Kids' Wellness Matters Podcast Ep. 18: Building Confidence in Shy & Anxious Children

In this episode, Sara Budowsky, LCSW, a Lurie Children’s clinical social worker and psychotherapist in The Pritzker Department of Psychiatry and Behavioral Health, shares insights on differentiating between shyness and social anxiety, the types of fears children experience and supportive strategies to build confidence in young people. She also dives into the importance of validating children's feelings, breaking down fears into manageable steps and the role parents play in fostering emotional resilience.

“Bravery is about doing something even though it's scary. It's not about not being scared. That the truly brave kids are ones who see something, it's hard, and they do it. But also not shaming them if they're not ready. Normalizing that everybody feels anxious, including you.”

-Sara Budowsky, LCSW

Show Notes

• Drs. Sanchez and Alfieri share personal stories about their children’s situational shyness and how they help young patients in their clinic open up when they show signs of being shy at the doctor’s office. 
• They welcome Sara to the show and she shares her journey to becoming a therapist, inspired by childhood experiences and her passion for helping families. Sara dives into developmental anxieties children may commonly face, such as school transitions and new sibling adjustments, reassuring parents about normal reactions to stressful situations.
• Sara explains the concept of anxiety as a built-in "alarm system" and shares how parents can guide children to understand and manage their fears. She also clarifies the difference between a personality trait and an anxiety disorder and tools available to families with a child who has persistent fears.
• She says parents can help children with school anxiety find comfort through parent-teacher partnerships and encouraging bravery. When it comes to other, more specific feats, Sara works with families through  play and gradual exposure to help kids overcome their anxieties.
• Seeking professional help, such as child-parent psychotherapy, is recommended when children experience a truly traumatic event or have red flags for anxiety, such as missing a lot of school because of fears or anxiety
• Nurturing parent-child relationships and positive attachments help families build resilience to anxiety and may protect against future mental health challenges.

Transcript

[00:00:00] Dr. Nina Alfieri: Welcome to Kids Wellness Matters. I'm Dr. Nina Alfieri.

[00:00:04] Dr. Rob Sanchez: And I'm Dr. Rob Sanchez. We are both parents and pediatricians at the world renowned Ann and Robert H. Lurie Children's Hospital of Chicago.

[00:00:12] Dr. Nina Alfieri: On this show, we'll chat with a wide range of experts about caring for children from newborn to young adult. Because Kids Wellness Matters. 

[00:00:27] Dr. Rob Sanchez: Nina, tell me if this has ever happened to you with your daughter. But you know, my three year old son was behaving well. And so I decided to give him a little treat. And so we went to a little coffee shop in the neighborhood and they have these little, little tiny donuts that he likes. So I encouraged him to order it at the counter and this guy talks all the time, says all these things. But the second he gets up to do it, he like just curls up. As I'm holding him up and then just whispers, you know, like, may I have a donut, please? And it was, it just cracked me up because you know, he just got the shyness, just overtook him completely. Has that ever happened to you?

[00:01:02] Dr. Nina Alfieri: Oh my gosh, this happens all the time to us. And this is like Mia with a bright personality sequence skirt, big sunglasses, who cannot stop talking usually. And then all of a sudden we go into her pediatrician's office and they're like, Mia, what's your favorite color? And there's just silence. And I'm just like, that is. Shocking! And this happens all the time in the office with our patients too, doesn't it?

[00:01:25] Dr. Rob Sanchez: Yeah, I see it all the time. I have my little tricks to try and get them to open up a little bit. Like I always like to give them my stethoscope and say, Hey, you want to check this out? Do you know where your heart is? And then that opens it up. Do you have little tricks? I might be stealing one.

[00:01:37] Dr. Nina Alfieri: Oh, yeah. I mean, I always try to keep bubbles around and I think, letting the kid, the kids play with the little light, you know, when you put your, your finger on top of the otoscope light, how it

[00:01:47] Dr. Rob Sanchez: Oh.

[00:01:48] Dr. Nina Alfieri: Very.

[00:01:48] Dr. Rob Sanchez: So good. So good.

[00:01:50] Dr. Nina Alfieri: Party trick in the office, uh, stickers, et cetera. But yeah, some shyness is totally normal. Adults and kids have such a wide range of personalities, and it's one reason I love being a pediatrician, because you get to know so many different types of personalities.

