we wanted to support this person. And I would tell them, I’m not going to respond when you start getting anxious or when you start physically looking like you’re anxious. And I want you to know that I’m going to be doing that because I want you to experience what’s called habituation, you know, it’s a habituation curve, which means that your anxiety is going to peak, and sometimes I do have my patients being like, “Dr. Hsu, this is terrible.” They said a lot of things to me, and I had not responded, but I also prep them that I wouldn’t respond, and I also got their consent, and I told them there’s going to be this habituation curve where anxiety is going to rise and then it’s also going to decrease and we need to get to that decrease. We need to ride that wave again and again so that you can feel that your anxiety will peak and it will also get better, but I need you to trust me. So I will do that and if let’s say like somebody’s anxious, and I didn’t have the time to prep them you know what I’ll do is I will validate, will be like, yep, it makes sense that you’re upset, and we’re gonna get through this. So I validate because it does make sense that they’re anxious sometimes, but again, I’m not here to agree. I’m not here to be like, well, actually not. I’m here to do hopefully what’s helpful, especially for someone that I’ve just met if I am ever pulled in, and then I’m like, we’re going to get through this and then I sometimes talk them through it or I say like, “well, it’d be helpful.” I’ll be like, “hey, I noticed that you’re breathing pretty shallowly. Let’s try to like fill up your lungs with air.” So I’ll start kind of doing like guided exposure, especially with like panic, which typically is something that I have been pulled into. So depending again on like the presentation, panic will look different for me than OCD, that’s how I would respond typically.
Cindy Lopez: You know, as a parent, I’m sure when you sit and watch and do nothing, it feels like you’re, I’m going to say, being a bad parent, if there is such a thing. So what do you say to a parent who’s in that space?
Julia Terman: Well, first of all, I think something to acknowledge is that there are absolutely situations that would make you a bad parent for just sitting back, right? So you want to make sure that the situation is something that’s not actually dangerous to your child. And the kinds of situations we’re obviously talking about are when kids are anxious about things that are safe physically and that we want them to be able to do to live a healthy, happy day-to-day life, right? But it still feels bad, right? When your kids feel unsafe, even just emotionally, but I think first helping parents remember that their kids aren’t actually unsafe and talking about it with the kids too to help them recognize, okay, on a cognitive level, I understand maybe when I’m feeling a little bit more calm, and I’m talking about it with my parents, I can understand that I’m not actually physically unsafe in that situation. And sometimes people are able to do that. And that can be really helpful to kind of remind yourself of that in the moment. And there are other situations with sometimes a little bit more severe anxiety or sometimes with OCD, where kids might not quite be in a place where they recognize that they’re not actually unsafe, but I think getting them on board is a really big part, like Dr. Hsu said, making sure that they’re consenting to this process of learning to ride the wave. I love that analogy. You know, you’re helping them learn to ride the wave of life.
Cindy Lopez: Thinking about, like, the difference between accommodating and effectively supporting your child, how do parents know the difference? Is there anything that you can help them with there?
Julia Terman: I think a really straightforward question you can ask yourself is the action I’m about to take going to help my child avoid their fear or face it? And so I think if what you’re going to do is going to help them face the fear, then that’s supportive and helping them learn to cope with anxiety, but if you’re going to help them avoid it, then maybe not so much.
Cindy Lopez: Is there any situation in which it might be okay to alleviate the child’s anxiety?
Emily Hsu, PhD: That’s a really great question. It’s something that I was like, hmm, alleviate. I think it kind of goes back to why I was excited about this topic. I don’t know if I can think of a good time to alleviate anxiety or any perceived negative emotion because as I mentioned before, you know, the goal of having emotions is to get better at experiencing them, get better at managing them. And because again, when it comes to like, for example, specifically anxiety, alleviate, is that your word for manage? Is that your word for decrease? Because again, we don’t want to get rid of emotions. We need all of them. So I think that question is really interesting because alleviate to me is a different way, potentially, of getting rid of or avoiding something that you might need because if you think about worry, anxiety, and scared, those words that kind of seem like they’re all different, right? And they’re also related. We need a little bit of worry. And of course we don’t want our children and ourselves to be so worried or so anxious that we can’t do what is needed, and so maybe we do need to decrease the anxiety. Not alleviate, you know, like when I think of alleviating pain, I think of that meaning, to me at least, that we’re taking away the pain, right, like why we do pain management is we take away the pain, right? We’re helping the patient with that. So I think of it as how do we maybe decrease the anxiety so that you’re still feeling it, but that it’s manageable.
