Understanding and Dealing with Children Who Refuse or Avoid Going to School: A Cognitive-Behavioral Approach

0:00 My name is Kelly, and I’m with the New Jersey Center for Tourette Syndrome and Associated Disorders. I will be your organizer for this evening. I’d like to welcome you to our webinar on Understanding and Dealing with Children Who Refuse or Avoid Going to School, a cognitive behavioral approach. Thank you all for joining us. Before I have my colleague introduce the speaker, for tonight, I’m going to cover some housekeeping items with you. All participants are muted. 0:33 If you have a question, please type it in the bottom of your question box and click send. You may. You may send questions during the webinar. However, we will have doctor … answer the questions at the end of his presentation. We will get to as many queries as time allows. And, in addition to tonight’s presenter, will be available to take your questions on the Wednesday webinar blogs, which is accessed from our homepage under the Heading programs, This blog will be monitored for the next seven days. Feel free to post questions as often as you like. Answers will be archived for future reference. 1:12 If you missed part of the presentation, or would like to watch it again, an archived version will be posted to our website shortly. We value your input, and in order to expand the webinar experience in the future, we need everyone to fill out the survey as you exit the webinar. 1:31 NJ Center for Tourette Syndrome and Associated Disorders. Its directors and employees assume no responsibility for the accuracy, completeness, objectivity, or usefulness of the information presented. Nor do we endorse any recommendations, or opinion made, by any member or physicians. We do not treat you are responsible for your own medical decisions. Now, I’m going to turn over the introduction of our speaker Marty Butterfield, the Webinar co-ordinator of CTAS. Thanks, Kelly. Good evening, everyone. Welcome to tonight’s webinar. Thank you for joining us. This is our first webinar of the 2019, 2020 school year. And we thought it would be inappropriate time to cover the topic of school refusal. 2:21 Before I introduce tonight’s presenter, I would like to remind all of you folks, joining us tonight, that we will be at the Convention in Atlantic City Boost 12 oh 9, on November seven. And if you’re attending, please stop by our booth, and say Hello. 2:39 Additionally, we will be presenting a workshop on Tourette syndrome at 11 AM on Friday, November eight. 2:48 For those of you in the education fields, the workshop would be well worth your time. 2:54 Now, to the introduction of tonight’s presenter, Meir Flancbaum, Psy.D., received his doctorate in Clinical Psychology from Rutgers University, with a specialization in Cognitive Behavioral Therapy for Children and Families. He completed his internship in child and adolescent psychology at the New York University Child Study Center. 3:19 Additionally, he provided clinical services and received specialized training at several prestigious programs, such as the Child, Adolescent, OCD, and Anxiety Group at the University of Pennsylvania School of Medicine, the Tourette Syndrome Program at Rutgers University, and the Institute for ADHD and Disruptive Behavior at NYU Child Study Center. 3:48 Doctor Flancbaum is a clinical psychologist and director of the Center for Cognitive Behavior Therapy in East Brunswick, New Jersey. 3:58 He provides therapy school based consultation services and professional development workshops focusing on the evaluation and treatment of children and adolescents with a variety of social, emotional, and behavioral difficulties. Additionally, he has specialized in the assessment and treatment, that’s Tourette Syndrome. 4:20 Hair pulling, skin picking as well as OCD, ADHD, and a range of anxiety disorders. He also has a specific interest in school phobia, and parent training. 4:34 In addition to his clinical practice, as clinical Assistant Professor and co-ordinator of cognitive behavior therapy, training for the Child, Psychiatry cellos in the Department of Child and Adolescent Psychiatry at Rutgers Robert Wood Johnson Medical School in New Brunswick’s. Doctor Flancbaum, Welcome to our Wednesday, Wednesday webinar programming and I’m pleased to turn tonight’s presentation over to you. 5:03 Thank you very much, Marty and Kelly, especially for that warm introduction. 5:08 I’m honored to be able to present today for …, an organization that I’ve had the opportunity to follow and found to be a wonderful organization with passionate staff, and a really important mission. I’m grateful again for the opportunity, and thank you all for joining for my talk tonight. 5:33 We’re going to talk today about school attendance and how to get kids to go to school. Formally understanding and dealing with children who avoid school cognitive behavioral approach. 5:46 While we’re not, specifically talking about Tourette syndrome today, I am, you know, I certainly welcome some questions in particular about it at the end if people do, if people do have any. 6:01 I’m sorry, I’m doing a webinar for the first time, which I’m very excited about. 6:06 Kelly, is there a green thing on my screen? I don’t know if you’re able to see, oh, here we go. I apologize about that. 6:17 So just to give a brief overview, today, what I’d like to talk about is little introduction to school refusal behavior. We’ll talk a bit about how to understand, how to think about children who refuse or have great difficulty attending, going to school. And then we’ll get into some strategies we’ll talk a bit about in addressing anxiety based school refusal. 6:40 Then we’ll cover some general accommodations that can be useful for, for schools to consider. And I’m hoping at the end that I have the opportunity to take some of your questions. If we don’t get to your questions, Kelly mentioned that there’s going to be a blog at the end. You’re welcome to reach out to me that way. My e-mail address, you know, is also a good way. You’re welcome to reach me with any questions there, as well. 7:13 Going on with my script, with my screen here, There we go, OK. 7:28 OK, so just as a, as an introductory remark, let’s talk a bit about the problem. John is not a particular patient, but a hybrid of a number of patients that I’ve seen over the years. John is an 11 year old boy. 7:46 And he has some difficult mornings. He complains of stomach pain. In the morning, he’s often getting into arguments with his parents, about going to school. He says, he really doesn’t want to go, he doesn’t feel like it. When John does go to school, he’s anxious about failing. He tends to feel really uncomfortable around others, And so key. 8:10 And so, when he is, know, when he is entering questions in school, his heart starts to beat very quickly. You know, he often tends to put his hands down when he has a question. He’s really uncomfortable asking them. He’s also very concerned about how he’s going to do in class. He’s worried about failing, which is really interesting, because John actually does pretty well in school, but the fears are there, and he’s very uncomfortable around other socially, he’s worried about saying something silly or embarrassing himself. As a result of not being in school, though, John has come to fall behind in his work, and he is very worried about how he’s ever going to catch up. 8:48 John really does want to go to school. He just can’t seem to get himself there on a regular basis. There are a lot of things that we could say about, about John from a diagnostic perspective. 9:01 You know, this case was deliberately, deliberately vague. But one of the areas that stands out for John would be a problem that’s often referred to as school refusal. 9:14 So let’s talk a little bit about what school refusal is. 9:18 To begin, I would say that school refusal is a, is a condition, or is it really a term that I believe is pretty poorly named, but nonetheless, well defined. So let’s talk about a couple of characteristics of it. When people talk about school refusal, they are referring to child motivated, absenteeism from school. In other words, children who, for some reason, and we’ll talk more about that. That notion of motivation later, for some reason, are not going to school. They may be chronically tardy or leaving school early. 