 Good evening everybody and welcome to everyone who has joined us for tonight's webinar and also to our viewers who will be watching this later on. MHPN, or the Mental Health Professionals Network, would like to acknowledge the traditional custodians of the lands, seas and waterways across Australia upon which our webinar presenters and our participants are joining us tonight. We wish to pay our respects to elders past, present and future, for the memories, traditions, cultures and hopes of Aboriginal and Torres Strait Islander Australians. I'm Dr Nicole Hall, I'm a GP in Sydney and I will be facilitating our webinar tonight. Now I'd love to introduce our fantastic panellists to you, you have already received their bios, but we have Tim, Matthew and Marie. So first I'd like to introduce Tim who's a GP in Melbourne I think. So Tim, how common is school refusal in your practice as a GP? It's been very common Nicole and also it follows quite a bell curve. I see everything in my practice from kindergarten students struggling to adapt to that transition all the way through to grade 12 students seeking a medical exemption from their examinations, but the vast majority of my presentations are clustered around late primary school, early high school ages. Something I hopefully won't have to deal with with my kids. Matthew, as a rural practitioner, you see something different in kids who refuse to go to school than perhaps we in the city might see. Yes, we see a number of barriers with issues such as transport, but also a lot of issues around intergenerational trauma and a lack of access to regional or rural services to support young people. So that ends up being a huge barrier in a number of areas that you think conglomerates and then we just get this really difficult presentation that is really hard to support when we've got lack of resources. And Marie, can you please tell us about what new areas of research your team of psychologists are currently exploring in terms of developing tools to help in this difficult area for families and for parents? Sure. We have been working on increasing the reach of our programs, including working with existing health services like Headspace National to let parents access our programs through their website. We've also been working to develop some newer versions or adaptations of our programs to address additional needs like children with trauma exposure, as well as children with autism, to better support their parents to support their child's mental health in the context of these specialized needs. And in addition to that, we're also working with different cultural groups both locally with immigrant populations as well as internationally to see how our programs could be cross-culturally adapted to better suit their needs to. Fantastic. I'm looking forward to hearing a little bit more about that during your talk. So next we'll move on to talking about the instructions for the web player so you are able to get the most out of this webinar tonight. So to interact with the webinar platform and to access resources, there are a few buttons. The first, the view supporting resources button under the video panel has the slides, the resources and a survey about tonight. There is a chat area in the top right to open the audience chat box. And if you need any technical support, you can probably see on your screen in the top right hand corner, a tech support button. If this webinar stops working at any time, just refresh your browser. If you miss anything, there will be a recording of this made available to you later on. A few little rules because we're going to have a lot of questions and answers I suspect tonight. Please be respectful of other participants and of the panelists and please keep comments on topic. Because we have such a huge number of questions already registered, we won't be able to address very specific individual patient scenarios. Okay, so now we're going to move on to our panelists giving their chat, their talk and then we'll move on to our question and answer panel. Now just to move on to the learning outcomes, I'm not going to read them out. I'm sure you can all read them yourself. So let's move on to the good stuff. First up, Tim. Thanks so much, Nicole. If we begin with my first slide. One of the wonderful things I was taught as I was training as a GP down here in Tasmania is that anyone who enters one of our consult rooms fits into one of three groups. They're either a prisoner, they're there because someone else wants them to be there. They don't particularly want to be there. They're a visitor, they're trying you on exploring whether you can have a therapeutic relationship or they're a patient or a client, someone with whom you're well established and you're working towards some common goals. One of the wise things I heard was that at any consultation, you can only move someone one space along that spectrum. And so I take pride when these sort of presentations come to me in trying to make an environment that that young person and that family feel safe to be in and want to keep coming back to. As that lovely Walt Whitman quote of be curious, not judgmental. Investing in trying to find out as much as you can about the lived experience of what's going on for the people you're interacting with will be the solid foundation for which as a GP you can continue to make good progress. The next slide please. So if we look at the case of Carline, my first initial reflection is that there's plenty of people in that case who aren't currently in the room with me and finding out about them as part of that initial contact, knowing how they all interact and knowing how they communicate is again just giving me information that's going to help me know how to help support this family and the last people that aren't in the room of the school themselves. Whenever we talk about behaviors in evolving school, we need to acknowledge that there's a whole environment that as health practitioners, we tend not to occupy and being able to get in touch with that is really important. Next slide please. So there are lots of potential directions in initial consultation could take, but one of the areas I really love to start with is just looking at mornings because they really do set the tone for the day. And looking at potential enablers and barriers of what could help Carline and her family make a positive start to the day. One of the early things we can do to start to change the narrative of what's going on around school. And I also love to engage with the teacher early on, I just send a brief intro email introducing myself introducing the situation as I understand it, welcoming their input and offering to collaborate about how we can be child centered in our approach. The next slide please. If we move on to the case of one of the things that first strikes me is that I shouldn't necessarily be making any assumptions about whether there's any cultural overlays. But again, I need to have that curiosity and willingness to understand. But the other main area that stands out to me about that case is we've got physical symptoms. We've got potential functional or somatic symptoms. And I find it's both really important as a GP to be able to get to that point of discussing them, not avoiding it, but also to get through that point of realizing that they're just a symptom of what's going on in that child's experience. And so we walk a narrow path between those areas. And we need to filter that a bit through what Pong's past school experience has been like. That's an area of uncertainty I have reading the case that I want to explore. So if I move to my final slide, I think one of the things that's really important as a GP is that we need to be confident in approaching patients who present with pain or other physical symptoms. And we need to be able to shape that discussion in a way that's positive and non-stigmatizing. One of the really nice frameworks I use to discuss with patients like Hong and families is that we can look at