[00:02:05] Dr. Rob Sanchez: And I always have to remind myself that, yeah, this little situational shyness is totally normal, can even be a part of normal development, especially in the younger ages. But it can be hard to know if it's all okay, especially with, I mean, no surprise to you, when I was a kid, I wasn't very shy. I was, you know. Bit of a ham.

[00:02:21] Dr. Nina Alfieri: You, a ham?

[00:02:22] Dr. Rob Sanchez: I know, right, were you a shy individual or were you always getting out there?

[00:02:26] Dr. Nina Alfieri: Like the quintessential middle child, I would say I was right in the middle. I was, I think I was warm most of the time, and yes, I would say I was.

[00:02:34] Dr. Rob Sanchez: But it can be hard to know, right? you had a great conversation with one of our wonderful behavioral social workers, Sara Budowsky, about this very thing, about, you know, Anxieties in children and what to look out for.

[00:02:44] Dr. Nina Alfieri: Absolutely. And this was a really special episode for me, because Sara helps all the time with our patients in clinic. And I've learned so much from her wisdom. and I really am excited about getting some of her tips and tricks out to all the parents. Sara talks a little bit about how to distinguish when this is just a personality trait or situational versus when it can become a little bit more impactful in a child and family's life and where to seek help and how to seek help.

[00:03:09] Dr. Rob Sanchez: Let's take a listen in, let's not be shy about it.

[00:03:16] Dr. Nina Alfieri: Social anxiety disorder is one of the more common psychological disorders among children, and it can be diagnosed as early as age eight. But it's often misunderstood. Today we're going to dive into this topic with Sara Budowsky, a clinical social worker and child and family psychotherapist at Lurie Children's Pediatrics at Uptown. She's also a mother of two young kids, and I'm very lucky to call her my colleague in clinic. We're going to be exploring the differences between shyness and social anxiety as well as other worries and fears young children experience. And we're also going to talk about some supportive strategies to help kids build confidence and improve their long term emotional well being. And this is a topic near and dear to my heart as the mother of a toddler who just started school and we had to do a lot of talking about separation and starting new things. So I'm very lucky to have wonderful colleagues like you, Sara, to chat about this with. Welcome.

[00:04:07] Sara Budowsky, LCSW: Thank you so much. I'm really excited to be here.

[00:04:09] Dr. Nina Alfieri: Sara, can you start us off by telling us a little bit about how your career led you to support children and their families through therapy? What's your role as a therapist?

[00:04:18] Sara Budowsky, LCSW: So I'm a clinical social worker, like you said, and a child and family therapist, and I'm part of what's called a collaborative care team. So I work with a psychiatrist in a kind of a consultant role to you and your colleagues at Lurie Children's Uptown Clinic. And we provide just guidance to pediatricians about talking to families about mental health concerns. And I have been working with kids and families in different capacities for about 15 years.

[00:04:45] Dr. Nina Alfieri: That's so great. What first got you interested in being a therapist?

[00:04:48] Sara Budowsky, LCSW: When I was a kid, I initially thought I wanted to be a doctor and then soon realized that I was way too squeamish. Like I couldn't handle blood and any of those kinds of things. But I knew I wanted to be in a helping profession. And I just have this vivid memory of watching full House, which people my age will remember. And one of the characters, right? Stephanie, the, I think the middle daughter was going through something and she was really pulling away from her dad, but also being clingy. And he took her to this special doctor's office where she played with toys and she drew and through that, the specialist was able to help her talk to her dad about how she was feeling. And that for me, it was just like a light bulb moment. I was like, that is the thing that I want to do. And I haven't really veered far from that throughout my career.

[00:05:36] Dr. Nina Alfieri: What an amazing story and what a great throwback to a wonderful show of Our Generation Full House. Well, we're so lucky that you found your calling and your passion and you've made so much impact in our clinic and in the Chicagoland community. Can you tell us a little bit about what are the common concerns parents and caregivers come to you with

[00:05:55] Sara Budowsky, LCSW: I work with all ages. I know today we're talking mostly about younger kids. And so the big things that I hear are, kids, like you were saying, having a hard time, you know, parents are having a hard time and the kids are having a hard time getting used to going to school for the first time. There's a new sibling and kids are having a hard time adjusting to that. I often hear, too, a lot of concern about that kids are shy, that they're not talking as much to other kids or that they have different preferences. Phobias, different things that they're really afraid of or unwilling to do. Parents are often really worried like, is there something wrong with my kid? I always assure families, it's really developmentally common for little kids to have a lot of different anxieties because they're learning how the world works and how to assess danger.

