Greg Fritz, MD (Host 1): As adults, we often joke with our colleagues or friends about reentry after a vacation or extended time off from work. It's hard to get back into the swing of things and even harder for kids and teens, especially if they've been out of school receiving medical treatment or therapy. It's normal to feel anxious and scared and nervous.

Host 1: Today, Dr. Jennifer Hellmuth, a clinical psychologist at Bradley Hospital, is going to be talking with us about how we can ease those fears for ourselves and our kids.

Anne Walters, PhD (Host 2): Welcome, Dr. Hellmuth. It's wonderful to have you with us today.

Jennifer Hellmuth, PhD: Thank you for letting me join you today. I'm very excited to be here. This topic's very near and dear to my heart. I actually worked in education before going into psychology, so I still like to support students among both settings. Of course, getting back to school or work is hard, especially if you've been out of practice. Kids can do hard things and they do them every day. With the support of some key strategies and tips and a lot of collaboration, they can reduce some of the stress and uncomfortable feelings and get back to a routine where they are in school, they're learning, they're growing, building those relationships back up with their friends.

Host 1: Great. So, let's get started. This is Mindcast: Healthy Mind, Healthy Child, a podcast from the mental health experts at Bradley Hospital, leaders in mental healthcare for children. I'm Dr. Greg Fritz with my colleague Dr. Anne Walters.

Host 2: This topic is so important, especially as a clinician who sees children at acute care settings and, as a result, may miss school for an extended period of time. Much of their time is devoted to getting kids back to school, and that means back to their lives as well. What do you see as the first step to get kids back to school?

Jennifer Hellmuth, PhD: One of the first steps is to make sure the school even knows what's happening and what's their status. It usually does tend to fall on the caregivers, but making sure that schools know that, have they been admitted to a hospital, are they doing a day treatment program, that there is an extended absence. Sometimes the school might need a note or something to excuse those absences, and that really lets the school know to start preparing on their end. Do they need to start getting schoolwork together? Can they send schoolwork to where the child is? And so just having that initial step can be very important and it's a very good key step. Otherwise, sometimes the kid just goes back to school and there's no preparation and they've no idea what happened.

Host 1: So, tell us a little more about what are some of the risks of not having a plan in place or a lack of a transition support structure.

Jennifer Hellmuth, PhD: I think one of the biggest risks is some sort of relapse, which could even lead to a re-hospitalization, which is really difficult. But if you think about it, schools are the major discharge resource. That is the most likely place that a kid is going to go back to, and they spend a large majority of their day in schools. So in order for them to have the best transition to stay out of a hospital or another acute care setting, they really need a lot of supports put in place. They haven't been in school, so there's a lot of anxiety with them going back in. And without any sort of support, acknowledging that there was an absence and what those needs might be, there is a big risk of actually just all of those symptoms kind of flaring up again, and the same thing could happen.

Host 2: So, you mentioned anxiety as one thing that children might be feeling when they're anticipating reentry. What are some other signs and symptoms that might come up at that time?

Jennifer Hellmuth, PhD: There actually is some research in this area. There isn't a ton about the reentry process, but some of the studies that have been published are really able to actually take a look at all of the concerns and the risks in these three main areas, socialization, academic concerns, as well as emotional concerns.

So in the social domain, there's a lot of anxiety about, "What do I tell kids about where I was?" They don't really want people to know that much private information, but they also don't want to lie. So, there's a lot of concern about that, which transition, that's one of the first things they address, is, "Well, what do we tell the other kids?" And then, "What do other people think of me?" And so, there's a lot of worry about the stigma that might be around why I was gone. And there's always rumors. There is always going to be a rumor mill about what happened to a kid and why they're not there, whether we like it or not. That being said, there could be negative social consequences, either when people find out about hospitalization or just in terms of the rumors that the stories that were made up and the lack of information. And then also, sometimes their friendships could be negatively impacted. So, some kids might think, "That's not a kid that I need to be around." Some kids might be mad, "You didn't tell me where you were." Sometimes other kids, their friends' caregivers might actually say, "I don't want you hanging out with that child."