And if that’s what alleviate means to the parent, then I’m like, yeah, I think there’s many situations in which it would be helpful to alleviate anxiety and some situations I could think of is situations that is going to allow your child to experience the world, open their world, right? Because you don’t want you to just be their world, right? You want Nana, you want, you know, their teacher, you want the neighbor, you want so many people to be part of it. So I think that might also answer your question about like, am I doing something that’s helping my child or helping my child, like, right now, but not long-term?
Cindy Lopez: Yeah. And I think it goes back to what you’ve both talked about and that whole validation piece and just to our listeners, we are actually going to do a whole episode on validation later this season. So, be watching for that one, but the whole validation piece and just being curious. What am I trying to do here? Is my response really helping my child build confidence in this situation that they can respond? Or is it really kind of wanting to take it away, which is giving them the message that they can’t handle it?
So I think just for our listeners, at least those are two things that I’ve heard from both of you in this conversation that have been helpful to me. And again, as you both said, the goal is to help kids manage uncomfortable emotions. So, like, anxiety. So really appreciate your time today.
Emily Hsu, PhD: Before we close, just want to thank you, Julia and Dr. Hsu, for sharing your thoughts and insights with us. And I’m wondering what you really want our listeners to hear from you today.
Julia Terman: I think a lot of those points you just made kind of hit the nail on the head. I think you can be an emotionally supportive parent who makes sure your kids know that they’re safe and make sure that they feel heard while also supporting them and facing their fears and learning that they can do all of these amazing things in life that sometimes cause a little bit of anxiety.
Emily Hsu, PhD: I would agree. I mean, I think, you know, being a parent, a caregiver, an educator, all of these positions, jobs, you know, they’re very, very hard, right? And I think it’s always difficult to know, and I think that’s also valid, to not always know what the right or best response is. I want to say that because I don’t always know. And the best and right response, if I’m even to use those words, changes depending on how you’re feeling, the situation, and if the person is able to receive the intervention. And so I think, you know, I want to empower parents, you know, too, if you’re noticing like your child is anxious and you’re wondering, “Hey, am I doing what’s best for my child?” And if you’re wondering if you might need some extra support, you know, I would empower parents to talk to someone, ask questions.
A question I used to get more often at Kaiser Permanente was as an adult psychologist, “Am I doing okay? Like, I’m just here for a mental health checkup to make sure I’m okay.” And I really appreciated that my patients did that at Kaiser because I think we should be asking that question, like, especially when we want to intervene to support our child, am I okay, like, what am I responding to? Kind of like how I said in the beginning, before you respond, take time to be like, okay, what’s making me want to respond? Is that what’s needed right now? Just be really curious about it. And then basically I’m telling you to be mindful and curious and then respond and I hope that’s something that you know parents will give themselves permission to do to take a pause and not feel like you always have to respond or you always have to have the answers. Because, as humans, we’re not always going to have the answers, and that’s okay. And to know that there is a community out there. We at Children’s Health Council, we want to support parents. We want to support caregivers, foster parents, educators. And so we’re here to consult and also work with you.
Cindy Lopez: Thank you. I really appreciated the note too, about like just taking a pause, and sometimes that’s, like, one of the most helpful things we can do. And as Dr. Hsu noted, if you’re in that space, and you’re not sure, like, what to do, or next steps, or you need some advice or guidance, please reach out. At CHC, you can get in touch with our care team at 650-688-3625, or you can email them at careteam@chconline.org. So thank you again, Julia and Dr. Hsu for joining us this evening. Really appreciated your words. And your expertise guiding us through this topic and to our listeners, thank you for joining us as well.
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