[00:06:36] Dr. Nina Alfieri: And how do you talk to families about anxiety? And as a branch of that, how can parents talk to kids about anxiety so that they understand it and have some sense of control over it? Since it is somewhat developmentally normal?

[00:06:47] Sara Budowsky, LCSW: I mean, I use the same language with parents that I encourage them to use. Them to use with children so that it's kind of this unified message and it's something that probably people have heard some version of this to some extent. But I describe anxiety as the built in alarm system that we all have, right? And it's there to alert us to a possible danger. And what we have to do is we have to investigate And decide, oh, is this danger real or are we okay? if we lived in a tropical jungle and there was a danger of like lions and tigers and bears or whatever, it would be important to have that, but in our modern lives, these alarms go off at times that They don't need to be going off and a parent's role in that and kind of what I really explained to them is that their job is to help the kid realize that there's no lion or tiger or bear. So if the kid has an idea that there's a monster under their bed or that there's something dangerous in the park, they need to take their kid to the park or show them what's under their bed so that the kid doesn't go on believing that monster is really there. And so even if the kid is scared of getting there, they kind of, they need to see it to have that evidence that their alarm can be turned off.

[00:07:55] Dr. Nina Alfieri: I really like this model of holding a kid's hand and walking through it with them. How can anxiety impact a child's life if it's not addressed if our tendency is to always reassure them or kind of brush it off?

[00:08:07] Sara Budowsky, LCSW: Bravery is like a muscle, right? And we have to keep that muscle strong. And so if any of us have ever broken a bone, if you're in a cast for a long time, and then you have the cast off, you can hardly lift anything and you have to do physical therapy. So kids who are overly reassured or whose parents protect them from doing hard things, they not only miss out on realizing, hey, I can do this. And it's not as hard as I thought but they also miss out on learning social skills. And, little kids are having to figure out how to share and how to take turns and how to navigate little disagreements and things like that. And if we're protecting them from ever having that discomfort in the first place, they're then also not learning that this stuff is normal and having the skills to navigate those situations. And it might make them more avoidant of those situations in the future.

[00:08:57] Dr. Nina Alfieri: That's helpful to know. I want to pivot a little bit and talk about social anxiety. I think everybody has a little bit of it to some extent, but can you tell us a little bit about what social anxiety is, especially in younger kids, and how that differs from shyness or like a core personality trait?

[00:09:13] Sara Budowsky, LCSW: I always coach parents to be careful with the word shy, or even seeing it as a personality trait. People are naturally more outgoing or introverted, but um, if we call people shy, then it makes them feel like it's not something that they can really change when really, for anyone, we can change and work on it given the right tools. Social anxiety is what you said we all experience when we're faced with a new experience or meeting new people, and it's again our alarm system telling us, Oh, this might, this is unfamiliar. I don't know if this is going to be okay. Kids who get called shy are just kids who tend to have that experience more than other kids.

The little bouts of anxiety that come and go, that's normal. When it rises to the level of a disorder is really when the alarm cannot be turned off. And so it's persistent, consistent, it's happening across settings. And so it's not your kid's afraid to go to this one particular birthday party or they're afraid to try this one new food. It's when they're globally afraid to do really anything new, or they're really, not able to consistently attend school or are just really terrified of different things in their life.

[00:10:25] Dr. Nina Alfieri: That makes a lot of sense and it kind of goes hand in hand with how we view mental health and globally that everyone has certain symptoms, but when it really impairs you is when we really want to kind of act on it and and really focus on the core of the issue. I wanted to talk a little bit. As a mom who has recently gone through this school anxiety, being a parent and supporting your child through feelings can be really hard.

And I was curious as someone who talks to so many families, from your experience, what are some of the biggest pitfalls that we as parents make in helping a young child deal with their anxiety?

[00:10:58] Sara Budowsky, LCSW: I want to just preface this all by saying I make these mistakes all the time. Everybody does. So this isn't at all to shame people, it's just to kind of draw their attention to things that we all do.

[00:11:07] Dr. Nina Alfieri: I'll give a first example of doing the wrong thing by lingering at daycare drop off for too long. The teachers are so sweet, but they always give me the eyeballs like she's really okay, and it's that 30 second hesitation that can unravel a great morning,

[00:11:22] Sara Budowsky, LCSW: Oh, absolutely. And the kids see it and they see they're in to get you to stay even longer and longer. If you let a kid skip school for anxiety even one time, may know, Oh, this is a thing that I can do that I can get away with. Kids are smart.

