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In-person and virtual learning has brought new levels of stress to kids, teachers and parents alike during the COVID-19 pandemic. From normal signs of anxiety to symptoms of coronavirus, navigating this school year will be like no other. Pediatric psychologist Ethan Benore, Ph.D, explores social anxiety, technology challenges, learning disorders and how you can help ease your child’s school stress.

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Managing School Anxiety During COVID-19 with Dr. Ethan Benore

Podcast Transcript

Nada Youssef:  Hi, welcome to the Health Essentials podcast brought to you by Cleveland Clinic. I'm your host Nada Youssef. As 2020 continues with COVID-19 and its associated precautions like social distancing, masks, and hand hygiene, distance learning is moving towards classroom or in-person learning again as schools reopen. However, as kids have back to the classroom, new or preexisting anxiety or other learning differences may affect their comfort and abilities of school year to help us navigate the situation is Dr. Ethan Benore. Thank you so much for being here with us today.

Ethan Benore:  Thanks for having me. It's great to be here.

Nada Youssef:  Dr. Benore is a pediatric pain management psychologist. He currently serves as center head for Cleveland Clinic Children's Center for Pediatric Behavioral Health. And to our listeners, please remember this is for informational purposes only and it's not intended to replace your own physician's advice. Also, please note that this interview was prerecorded and does not reflect any changes to COVID-19 precautions that may have taken place after this recording.

So I'd like to start by talking about school reopenings and all the stress and anxiety that's coming with it. So schools that have been opening slowly, moving from virtual to hybrid to in person learning, and going back to the classroom amid this pandemic causes a lot of new heightened anxiety in some kids. Is there anything we can do for our kids to prepare them for in school learning, so we might ease it before it even starts?

Ethan Benore:  I think so. So there's a couple of things that will be helpful. One thing that we know is that providing information, age appropriate information and not overwhelming kids, but appropriate information can help reduce anxiety. So let them know what it's going to look like. What are the changes going to be? Not in a scary way, but in a matter of fact way. They're going to be doing temperature checks, people are going to be wearing masks, you may have some scheduled seating. Things are going to look a little bit different. Beyond that, it's important to let them know that they're safe, that we're doing these things to help manage some safety. And that, one, is a good thing, and two, that they are safe to go to school.

Following these recommendations, the goal is to try to educate kids to try to encourage appropriate social interactions, and at the same time, try to mitigate or reduce the spread of COVID. And so we're doing two things that are important. We're educating our kids and getting them back to school, and being safe and responsible citizens to try to reduce COVID. And I think it's important that kids feel they're part of that, a part of that process of helping society fight COVID. I think the other thing that's important to let kids know is what to do if you have concerns. Ask. Ask me, ask your teachers, but please reach out. Because we want people to continue to feel safe and comfortable going to school, so that you can learn.

Nada Youssef:  Great. And one thing you did mention with wearing masks. Going back and seeing that everybody's wearing masks, their teachers, their friends, everybody. How do we explain to them the safety precautions of how to wear a mask? Because kids fiddle with their face, and I know my kids are always touching their mask. How do you explain to them the effective way of wearing a mask without scaring them that the virus will come through if you don't handle it properly?

Ethan Benore:  Yeah. So your point there is really good that the whole point about wearing a mask is not to scare people. The point is to try to prevent COVID or prevent spread, potential spread, of a virus. A virus that either you may have, or somebody else may have. And so in the same way that we teach kids how to wash hands, that we teach kids how to hold hands before crossing the street, there's a safe way of crossing the street. And it's not running across the street without looking. There's a safe way to go to school now, and this is what it looks like. And then walk them through the steps. There's some great videos on hand-washing, there's some great videos on how to wear a mask. The importance of not touching it too much.

I think it's important not to be punitive about it. Again, if you stay mindful of the goal of feeling safe and yet a part of this larger process to prevent COVID, I think that's a much better approach than your child is either doing a good or bad thing by touching the mask. This is hard. It's hard for all of us. So keep that in mind when you're also talking to your child. I think it's hard for all of us to wear a mask for 30 minutes, let alone six hours during a school day.

Nada Youssef:  Yeah, but they're happy to wear it so they can give back to their friends and their school and outdoors. They're definitely excited to be back. Can you talk a little bit about anxiety and how it might show up for our kids and how parents and educators can help?

