TRANSCRIPT - The Stress-Trauma Continuum in Students with Visual Impairment Ð 5/13/24

>>Erika: I am talking to you from Fort Collins, Colorado, where I am a low vision therapist. And the topic today is both professionally and personally meaningful to me. I'm excited to talk about it. The CLVT for nearly 25 years. The topic The Stress-Trauma Continuum in Students with Visual Impairment, even though those aren't the words I first used, has been something creeping up in the settings I have been in. I have work with kiddos in school systems on a pediatric research project focusing on optical devices and low vision specifically. And then in other spaces and university settings but also with school systems. And then also the VA and now I'm in private practice. And the way that I saw this topic coming up, as I'm sure resonates with so many of you too, is that I could do so many things with clinical skills, educational training. But what often happened with educational outcomes and vision rehab outcomes in the clinic was that psychosocial issues would surface that would often become a sort of barrier to hitting your goals. I began to dive into the literature from early on trying to find how you address these things. And then I along the way also got training in 2018 to 2020. I participated in a two-year program focused on mindfulness practices that also addressed nervous system regulation and trauma and an overview of spiritual practices that weren't religious based. Now I'm getting my certificate in traumatic studies from the trauma foundation. And that is the foundation that if you're familiar with the body keeps the score, Dr. Kulk founded that and it's been a great source for helping me get past some of the barriers I would face as a teacher, as a clinician. That's part of what I'm going to share. And personally meaningful to me, because both of my parents come from severe childhood trauma. They are both immigrants who experienced hardships in their home country before emigrating to the U.S. and becoming citizens. Learning these strategies and implementing them personally has also been meaningful as I kind of worked through some of those things. I'm going to handle this in terms of questions. If you want to put them in the chat, I'm going to keep my eye out on the chat. But then I will answer questions at the end. So we'll go to the next slide. I want to put in a disclaimer here, pretty important. I am not a medical provider and the information provided in this presentation is strictly for educational purposes and the strategies addressed do not replace mental health services. Next slide. I'd like to begin with a story. And this is Leslie's story. This is the story of a dear friend of mine who has low vision. I was talking to her about this presentation and as we were talking she shared with me. She's like, Erika, I have never shared this story with anyone before but I think it's relevant to what you're talking about. And she gave me permission to share. I'm going to read a little bit of her story. So picture a junior high school in the 1960s. Leslie has been inducted into her school's honor society and invited to enter an essay competition for scholarship, citizenship, and service. The winners would read their essays at a banquet for students and parents. All the essay submissions were anonymous and Leslie won in her category. When her assistant principal found out she won she called Leslie into her office and Leslie thought we're going to rehearse. This is something that happens as part of this event. Well, the assistant principal had Leslie stand at the opposite end of the gally while she sat behind her desk and she asked Leslie to read her essay. Leslie brought up her essay up to her nose and she began to read. And as she read, not far into it, the assistant principal interrupted her and says you're not going to be reading at the event. You will embarrass yourself, your parents, and the school. Leslie summoned all the courage she had, after taken aback, she gathered herself -- again, this is a middle schooler. And said I will be reading at the banquet. At the banquet, she brought her essay. She held it at arm's length, and she read the three pages without a stumble. And every single word was memorized. After the event, Leslie lost her voice. She never told her family or anyone about what happened with the principal and now decades later she says that she looked back and knows that even as a middle schooler she could feel it was the cost of speaking up and using her voice for the first time. I like using that story for a framework and I'm so grateful that Leslie shared it with me because it ties together so much of what we will be talking about today, how the nervous system impacts us physiologically in an involuntary way. So the objectives for our session today -- that's going to be the next slide -- is we're going to look at reviewing the process of nervous system regulation in broad strokes. We're going to discuss factors that influence how children process stressors. We're going to identify visual impairment specific triggers children might experience. And we're going to describe strategies that you can use with students to improve nervous system regulation. I am aware that TSBVI has a long history of focusing and being cutting edge on these kinds of issues. And so I'm excited to hear as we do the questions in the chat afterwards, kind of what your experiences have been. I'm going to start off with taking a look at some mechanisms of stress and trauma and I want to share that the way I'll be doing this is sort of like an onion approach. The first part I'm going to share is straightforward. How the mechanism works. Because I feel like that's a really clean way to look at it, applicable for ourselves as teachers, educators, providers. As human beings. Because these nervous system regulation issues aren't just for children, they're for all of us and when we can show regulated, we're better able to help children regulate, especially when we actively work through those strategies