and explore both internal and external causes for physical symptoms. And we need to be able to make a shared decision with Hong and their family about what level of medical confidence is required for us to be able to settle that these are truly functional symptoms and that we can embrace working on supporting them collaboratively. And hopefully using all of that, we can scaffold that into creating some shared goals and starting to already set a bit of a therapeutic path forwards. So that's my presentation. Thank you so much. Thank you, Tim. Okay, we'll move on to Matthew to specifically give us some perspective on how things work in the rural side of medicine. Excellent. Thank you, Nicole. So I'm just going to start diving into this. The first thing I'm going to be looking to do with Hong is looking at getting a full picture. And this is going to be a full bio-psychosocial cultural spiritual assessment, which is really designed to work with Hong, but also bringing his family in. And what I'm doing at every point of this process is I'm starting to paint a picture of how Hong has got to this point, but also other factors along the way that have been contributing. And not just for himself, but also for his parents, things that might be going on in the social environment. I also want to be looking at culture. I want to be very sensitive around that and doing this in a culturally sensitive but yet supportive way. And that's going to be so imperative why we need to bring the parents in. So I'm very big in the work I do. It's both parent and child-centered. It needs to encompass the whole system, but it needs to encompass this bigger macro system, including the school and the other stuff. So this comprehensive assessment starts my building blocks to really work, looking at where I need to go from there. So if we go to the next slide, please. Largely, what I'm going to be doing when I'm doing this is really spending some time with Hong to build some rapport. I'm really understanding from his perspective or their perspective what has been going on. And if you sort of consider this lining yourself up, sitting alongside the client, looking at the problem from the same perspective as them, really trying to step into their shoes. And we can then look at this as what we call empathic validation, which is the ability to connect to the internal experience, but the state this leaves them in. So an example might be being bullied or not feeling connected to other people is you feel alone, but you also don't feel heard or you don't maybe feel you're valued. So I'm really trying to connect to those deeper experiences to also then understand what makes it hard to potentially help seek as well as the cultural aspect I need to be aware of. Is there something in that avoidance pattern of environmental factors here as well? Transport is so vital. Looking at what's happening in the playground and where things could be going wrong or where we might be able to intervene, even in the home as well. Can we go to the next slide, please? So I think this is where you would then look to work and bring in the school, but then any other services that would potentially need to be appropriate. As well as working with the family to understand their dynamics, potential cultural dynamics, the way they parent, other expectations on home. Also that we need to consider is Hong sensitive to his environment and other people as well because the targeting from the teacher that does make me curious what that perspective is on both sides. Again, working with the school bringing the teacher in. Getting consent is going to be a huge thing here as well and I think that's vital to keep in mind that's why we work with a family from the outset. Looking at culture as well, looking at other potential support services or health services that could be a bridge between looking at what we call bi-culturation, which is between one culture and another. And young people today potentially being stuck between them and being lost in self-identity. Can we go to the next slide, please? So then what I want to stay engaged as long as I can until I know Hong and the family are connected to where they need to be. So that's going to potentially include therapeutic support but also case management as well as systemically working with those supports. It's also supporting Hong to develop a better sense of self-identity and what we might call reflective functioning, which is a capacity to understand our own states and communicate. These of others and understand what drives us to avoid things. I'm also going to try and do the same with Hong's parents. So through reflective parenting, these are both attachment focus interventions to attune them better to Hong's needs. But I need to be very sensitive about what those needs are to fit with really not set of the therapy relationship and to continue that going. And I'm going to continue to review the goals regularly and also look at things like the scoring systems. Are we getting outcomes of the scoring systems culturally appropriate? And also are we achieving or are there roadblocks that we need to reassess and reformulate? Next slide, please. Okay, and that's me done. Thank you. Thank you so much. And before we get into the question and answer session, Marie, very much looking forward to hearing your perspective as a psychologist. So with the work that we do, we see fundamentally parents as key partners to work with and empower, not problems to solve or overcome. So whether that's in the context of children and young people with mental health challenges or with school refusal or school attendance difficulties specifically in this instance. So in that context, the research is clear that when it comes to school attendance difficulties, there's a whole range of different factors that could be at play. And the picture would be quite different for each child. So it's really important to work with the child and the family to try to get as complete a picture as possible as to what underlies that particular child school attendance difficulties. And what the literature has, has recommended is that, you know, as a practitioner working with these families that you would look at you will consider what is at the student or child level, what's at the family level. And then of course the school context and broader community or social cultural level as well. In terms of the approach we, you know, we would definitely be recommending maintaining curiosity, you know, in part because of, you know, the fact that it's really quite unique a picture for every single child. But the empathy to bring into the room with you is also really central because we know how much school attendance difficulties impacts not just the child themselves but also the family, especially if it's a problem that has been ongoing. Whether that's brewing in the background and then surfaces in terms of actual absence from school, or it's absence that has been going on for a bit of time so just keeping that in mind is really important. And then, ultimately, we want to be looking at identifying with the child and their family, what is the child's school education engagement goals. So, so in some instances when completing that picture to understand what's underlying the school refusal or school attendance difficulties. It might become apparent that the current school that the child is enrolled in or the current school system might not be the best match to the child's needs and learning approach. So, so identifying alternative ways to re engage the child in the education could actually be the goal that the child would want to work towards so working with the family towards that goal is really important as well. Next slide please. So looking specifically at Colleen as a case study to apply these principles. One thing that I would do is to really work with her to explore the fear that she has about leaving her mom alone all day so you know what what is that all about you know from her own perspective. Is this