Ethan Benore:  Sure. So I think anxiety, depression, stress, that's important to keep a lookout right now. There's a lot going on, and some kids might not be so overt or out in the open about their symptoms. And so you might notice that your child is more sullen, staying to themselves more. You might notice that your child is more irritable, and you might be more irritable and sullen yourself, but pay attention to any behavior changes. Especially the kind of removing themselves from other activities or from social engagements.

The other is sleep difficulties. And then a lot of kids, younger kids and older kids, have physical complaints. So stomach aches and headaches are common. And so use any observation that you have about your child's behavior or about an ache or pain that they notice as a jumping off point for a conversation. "How are you doing right now? How are you doing in this situation? How are you feeling, and what are you thinking?" And so use any observation that you have to start the conversation about just checking in on their mental health.

Nada Youssef:  That's a great point. And in the past three, four months, I've literally seen my kids grow and there's a lot of change behavior being with them 10 hours extra a day or so. And so I wanted to talk, because I think it's very important to pinpoint change behavior as kids are literally growing in front of our eyes, versus something is wrong. And you mentioned isolation, sleeping patterns. Is there anything else to pinpoint that could be different than normal growing pains?

Ethan Benore:  The big ones I would take a look at would be sleep, irritability, and complaints of pain. Sullenness, or kind of avoiding others. I think those are the biggest, but in all honesty, I think the key for parents right now is going to be to step up. We do have more time with our children now, maybe more than we more than we expected. I don't know if it's more than we wanted, but it's a great opportunity to start having these conversations with your child. If you're having these conversations regularly, it doesn't feel so weird when there is a problem. And so if you have a thought or a concern, ask. Bring it up. If it's nothing, that's okay. But your child might feel even more comfortable if they come back to you two weeks later and there is something there.

Nada Youssef:  Sure. Now is there any way that this anxiety, irritability could be so extreme that it's interfering in school, and how do you think that we should know as parents? And another question to that, because as a parent, you want to talk to the teacher and you want to ask them about your child, but you know they're already under a lot of stress. I'm sure everybody's communicating, there's so many problems technology happening now. How do I know if my child is affected in school?

Ethan Benore:  Yeah. That's a good point. And I would go back to communication is most likely the answer. In terms of children's struggling in school, struggling in school can be a symptom of emotional distress. In this situation, it actually might be a cause of distress as well. And so some of the things that I'm hearing is lesson plans that aren't getting introduced effectively because of what the schools are going through with technology. A lot of downtime in school, so there's some boredom that also stresses kids out. And then not establishing a clear, supportive relationship with the teacher, whether it's the masks or whether it's some of the online work. And so feeling like I really don't know who to go to for help. I think having those conversations with your child to identify whether it's mental health or whether it's academic issues are important so that you can problem solve.

I think having conversations with the teacher is important. One thing that I would recommend for parents is be compassionate. Be compassionate when you talk to your child if they're not getting the grades that they got last year. This is not last year. This is different. This is a different year we're going through. Be compassionate with the teacher. You may have two, three, four children at home. Your teacher may have 20 or 30 kids, or they may have multiple children that they really only see for 90 minutes, two, three times a week.

And so everybody is struggling a little bit. I think if we can check in with each other and really prioritize what the issues are, the issues that could make my life easier right now is if my child understood her algebra homework. And so have the conversation with the teacher about that, but be compassionate about it. I think that will reduce some of the defensiveness and everybody will help each other a little bit more.

Nada Youssef:  Great. Now with kids going back in person schooling with the coronavirus precautions, we're seeing that schools are sending kids home more often with things like stomach aches and headaches. For kids who have anxiety that manifests as pain, how can we tell if that symptoms is a sign of anxiety versus something like COVID-19?

Ethan Benore:  So there are some specific symptoms for COVID-19 to check, and if you are concerned, whether it's been exposure or whether it's been the COVID-19 symptoms that you present with, or the symptoms that you present with, the school will definitely help in terms of assisting you for assessing whether or not it is COVID-19. Now schools have gotten very good at this, and they've gotten pretty good at communicating what they're doing in this regard.

I would also encourage parents to stay in touch with their primary care provider. If you need to get tested for COVID-19, you get tested for COVID-19. But much of the safety guards that are in place, the same ones that we use here at the hospital, are meant to protect people, because we don't know everybody who has COVID-19 and those who don't. And so the idea of everybody washing their hands, of everybody wearing a face mask, of trying to maintain social distancing is the best behaviors that we can do to mitigate, or to try to prevent the spread of COVID-19. But if you have those kinds of somatic questions, or questions about stomach pains, headaches, talk to the primary care provider.