9:51 In other words, it’s, in other words, they, they, may make it to school, even if they’re considered school refusers, but they’re often late. They go home early sometimes before they go to school, they have a significant tantrum or a lot of complaining or conflict at home. 10:08 Other times, children who have school refusal do actually make it to school. But when they are in school, they exhibit extreme distress. The reason I referred to school refusal as being poorly named, but nonetheless, well defined is because while I think the criteria above are pretty clear, there’s something about the term school refusal that I don’t, that I don’t love. It has a connotation perhaps, to some, that a child is choosing not to go to school. 10:34 And in reality, that’s not always the case. Somebody, someone with school refusal may be making a voluntary choice to stay home, but other times this is his decision may be more involuntary. Or, perhaps one could call it semi voluntary. in the sense that he is not going to school, but because of the fact that he or she may be anxious or really uncomfortable when at school. 11:00 School refusal is an umbrella term for chronic absenteeism. In other words, school refusal is not a formal diagnosis. Oftentimes, though, children may have some other diagnosis that goes along, or comes along with school refusal. In other words, absenteeism is really only the tip of the iceberg. According to this particular research that I cited here, about a quarter about a third of kids with school refusal behavior don’t meet criteria for a diagnosis. 11:34 Then a good chunk of them have separation anxiety disorder, particularly the youngest kids. 11:40 Some of them are diagnosed with a generalized disorder, generalized anxiety disorder or GED and others have ODD major depression specific phobia or other conditions. In my clinical experience at different points in time, my practice has had a pretty significant numbers of children who are avoiding or refusing to go to school. I would say that I rarely see children who don’t have a co-occurring diagnosis. In other words, in my experience, children tend to have a co-occurring disorder. I would say the vast majority of the time. 12:20 That doesn’t mean that it doesn’t exist. Otherwise, you know, the research studies are based on large sample sizes. But just from a clinical perspective, I often do see a good chunk of kids. And they seem to often be having these co-occurring conditions. So why do we want to go about treating school refusal? 12:39 School refusal has important, important consequences, both in the short term as well as in the long term. 12:45 In the short-term, with school refusal, as many people, especially those, you know, professionals, and parents on here, who have children, or students with this condition, they tend to have poor academic performance, impaired social development, And oftentimes, no depression, and suicide ideation. The logic behind these short-term consequences is that when children are not going to school, they’re often going to begin to struggle with academic performance. Social development is often a set of skills that is shaped from being in school and from interacting with same age peers. 13:24 And when you’re consistently not in school, you don’t have the opportunity to practice those social skills and then they often become underdeveloped. When children are very isolated, from not going to school, that in many cases can trigger, you know, depressive episodes and even unfortunately, suicide ideation. 13:45 This is the reason it suit that, know, that addressing school refusal promptly becomes so important, The short-term consequences kick in, additionally, some long term consequences when children refuse to go to school and then often don’t make it back. Is there at greater risk down the road for engaging in criminal behavior? 14:07 They often have greater interpersonal difficulties, marital problems, social isolation, difficulty with maintaining jobs, and a higher occurrence of psychiatric problems. 14:19 So what are we going to do about children with school refusal behavior? 14:24 The first step is always going to be a comprehensive assessment. This is important for most psychiatric conditions, most medical conditions, and particularly important with school refusal, because there are a lot of different components that can come into play. 14:37 So when I’m working with children with school refusal, I recommend a, a multi factor, you know, a multi multi component. 14:47 Multi component assessment, I often speak to parents about how I view addressing. School refusal is putting together the pieces of a puzzle. And so I’m going to have a child component of my assessment, a parent component of my assessment. 14:59 Very critical, as well as a school component of the assessment, and if children do have a history of any psychiatric difficulties, I will want to speak with their psychiatrist, and oftentimes they touch base with the pediatricians as well just because they have a long history oftentimes are several year history of knowing via knowing the patients. 15:19 So in terms of the clinical interview, What I often find to be beneficial in these situations is to really try to connect with the student and understand some of the student’s interesting goals. 15:31 So, whether you’re a psychologist doing this evaluation, or whether you are school personnel, it’s really important to try to get into the child’s world a little bit. Sometimes, people consider understanding the student’s interests, talking about the students goals as being part of rapport building, or just kind of getting to know the child. There is some merit in that, but I think that, it is also really important component of trying to do effective treatment. When we understand the student’s interests, we often can come up with better metaphors to be able to relate what we’re doing in treatment to the students, to the student, to, in order to build motivation. Similarly, when we understand what the child goals are, particularly something like career goals, that can be really helpful. And I wouldn’t be turned off by the notion of, oh, my child is nine years old, he doesn’t have career goals. He may not, or she may not have really thought out goals. 16:26 But just having a sense of, you know, the child wants to grow up and be a teacher like Mommy or Daddy or Grandma or the child wants to be able to child be able to build cars one day or two, You know, make video games. 16:40 Those are nonetheless little nuggets that we can use in order to be able to help connect, help bridge where the child is at, with not going to school and how the child would benefit from going to school. 16:55 Additionally, in terms of the clinical interview with the child, we want to get a good sense of what are the different, different psychological, psychiatric symptoms that might be going on. Particularly, among children who refuse to go to school. There’s a high co occurrence, like we talked about earlier, with anxiety disorders and with depression. We also do want to be on the lookout for suicide ideation, thoughts about deaths. It’s not something to be paranoid about. It’s not something I know that’s clinical word is not something to be overly concerned about. You know, it’s not very common. But certainly it’s something that we want to be vigilant about in our assessment. 17:36 In case we need to change the course of treatment to address that, as that would obviously be, the most pressing concern, were that to be the case, that’s in terms of the child. Understanding the home environment is very important for addressing school refusal, because parents are a really important part of the treatment process, whether we’re talking about a little kid or an adolescent, or even adolescent. You know, whether we’re in elementary, middle, or high school. 