something that she has actually opened up and shared with any other supportive adult around her, whether that's mom or anyone else. So, you know, in direct in directly in this context is mom herself aware that that she is the underlying reason for coming in this in this instance not going to school. And then importantly, you know to to not just looking at the not just look at the deficits or the challenges but also look for strengths and protective factors within Colleen herself you know there's some strengths that we could leverage are there than interests or protective factors at school relationships within the home, you know, her own interests or goals in terms of schooling or with her friends and other co care activities at school. For example, that we could actually use as motivations for her to consider re engaging in school. When we look at the family level, of course, in the context of grief with this family to also think about how mom herself and all and dad and her older sister how have they coped with known as passing. Because different people grief differently it is a shared experience in this instance with the family. So looking at how each one of them is coping would also be important. And along alongside with that to identify whether any additional support might be required for those family members as well. In the context of helping Colleen to to manage a school attendance difficulties to find out what capacity mom or dad, or even her older sister might have to support Colleen in re engaging the school is of course something to to look into as well. Next slide please. Moving to the school level. You know, as I mentioned briefly but kind of what school level factors are their connection with school whether it's specific teachers specific peers and friendships that that are actually really protective for her that that we could try to engage her and motivate her to consider actually going back to school whether it's even for a couple of subjects or a couple of curricula or curricula, curricula activities to consider whether any risk or main hinders factors you know whether there are certain challenges at school that she is also facing which then becomes an additional disincentive for her to consider going back to identify those could be would be really important as well and to work with relevant people in the school to help address some of those factors. In terms of the parents on work arrangements, more broadly speaking, it sounds like that has long hours away from home for work and mom has shift work kind of responsibilities which could potentially have limit their capacity of flexibility. In terms of being there with Colleen if she's not attending school so that will be potentially be an additional stressor to the parent the family would face that you want to work with them to address as well, including the potential impacts of of the ongoing school attendance difficulties on the parents on employment and financial situation. And finally, just, it sounds like they live in a rural original location where we know that there could be limited access to supports and services. So trying to identify those that are actually available, wherever possible, you know whether some of this could be remotely accessible, such as online and telehealth type services could be something to explore for these for this family as well. We just skip forward to the couple of slides ahead please. Next slide. So just touching on currently available resources. There is the partners in parenting education or pit at program that my team has developed in collaboration with Deakin University. So this program is currently freely available across Australia to all parents of adolescents, so high school age children so it's an online program that's based on the current research evidence and international expert consensus about what parents can do to respond to school attendance difficulties. So you're you're very welcome to recommend this program to parents that you work with and young people you work with where where you think the parents might benefit. Next slide please. These, these are just the different module topics that are available in the pit at program sorry next slide. The partners in parenting program more broadly is evidence based program that we've developed over 10 years ago now. So this is currently available by the headspace website so again if you have if you work with families where the young person struggling with a mental health. This is a program that's freely accessible by headspace. Next slide. And finally we also have parents parenting guidelines that we've developed, which are essentially resources that involve translating all the evidence that's currently available about what parents can do to support their child's mental health into actionable strategies for parents so so there are different sets of guidelines for parents of primary school age children as well as parents of teenagers. So if you go to the parenting strategies website you can access all these guidelines for free as well. This is the last slide just shows the specific guidelines for school refusal. This is also one of the guidelines that's available by the parenting strategies website. Fantastic they are some excellent resources that I'm sure we will all be having a good look at. Thank you to our wonderful presenters let's move on to our Q&A section so before we get into it. First question click the three dots in the bottom right hand corner of the video panel and click ask a question. I'll be keeping an eye on this throughout our question and answer section. And we've also had lots of questions come in before the webinar so let's get into it shall we. First of all Hayden has asked which I think is an excellent question. Does anyone on the panel have advice about getting schools to actually implement recommendations or make accommodations for their students. You know sometimes it feels as though we're sitting on one side of the wall and they're sitting on the other and no one's communicating. So Matthew I might direct that to you to start off with. I the biggest thing I would say here is always aim to build relationships and no matter how small so what and with all staff all students and really try and keep it warm. I'm very aware teachers are under such duress at the moment that it's really important to factor that in so my two senses. Definitely keeping those relationships strong doing a lot of follow up don't let things drop because the warmer we keep stuff the more familiar people get. And then it opens doorways and opportunities for connection. And do you tend to find that the when you engage with schools they first phone calls email I mean obviously every schools different but. This is it's a really good question and I think part of that comes down to organizational aspects but. I think in first instance if you can actually be face to face that's the most ideal because you can actually see a person you can do a mental state examination and actually get a sense of what's happening. In a regional area it's not always possible so sometimes we do need to get on to tell a health and this times even with schools where we can't get on the Wi-Fi so we will do full psycho social assessments. They can take an up to an hour and a half two hours on the phone to really get an understanding so I'm going to do whatever I can to meet them where I need to. Okay and Tim you mentioned you like contacting schools fantastic what how do you tend to do it do you ring do you email a teacher what's your strategy. Yeah I'm probably sitting at the other end because I I often only have time in my days to send an email. But it's one of those ones where it starts slow but as you start to connect to the networks of teachers that are working in the same community you work in. You begin to have a bit more of a professional relationship I have to be very very careful when I contact schools not to ever lead with what I'd like them to do. But the same things we were talking about the