Academically, they've been out of school, so they've missed work. So, it's very helpful that there's an actual plan in place of how are they going to make up that work. And then, some kids are really anxious about their grades. Some kids could care less and they're like, "Great, I missed all of that." But other kids are actually concerned, you know, "Am I going to go on to the next grade?" I hear that question a lot actually. "Do I have to repeat things? Do I have to do summer school?" And then, what is the impact on them, you know, their credits, their grades, and then how much work is it going to take to make up the work.

And then just emotionally, the toll that all of that takes, like there was a reason why the kid was out of school in the first place, so the reentry process adds another stressor as a whole. And so, it could be about all of these anxieties and concerns that we talked about, how people are going to treat them differently, but then also how are they going to continue to work on the things they were first out of school for, whether it's substance use and they're going back into a triggering environment. Whatever those stressors were when they left, they're still there when they come back, and so if it's depression, et cetera. And so, it's not only the extra stressors added when they go back to school, but it's what was already there when they left.

Host 2: That makes so much sense. And I think also the worries are present for parents as well, particularly around whether these absences are going to result in a child not being able to progress in some way. And even just hearing that the absences are medically excused makes such a big difference.

Jennifer Hellmuth, PhD: Yes. That can be very validating for a lot of kids and the caregivers as well, and just alleviate that, "Oh God, okay. So at least they didn't do that." It doesn't always help the most because then there are some kids that really take a lot of pride and accompanying anxiety in their grades and say, "Well, even though it's excused, I still need to know the content." Or with one of the children I recently worked with, "Even if it's excused and I get a good grade, I didn't earn it." And so, that just plays into this negative self-concept they have.

Host 1: So, what are some other things that parents and caregivers can do to alleviate this stress or convince that it's an important part of treatment? What sort of things can be done?

Jennifer Hellmuth, PhD: For the caregivers, just being an advocate. The squeaky wheel always gets the grease. And when it comes to education and mental health, that is always the case. And so even though, you know you might think, "All right. Well, my kid's school is really overburdened." I hear a lot of parents, they count the school out before they even ask, saying, "Well, they're not going to do anything" or "They don't have enough people to help with this." And so it's, "Nope, we still ask." So like I was talking about before, making sure the school knows the status of the child, that they're out of school, they might be gone for this amount of time, providing contact information to the people at the school. Whether or not they make that contact is on them. But I think the caregiver, the most they can do is just be an advocate. And so, letting them know that they're gone, but then also saying, "All right. They're about to come back. So, what supports are they going to need?" "Here's what's been helpful while they've been out participating in this other mental health program." And so, giving some information, but also really making sure, you know, "Well, we need to talk about when so-and-so comes back to school. When can we meet?" I would hope that there's someone at the child's program, whether they're in the hospital or in a day treatment program, who is taking that on. But just in case, that's one biggest thing that I think a caregiver could do when it comes to school reentry.

Host 2: So, these are great tips. And if you're even going to go a step further and say, "What would be the ideal process for school reentry?" What would that look like? And you've already said how parents can help with that, but let's talk a little bit about what the components of ideal would be.

Jennifer Hellmuth, PhD: One of the first steps to reentry is to actually just set up a meeting. Have key people from the school that could be a social worker, school psychologist or guidance counselor. Sometimes there are more people involved. But at least someone and, you know, hopefully, someone of those few positions that I just mentioned. So, getting someone from the school to set up a school reentry meeting that does include the caregiver, someone from school, and then someone from the mental health program that the child is participating in. Their clinician most likely would be the one who would participate in that meeting. It could be their psychologist, a social worker, usually one of them. So, setting up a meeting where then they're going to go ahead and talk about all of the needs of the child, the progress that they've made, recommendations from the clinician on how they're going to maintain all the progress that they've made across settings.

And then from there, also talking about what does the actual reentry look like. Is the kid allowed to do visits? In some settings you can, in some settings you can't because, obviously, in terms of acuity and things like that. But it is really helpful if a child can actually go and visit a school, especially if they're going to a new school, if they're going to a new program. If it's a new setting, that would be best.

Sometimes, for example, in an inpatient setting, a kid's not able to get like a day pass to leave and visit, things like that, so the reentry process might look more if the caregiver can accommodate this, if the kid goes home, does a half day in the program or just does a visit that first day, home for the rest of the day, then a half day the following day, leading up to that full day. And again, that just really depends on the resources of the caregivers and what they're able to provide. And then in something like a day treatment program or maybe residential setting, that is usually a bit easier for a child to get, do a half day in the program, a half day at school, while also having all those clinical supports to come back to as, you know, they do that transition right back into school.