18:04 So in terms of the home environment, understanding the parent’s attitude, about school refusal, how they use a child, not going to school, Understanding the parents discipline style. Some families are very heavy on love, they’re also very heavy on limits. Indiscipline, other families are very heavy on love and light on the limits, and others tend to limit both of them. You know, they don’t have enough positive attention that they’re giving their children, and they also don’t have enough limits. Understanding these factors, you know, where parents kind of fall on the scale from being kind of over protective, leaving their child thinking their child is independent, is really important, because parents are going to be given strategies to be able to assist the child with making steps towards returning to school. And, of course, understanding the stressors that are in the environment can be really critical as well. 19:01 Know, if there are limited resources at home, if parents are working multiple jobs, if there’s only one parent or grandparent home who’s taking care of the child. And another thing to keep in mind, in terms of the home environment, is sometimes, children go don’t go to school. There is a legitimate stressor that’s going on. So occasionally, what happens is, children may not be going to school because mommy or daddy or grandma or caretaker is sick. And that’s an important component, while certainly, we would encourage the child to go to school, and that may be a treatment goal nonetheless. We would want to have proper sensitivity regarding that. We also want to make sure that we incorporate the school’s view of the challenging behaviors. Getting information about what actually happens when the child is at school, and the needs that the child seems to have. 19:53 At school, where’s the child successful, where’s the child not successful? Those are all critical components. one of the cool parts about the webinar is, before I presented here, I got some stats from … 20:05 about, know, who is actually attending this webinar. And it seems that we have a nice mix of school based professionals, mental health clinicians, and parents of children, you know, who exhibit school refusal and, and some others. So I will try over the course of our strategies to, to hit avenues of intervention that could be helpful for all of you in each of those in each of those different settings. Just quickly in terms of assessment, I know this will probably be more relevant for, for folks who are school prep, school professionals, mental health professionals. There are a couple of questionnaires they’re listed here. I would encourage you to incorporate them into your assessment. The School Refusal Assessment Scale, we’ll talk about in a moment, in terms of what it does. The scared is an anxiety, anxiety, screening measure. 21:00 It’s available free, You can just Google for it. The child depression inventory is a, is a measure that can be purchased. Questionnaires are really not a way of making a diagnosis. But they are a way of gathering information. They are a piece to the puzzle. 21:17 That school refusal assessment questionnaire is designed to help us with getting to the root of the problem, and ultimately, when we are effectively addressing students who are exhibiting school refusal behavior, we have to figure out a way to get to the root of the problem. The root of the problem when it comes to school refusal tends to be 1 of 2 areas. Either written access function, or an avoidance function. And let me explain what I need. 21:44 When we’re referring to the access function, we’re referring to students are not going to school in order to gain certain things at home. 21:55 The avoidant function refers to, students are not going to school in order to avoid certain things situations at school. 22:07 So for example, students may not go to school because they are fearful, they are avoiding, certain objects are people, maybe it’s the alarms, the playgrounds, the busses teachers. 22:22 The locker time is a common one. 22:25 The noise in the hallways. 22:26 Students may also also be avoiding certain anxiety provoking situations, performance, situations, taking tests, having to give presentations being worried that the teacher is going to call on them and they are going to make a silly remark or everybody is going to laugh at them if they say the wrong answer. 22:47 So, children refused to go to school in order to avoid these objects, or people, or performance situations. 22:55 Other children are, not, per se, avoiding school, but they’re staying home from school because of what they gain. Sometimes, it’s the case that some type of tangible reward, You know, they get to sleep late. They get to hang out and watch television. You know, maybe they have other friends who are not going to school and they are, they are talking with them. They are, you know, drinking or using drugs, or vaping, or some other, some other reinforcing activity for them. Sometimes it’s not that tangible thing that they’re gaining. But sometimes it’s the attention that they’re gaining. An attention can come in different forms. I often talk, when I talk about behavior management, either teaching parents are presenting at school workshops. I talk about the idea of behavior, man. I talked about the idea of attention is having three levels. First prize as positive attention. 23:44 Positive attention, as we know, is gaining attention for engaging in inappropriate behavior. 23:49 The second prize though is negative attention. 23:52 Negative attention is gaining attention, gaining attention for problematic behavior. The notion here is kinda like the expression of some children would rather be wanted for murder, then not want that at all. At least somebody’s paying attention to them. And so this is why even when children are having tantrums at home, and parents are tending to them and trying to calm them down, that can actually be maintaining school avoidant behavior. Because even though, as parents were saying to ourselves, gee, there’s no way that he wants me yelling at him, there’s no way he wants me telling him, it’s almost time to get to the bus. Nonetheless, we are giving them a tension, which is perhaps better than no attention. And then third prize would be no attention at all. So we have positive attention, attention for negative behavior, and finally, no attention at all. 24:38 So, understanding the root of why children are not going to school, whether it’s the access function, or the avoidance function, is really the key to trying to figure out how we’re going to effectively and efficiently do facilitate treatment. We definitely can just ask a few questions with our assessment and say, go and start with strategies. I find that it is really important to spend a good amount of time doing a thorough assessment. I really, you know, I often share with families that I’m working with, that, you know, I may spend a little bit more time on the assessment than others, But I think that it is well worth it. Because while we can start right away with strategies, it would be really frustrating to just pick up a couple strategies based on our quick assessment. 25:28 And then, when nothing is working, then we have to go back and figure out another strategy to do, and try that one only to find out it didn’t work. 25:36 It didn’t work, because it was a poor strategy, but it simply didn’t work because of the fact that we weren’t targeting the right function or the right motive. We didn’t properly understand why the child wasn’t going to school, and for that reason, we weren’t able to to address the school refusal behavior. 25:56 So why don’t children go to school? We talked about those reasons just a moment ago, for the younger folks, they tend to be avoiding the objects or people that evoke anxiety for them. They tend to stay home in order to receive attention from parents or caretakers. 26:14 The adolescents tend to be avoiding the social or other evaluative situations at school, or they stay home in order to gain access to those tangible rewards. They want to sleep, wait, hang out with their friends, watch TV or play video games. 26:33 So let’s talk a little bit about anxiety based school refusal. 