start seeking to understand what the experience of the school in this situation is and looking at opportunities to connect and support. And the safest area found to explore in just you know nonlinear email communication with teachers is just what could be our shared focus what what is the one area where if we're all aligned. We're going to get the greatest positive impact for a family. Yeah fantastic. I'm actually going to combine the next two questions so Kim and Shabina thanks very much for your questions. First of all, sometimes a child just doesn't really know what the issue is so can you give us some tips for exploring how to interact with a child or an adolescent if they're not really sure what the issue is. And also Shabina would sort of like to know you know if they're not willing to talk to you. What are some tips for getting information out of adolescence and children I mean we've all had consults where we ask and all we get back in return is nothing don't know not sure don't want to talk. So I might start with Marie for that what strategies that you've got in terms of finding out what the problems actually are and getting people to talk. I think this is where the collaborative approach could be really useful. So it's kind of you're trying to piece together a puzzle here. The young person you know if you were to to rely on the young person to put all the puzzle pieces together you know it wouldn't be surprising that that it would be a challenge. If you could try to find additional puzzle pieces around them you know speaking to their family members became to their teachers and you know any student well being related staff members at school. People that they trust and you know might share with or you know engage with at a fairly semi regular basis for example people in their media environment. So if you could get some of those pieces to start with I think they'll be a great start of course with consent you know wherever possible. And sometimes just having some of those seeds, you know that you gather from the people around them to then come back to the student oh you know you could it be related to this or you know has it got something has it got something to do with that you know and that kind of helps to cue them as well and sometimes even that could hook them to actually maybe you do understand or you're not judging me about the context of that and that could help them open up as well. So I think that's that's one possible way to do it. But I jump in because. Sorry Tim go for it. This is just a passion project for me about how do we translate children's lived experience into brief points of GP contact. I love engaging different senses. Sometimes if kids can't tell me about their experience. I can ask them to draw me a picture. I've had young kids draw a picture of a school environment where the teachers are warm and the sunbeams and but then there's this other student and there's kind of lightning bolts or laser beams and you're like oh I think there's something to this. Conversely I remember a teenager who was famously completely non communicative in my room. But they loved music. And I said could you bring me a playlist of songs that tell me about your experience at school. And the first song they loaded was every day is exactly the same. And I just thought oh this is amazing because it's communicating and they feel understood. But they're not as daunted by the questions I'm asking them. That's fantastic. I'm going to steal that idea. Sorry go for it Matthew. I just had an interesting thought on this and one thing that I often do is if a young person comes in they're genuinely sort of worried about opening up or there's that hesitancy. That's where I start. I actually sort of say to them you know I think we need to chuck all this other stuff out for a second actually talk about what's happening for you and what you might be worried about you know you worried mom and dad might think or say something. Are you worried about other people might perceive things getting into their world and understanding that worry unpacking that usually then starts to give you gateway into everything else I generally find. So it's just my two cents. Yeah fantastic very good thoughts. All right. When saying and I'm so sorry if I've got your name wrong has asked an interesting question. How do we disable the enablers, namely the parents. So Tim you're smiling at me so that means you get to go first. Thanks Nicole. I think maybe this is an antidote to imposter syndrome as a practitioner sometimes we don't have to know how we just have to know they're there. We have to all agree that that's what we're trying to work on and we have to. I think tease out those hidden strengths that may have been suppressed or confidence has been lost in. I think one of the very translatable skills of general practice is we take goals and we break them down into smaller more achievable sub goals. And sometimes pointing out to people that there might be an Everest that's too daunting for them. But how about taking a nice stroll in your local park to use an analogy. What does that look like? How can we move you one step along that spectrum. Marie or Matthew would you like to add anything to that. Yeah. So just clarify the question Nicole is it to disable the enablers. How do we disable the enablers. So the parents that obviously perhaps how do we say it correctly. Reinforcing the school avoidance is that way. Correct. Correct. I think and of course that does happen. I think it's really important if you're working with the parents to to be able to build that rapport in the first place you know so that you can actually broach this topic. You know what we do know from from all of our research is that you know inherently parents would would all would feel a sense of self blame and sense of stigma whenever there's some challenges that child is facing whether that school avoidance or mental health challenges or anything like that. So so being being empathetic towards that is really quite critical and parents would sense that from a mile away. So so I think that's the really important first point and and beyond that to then be able to broach the topic about you know what is it like for them you know that their child is so anxious about school to find out what it is that that triggers their own response. Or you know they they repeat of their response whether that's in kind of accommodating the child's anxiety or you know enabling the child or you know giving permission to their child to stay at home. Because oftentimes that's a much easier way you know to to manage or respond to the child's anxiety about going to school so so I think really being with and I really like Matthew's analogy about kind of sitting a lot side by side with them seeing what their perspective is on this because that's that's the only way you can unpack it with them in a way that they don't feel like you're blaming them but that you're actually there to empower them to do something different. Because ultimately they would share the goal to help the child get back to school to re-engage with their education so then you'll be able to leverage that if you've already built that that trust and alliance with them. Yeah it's almost like we're treating the parents and the patient the child you know it's almost two different patients sitting in the same room. Matthew Shell has asked and this is an interesting question what are your thoughts around removing Wi-Fi access etc. If it children doesn't it that like attending school so basically making home boring taking away the stuff that makes home fun what are your thoughts about that. I think it depends on the child because if you've got a child who's actively absconding from home or who's got no concern about leaving and you take the Wi-Fi that's a problem because you take the Wi-Fi they're going to leave. So I think what this comes down to is and a lot of research shows us if we negatively reinforce something it only works in the short term but long term