Nada Youssef:  That's a good point. So as a parent, what should we look for? Let's say last year, my daughter has a fever. I would not send her to school. Or if she threw up, something like that. Now, if a kid shows up ... Or wakes up, I'm sorry, with aches, pains, coughing, is that something that I should keep my kid home? Or should I send them to school and have them do their own precaution testing?

Ethan Benore:  Yeah. So it's a good question. And in what I would recommend actually is every school has posted their rules for school attendance. So I think it's important to check with your local school district in terms of what the steps are if your child wakes up with a fever. It may be really just the amount of fever that says whether or not they're comfortable bringing the child to school. It may be fever with some other symptoms. But check with your local school district, and if you have concerns even the morning of, go ahead and give them a call. Again, we're all doing the best that we can to try to mitigate the spread, and if you feel more comfortable double checking with your school prior to bringing your child in, I think you're being a good citizen there.

Nada Youssef:  Now for kids who have been more isolated at home over the spring and the summer seasons without many people or outside interactions, is there anything we could do as parents to ease their transition back to school, where they're all of a sudden surrounded by a lot of people?

Ethan Benore:  That's a very good question. I think some kids are desperate to see other individuals and get back into some semblance of normal state. I think for other kids, whether they're they're socially shy, anxious, whether this might be a new school year or a new school, it can be a bit overwhelming to go from zero to 60. And so it's the same concept of give them a plan, reassure them that they're safe, and walk through the strategies of how going to get through the school day.

The other thing I think that's important is take it in bite sized fashion. And so if your child is feeling anxious or scared, just make it through the day. Just make it through the morning, figure out how your child is going to get through a shorter portion of the day. Not the entire week. Once your child feels successful, "I made it through my first two periods. I made it through my first day," that self-efficacy, or that sense of confidence will help ease some of the anxieties for either the rest of the day or the rest of the week.

Nada Youssef:  Now I want to talk about learning differences with kids. Because kids with learning differences like ADD, autism spectrum disorder, or sensory processing disorders may have a challenging transition from virtual to classroom learning. Can you explain what these differences are and what kids might experience?

Ethan Benore:  This is actually an excellent question. It sometimes feels, I think, that we're trying to have one solution to help all children, and not all children are the same and not all children learn the same. Also, there's a lot of kids that are on IEPs, individualized education plans, or have certain accommodations in school. Some of those may be relatively easy to continue in this school year. Some of those may be different, or difficult to do. I think it's very important if you have a child on an individualized education plan, check in with the school, check in with the school regularly, at least periodically, to see how your child is doing, how the plan is being rolled out, and above all I think, what you can do as a parent to jump in.

Again, we are going to have to prioritize some things this year. I think keeping children, schools safe is one. Addressing the mental health, reducing the level of panic that we're feeling right now is going to be important. And also addressing their academic growth. And so we've got three things to work on. Kids are very resilient. I think that's important. I'm not saying that we should not address certain things, but I hope that that gives people some comfort, that even though it's difficult, for the most part, kids are resilient and you'd be surprised what they learn and grow from this experience.

So it's okay if you need to prioritize some things. It's okay if, and it might actually be important, for you or somebody else to jump in and get creative in terms of meeting some of the educational needs that your child has to make it through this year.

Nada Youssef:  Great. Now, is it possible that coming back to school after such a long time not being in a classroom could expose a learning difference or disability that was maybe unknown before?

Ethan Benore:  You know what, it's a really good point. My first thought is no. And honestly, I think it's because there's so much else going on. So if you do have a concern, I would really highlight it. I would pay attention to it, because a lot of kids go with undiagnosed or underdiagnosed learning difficulties. And I do think this is one of those years where there's so much that's going on, that a learning difficulty might go unnoticed. And so if you do have a concern, please raise it. Please monitor your child and please raise it to make sure that it doesn't go under assessed or addressed. There are some situations where a child's anxiety or mood might present as an additional barrier to going to school or attending class.

And I think this is a tricky situation, especially when it presents with physical complaints. And there's a lot of concern right now for individuals being sick. Schools may prefer just to send children home with they're concerned about physical complaints. Stomach aches, headaches, maybe fatigue. I think if the parent knows that this is more on the mental health side, more anxiety, it's very important to have a conversation with the school. Just like with ADHD, autism, other learning disabilities, it's important to have a plan for how that child's emotional health is going to be addressed so that the child can participate to the best of their ability in school.