because then we know what it really feels like. So we're going to talk about what is the stressor. And the source I used for this is one that I just thought was really accessible. I like this description. It's pretty clean trying to keep it pretty basic for the beginning of this conversation. So stressor is anything that creates demand or feels threatening. So this could be threatening to physical safety, which would be an external stressor, or threatening to emotional safety, which might be an internal stressor. And a stressor involuntary activates the auto nomic nervous system and triggers a fight, flight, freeze, or fawn response. Fight is clearly what it says. Flight is trying to get out of the situation. Freezing is you're unable to really process or make a move, make a decision. Respond in any way. And then the fawn response is like a people-pleasing response. This is what has been used to describe kind of an evolutionary physicallogical response. Picture a caveman trying to run away from a lion. We might have one of those responses and we see these in animals as well. It's just an involuntary process and which one we go to has a lot to do with our prior experiences. I want to relate early on to the kinds of vision-specific stressors that our students might experience. So performing a visually demanding physical task in front of others such as sports can be a stressor. Attending an eye appointment. Assistive tech malfunction. Disclosure of visual impairment when using a tool, like an optical device or a cane. Or an unexpected question related to their experience with visual impairment. Next slide. So stressors can result in a positive or negative stress activation. The thing that's important to know, take away from this slide, is that stressors aren't all bad. Stressor just equates to nervous system activation. And in this slide at the bottom I have a diagram and the diagram starts us off with -- I do have the description alt text. It starts off with stressor in box number one. It's labeled stressor. A relevant stimulus that puts demand on the individual. That word "demand" is chosen because it keeps it kind of more neutral. And then from that, the flowchart then moves on to individual appraisal of the stressor. This is really key because it's the prior relational experiences that comprise the lens of how someone evaluates whether a stressor will be feeling negative or positive. If it's good stress -- good stress might be something like a sports game that you want to be playing or a test or it's a challenge. And so we need nervous system activation to help us muster and pass and get ourselves energized to do something that might be challenging for us. On the other hand, a stressor could be used distress, which is negative, undesirable, harmful response to a stressor. From the individual stressor that flowchart breaks up into a V which has the two boxes of distress and Eustress is good stress. A characteristic of good stress is it's short term and manageable. The distress or bad stress can have implications but negative implications for overwhelm in the present and in the future. So that flowchart ends in outcomes. So distress or eustress are going to have impact in both the present and possibly in the future as well. That's kind of the basic way of thinking about it. So now we're going to go to how stressor, how all those pieces are part of the stress cycle. So when a stressor occurs, it activates a sympathetic nervous system. And so the sympathetic is the gas, it's kind of what releases the cascading effect of involuntary physiological responses including the release of the hormone cortisol. The reason this is important is because it's what gets -- it's involuntary and once it starts triggering, unless we do something that's built into the body as safety, we don't actually downshift. We stay in a hyperaroused state. As the hyperaroused state builds on each other, we develop chronic stress. The body has a experience feeling unsafe to safe to shift from the sympathetic nervous system to the parasympathetic nervous system which is the break. It stops the release of cortisol. It stops the shortened breath. Increased rate of heartbeat. Those are the physiological responses that we have no control over that once they're activated we have to do something to shift out of it. And get back to calm. When we shift out of that activated state back to calm, we can describe that as having completed the stress cycle. Next slide. So on the stress cycle the big takeaway is you can't think your way out of feeling stressed. Your body has to feel safe to complete the stress cycle. When the stress cycle isn't completed, chronic stress or what's also called allostatic load, builds up over time and it negatively impacts health such as increasing the risk for systemic disease. Heart disease, almost any kind of organ function can be impacted by this. There's so many ways cancer is related to a buildup of allostatic load. It's a pretty serious health concern. Now how do we shake it off? So to feel safe, the body has to shake off this threatening feeling. And there are multiple ways in which it can be done and all of them are body based. All of them are what we call somatic body based. Movement is one of them. Taking a walk, having a dance party, getting up and moving is one way. And actually literally shaking. In nature, if a deer is being chased by a lion and it can play dead or -- rabbits do this. And the predator moves away, the rabbit or the deer will still continue playing dead once it senses danger is out of its way, it will get up and it will just shake. And it shakes off that activation. And then it moves on and returns back to calm. Other ways that we can shake it off is through creative expression. So singing, painting, any kind of pottery, any kind of creative expression that uses our body, engages our body helps with regulating and completing their stress cycle. Also emotional release like crying. So if you ever had a moment where you were just really impacted emotionally and