it absolutely falls apart generally. So what I'm going to do again is spinning Wi-Fi off maybe not a reward system could potentially work a bit of a graded exposure system. I'm still going to need to understand the problem because I'm going to hazard against the Wi-Fi itself isn't the problem itself it's probably something much more than that so that's what I'm going for. But as a short term thing if they can find it or build it into where this can be really good is later on once you've understood the problem and actually started to make progress and things have stabilized somewhat then bringing this in a reward system that's also where it can be highly useful. So I think it's choosing a time and place but it also depends what you're looking at. And Marie I'm really interested on your thoughts on this as well. Rewards, punishments you know it's a hard call as a parent sometimes. Yeah I would agree with what Matthew has already said but I guess the only other thing I might add is whatever approach you are taking is really important as far as possible to help the child to understand where you're coming from. So I think instead of going like that's it you're just enjoying being at home too much I'm going to switch off the Wi-Fi which is punitive to actually talk with them about what that means or what that looks like. So you know what what we know is recommended by experts in the field is you know you if the child is staying from staying home from school. What you want to try to do as much as possible is to kind of be to communicate with them that the goal here is you know that this is temporary that you're going to start working towards your re-engagement goal you know whatever that might look like in with school. In some instances if the child is at a stage where they are they are prepared to engage with that idea even in a remote sense you know that you would actually try to structure that day you know like a school day you know and starting at nine and finishing at three whatever the school hours are these other things that you would try to do and fill your day with you know so that it's not like oh yeah great you know a whole day I'll just be at home gaming you know and online and so on. It would be part of that as well having some structure in the day so there's not just you know you don't get to go online. But you know yes there's this school hours and there are these things that you do which which is still expected because we are all in the process of getting you back so that it's not reinforcing being away from school in that sense. And Phoebe has asked an excellent question aside from our standard mood question as that I'm sure we all use. Are there any question as more specific to school refusal that are useful and in particular are there some that are different from primary school is it worth using the narrative approach for primary school kids. And is it different to the question that you would ask an adolescent so Tim I might start with you if that's okay. There's two that I sometimes use in my clinical practice the most common one I will use is strengths and difficulties questionnaire which is a very balanced assessment. Not a diagnostic assessment in any way but quite useful sometimes in terms of a severity of impact measure of the different facets of a child's life. And a really good way of interrogating for hidden strengths as well and changing the narrative that you explore with the family. In some of my younger kids too I will use the scared questionnaire, which is a specific questionnaire for anxiety and worry, but breaks it down into subsets, including separation fear from parents, social fear, general fear all sorts of different things. And again I'm not using it to know where to start. I'm much more interested in using it in terms of this is a tool that perhaps captures some of that information that's flowing in the consultations. Marie do you have any other suggestions I think they're both fantastic Tim I've written them both down but Marie have you got any other ones you'd like to mention. Yeah, so scared is one that I was going to mention I think they have a school school related anxiety subscale as well so so that's something that you're particularly interested in you can look into that. There's a less widely known one because I think it's still fairly new it's I think it's called school refusal evaluation questionnaire so it kind of touches on different domains of kind of behavioral cognitive emotional aspects of school avoidance. So, so if you're trying to get a better understanding of what it is or whether that's specific aspects of school that the child is struggling most with that could be a useful tool to look into as well. Thank you for that. Now, Matthew. I'm going to delve into the homeschooling side of things so lots and lots of questions have come through about homeschooling the merits of it at what point do we. You know agree that yes homeschooling is going to be a big thing are we actually making the problem worse because you know if they're not interacting with the school environment and we're homeschooling we just for longing the problem so I'm interested to hear everybody's thoughts that Matthew I'm going to start with you. I think it's a really interesting question and again I'm going to come back to it depends on the context but I do we think they're recently we have seen a big increase in homeschooling. And they're absolutely times where there are situations where young people are being homeschooled where it may not be appropriate. So I think it comes down to them working very closely with the school as much as possible as well as the parent and young person to really accurately assess that. But in terms of homeschooling in general. That's where then I sort of think you then need that bigger bio psychosocial assessment to factor is this something that's an appropriate fit someone has really chronic illness or they've got immunocompromisation. Yeah quite likely. But what we also see elsewhere with the homeschool side is that we can get young people who can really really push for that. And then it may not always be the right fit but then parents can also have stuff going on that makes it easier or you could live in a rural area where it's really hard to access school parents start work early finish late. It's it's really really difficult so I think these all need to be factored in before real decisions made on that one but you also can't be doing it in the place where it's reinforcing avoidance. And Tim I might jump to you next banks. There's an analogy that's helpful to consider which is, you know, the creature trapped in the pot of boiling oil. They just want to get out of it. And school refusal can feel like that. And the temptation can be sometimes to see bringing your child into a very familiar home environment as the absolute kindest thing you can do. And to in many ways it is what I think is really important to bring into early discussions with a child and family is that idea of long term goals. Because a child may have some very clear visions of where they want their preferred future to be. And if those goals cannot be obtained in the homeschool environment with the resources and skill sets that family has available, then it can only form a very small part of that child's overall journey. And so taking that long term view early on is really key. There's another question in all of this that comes up and we see it discussed in the mainstream media a lot too which is that idea of how do we foster resilience. And how do we learn out of our approach to situations that were overwhelming and difficult about ourselves. And again, this is not something I seek to direct. But it's definitely a touch point I want to keep returning to with families about just what are we trying to teach but also what does this child most benefit from learning and are they synced up. And Marie, what are your thoughts? Yeah, I just quickly add to that. One one key point really is just looking at the how