And so once you open that door, you're probably going to see it happening more and more. And so it's good to kind of catch it early or really not to let it happen from the start. Oftentimes parent responses to kids anxiety is kind of fall on two ends of the spectrum, So you've got the parents who, like you said, who just really want to reassure and comfort and kind of wait until the kid is ready. But if we never give them that gentle nudge, they're never gonna dive in, right? Just if you give a kid a bowl of candy, they're not going to stop on their own eating it. They want to stay in their comfort zone. The other end of the extreme, you've got parents who tend to kind of downplay the kid's worry and want to really push them.a lot. And it's coming also from a really good place. They know school's not scary. They know that the bugs or the needles or whatever it is, it's not something that's really dangerous. And so they just, when the kid says, Oh my gosh, I'm so scared. They just say, don't worry about it. You'll be fine. But what can happen is then the kid feels like they don't know that I can do this because they don't actually get how hard it is.And that makes them dig their heels in even more. I don't think I mentioned this, but I mean, I think in most co-parenting relationships, oftentimes one parent falls on one side and one falls on the other and people are probably like, who's right? Neither's right. The answer is really in the middle.And it's working as a team to provide just the right amount of support to your kid while also giving them a push to help them really realize how brave they can be and how strong they can be.

[00:13:05] Dr. Nina Alfieri: Yeah, it sounds like a lot of this is support, confidence building, but also challenging them just a little bit out of their safe place in a very supportive way. As we're talking about school avoidance, school anxiety, are there factors at school that parents should think about, before they go to gently push or reassure what are some questions parents might want to ask their child before if they're having trouble with going to school?

[00:13:26] Sara Budowsky, LCSW: It's really important for parents to understand exactly what's going on, and I think the way that you're going to get that information is by validating how the kid is feeling. As soon as they know that you care, I think um, I think that the more people get that like that they're really scared, then they're going to be more receptive to you asking questions. so I think you want to find out, is there a particular child that they're having trouble with? Is it something about how the teacher is responding to things? Is there something going on at school??, I think it's also important to, also triangulate that with talking and partnering with your kids teachers to find out their take on it, and then also to, be able to work with your child's teacher and their staff to have a plan for how you're going to help address this for the kid. And so oftentimes for kids, it's that they just don't know what to do with themselves when they first get into the school room and they feel anxious in that moment and knowing, oh, hey, they just don't know. They feel a little uncomfortable. Maybe we can have the teacher greet them or give them a special job or help introduce them to a friend, something like that.

[00:14:33] Dr. Nina Alfieri: I found that some of those strategies really helped with our journey through school anxiety, not lingering too long at drop off. I know she's in a warm, friendly environment and gets along with her peers. And so I noticed when I dropped her off, the teachers would immediately take her hand and bring her into an activity and there'd be a lot less tears and tantrums and the transition was much easier. Kind of working with teachers, they're so knowledgeable

[00:14:54] Sara Budowsky, LCSW: I think it's also important to find out from the teacher how long your kid is struggling in the morning. Parents do have to leave their kid who is crying and is seeming really upset, and that's a really hard thing to do as a parent. It was certainly really hard for me to do, and it was one of those things I'd been telling parents, Oh, you just do it, they'll be fine. And then when it was my kid, it was really hard. But then, oftentimes kids who are just dealing, again, this comes to, is it a diagnosis, you know, is it a disorder or just anxiety? Most kids, even if they've cried. At first, they calm down very quickly. It's important to check in with the teachers. Is my kid just crying while I'm still there when they can still kind of see me and they're maybe seeing if I'm going to come back or they're just kind of getting used to the transition or are they crying the whole day? Are they not engaging the whole day? So I think that's also really important data to have.

[00:15:46] Dr. Nina Alfieri: Yeah, that's such a great point. What are some of the strategies or routines that parents can implement at home to help their child manage social anxiety or even other worries that they might have? You know, I think some of us worry that we're causing additional stress by talking about the issue. It's always kind of this age old question of how much do you address it and how much do you reassure? What do you advise on that?