So, that's the other thing to really talk about, is what is the actual plan and then, working up to what is the plan once they're back in school. Sometimes schools will make up a plan that's specifically just for the transition period of up to, you know, just a couple weeks. Sometimes they have to talk about things like updating or initiating a 504 plan or an IEP, which most likely should be the case. This is really difficult because 504 plans and these support plans, it could be for academics as well as social and emotional supports. They're always up to interpretation, so it can be really difficult. I do like to sometimes give the information for an educational advocate to caregivers so they have this additional support going into these meetings to really advocate for the needs of their kids. However, I personally think that if a kid has been an acute care setting, they should automatically qualify for at least a 504 plan. That's a different podcast episode.

Host 1: So, this is really interesting. And as far as I know, there's no manual or a standardized procedure for this that everybody is in lockstep about carrying out. And there must be a lot of variation among schools based on location and staffing. And so, who should be the primary point of contact in the school for when you're getting this going?

Jennifer Hellmuth, PhD: That does really vary. Oftentimes, talking to a guidance counselor or the school social worker. However, it can also be a special education teacher. And so, it really just depends on who in the school takes on this kind of role. And it usually falls within either the school social worker, the school psychologist, the guidance counselor, the school counselor or sometimes the special education coordinator or teacher. If the child already has special education supports or if the caregivers are trying to initiate them, there's usually a special educator included in those meetings. But I mean, sometimes when I have no idea, for me as a clinician, I first ask the caregivers who should I contact at school in case they already have someone that they're used to speaking with, which typically tends to be the case. And if not, I just call and say, "Hey, you know, this is where I'm calling from. Who should I speak with?" And they usually forward me to one person or the other. And sometimes I just leave messages on multiple answering machines or in multiple voicemails, because who has an answering machine these days. I just really dated myself there.

Host 2: Now, how about for adults? Do you have any tips for us as we come back to work after some time off?

Jennifer Hellmuth, PhD: Planning ahead. It's the same thing of knowing that it's going to be hard and knowing that there are just going to be things that are really difficult about that first day off. If you're so lucky, maybe you plan for a day off in between your vacation and going back to school to just give you time, but also just being kind to yourself that first day back and not planning any major meetings.

Host 2: So, just looping back for a minute, anything else that you think is important for us to know around specific aspects of programs are important?

Jennifer Hellmuth, PhD: Yes. And so, there are some programs that do have some good research behind them so far that are very helpful. One is called the BIRCh Project and it's B-I-R-C-H project. That one's pretty comprehensive. Actually, I would say for right now is the one I most recommend, but it is also very thorough, and not all schools have the resources to implement it, but that one is very great and it really outlines the whole process from beginning to end and has some recommended supports in there as well.

Another one, there's a couple different kinds of bridge programs out there. They might have a couple different names, but those are very helpful and those really just talk about bridging a child from an extended absence back into the school and how to do that. They also have some recommended supports along with documents that actually help support the meetings that happen for school reentry, and the followup that happens after the kid goes back into school in that process. And then, there's another one out of University of Maryland called Be Fast, and that one also has some really great handouts and supporting documents that kind of take you through the steps and scaffold and meaning of which topics and which concerns to address specifically.

And just kind of looking through all of those along with the just various experience that I've had, some of the recommendations I tend to consistently go over and review in these school reentry meetings will include things like, you know, first talking about the school visits. You know, is there a visit? What is the actual logistics of going back to school going to look like? Who does the kid meet with? Is there a transition classroom? This is, you know, ideally in a perfect world. These kids will actually have a different class that they can access and have all the supports from a teacher where they're having a plan to make up all of their work, prioritizing assignments, and then it's their own little classroom to go back to when they're having a difficult time. That is not typically going to be the case.

So, other things that I think about or will recommend is having some sort of break pass or flash pass or a red card, it might be called something different in each school that the teachers are aware of. And if the student, you know, maybe puts that on their desk, they can go see a specific identified person, like a guidance counselor or the school social worker to check in with them as needed. Access to a supportive staff, if it's a different person. A check-in checkout model, I very much recommend that for the first week back at least, or when they get to school, they go and meet with a specific person, like the school counselor. Right when they get in, they kind of do a debrief, prepare for what their day looks like, anticipate any challenges, how they're going to use some coping strategies or supportive skills. And then, they also check out the end of the day for the same reason.