how well equipped and the capacity of the family to support homeschooling, both as a short and a longer term kind of arrangement. So in addition to the avoidance and reinforcing the avoidance and so on, it's also thinking about the other aspects of school that a structured school environment that the young person will be missing out on and how else the homeschool arrangement will try to cater to those needs as well, you know, including in a peer relationships and social skills and so on, which we know are of course, you know, central to to a child and young persons development. So so it's there's there's a lot that the essentially the family is taking on if they if they go towards a homeschooling arrangement and and actually working through the the reality and implications of that with family. I think it's really important because what does happen is some families think that it is an easy way out until until it hits them, you know, the reality of what it really involves. And I guess, following on from that, other people have asked about changing schools, you know, if a child keeps saying I'm not going to school but I'll go if I change schools, you know, coming back to resilience. It's a hard question but any thoughts from the panel about at what point do we say alright, maybe we just need to change schools. I might jump in and say that it's an to me it's a never say never and a never say always. But again, I see it not as a first line intervention really for the situation, because it's not just in terms of what might benefit that child there's no argument that sometimes situations can get pretty toxic and a change seems really appealing. But it is that idea of translatable skills. How are you going to be equipped to the level that if those changes are made, and then the situation recurs, which is what the evidence tells us problems have legs. How are you going to approach it then. And maybe it's easier down here because it's it's small enough that people run out of opportunities to change after a little while. And they're pretty accepting of that. Alright, I'm going to move on to an area where a lot of questions have come through and that's moving on to ASD and pathological avoidance. Now I just want to highlight there will be a webinar on neurodiversity in June. So I highly recommend everyone tunes in for that as well. But given there's a huge amount of questions coming through, I think we should touch on that. So there's a lot to say. Maria, I might start with you. So. Ampia has asked the PIP ed program that you mentioned says it's not tailored for people with ASD. So I'm going to start this discussion by are there specific resources for parents whose children have a disability in the school refusal space. The short answer to that is I'm not aware of these in terms of an actual kind of parenting program as such. The PIP ed program as this audience member has identified is, yeah, we do put that disclaimer up because we are aware that there are some specific needs that our program really is not designed to cater for in its current form. That is something that we're certainly looking into addressing better in the next iteration. But I think the program could still be usable by parents who have the ability or feel like they have the ability to tailor the strategies to their child's needs in the context of the neurodiversity, which for some parents, that's actually something that they would just do quite readily anyway. We certainly have had families who have used our program and were able to still apply a lot of the strategies or in an adapted form and still find them useful. So, so yeah, that's that's probably as good as it gets at this point. And just in general, can you, before I move to Tim and Matthew, ASD school refusal? Do you have any specific comments you want to sort of make in that space in particular strategies that can be really useful for for working with neurodiverse children in terms of getting them back to school? Yeah, I think one thing that has come up a lot in the work we've done with families is to actually help the family to best understand what it is about their child's neurodiversity that could be related to their school attendance difficulties. So kind of understanding that part of the picture for the child. Because in some instances, it is right smack that's central to it, you know, it's all around, you know, they're not feeling like they belong, they are struggling to keep up with the work and it's all related to the challenges inherent in their neurodiverse condition. But in other instances, it's actually quite peripheral, it's, you know, a specific incident that was, you know, had nothing to do with their ASD, for example. So I think not making those assumptions is important, but to actually try to understand the picture again for that specific individual and for that family. I think the other thing that has come up is, you know, for some families, it is still a query. So it's kind of like, oh, you know, they're having trouble, you know, or they're feeling anxious about attending school, so they're stopping, but it was raised that maybe they have a learning difficulty or maybe, you know, it's related to ADHD or, you know, like, but it's not been diagnosed. So for some families, it was never even in the radar. And when the school attendance difficulties surface, that's when it becomes a query and for some, for some of these families is like, if only someone had told us this earlier, you know, like all pointed us in the right direction to get an assessment to get an evaluation, you know, and then to better understand what is happening or has been happening for our child in past eight years of their schooling. You know, so, so I think wherever possible to support the family if there are any concerns in that direction to get the appropriate assessments and evaluation so that they can then better understand the child's needs earlier on. Yeah, that's a really good perspective on things. Matthew, would you like to comment on the ASD neurodiversity in terms of school refusal? Yeah, and I think there's actually so many factors in this. So I definitely don't think we can cover it all, but I think one of the big things that we need to factor in is the other factors beyond us, which is things like working with an OT and sensory profiling, making sure additional testing has been done to allow other coping with diagnosis and also looking at the environment because the environment actually plays a big role with things like sensory overload, too much social stimulation can cause shut off and executive dysfunction. So I think with ASD again coming in, working as much as you can as a multidisciplinary team, very much staying in your own lane, but trying to bring all the pieces of the puzzle together as a whole with the school is like the best way to try and reintegrate. But also other things recently trying to get people connected with out of school social groups like Headspace does and other youth organizations offer a number of different groups that might have ASD specific or neurodivergent specific where there's that ability to just click with peers. So I think as well just broadening this outside of the school is also really important because you can then translate those skills later on into school. It's a lot less formal and intimidating at times. So I think you really need to be thinking holistic picture whole life here and tackle that as a big systemic approach. Yeah, some great thoughts there. And Tim, what do you want to say about this topic? Well, like all areas that are really important. There are so many different perspectives and opinions and all of them have value. I think one of the areas I really like to engage with families as the advocates for their child over is that idea of this spectrum of what are we doing to support your child. Because at the polls you will see schools of thought that say we have to equip our children with neurodiversity with skills to enable them to deal with a pretty rough