you just ended up sobbing. And then afterwards you kind of felt better. That's also true of laughing. The next way that we can complete the stress cycle is connection. So physical affection, like a hug, or supportive conversation. And the key here is that the conversational partner you feel a sense of warmth with them and connection. You feel seen and heard. And then lastly is breathwork. So there's a lot of strategies we'll talk about in terms of breathwork. It's become very popular post-pandemic. I think it's kind of universally known as a way that we can kind of regulate our nervous system. Maybe a little bit harder to put into practice, even though we know that it can be helpful. So what managing stress looks like. You can't control every external stressor that comes your way. The goal isn't to live in a state of perpetual balance and peace and calm. The goal is to move through stress to calm so that you're ready for the next stressor. And to move from effort to rest and back again. So that's kind of the basic way of looking at what happens with the mechanism of stress. Stress also exists on a continuum and the continuum looks like positive, that stress, that eustress where there are brief increases in heart rate and stress hormone levels. Then, kind of the middle. The picture that I have here, the graphic is a Venn diagram that's stacked vertically and it also conveys like the metaphor of a traffic light. Green light, red light, yellow light. I know that green light, red light, yellow light is often used to teach children regulation skills. So that's maybe a familiar metaphor or way of talking about this topic. So on the continuum we have positive with those brief increases in heart rate, mild elevations in stress hormones. Then the tolerable, which is now hitting the cautionary zone. It's a serious temporary stress response but it's buffered by supportive relationships. So it's a type of temporary stress of getting scared. Maybe kid's riding a bike and hits an object or swerves out of the way of a car and is really scared but then a loved one is nearby and comes -- rushes over to them and gives them a hug. That's the kind of serious temporary stress response but it's buffered by a supportive relationship. Then on the other end of the continuum of stress we have toxic stress, which is prolonged activation of stress response systems in the absence of protective relationships. So these can be associated with adverse childhood experiences. So ACEs is probably a term most people have heard. It's based on a study that looked at what were the kinds of experiences that have negative health impact on children's current and future health. They've done longitudinal studies in adverse childhood experiences have long-term impact even of adults, if that sort of buildup of stress, chronic stress and trauma does not get resolved, does not get addressed, does not get released. So there are ten areas or ten factors that have been identified adds part of ACEs with three main category areas. So the first category is abuse. So that could be physical, emotional, or sexual. There's also neglect as a category, which could be physical or emotional. And then household instability. So these are kind of also related community factors. It might be mental illness within the family. The mother being treated violently and witnessing that or feeling the repercussions of that. Having a relative that is incarcerated. Substance abuse in the home and divorce. So the statistic tell us that approximately 64% from the study that was conducted between 2011 and 2020 report one type of ACE. One -- there's a test that you can take and you can find it easily online if you Google "ACES survey" or questionnaire. I think it's ten questions. One type of ACE. And then 17% of adults have four or more ACEs. When you have four or more ACEs that typically looks at predictors of significant impact in a later -- in adulthood. So when we look at factors impacting how children experience an ACE stressor, we have risk factors and protective factors. The risk factors have to do with severity of the event. Was it a house burning down, was it a scare like the bicycle scare. How close were you to witnessing whatever was a factor that was involved in that ACE experience. Whether it was substance abuse or types of violence. The frequency of the event. How that child's caregiver reacted to the event. A prior history of trauma. A prior history of other ACE factors. And then family and community factors. Are you in a neighborhood where there's violence or substance abuse, not just within your direct family but also in the community environment. And then the protective factors are, at an individual level, just positive coping strategies that children might have, just part of maybe their genetics and their innate personality. But then also family. Family support and parental warmth serve as protective factors. And then we have with the community a broader support, positive relationships, for example with teachers, peers, and high friendship quality. So I want to bring back -- now that we have provided that context both on how the mechanism of stress works in all human beings and how severity of stressors impact children specifically. Then we're going to talk about mental health in students with visual impairment. So there's -- first of all I want to say there's not a ton of studies and the quality of studies aren't great. There's so many different variables in the way that each study looks at visual impairment and different terminology when they're talking about mental health issues. You probably know -- I mentioned earlier about how in my career I first started looking at psychosocial factors and that's still a term often used for visual impairment but now we have these other terms that have come through psychology and neuroscience such as nervous system regulation and those kind of factors. I pulled a little bit of information I thought might be helpful. Depression. The rates of prevalence of depression look at like 14% of children with