Having a specific plan that addresses any outstanding work, even though if there is a medical absence, if there's some core content that the child has to make up, has to focus on, making a plan for that and really just prioritizing the must-dos that has to happen for that kid to receive credit and to make sure they have enough content knowledge to move on to the next grade. Sometimes an abbreviated or a modified schedule is what's going to be best for that child.

And it depends. I mean, there was one child I had worked with that had just such severe traumatic grief that had happened from such a tragic loss in her life. For her, that was to finish out high school, they just pared it down to like what was absolutely needed and then added in some other courses and an independent study type of course in preparing her for what those next steps looked like. And it was much more complimentary to her emotional needs at the time.

A space to get started on or to complete homework, not all kids have that at home. And so if this is something that really holds them back and impacts their grade, causes a lot of anxiety, whether it's an academic or, you know, a community-based factor, that can be really helpful for a lot of kids, to just have a space to just get started so then they can finish it later, or to at least receive half credit.

Support accessing school-based groups or activities and after school activity or a school club. Not only does it promote connectedness to the school and feeling more like a part of that community, which has a lot of positive emotional benefits, but it also can promote positive social interactions and more positive pro-social relationships as well.

There could also be a behavior plan that targets specific behavioral concerns from that child. Oftentimes the clinician will talk about what they used in, you know, the acute care program that the child's been participating in, and will say, "This is what's worked here for us. What might that look like?" And they can do some problem-solving what the school team about what that looks like back in school. Addressing if the child is going to need any risk assessments, if they have ongoing suicidality, ongoing self-harm, how can that be handled, so it's not constantly resulting in referrals to the emergency department if that's not needed.

And ability to earn very frequent recognition, some very specific-labeled praise. Does the kid need some sort of reward plan that they're working on to help motivate them? And service providers like speech and occupational therapy, nutrition or physical therapists, things like that. Oftentimes our kids really benefit from occupational therapy strategies, so it's really nice to detail those and list those out as well as any communication support strategies.

Host 1: You haven't mentioned stigma. I think it's the case that whether it's a mental health problem that the child has been absent in school for or a serious medical illness, like cancer or something, what people don't understand often makes them uncomfortable. How do you address that?

Jennifer Hellmuth, PhD: That comes up so much when we talk about with the kid. "What am I going to say to my friends when I get back? What do I say to other kids who maybe aren't my friends, but they're my classmates, they know I wasn't there?" Or even just the teachers and the other personnel at school. We role play that, we practice that a lot, and we're always stuck between I really want to reduce the stigma by making this, you know, more present and bringing awareness to how often this is happening. I also don't want the child to become a target and to be unfairly treated. And so, we do try and balance those. For me personally, when I talk to kids, I say, "Well, who are you comfortable with? Who do you trust with this kind of information?" And we talk about what I would say to them. And then for all of the other kids or the other teachers and stuff who you're not really close with, then we just practice on saying, "Oh, I was away for a little bit, but I'm back. I feel great. How are you?" We make it more of a practice in social skills as well, of acknowledging, not lying and then just turning the conversation back around.

Host 2: I've been really struck by how much more in the last couple of years children have been willing to share the information, which I think is incredibly brave and also very hopeful in terms of going a long way towards reducing stigma.

Jennifer Hellmuth, PhD: I agree along with the parents and the caregivers also saying, "I think we should just tell people. I think we should be out with it." There's been a big change in the sentiment around that and I would say a lot more openness to providing these supports that I talked about to these children from the schools as well, which is really helpful.

Host 1: Progress is possible.

Jennifer Hellmuth, PhD: It is.

Host 2: This was wonderful. Thank you so much, Dr. Hellmuth. Another tip is that kids are very good at reading their parents' emotions. And so, it's important that the adults stay calm. Easier said than done, but still important. Thanks so much for being here with us.

And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library at bradleyhospital.org/podcast. This is Mindcast: Healthy Mind, Healthy Child, a podcast from the experts on mental health for children at Bradley Hospital. I'm Anne Walters with my colleague and friend, Dr. Greg Fritz. Thanks for listening.