[00:16:07] Sara Budowsky, LCSW: You really want to give your kid the full range of, you know, vocabulary to be able to express themselves and to validate your kid's anxiety. We throw that word around a lot, and we realize not everybody knows what it means. validate really means, just reflect back what you're hearing the kids say and to express that you really get how hard it is. It doesn't mean that you agree with them that it's really hard or that it's really scary. I think that's what a lot of parents are afraid of. That if I say, oh, I know you're really scared to go to school, I hear how scary that is, that the kid's going to be like, oh, okay. It is, like it's going to reinforce it. And actually that just shows them that it's safe and it's okay to talk about, and then they're going to, like I was saying earlier, be more receptive to guidance that you have for them about how to navigate it. asking specific questions to understand what the anxiety is and doing just a lot of playful things to help the kid investigate their fears. So, my daughter was afraid. I found out eventually that she didn't want to go on the toilet in public places, so when she was three and four years old, she'd been toilet trained for a long time. She would not go on the toilet anywhere that we went out. And we finally figured out it was because she was afraid that she was going to fall into the toilet. And so we had to do a lot of just playing around toilets and flushing the toilet and putting colorful stuff in there. And making it not something that's scary, not something that we don't talk about, but something that we integrate into our lives and it's also a bonding experience. And then when we were out in the world, we could be like, Oh, remember like, nothing going, look at how little that is. You know, look at how little that is. The hole in the toilet is nobody's going to fall in.

[00:17:46] Dr. Nina Alfieri: What a great idea. And what is it with public bathrooms and kits? My toddler is very afraid of those electric hand dryers.

So we had to do a lot of talking about how it's a rocket ship. But to her credit, they do come out quite vigorously. So the validating step is really important. Can you tell us a little bit about once you have an idea of what a fear is, how do you actually help a child address it as a parent? How do you help them face it with bravery? And what are some tips you can give us?

[00:18:13] Sara Budowsky, LCSW: Yeah, so I think it's about breaking the scary thing down into small steps. So if your kid is afraid to go all the way into school, maybe the first goal is like just going to check out the place. And then the next day you go with them, but you stay around for a few minutes. And then the next day, they can check in with you and it, you just kind of make a plan that they're going to do it step by step. It's not pushing them really hard to do the most difficult thing all at once. Um, And it looks different depending on what their fear is. And oftentimes, you can even incentivize it a little bit, you know, a lot of parents are afraid of Bribing their kid, right? But we don't want to buy our kid a gaming system every time they go to school or every time they do a new thing. That doesn't work. But giving a lot of praise, giving a sticker, giving special time to your kid to reward them for being courageous. That is really valuable. Just in the same way that we get a little, a tap pad on the back from our boss or from our partner can be really helpful. We want to avoid yelling at kids. It can be really frustrating when our kid won't do the thing. And so sometimes parents yell or they want to resort to punishments like, if you don't do this thing, this will happen. It might seem like it works in the moment, but it really can backfire and actually create more of a negative kind of feeling around the situation. And so it's much better if you're feeling really stuck in your kid, you're trying to incentivize it, you're trying to break it down into small steps, and it's also important to develop those steps with the kids. even having them say, how afraid are you to do this thing? Show me with your hands and then say, okay, well, if it's 10 out of 10 hard what would be like one out of 10 hard? And with a little kid you're doing like this and then start there. And then say, okay, well, what's something that's a little harder than that? And then do that thing. But you want to, Yeah, just really have a lot of warmth and understanding around it and partnering with your child and not making it a scary thing. And that's going to build their internal motivation to do it, that they're not just doing it because they're afraid of punishment.

[00:20:17] Dr. Nina Alfieri: So Sara, we talked a little bit about some lighter examples, like being afraid of things like the toilet flushing or the dryer in the bathroom, but we live in a world where there are scary things that actually happen, and kids unfortunately are exposed to scary things and can witness traumatic events first hand, second hand, or just watching on TV. So how do you advise parents to help children through events that are truly traumatic and some of the anxiety that can arise from those situations?