visual impairment would have maybe what's considered clinically diagnoseable depression. And about 25% in adults. That was from a study in 2023. However, these numbers don't really reflect post-pandemic mental health issues. So we know kind of as a society that mental health has kind of reached this crisis sort of standpoint in society. So these numbers don't take that into effect. One of the areas that studies have identified -- specifically a study by Denmin and Silverstein. Kind of exciting that ophthalmologists would be involved in highlighting the need for mental health. They identified that vision loss early in life may be associated with less severe depression, perhaps a lesser need to relearn life skills. A study was done in China and it was part of a study so it was pretty significant in looking at myopia and strabismus, and that is children with myopia experience significantly higher levels of depression and anxiety of their peers without visual impairment. So that was a large-scale study that had some good science behind it but, again, that is a very, very -- kind of scant findings in the research. Anxiety is another area that's discussed a lot in relationship to the experience of visual impairment. There's -- these numbers really vary widely and there was a study in 2001 that listed 25% among children and youth in the U.S. And a more recent sort of -- I think that one looked at 45%. I saw other statistics that said 58%. There's a huge range. I think the biggest takeaway is that it's significant and we as educators know that. We don't necessarily need a study to tell us that. And then one of the things the studies found, they had a lot of conflicting information specifically around anxiety. Things I noticed were adolescents with visual impairment had higher anxiety than those without. But however there are studies that visually impaired in quality. They used different populations. Some studies found that girls were more impacted. There was a study that found that boys were more impacted. So there's a lot of work to be done in terms of looking at anxiety in children and adolescents with visual impairment. The issue that I wanted to bring up that is very specific to the experience of visual impairment is bullying. So there's a statistic that says the lifetime prevalence of bullying in visual impairment may be as high as 41%. And possibly even higher because it's underreported. Students with visual impairment -- there's a study that I looked at that I really loved. This one was in 2017. It was an interview -- so qualitative type study. It was a small number but the storytelling involved in it resonates so much that I wanted to share it with you. Students with visual impairment are most susceptible to bullying in comparison to typically-sighted peers and those with other disabilities. One study -- I'm pulling some of this from the literature review. One study found that 40% of students with visual impairment reported bullying one to two times a month. That was almost two times the rate of students without disabilities. And the bullying, 90% was verbal, 81.9% social or relational. So like exclusion from participating in friend groups. And then 50% was physical. And one thing that was highlighted -- there are actually several studies on bullying associated with physical education or PE. PE may be a particular forum for bullying as differences and vulnerabilities are put on display. The study, because it was interviews that looked at themes emerging from adults with visual impairment reflecting on school-based bullying experiences. This is retrospective so there could be bias in the way someone reframes their story but I don't think that devalues the meaningfulness in our educational settings. So the three areas that emerged around bullying from the interviews would it would be when there were teachers watching. Bullying experiences in unowned and unstructured spaces. The other theme was going through the motions. Feelings about verbal, social, and physical victimization. How being a victim impacted their world. And then the last one was they had their own insecurities. Understanding the bullies and bystanders. Reflecting on the why as to why the bullying occurred was the theme that emerged. I wanted to read a quote from each of the themes because I thought they were just really powerful. Abigail says -- and these were adults were interviewed, I believe in their late 20s, early 30s that were the participants in the study. So Abigail said with regard to the theme of unstructured and unowned spaces. She said: When I would be left alone in the hall, I would just be waiting for bullying. It would be when they knew -- the bullies knew there weren't teachers watching. Like when I was waiting for the bus. The bullies would know, the kids that were doing it knew if anyone was around or with me to deal with it. And then for the second theme, which is looking at feelings about verbal, social, and physical victimization. Audrey said: I was constantly on guard and going to school thinking what's going to happen today? Is this going to be a bad day? Are people going to bother me? Just that extra alertness was exhausting. So, I would get home and be so exhausted and just go to bed. So and you can hear specifically in that one that nervous system impact with the extra alertness and exhausting. The way she articulated that was powerful. Terrell said being the only legally blind person in the school district, I was always different. Everything was always different so I had large textbooks and large print everything. Low vision aids. For kids, that's different and kids don't seem to accept the difference too well. I just didn't fit the mold of a normal kid so I was always bullied. So that kind of paints the picture of the challenges surrounding mental health and what our kids are experiencing, the students that we serve. So now I'm going to play a video, as we turn towards tipping the scales and the ways that we can support students' mental health. This is going to provide a framework. 