world. And at the other poll you'll see we need to adapt our world to embrace these children. And I think like all polls to me the truth will tend to lie somewhere in that spectrum in between. But it has to be individualized to each specific situation and each specific person. I have a colleague who is quite renowned for saying if you've met one person with autism, you've met one person with autism. But when you start to talk about it and when you start to engage with people over it, you do see these blanket structures and rules being applied. And sometimes just exploring what's actually already happening. I've got a lovely anecdote of a child I'm currently seeing who has an ADHD diagnosis and is a beautiful contributor to their classroom. And when their diagnosis was reached, we did engage with the teachers over what's that going to mean practically for you in the classroom. And the teacher came back with I'm going to give them more chances to sit on the mat rather than less. And we just had to filter that through. This isn't a child who benefits necessarily from more chances to get it wrong. They benefit from earlier support in helping you and getting it right and getting that positive praise and engagement. But that teacher was just honestly doing the best job that they thought they could for the child. And as the health professionals with a little bit of the knowledge, not just of the label, but of the child. We are sometimes very well placed to navigate that whole in the in the micro and in the meta. What are we actually doing with these labels and things that we are using to describe this person? Yes, some wonderful thoughts there. The questions come in from Sandeep, which I think is a fantastic question from a teacher's perspective. How should you know, are there any tips for teachers about orientation of a classroom, classroom setup, things on the walls, etc. So that kids feel validated in their early years and particularly primary school, early high schools, so that we can work more as a proactive way to reducing school refusal. Maria, I might start with you. Sorry, I can't find a mute button. I think that's a very beautiful question. I think my first response is take time to understand each child, to engage with each child, and to be prepared to embrace a whole range of preferences and needs and inclinations. I think being tuned in to that range is probably a really good place to start, so that you're not operating by assumptions, but you are actually creating opportunities to cater to different students, learning preferences and styles, and also respond to needs that do still arise in the context of your best efforts. So I think that there is certainly value in teaching staff having that awareness and that preparedness to allow for variations in the approach, because there is the appreciation that students learn differently and engage with different approaches differently and have different preferences. And in doing so, the students then feel like there is something for them as well, and not just only for the kids who are able to sit on the mat quietly, or only for the kids who are able to hand in their work with beautiful hand writing, but to actually feel value for their unique strengths as well. And just in the interest of time, Maria, I'm going to stick with you. Kirsten has asked, can you comment on the research that is often cited that we need to work really hard to get kids back to school in the first two weeks of school refusal? Is it actually true? Is there evidence that the quicker we get them back in there, the more likely we are to be successful? Well, I think the short answer is there's still very little research on school refusal, whether that's in terms of the causal factors, like in terms of experimental designs that say this is definitely a cause of, a lot of the evidence is correlational. So this is associated with school refusal. So that's one thing. But in terms of responses, I think generally speaking, there is the belief that earlier intervention, kind of nipping in and about kind of approach, has benefits because it reduces the kind of compounding impacts of some of these behaviors or symptoms of, whether that's like mental health related or school refusal. Because as you can imagine, the longer a child has, the more days of school the child has missed, the more impacts they could experience both socially and academically in terms of their anxiety building up because it's like now they have missed the whole term of school or they're falling behind their work or their friends have moved on. There are all these things that students would then miss out on and then feel more anxious about. So I think just from that perspective, there is value in terms of trying to intervene earlier. But it's also important to acknowledge that not all students and all families would be prepared to have that, let's go cold turkey, let's just bring the child back into school after they've missed three weeks of school straight. So I think that's really important to keep in context and the approach or the solution that you work towards has to be contextualized to what the understanding of the child's reasons for missing school is in the first instance. And Matthew, Karen has asked how do you approach school refusal when adolescents are using substances at home whilst their parents are at work when they should be at school? What are your thoughts? This is a really multi-prong question. Firstly, it's going to depend on what your current child protection laws are. And I think that's going to vary with your state. So that's the first thing you're going to need to look at is looking at what it constitutes as being a mandatory reporter. I also think this is why it's also really imperative with the outset of any form of treatment that we are actually going through the limitations of what consent is and confidentiality is in this context. So it doesn't trip you up later in the therapy relationship. From there, though, I'm not going to jump the gun. I'll go into that. I'm going to really try and get an understanding and be talking with a parent. I'm going to be trying talking with young person. I'm risk assessing. I'm doing all this stuff first just to make sure stabilization risk is assessed and managed as much as possible. Then I'm going to start getting into the nitty-gritty a bit more. I'm going to start asking questions that are going around into this. And also then looking at the level of severity, how long has this been going on contributing factors, trauma, grief, loss is social isolation. So there's so many things that need to be factored and then linking with other services supporting. I just go from there, but it really starts with that risk assessment, the mandatory reporting laws. But then once we've got through that, I want to back off that a little bit and then focus on the young person, the family to really understand how I can support them. Also working with a school with that one and wider systems is imperative quite often as well because it's not often just school that's being affected. Other stuff's usually fallen off and being affected at this point in other areas of life. Yes, definitely a complicated area. That's for sure. And I guess that's absolutely where your multidisciplinary team has to come into play. Tim, a question from Amanda. How do we make parents feel safe that sending their child to school even if they really don't want to go is, you know, is okay? How do we take away the guilt about parenting and how do we address the fact that parents are worried that the school is judging them about the way their kids are acting? Yes, parental guilt is a powerful, powerful tool for many, many things. I find it most helpful from where I'm sitting to explore when I have that safe time with the parents, their own experience of being a child. And most parents I'm with can recount those stories of not wanting to get up, not wanting to get out of bed, not wanting to get on the bus, got the mean teacher