26:39 With the three minutes, school refusal, the most important component is to understand why kids keep avoiding school, not just the origin or when it first happened. The key to understanding school refusal, in other words, is we need to be understanding what is maintaining the school refusal behavior, why does the child continue, cannot go to school? I talk about this. This, with older kids, I often use analogies for it, going back to interests. So oftentimes, I’ll related to a roller coaster. Sometimes I’ll related to, you know, having your dog and feeding your dog. But, the analogy, I think, helps to make it stick with younger children. I often still tried to explain this model to them. 27:25 Because when children understand why they are not going to school, you know, and kind of make sense of their own thoughts and feelings. And then, when they have to go ahead and undergo treatment and actually face their fear and go to school, In other words, to be brave, we can be more effective in doing so. 27:44 Because it children, recognize that my short-term discomfort is, ultimately, for long term benefits. So, let’s run through this chart quickly here. 27:54 What you have on the, on the top, you have anxious thoughts and anxious feelings, so what happens is, let’s say, to the situation here, where, you know, the child is, you know, he wakes up that he wakes up in the morning, he has the best of intentions, and he says, Mommy, I’m going to school today. Daddy, I’m going to school today grandma going to school today. He’s got these anxious thoughts and he’s thinking to himself, so all of a sudden, as soon as he starts, pops out of bed, starts putting on his clothes, and then he goes to himself? 28:20 Oh my gosh, I’m so behind on my work. I’m never gonna catch up. He starts thinking, his racing thoughts kick in and then he starts to feel really uncomfortable. He starts to feel a little dizzy, his heart’s racing. Now, he’s having these anxious feelings, so what does he do in order to make himself feel better? 28:38 Well, if he can somehow avoid going to school, then in the short run, what he’s done is he has escaped from the behavior that’s making him and he has escaped from the situation, is making him uncomfortable. And he feels better. He has calmness at home. You can think about this as if you’re going on a roller coaster. Usually kids like this one because kids like roller coasters and oftentimes parents don’t like roller coasters anymore. 29:08 It’s the equivalent of when your child is trying to get you going on a roller coaster and you get in line, you know, one of those real longlines that they have a Disney World or six Flags. 29:18 And as you get closer and closer to the front of the line, you start to be thinking to yourself, this really isn’t gonna go well. You know, the start, you know, the butterflies kick in and when you make that decision to get out of line. How do you feel in that moment? 29:35 In that moment, you’re going to feel better. 29:38 You’re going to feel better because you have just escaped from the uncomfortable situation. But of course, just like with that, just like, you know, in that roller coaster situation, what you’ve done is you haven’t really gotten online. I mean, you haven’t really gotten on the rollercoaster. And so when you get back online to try again, you’re going to, once again, continued to be scared. The same is true when it comes to anxiety and school avoidant behavior. The child is thinking, I’m not going to do well in my work, and therefore he is anxious and he’s dizzy. He avoids by deciding, you know what? I’m not going to go to school. I’m just going to stay home here, Robbie much calmer. In that moment, he’s feeling better. But in the long run, what’s happening is, the next day he wakes up. Now, he’s not only behind on his works, but he’s another nut from the previous days, but now he’s even an additional day behind, And so now, he will continue to be anxious. 30:32 So, in essence, what happens with our treatment, in terms of the principles here, is we’re going to teach children that even though they are uncomfortable with the idea of going to school, they need to cut out the avoidance behaviors. Even though we are anxious, Our heart is racing, We’re feeling really dizzy, are headed, you know, our, you know, our body is a little bit shaky, our faces are flushed. What we’re going to do is, instead of avoiding, we’re actually going to approach we’re going to face the fear. It’s the equivalent of, when you’re getting more and more nervous, said you’re getting closer and closer to the rollercoaster, being able to tell yourself, I’m going to do this. And then actually getting on. 31:16 And so what happens, of course, when you get on the roller coaster? Well, if I were to ask you, which I can’t totally do here but you can think about which would be more scary? 31:26 to get on the rollercoaster, You know, the first time or to go on a rollercoaster for the 50th time. 31:35 The first time you go on the roller coaster, it would be really uncomfortable. But by the 50th time of going on the roller coaster, you may not love rollercoasters. But you’re probably not going to be petrified anymore, because essentially what you’ve done is you’ve gotten used to it. And informal and psychologies jargon We call that habituation. And so what happens is at first when you are scared, you are avoiding. 31:58 And what we’re going to try to help children do is to gradually worked their way back to school taking small steps. You know, and as they take those smaller steps They become Braver and Braver and Braver. They are slowly going to get used to, Hey, I can do this uncomfortable situation, I can face a sphere and that’s how they’re going to be able to ultimately return to school. So that’s the conceptual model, the conceptual models. We have a cycle of avoidance and we have this process called habituation, presumably. You know, which plays, which plays a role in helping children, you know, eventually return to school. This isn’t the only way of thinking about it, by the way. There is some, some new research to suggest that there are other models besides habituation that are at play. You know, but certainly for working with children, I think explaining this idea to them broken down into parts for younger children. 32:51 The bottom line here is, the more you do, it is, the easier it gets, you know, understand, helping children, and adolescents understand that concept can be really helpful. 33:02 So let’s move into the strategies. 33:05 So in terms of strategies for parents, for teachers, for counselors, the three E’s are what I keep in mind here to externalize Empathize, and encourage these are broad strategies which are not to be underestimated even though we’re going to get into some specific ones in a few minutes. 33:21 When it comes to externalization, what we’re doing with externalization is we’re separating the child from his behavior. 33:27 We’re trying to kinda create some distance. How do we do this? 33:35 With younger children, often talk to them about naming their anxiety. You know, often we’ll call it the worry monster, or they’ll worry bully. We can have children talk about the worry bully with older children. I sometimes use that same analogy to be quite candid with you. But oftentimes, what I do is I just talk about the idea that you and your anxiety are kinda like two separate entities that are, you know, that are at war with each other. 34:05 And so what we do by separating the child from this anxious behavior is it helps to avoid seemingly blaming the child gianni, it seems like it’s really hard for you to go to school today. Your anxiety is really being very overpowering. That’s a lot different than Johnny stop, You know, stop fussing around and get to school, you know, it’s Jonny. Your anxiety was just too strong today, You know, it one today. 34:33 So it, one is kind of creating that distance. So when we can, when we can label our anxiety, You know, and we can label the thoughts, the feelings, the triggers, you know, this helps children to be able to build awareness, this is part of emphasizing, so what does it mean to emphasize? We want to listen to the children when children are telling you, when students are telling you, I can’t do this, Don’t just say, Yes, you can. But acknowledge, This is really challenging for you. Your anxiety is really strong. It’s very hard to be able to do this. I know you’d rather be home playing your video games. It would be much easier and even more fun if you and Daddy got to hang out today. We can acknowledge the realities for kids. 35:20 We are still, but we also want to You also want to encourage them to be taking steps forward. So, we need to be cheerleaders. We need to provide labeled praise white label praises behavior, specific praise for the steps forward. Children are taking towards returning to school mostly. I incorporate language, such as being brave and facing your fears and doing the thing you’re afraid of We want to problem solve with the child. We want to encourage the child to be able to think about What’s a step that I can take here? If going all day to school is too hard, what would be another step I can take? You know, What would be something I can do? I’m going to school today. It’s really hard to raise my hand know. What is it that I could do in order to be able to help me raise my hand? What is it that I can tell myself, problem, solve and help children to be able to identify coping strategies? 