That might mean that a child is not being sent home if they're having physical complaints, unless there are certain criteria that are met. It might mean that the school and the parents identify a different approach to educating the child currently than what's happening with other students in the classroom. I think it's important to address mental health issues. I think it's important to try to include children as much as possible for social purposes and what's happening with the rest of the class, but if physical complaints or physical reports are really just manifesting emotional distress or emotional difficulties and children, I think just like other academic or educational concerns, the school and the parents need to talk about that and have an individualized plan for how they're going to address it.

Nada Youssef:  And how would you say that we should be advocating for these students right now?

Ethan Benore:  I think the best way to advocate for the students right now is establishing a coalition or collaboration with their teachers. Teachers are having a rough time right now too. This is not easy for them. Your work is not easy for you, and their work is not easy for them right now too. And some schools are actually adjusting based on the levels of cases in the community. And so it's quite a period of stress and transition for everybody, your teachers included. Form a coalition with your teachers to really work as a team to monitor how your child's doing, identify any difficulties, and then work together to respond. I think teachers would feel very grateful to know that they have a parent in their corner, and would feel very motivated to help a child when they have support from the parents to help that child.

Nada Youssef:  I agree with what you said, because the parents can help the teachers and the teachers can help the parents, and that would be excellent. Now I'll do want to switch to parents' health right now, and the anxiety that the parents are affected by. So parental anxiety is very real right now with balancing schools to jobs, homework, technology challenges. How do we prioritize?

Ethan Benore:  It's a very good point. Prioritizing is one of the things that we talk about in psychological first aid. That it's okay and it's important to do. Prioritizing, I'm not going to set the priorities for you, but I am going to give parents’ permission to prioritize. You might need to take care of one child who's really struggling. You might need to focus on your job so that you maintain your job, maintain your benefits. You might need to pull back from your job to focus on your family, because you guys are going after each other and really need to create some space and create some fun and bring back the love. But I think it's important to sit down and prioritize that. How to do it, I would have the parents sit down together, whether it's one parent gets some other adults to get some input, two parents, multiple households. Have the adults sit down and write down what they think the priorities are so that we're sure that the kids are being considered in that.

And talk to the kids about what the priorities are. I think it's important that kids understand, again at their level, so that they know what they need to focus on, what they should be thinking about and what they don't need to worry about because mom or dad or aunt or uncle kind of taking care of that part.

Nada Youssef:  Great. Now our children are like sponges. And as a parent, my stress levels can affect my kids' mood, and their school and stress levels. Balancing our own work kids' schooling and everything in between, we keep hearing the term, "We're in this together." But what do you say to the parents having trouble dealing with their own stress with these life changes, maybe feeling alone before helping the child?

Ethan Benore:  It's difficult. It's difficult when you feel alone. When you feel alone, reach out. Reach out to whomever can be there to help you. There are a number of resources out there. If you don't have a family member, if you don't have a friend, if you don't have a neighbor that you can reach out to, reach out to some resources. There are very good resources through the Ohio Department of Health, through your local county. But take care of yourself. It's important so that you can take care of your child. We are in this together. We say that because it helps to deal with this. But one of the other things that I tell parents, one, take care of yourself so that you can help your child. But two, this is actually an opportunity for you to work on mental health, mental wellness, physical health, physical wellness, as a family. You guys all probably need to get off the couch and do some exercise. So go take a walk together. You're not getting a lot of social attention from other individuals right now, so play some games together. Get creative, but address all of those things from nutrition to sleep, to exercise, to social engagement, so that you guys are filling yourself up with the resources that you need to manage what is a really stressful time for everyone.

Nada Youssef:  I agree. And I love the silver lining, Dr. Benore. That was great. And thank you so much for everything. Thank you for being here today. And if you would like to schedule an appointment with Cleveland Clinic Children's Behavioral Health specialist, please call (216) 448-6110. And for more podcasts like today's experts or more, you can visit Clevelandclinic.org/hepodcasts, or subscribe to this podcast wherever you get your own podcasts. And for more health tips, news, and information, follow us at Cleveland Clinic on Facebook, Twitter, and Instagram. Thank you for joining us. We'll see you again next time.

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