today. But they pushed through, they found something there. And maybe that was the time when they, you know, the parents surprised them by taking them out for a hot chocolate after school, or they met the person who would become their best friend. And they just see it in a broader context that being the friend to your child is a different to being the parent to your child. And neither are easy jobs, but at the end of the day, being the best parent to them, you won't always feel like their best friend. And that's okay. Yes, very good advice for all of us who are parents, I think. And finally, before we start to wrap things up, Marie, this is a loaded question, so I'm not expecting a thesis, but a few people have asked about complex trauma. So Chanel, in particular, has asked if someone's in a complex trauma situation, domestic violence, etc. Are there specific strategies we should be thinking about with those children and adolescents? So we're talking about school attendance difficulties in the context of the child having experience or being exposed to trauma or having experienced complex trauma. Correct, yes. Well, it sounds like something that is in Matthew's realm of expertise, but my brief comment would be to try to address that and understand the role of that as much as possible in the presentation of school refusal. If there is, if it's identified that there's complex trauma involved, I would focus on addressing that more than, you know, we just need to get you back to school, you know, I'm sorry to hear that you've had, you know, these traumatic experiences. So the safety is going to be paramount in a current safety, obviously, and any other safety concerns and the need for addressing the complex trauma that's actually been revealed in this instance would take priority, I would say, over just getting them back at school. And Matthew, I'd love your perspective as well. I think a really important comment with complex trauma is the fact to read that if trauma comes up being very mindful of your position with that young person because if you're not a trauma therapist, you can be opening Pandora's box sometimes to being really sensitive for your own self care and the young person self care. If things start to go into too much detail, just really gently controlling the conversation and go, look, I'm not a qualified therapist, but it's really important that we do understand this is a really important part. But I also then I agree with what Marie said, what I think I'm going to then do if you're in the therapy sort of space with this in the therapy space is actually starting to look at what how the trauma has got them to there today and led to avoidance behaviors. And I'm going to further unpack that and help that to help understanding as a therapist over this side. But then I think over this side you need other systems and supports in place in the social group with teachers with the parents because complex trauma is a ripple effect across the whole family system generally and even sometimes a school system. So this is where I think that you want to bring all them in and you've got to look at where what your position in their life is and what you can and can't do in that. So we all play a such an important role in this one though with complex trauma, but I really think it's about validating what they've been through wasn't okay and was really, really, really horrible. But we also then need to start getting back on track because we get stuck was really, really, you know, unfortunate that it can get us stuck. So I want to help understand how do we get unstuck and then working with everyone to start putting towards that and baby steps do not the major thing is not to rush. Thanks for all of your fantastic advice. Tonight to our presenters, I'm going to get you to give a two minute little sum up what's what's your main take home message from tonight so Tim I'll start with you. I get the easy one if I'm going first. The biggest thing that struck me listening to the questions and listening to the responses is that collaboration is key. The more we can unify the world of support around a child and their family. And the more we can keep the goals focused on what actually most benefits, not just the short but the medium and long term of that child's trajectory through life. That's going to be positive therapeutic useful. If we're ever getting stuck or lost. I think that's where we need to come back to as well to just really center around. Hang on, where will we pointing. And are we still pointing that way. Matthew really listen really ask questions and get curious about everything like even little tiny things that happened in session like I even you know someone even makes a comment around. They looked at me this way will tell me a bit more about that. I think the big big takeaway as well is make we're all doing amazing jobs and we all do different things but we all play such a key part in that to never underestimate that and also sometimes ourselves taking the backseat and being curious and patients versus going in with an agenda because I think sometimes school stuff. Even I'm a victim for this where I go in with an agenda. And it's absolutely not where the young person is and I need to review myself so really important and critically self reflective practice I think so key to this too. And Marie. I think two key takeaways I would highlight is again. Remember to to look for that complete picture or try to complete the picture as much as possible with every young person that you work with. And I was thinking about, you know, as I mentioned the student level family level school level community level factors to to best understand what is happening and to identify in that process which is my second takeaway is what key protective factors and strengths. Can you leverage in this in this work that you're going to do. Because it's so easy in the context of something like school refusal to just see the problem. You know, the child is not going to school they want to go with the family wants them to go to school the school wants them back you know this. There's just so much that can be it can overhaul the you know or distract from the focus that this is an individual here you know they have strengths, they have interest. They have a future you know and and you have an opportunity here to to help them tap into that to see past the cloud and the haze of the current challenges and the complete picture that you try to that you help them to put together in the process of working with them. It's a really important part of of helping them to reach their end goal with addressing this problem and the strengths there to leverage in themselves and the people around them. So some some excellent thoughts to finish. Look I'd really like to thank our panelists tonight you've all been absolutely wonderful your thoughts your insights. I've learned a huge amount and I'm sure everybody else has as well. Thank you to all of the wonderful questions that came through thank you for being brave and asking. Now I am going to ask people to complete the exit survey and provide feedback on this webinar. You would be able to see on your screen a banner linked to that or a QR code which will enable you to complete the survey. Also this webinar has been recorded and you will receive follow up communication with the recording via email shortly. Now there are some excellent other webinars coming up so on the 17th of April we have working alongside Aboriginal and Torres Strait Islander children in out of home care. It's a culturally safe framework and on the 26th of June a webinar which I suspect will be very popular supporting the mental health of a neurodivergent person with co-occurring autism and ADHD. So I think there'll be a lot to learn for all of us from that webinar. Finally tonight I would like to acknowledge lived experience that people and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present. Thanks to everybody for participating tonight and have a good evening.