36:10 What’s most important? Or what’s equally important is We want to make sure that we’re not being overly re-assuring or enabling school avoidance. In other words. 36:19 Sometimes what happens here is we have very well intentioned parents and educators and we don’t like to see children in distress. That’s completely understandable. 36:30 Sometimes what comes natural is apparent. What comes natural as a teacher, is not necessarily in the child’s best interest. And one of those cases is when we let our children off the hook, and we allow them to stay home, or not continue to face their fears. 36:44 So what are the types of interventions we’re going to we’re going to be using? 36:49 At the beginning, we started out with education talking about the cycle of anxiety, or avoidance of school that I spoke about earlier. Another analogy that I often use is one of a false alarm. A false alarm is the notion that I’m thinking bad things are going to happen. I am feeling bad things are going to happen. I’m going to act as if bad things are going to going to happen. When the alarm goes off, you know, when you’re, let’s say, at school, what happens? We think danger. We feel danger and we act as if there’s danger we promptly leave the classroom. But sometimes what happens is, the alarm is going off. We’re thinking danger. We’re feeling danger, but there is no fire. In essence, sometimes avoiding situations is a false alarm. We are unnecessarily leaving the situation. Helping children recognize, hey, this is, you know, this may be a false alarm. What is a real alarm versus a false alarm can be really helpful. 37:50 We want to help children recognize their thoughts, their feelings, their actions, and how they are all connected to each other. So just to give you an example here. Let’s say you have a situation like, you know, you’re walking in the hallway and somebody bumps into you. 38:05 If someone bumps into you and you think to yourself, what a jerk I can’t believe he did that, you’re probably going to be feeling frustrated, and you may be inclined to engage in some kind of impulsive action. Like to say, What’s wrong with you, were to shove him lightly back on the other hand, if what you were thinking in that situation is, oh, it was an accident you should look where he’s going and you’re probably going to stay calm. And you might be inclined to engage in the action of inaction. In other words, you would just ignore that particular behavior we want to help children recognize what they’re thinking. And feeling relates to their actions. And so when children are having thoughts, like, I’m so behind on my work, All the children are going to ask where. I’ve been. You know, it’s really uncomfortable. 38:51 You know, in the, they’re feeling it’s really uncomfortable in the lunch room, they’re thinking, everybody is going to be looking at me. 38:59 And then, lastly, we’re not going to be as successful in getting them back to school. But if we can teach kids that they can know what are they thinking, feeling, and acting, And, that, if they change their actions, their change, their thoughts, they can, in fact, change how they feel, and how they act. And then, we’ve taught them a powerful skill to help them approach their anxiety. 39:21 So, we have anxiety, education, we have thoughts, feelings, and actions, then we have cognitive restructuring. Cognitive restructuring is a fancy term for helping children begin to evaluate the thoughts that they’re having and I often talk with children with parents and children about how this is kinda like putting your thoughts on trial. 39:39 So just to give a couple of quick examples, if a child is not going to school, because he’s worried that all the children are going to laugh at him, or he’s worried about, You know, the noise at the belzer make, we may ask him, Well, how likely is it that the children are going to, let’s actually just stick with that example of these, where the children are going to laugh at him. How likely is it that the children are going to laugh at you? What’s the evidence for it? And even if it did happen that the children laughed at you when you gave an answer in class or when you said something in the lunchroom, how bad would it actually be? 40:15 You know, how is your worrying helping you, you know, to move forward here? Is it actually constructive or not? So, cognitive restructuring, which is a lot more complex. 40:28 What I’ve given you a very quick overview here, can help children to be able to come up with alternative thoughts. So, by challenging their thoughts, by answering these questions, they may come up with alternative thoughts. Like, it is really hard to go to school. And school is a safe place for me to learn. It is really hard to go to school. And, you know, the children don’t usually laugh at me. Or it’s possible that I might embarrass myself. But it’s really not so likely, because it hasn’t happened yet over the first couple of months of school when I was actually going. So we have those alternative thoughts. Children can think of. For younger children, we often focus more on what I, what we call coping talk. Coping talk is just kind of little nuggets of inspiration. You can do with the brave. I know it’s hard and I can do it. I’m going to face my fear and give myself a pat on the back. 41:22 Relaxation training. 41:25 Relaxation training can be in the form of what’s called progressive muscle relaxation, where tensing muscles and releasing muscles. Oftentimes we children will use analogies like for squeezing, making a fish, and letting go. We’ll talk about how we imagine that you’re squeezing lemons, you know, making lemonade, great job. You got it. You got rid of those, you squeezed all the juice, you can put it down now you relax your hand, then you can squeeze those lemons. again, nice and tight and you can relax, we can come up with different metaphors to use for each, you know, each part of the body that we want to attend, or relax, for. 42:01 You know, also for the younger folks, will often, you know, I often talk about pizza breathing, which essentially is breathing in through your nose, smelling the pizza, and then breathing out through your mouth. 42:12 Cooling off the pizza. You know, and we set it up nice and cute for them. You know, imagine you’re going into the pizza shop. You know, the first thing you do is you smell your pizza and then you throw your new, cool off, your pizza. You can have kids hold their hands in front of them like they’re holding a slice of pizza. Kids tend to enjoy relaxation now has an asterisk next to it which is relaxation is often problematic. And typically I would say I don’t use relaxation though There are occasions where it can be helpful. The problem with relaxation is in order for children to really make progress. What they need to do is they need to learn to face their fears. They need to face their fear in order to recognize that nothing bad is actually are dangerous, is actually happening. 42:59 And the more that they can actually be in a state of fear and experience it and live through it, the better off they’re going to be. 43:08 And so what that means for relaxation is that while relaxation can be helpful, it can be helpful. If children are not at all engaging in a situation, is taking a few deep breaths. Helps them move into it. That’s great. Otherwise, we probably want to try to avoid relaxation. Problem solving, like we touched on earlier, is, what can I do or say to make the situation less fearful? 43:31 Our final components here are going to be that when children are going to be returning to school, will touch on this a little bit later. What we’re trying to do is we’re trying to create some kind of fear hierarchy or a bravery. Now, children are not going to just return to school if they’ve been out for awhile. What we have to do is we have to slowly feed our way into school. This is what we refer to as gradual exposure. The practice, the mountain looks a lot less daunting from halfway up. And so what we need to be doing is we need to be helping children take small steps towards fully returning to school. 