[00:20:46] Sara Budowsky, LCSW: Yeah. Well, I think a thing that often happens and, you know, it comes from a parent's protective instinct is a lot of times when something terrible happens, parents don't want to talk to the kid about it and they try to really buffer and shield the kid from it, but oftentimes we can't do that, right? Oftentimes the kids pick up that something is up. They hear whispering in the house or they hear things on the news. And if your kid overhears on the news that there was a shooting and then you say, Oh, no, nothing. Nevermind. They were just talking about the weather. Like nothing happened. But that actually is scarier for the kid because they imagine all kinds of things and we're not having the opportunity to really control the message. And so I always encourage parents to really talk. So, being able to talk candidly with their kids in an age appropriate way about what's happened and then to talk to them about, like, their safety plan as a family. So, being able to say, there was a shooting in the neighborhood, there was a bad person who came and hurt somebody. The police were able to get them. We're safe. And here's the things we're going to do as a family to keep ourselves safe. But I know that's really scary. And if you need a hug, or you need to talk about it, like I'm here to talk about it with you. There's a lot of books out there that can be useful. And child parent psychotherapy is a great modality if your kid has had. If you've had extensive trauma or if you and your child have experienced a trauma together, that's a therapy that can help you both to heal from it.

[00:22:11] Dr. Nina Alfieri: I really appreciate kind of the wording and the modeling of how to break hard news to kids. And I think your point about doing it in a developmentally appropriate way is really important because, we recently had a death in the family and I had to break that news to my toddler and I think it would have been very different wording if she was nine years old versus, you know, she was almost three. But I needed to tell her there was going to be a lot of tears at the funeral and what was going on. So, I appreciate you rooting that in the child's developmental level because I think that's important. It's really important.

[00:22:40] Sara Budowsky, LCSW: Once you've told them, hey, this bad thing happened, see, do you have any questions? Is there anything you're wondering about? Because that will tell you where your kid is developmentally, and then you'll be able to answer and attend to their needs. If someone in the family has been very sick, sometimes when someone dies, we say they were sick. Um, I think kids are just, you know, they're just so sick and they died. And so kids might misunderstand that and think, Oh my gosh, every time anyone is sick, they could die. And so it's also being careful to use that nuance that grandpa was a certain kind of sick that doctors tried everything and they weren't able to help him. But I want you to know that's not the kind of sick that you get. That's very different from the colds that you get or that mommy gets or things like that.

[00:23:22] Dr. Nina Alfieri: Those are really great and practically useful tips. Thank you for those. Since I'm a general pediatrician, I have to ask you a prevention question. Tell me a little bit about what parents can do to bolster confidence in kids who experience shyness or experience lots of worries. How can we as parents prevent it from developing into an anxiety disorder?

[00:23:41] Sara Budowsky, LCSW: The big thing is finding all different kinds of outlets for your kid to get, a fun experience being around other kids or doing new things. So finding classes and activities, and just fun things to do and being really consistent about it. So not just trying it once and then giving up, right? If it doesn't go really well, but just be like, this isn't part of our life. We're going to go to these playgroups every single week and that kind of thing. I really love the films inside out. I, a lot of parents don't realize that they are, they were developed in consultation with therapists. And so I think, watching those early on to just introduce your kid to that vocabulary so that you can start to have those conversations and through that you really wanna teach them, bravery is about doing something. even though it's scary. It's not about not being scared. That the truly brave kids are ones who see something, it's hard, and they do it. But also not shaming them if they're not ready. Normalizing that everybody feels anxious, including you. And, it's really saying, anxiety is harmless. It can't hurt you. Parents who are anxious have anxious kids, and so it's really good to do work on your own anxiety, both so you have skills to give your child and also so you can use yourself to even be able to say Hey, I don't know anybody here either. I'm feeling a little bit nervous. My heart's beating. I feel a little shy. Should we take a deep breath together? Should we go get a drink of water? What do you think about, starting, we'll stay on the outside and then we'll work our way into the center of the group kind of thing. And that helps them feel like, okay, like my mom deals with this, my dad deals with this, like I'm not, there's not something wrong with me. This is just a thing that people learn how to deal with like anything else.

[00:25:25] Dr. Nina Alfieri: I love it. Those are such great tips. And I think kids look to us as role models. And so, modeling that behavior and how to face this bravely can be so impactful for our kids to see. Sara, I want to talk about separation anxiety because it's something that we see a lot in clinic and I know you help our patients with a lot too. Separation anxiety is a really big topic and can take many different forms. Bedtime procrastination, again can play into not wanting to go to school or feeling a little more apprehensive away from your family. What's your approach to separation anxiety? What can families do to help children through those feelings?