44:09 What I just described, in terms of those series of plans, has been described as helping children to build a fear plan. For your plan. is a great analogy was developed by a gentleman named doctor Psychologist named Phil Kendall Temple and essentially feeling frightening refers to recognizing I’m feeling anxious and what is my body telling me? I expect the bad things to happen, those are those physiological feeling. Those are those, excuse me, those are those thoughts that children are having the attitudes and actions, that can help. That’s the what can I tell myself. The cognitive restructuring, that’s the face, my fear, I’m going to be brave. And, of course, we want to review how it went and reward children so that they can feel good about their accomplishments. Let’s talk a bit about school accommodation, and then we’ll wrap up talking a bit about the Family School Partnership. 45:01 So, in terms of school accommodations, it’s important for teachers to be educated about school refusal. Oftentimes understanding what the school refusal is about is going to really help them be sensitive and have, you know, a better intuitive sense of what to do about children who are avoiding going to school. Teachers often have lots of good tools, but I think of it from it. Like with having a toolbox. There are many great tools in the toolbox. The question though, is which tool you need for a particular situation? A screwdriver is not going to help you if what you’re trying to do is get a nail into a wall. It’s a great tool but it’s not going to help in that situation. 45:45 So, we want to increase developmentally appropriate label praise in almost all situations. In other words, you want to be giving positive feedback for bravery. We want to be prompting the use of coping strategies. This is just a litany of strategies. Again, what we’re trying to do here is, you know, based on our assessment, based on our understanding, we can decide which of these strategies we’re going to use. We may make up a break pass, where the child is able to go and speak with an adult, speak with a counselor. 46:14 The child can call home, you know, you may say, well, why would I have an intervention, where a child who is anxious can call home? Isn’t that just going to get him worked up? The answer is, you’re right. It may get worked up in some situations, for other children, and may be, well, if they go to school for a half a day, and then they get to call home. That’s a lot better than not going to school at all. And so what’s important with these accommodations is that they are appropriately thought about and thought through for each child. Oftentimes and children are not going to school. We may start them off on a modified schedule. Maybe they’re only going to attend certain classes or maybe only certain preferred activities. Other times we may have children work their way towards prefer to towards preferred activities. They may be able to go to a certain class and as a result, and then they go to a club right afterwards. 47:09 Sometimes children have certain jobs around the school. The goal is, we want children who are not in school to be spending time in the building, and gradually increasing their participation in events. The last resort is really an alternative classroom setting. You know, thinking about, you know, Well, the child doesn’t go to school, So we need some sort of therapeutic program. 47:32 It’s important to know with accommodations that the accommodations are really based, like I mentioned before, on why we think kids are engaging in school behavior. And it’s important to recognize that just because we make an accommodation, doesn’t mean that we’re giving it. 47:46 But also, we don’t want to be too quick to give accommodations. What’s important with these accommodations is that they need to be viewed as temporary. And as children progress, the accommodations need to be stated. 47:59 I have a couple of comments on school accommodations, and then let’s wrap up. I’d love to take a few questions. 48:05 Number one is, I’m sorry, on school family partnership. So, in terms of the assessment and plan creation, it’s really important that this is a joint venture. Whether the school’s doing it, whether an outside professional is doing it, it needs to involve the family and the school. Once a plan is created, it’s important that there is regular communication. 48:25 I know that this sounds obvious, it is, to some extent, at the same time, I think, emphasizing it here, can help folks, when there are parents, who are listening, when they are teachers, who are listening, to be able to make a point of setting up some kind of structure. That every week. We’re going to connect with the school. We’re going to connect with the parents and discuss how things are going. We want to regularly review what is the plan here, what is the hierarchy, what does that list of, how are we Gradually getting the child back into school is the first going for the morning. And then he goes home or then he’s going to, you know, he’s going to English and then art. And then recess. And then he’s going home is he just, you know, as he gradually working his way up towards being in, school more, towards being able to raise his hand, the use of coping skills progress with exposure. 49:16 We want to make sure that we’re communicating parents to school professionals. It’s really important that we avoid blaming language. It’s important to recognize that there are parents who mean really well there, and sometimes what they are doing is seemingly enabling school behavior, school refusal behavior, But at the same time, usually it’s not that they want to, But it’s just very hard to be able to see your child in distress. And that happens with teachers as well. They’re trying to be overly coddling. We don’t want to be rough around the edges, but we certainly don’t want to be cuddling the child and enabling the child that doesn’t facilitate returning back to school. 50:01 To close on a formal level, it can be important to have discussions with child study team members, AMB, considering 504 IEP evaluations. And then, lastly, sometimes, schools are more equipped. and sometimes schools are less equipped in terms of dealing with more entrenched school refusal behavior, especially when it’s co-occurring with anxiety or some other condition. And when that happens, it can be really important to be working, you know, ongoing with a private psychologists who can be of assistance in making sure everybody is staying on the same page, and in ensuring the child is progressing. 50:41 Thank you very much, Everybody, for Listening, I really appreciate your time. Thank you again to NGA CTS. My contact information is here. 50:49 if you do have questions, concerns, or I could be of help to you and I’m open to taking questions if, if we still have time for it. 51:00 We do launch into one right away, we’ve had some, actually, some interesting questions posed, so, I’ll try my best. 51:11 OK, so first one is, is it appropriate for school personnel to administer the School refusal Assessment scale and the CDI? 51:24 That’s a great question. 51:27 In terms of the technical guidelines, I’m not 100% certain, I believe, with the CVI that is developed for, know, for Licensed Psychologist or social workers. You know, there is some training that can be involved in it. The school refusal assessment slash scenarios you might be more comfortable administering. That said, I think, what is, You know, the key take home point here is that, with all of our work, we want to stay within our bounds of competence. Or bounds of expertise. And, so, if we are learning a new skill, such as administering a measure, provided, that we get the proper consultation, and we know, number one, how to administer it, and, number two, how to properly interpret it, and in what context, then, I think it is fine to administer. So, for example, you know, the CDI is a depression screen. 52:23 We don’t diagnose depression, people, though, who are untrained, may unfortunately give the questionnaire and say, oh, the child met criteria according to the questionnaire, But really, that’s just one component of an assessment. So I would say that it can be fine in many situations. 52:39 But there does need to be, you know, there does need to be some kind of training, you know, that you get. 52:47 OK, thank you for clarifying that. 52:52 That’s a question about individuals’ kids. With Autism Spectrum disorder. So this has to do with ASD. Or sensory processing disorder, with their emotions. Olson are unable to be understood, Or the senses are overwhelmed by going to school, which would be a trigger from, from attending. So, could you talk about that? 53:22 Sure. I’m happy to comment on it. That the real answer to your question is going to be that it depends on the child, and this is a really great example of where you need a thorough assessment. I recognize that that’s probably a highly unsatisfactorily answer to you. In terms of working with children on the autism spectrum, what we need to be again, doing is pinpointing. So, what exactly are the concerns? If it concerns is, are they, a child is overwhelmed with sensory experiences, but he is sufficiently high functioning enough to be in a regular regular ed, you know, regular school setting. 54:00 And what we’re going to need to be doing is making some of the targets for treatment focused on focused on teaching a child how to gradually get used to experiencing some of those uncomfortable sensory sensations. So, For example, I had children know, I’ve had children who have a fear of the fire alarm and they don’t go to school, because they’re worried about worried about the fire alarm. And so, while the treatment seemingly on the surfaces, we need to get the child to school. 54:31 In reality, the treatment is addressing that sensory component, because no matter how many times we try to help the child be brave, reward the child, you know, for going to school. What’s happening is the child is not really having any of the core fears addressed it. You know, or in this case, you know, the case your question the child is not having any of the sensory issues addressed, which is why he is not able to properly function in school. So if we are able to help the child overcome some of those sensory challenges, you, know, then that becomes the component. And we may have to kinda, you know, take our foot off the gas, in terms of pushing be, back in school, be back in school. On the other hand, there are situations where the child can go back to school. one, would be that maybe he needs to be in a different classroom setting where there isn’t as much sensory activity. Or the other one would be, you know, as a last resort, you know, we would have to move the child into a different environment. 55:33 Nowhere, where some of the century concerns, you know, are, are made irrelevant. 55:39 But it’s a good question, and it’s a challenging what the answer, There’s a lot of, there’s a lot of factors that can go into it. In terms of how high, how high functioning, low functioning the child is, what the child’s skill set is, et cetera. 55:52 That would take a lot of co-operation from the school, to figure this out, then interact in order. 56:01 Correct, and oftentimes, when children are, you know, having, you know, these strong sensory reactions, there in environments where, you know, the school and the parents are co-operating, it’s just a matter of figuring out the right formula challenging. 56:20 I have a question, is quite actually intriguing to me. And say, so I’m going to have to cut it back a little bit to science to be able to present at all. But basically, it’s a question starts with the comments that they have students in this particular school whose diagnosed with having school Soviet. However, they don’t seem to be the typical things occurring in school. There’s no, there’s no asking. You know, there’s no signs of any of that no tardies, nothing like that go into the nurse, so everything in school years to be normal. 57:04 And the parent has never asked for the schools help, with school refusal situations witnessing at home. 57:13 So, so the question really comes down to this As a professional, ever dealt with the possibility of a parent demonstrating separation, anxiety and being anxious about the child being away from home. Which is absolutely true. 57:36 Turn of events that I had never seen before. 57:40 Absolutely. Just one more. Can I add one more thing about that, That your school is offering us, here at home? 57:51 And then, or maybe a half a year at homebound. And so, that’s part of the question. 57:59 Does that seem excessive? 58:02 Got it. So, what I would say is, you know, I’m gonna try to answer this question. You know, as it was asked, but if I may, I’d like to generalize it a little bit just so that it can be useful for people who may have similar types of situations. You know, you know, as well. 58:19 one of the common, you know, one of the common indicators. 58:26 Anxiety in parents is when children themselves are anxious. In other words, when children are anxious, oftentimes parents are anxious. So, when, that may not exactly be the case here. 58:38 But when I am doing an evaluation of a child, and the child is not going to school, one of the questions that I always ask is, who’s, who’s concerned about it? Who, who is the one? 58:51 know, who kinda owns the problem here? You know, this often happens as well when children are sleeping in their parents’ bed. Right, and I’ll say, when your child is nine years old and sleeps in their parents said, whose problem is it? You know, what’s the reason the child still in the parents bad? Is it the child or is it the parents like sleeping with the child? co sleeping? So, oftentimes, you know, school avoidance happens because parents are having a hard time with the situation of separating from their child. And at that point, it becomes critically important for the parents to be able to seek treatment in order to facilitate helping them cope with the anxiety of their child going to school. Because the child can actually, we run the risk of the child getting mixed messages from the parents. 59:39 Parents are inadvertently communicating to the child. School is a dangerous place. 59:44 For something may happen to me, you need to be home. And so, I would definitely say that that is a concern. The question of home instruction is a good one and a broad question. Again, I cannot speak to the particular situation here, but as a rule, I do not recommend home instruction, and when I do, it needs to be very carefully thought out, Particularly because home instruction has the unintended effect of enabling school avoidance. So, particularly in a case where a child is fine going to school, I think that that would be important. However, especially however, especially in a case where, you know, however, also in a case where a child is hesitant about going to school, I wouldn’t want to do that. 1:00:33 A similar issue with home instruction comes up when kids are in great distress and often today we have working parents and parents said to me, you know, I’m really thinking that I should take a leave of absence from my job, I just don’t know how to deal with my child. I do everything in my power. Again, this is generally speaking, to encourage that parent, not to take a leave of absence from their job, the minute that parent at home. It will be that much harder to get the child to school. 1:01:02 So, I think that touches on your question. If there’s follow up, I’m happy to. 1:01:09 What would you, how would you suggest that the school handle this situation, this home instruction time? So it’s doing what they think is the best approach. 1:01:22 Is this some other thing here you see. So the school to do. 1:01:29 Oh, meaning the child is not meaning, if the situation is that the child is not actually coming to school. 1:01:37 I’m not sure what else the school can do. If the child is not coming to school, I would be more inclined, but, again, I would need details to give a real clinical recommendation, which, obviously, I’m not going to get here on the phone. I would be more inclined to be pushing the school and the direction, the gifts, that you have to probably do, some home instruction. We don’t want the parents pathology to interfere with the child’s ability to get an education. So, they may not really have a choice, but to offer home instruction. 