[00:25:59] Sara Budowsky, LCSW: Well, I think it also really depends too on your child's background and their experience. So I think if you have a child who is. you've adapted from foster care or who has been through trauma, I think you're going to probably approach it a little bit differently than a kid who's just experiencing separation anxiety as part of their normal development. But assuming, that your kid hasn't had, some major, really traumatic, scary thing happen, I think it's really, and even if they have, it's about, again, doing it in, small steps and finding ways to help your child feel that they're connected to you, even when you're not there, right? And so having a predictable, consistent routine at bedtime or a drop off, having special objects that you give them, my kids, when they first started school, like they had a picture of the family in their backpack so that they could look at that. And we talk about, there's a book about this called The Invisible String, and it's this idea that, anybody who you love, who you're connected to, you have this string that connects you, even if you don't see each other. And that if you miss that person, you can kind of imagine, you can think of them and that pulls the string and that, that person feels it in some way. Even when my kids were little, I would put little string bracelets around their wrists and be like, that's our string. So anytime you miss me, you can look at the string too, to still feel connected to us.

[00:27:20] Dr. Nina Alfieri: I love that. Those are some really great strategies. I love using media books and songs and episodes to help. Our family listens to grownups come back by Daniel Tiger on

[00:27:31] Sara Budowsky, LCSW: A great one. Yep. Daniel Tiger's got some great

[00:27:34] Dr. Nina Alfieri: Oh my gosh, it's the absolute best. I was giggling when you were talking about the photo because there is a photo that my daughter carries around at school and when the teachers send pictures of her, she's often showing it to other kids. This is my family and she's the only one who has it. So it's great. But these are really tangible and helpful. coping mechanisms that can help kids who are a little bit more wary of separating. So thanks for those.

[00:27:58] Sara Budowsky, LCSW: And I just had one other one that I wanted to add to is, I think, using play. So kids, their primary language, right, even if they are already pretty verbal, they're still going to play about things that are hard for them to verbalize. And so, play is wonderful for the parent child relationship anyway, but I think also playing out with stuffed animals, or whatever, stories about families separating and coming back together, that can be a really valuable way to model for them that grown ups come back. And also, it creates a space for them to play out exactly what they are afraid of, so that you can reassure them or kind of address their specific worry..

[00:28:35] Dr. Nina Alfieri: So we talked a lot about the difference between. Anxiety that is kind of omnipresent and can be normal. And then we talked about the kind of anxiety that tends to cause impairments and functioning. How do parents really know when it's time to seek an expert opinion and who are the appropriate experts to talk to if parents are worried about this?

[00:28:55] Sara Budowsky, LCSW: I think the big red flags are if your kid is regularly missing school. So it's one thing if they miss, a day once in a blue moon, but if your kid is even missing like a day a week, that's probably the start of something and you want to catch it early before it becomes something bigger. If you as the parent are feeling really overwhelmed and stressed out, that's a sign to talk to somebody. And then if your kid's getting in trouble a lot. So that's something that we haven't talked about a lot. But there's some kids who present with the classic signs of anxiety. There's other kids who are just gonna look defiant or like they're not listening to their teacher or they don't wanna go to the next class or whatever it is. And oftentimes that's coming from anxiety. So if you're having that kind of issue, there could be other. So, I always recommend, now, if you have these red flags, it doesn't mean you have to go right to finding a psychiatrist. The first step is talking to a specialist who's already in your kid's life. So, that could be the pediatrician like you. It can be a nurse. The teachers, also school social workers, are, in almost every public school, and they're a really great resource just to talk to and to get a sense of if they think that this is something that you should pursue further treatment for. And they can help you troubleshoot some of the strategies that you're doing and help you figure out, oh, maybe I could tweak this, or maybe this is a different way to approach it.

[00:30:16] Dr. Nina Alfieri: Sara, I totally agree. Please parents reach out to us, reach out to your pediatrician and school teachers and social workers are a wonderful resource.

What's the next level look like? What types of therapies are effective for children that need therapy for anxiety? What are the goals of that therapy? Can you walk us through that?