1:02:10 At the same time, I think it’d be really important to lay the parameters clear that this is not the, that the parent is not living up to their end of the deal in terms of getting their child to school and to be in a clinically sensitive way, Ensuring that the parent is taking the appropriate steps, so that that parent gets into treatment. Because the research on school refusal is just so conclusive that not being in school is generally not good. 1:02:45 This is a little bit different because the child is fine with school. But it’s really important. 1:02:51 Yeah, OK. All right. Thank you. Thank you. 1:02:55 How can the school or the parent child out of the car, it saves driven them to school and they receives? 1:03:03 Is there a point at which you sit in the parking lot for 10 minutes and then go back home again, or just, you know, try the library first? or what’s the best approach? 1:03:15 This definitely varies by age. With the younger folks, it is much easier, and in that situation, you simply bring the child to school. 1:03:25 You walk him or her into the door, and then, you know, you have a, you know, you have a, you know, a counselor or somebody who is, you know, comfortable within the situation. 1:03:35 There often regulations in school, essentially, you know, you’re kind of passing off the child, that’s perfectly OK in situations provided that that is the appropriate intervention for this situation. This is a good example of that as a tool in your toolbox, but it may not be the right tool to be using. 1:03:56 With older kids, you don’t need to bother with that. It’s not feasible to just bring the child to school. 1:04:04 When children are completely refusing to go in, often what I’m thinking about is, we need to break things down into parts. And as, as parents, as school staff, were saying, Well, how much more? How much more can I break down going to school? You know, what we’re doing is go into the parking lot. And so the answer would be that we need, you know, this is where our fear hierarchy needs to begin with items such as, you know, going to the parking lot on a Sunday and just sitting in the car, standing outside, walking around the grounds with mom or a parent. You know, who you’re comfortable with. Going to school, you know, after hours and maybe there’s a guidance counselor who’s still there who can just meet the child and talk to them outside the building for two minutes. 1:04:49 Or a teacher then going during school hours. Not during the drop off and pickup time. When there’s hustle and bustle and walking and standing outside for a few minutes then walking in the door and then walking home, you know you’re really gradually. You’re taking very small steps towards going into school. 1:05:10 But sometimes that’s an indicator that we need to take a step back. 1:05:14 All right. 1:05:15 Just a question here about PTSD, And so the question is, what does parents kind of see the avoidance by labeling it as PTSD, but allow socialization with friends outside school? 1:05:33 It’s interesting because everything that happens in schools these days, unfortunately, I could understand PTSD a little bit, an issue for some kids, but this potentially is another situation. So I’d be interested in your thoughts on that. 1:05:53 Sure. I’d like to answer your question and also answer a different question that wasn’t asked, but that I didn’t touch on and think is really important. If parents are feeding avoidance, this comes down to parent education. This is why, you know, I may spend 2 or 3 sessions talking with families about what I’m, what we’re going to do, rather than just jumping into treatment. Because the parents don’t understand the rationale for treatment and how certain behaviors they’re doing will be moving them in the right direction and certain behaviors they’re doing, However, well intentioned, move them in the wrong direction. 1:06:30 You’re not going to be successful, parents feeding, quote, unquote, know, that their child has trauma, and shouldn’t be going to school, is not a good reason for the child, not to go to school, it’s a good reason for the parents to, know to, you know, to seek resources, to help them appropriately, you know, help their child go to school. 1:06:51 On the other hand, one of the things we didn’t cover is, sometimes, children don’t go to school. Not even sometimes often it is the case that children are going to school because of problems that happen in school. For example, children may be fearful of going to school because they are being teased or bullied. The solution there is not to be pushing the child to school. In those situations, there needs to be a careful. 1:07:22 Schools typically have protocols about this. And the the issue with the bullying needs to be addressed, it could actually be counter-productive for a child who is being severely bullied, to continue to endure the bullying. You know, in a perfect world the way I believe that could work, no, but I’m not a school administrator. Would be that the child who is bullying should be, you know, that process should be expedited and that child should be removed. But, unfortunately, sometimes, even with schools that are really well equipped, bullying is very sneaky and it’s very hard to stop. And sometimes, once the damage is done, it’s very hard to undo. 1:08:06 And so it’s really tricky. 1:08:08 But, know, where the child actually has been traumatized with school. That needs to be carefully evaluated when he trials is avoiding school as a result of a problematic situation. We don’t just want to put the child back into school, we need to carefully feed him back in, ensuring that it is, in fact, a safe environment. 1:08:29 OK, we’ve gone over a little bit, I have one more question, and then we’re going to wrap it up there, OK? 1:08:40 To this person with the question, and I have to agree, it’s kinda seems that way, to me, to why does this seem to be a rise in school avoidance, and school refusal does it seem that way to you, We’re seeing more of it, maybe it’s getting diagnosed differently or, or diagnosed better, or it’s really saying that there’s more of it. 1:09:10 I’m not sure. 1:09:12 There definitely is an increase in education, and there also is a change in the way, you know, kids are in, every, in every generation. I often hear from parents in my practice, like, when I’m dealing with behavior management, and listening, and compliance, and things like that. 1:09:32 Well, you know, if I would, I would just never have said something like that to my parents. 1:09:39 But now, all the kids do it, you know, this is what, you know, some of my patients, my client share with me. So I don’t know whether there is an increase in school refusal, because more kids are just comfortable being non compliant, or whether there are some situational changes. You know, many kids that don’t go to school are concerned about, you know, bad things happening in school, which unfortunately is, not only in the news, but a reality. And, you know, that’s why schools are are taking security very seriously, and sometimes that is what’s triggering triggering the avoidance. That is a better question, that I have an answer, unfortunately, OK. 1:10:24 I think we’re going to thank you very much. That was great. We do have questions left, and Kelly will explain how those will be handled. And that was a great presentation. Thank you so much for your time. 1:10:39 You’re very welcome. Thanks. 1:10:46 Thank you for joining, our webinar on school refusal. There is an exit survey, which we need everyone attending to fill out. The webinar blog is now open, and available for the next seven days on the CTAS website, for additional questions that were not covered in tonight’s presentation. Those questions that were posted that we did not answer, we will post to blog and have doctor …. I’m sorry, doctor … answer. That question, that website is WWW dot Js. 1:11:24 C T S dot org. Also, an archived recording of tonight’s webinar will be posted to our website, our next presentation: What To Do If their Child Is a Bully Victim, Will be presented, best means, scheduled for October 23rd, 2019. This ends tonight’s webinar. Thank you, doctor …, for your presentation. And thank you, everyone for attending. Goodnight. 1:12:13 Step.