[00:30:35] Sara Budowsky, LCSW: The main kind of first line therapy for kids who have anxiety is called cognitive behavioral therapy. The thing is it's really Most used for kids who are six and up. So I'll talk after this about some modalities for younger kids. But CBT really focuses on helping kids learn, relaxation skills, mindfulness, those pieces. That's what most people are most familiar with, but it's also about helping kids learn to more accurately assess danger, paying attention to their thoughts and realizing when their thoughts might be tricking them so that they can turn off their alarm if there's really, a situation that's not as dangerous as it feels. You know, we talked about trying things step by step. They do it in a more systematic way. So they would really be working with you and your child to make a structured plan of, okay, step one is we're going to do this, step two is we're going to do this, and how you're going to kind of reinforce that. And the goal is really, again, for the kid to have data that the things that they're scared about are not as scary as they think, and that they're stronger and braver than they think. Another therapy modality I really love that works well for kids who aren't as verbal, it's actually used for kids zero to six. It's called child parent psychotherapy and that was developed initially for kids who experienced trauma but now it's been found to be effective. With any kid who's experiencing stress. And CPP really, it's called CPP, really focuses on using play and using the parent child relationship as the source of change. And so it's really creating opportunities to reinforce and strengthen the parent-child relationship so that the parent can model and teach regulation to the child and sort of help them navigate the challenges that come up.

[00:32:19] Dr. Nina Alfieri: Sara, we talked a little bit about the different types of therapies that can help children.In addition to therapy as a first line intervention, what are some other interventions that can help children with anxiety?

[00:32:30] Sara Budowsky, LCSW: Yeah, so I mean, for me as a therapist, if I'm doing CBT with a kid and a kid is having a really hard time, working through the different exposure exercises and taking things step by step sometimes, different medications can help make that process easier, but by reducing the kids overall anxiety, and so when I'm feeling stuck in therapy, I might encourage a family to talk to their pediatrician or a medical provider about different medication options that might be available to them to help therapy work better.

[00:33:00] Dr. Nina Alfieri: Absolutely. Yeah, and we always encourage and recommend families to come to their pediatrician's office and talk about this because there are some times where medications are indicated and can be helpful if there's significant impairment and there's a wall that a child is having a hard time kind of breaking through. Some of the more common medications we might use are an SSRI or selective serotonin reuptake inhibitor. Or if after an evaluation, if it seems that some of the issues are more rooted in ADHD there are great treatments from a medication perspective for ADHD also. So, I totally agree with you that therapy is absolutely the first line, but. Keep your pediatrician's office in mind if your child is experiencing more severe symptoms or you're not seeing a ton of progress and you want to kind of look at the next step. And I also circle back to your point about working with school and, there's been many times where my patients have had tremendous benefit from having school accommodations. I feel like they have a hard time speaking up in class, just letting the teacher know that and having the child have a little more space to formulate an answer or more time on a test. Those things can be really immensely helpful and in my experiences, schools and teachers have been so supportive of individualizing care for my patients who have concerns or anxieties around school. I want to just close by asking you, what is your favorite part of what you do?

[00:34:21] Sara Budowsky, LCSW: I think kids are super fun and they think about things in a totally different way from what, how we do. But I think the thing that really keeps me involved in this work and like the thread through all the jobs I've had is supporting the attachment relationship between kids and their caregivers. I mean, I think that is just the most rewarding thing and secure Supportive attachment, like that prevents against so many things. And so it's just really been always meaningful to me. And especially now being a parent, I really recognize the importance of it and get a lot of joy out of it. And also it's fun to be able to come to work in color, play with blocks and do things like that. Be goofy and still have that outlet.

[00:35:03] Dr. Nina Alfieri: Sara, so much of what you said resonates with me because I also love it. The simplicity and the depth and the importance of building a nurturing family relationship for kids and this reminds me a lot of an episode from the very beginning with Dr. Glusman from our clinic where we talked about something as simple as just reading with your child and how just a couple minutes a day of that eye contact and deep connection can be so beneficial and it's kind of, It's coming full force here in this episode where we're talking about anxiety prevention and ways to help build confidence in your kids. What are ways that this nurturing relationship can help your kids and what can it prevent in the future?

[00:35:43] Sara Budowsky, LCSW: There's research that shows that even having one positive attachment relationship, so a connection to one key adult can. really increase a kid's resilience. So it can reduce their likelihood of having anxiety or other mental health conditions as they get older, and it can also make it easier for them to bounce back from different challenges that might happen in their life throughout their life. I think both just because the existence of that relationship is protective and also because the relationship is a place where they're going to be continuing to learn strategies for navigating those challenges as they come up.

[00:36:17] Dr. Nina Alfieri: That's beautiful. Thank you for that. Well, Sara, you're an absolute gem. Thank you so much for joining us. It's truly an honor to be your colleague and I learn so much from you every day. Thank you so much for joining our show today.

[00:36:29] Sara Budowsky, LCSW: Thank you so much for having me.