[ Video ] 
>>Resilience is the result of a highly-interactive process between individual characteristics in the person and the environment in which that individual has developed. 

>>It's really the counterbalancing of difficult things that may exist in the child's life with positive things that occur within the family. But even positive things that may exist in the community. 

>>The easy way of thinking about resilience is like a scale with a fulcrum in the middle of it. And there are things on both sides of that scale. Experiences of both bad things or good things. 

>>Our genes shape where the fulcrum is positioned at the start. There are certain genes that make a child more sensitive to the effects of maltreatment or parental neglect or witnessing violence. 

>>The fulcrum may start out kind of more towards one side or more towards the other side. And that's going to make a big difference in terms of how much these subsequent events affect things positively or negatively. 

>>Science tells us that experience moves the fulcrum for better or for worse. 

>>Even though we are born with genes, genes will respond differently to certain environmental situations as opposed to others. 

>>What the genes were actually doing are turning up or turning down the expression of chemicals in circuits in the brain and circuitry in the body. 

>>When children learn coping skills that help them manage stress the fulcrum can slide so it tips towards more positive outcomes more easily. That's what resilience is all about. 

>>There's always an adult or more than one adult who is key to providing that relationship that helps to build resilience. [ End of video ] 

>>Erika: So the takeaway is the framework of the fulcrum and the way that we approach addressing stress and trauma with children. We're looking at a number of factors but it's really simple when we think about we want positive outcomes to outweigh negative outcomes and when we think about that relationships -- supportive relationships are the number one protective factor for children in helping to tip the scale. So we think about the term "resilience" and how that can play a role as we tip the scale to help children develop ability to handle stressors in the future without being overwhelmed. And so children are not born with resilience. Resilience is produced through the interaction of biological systems and protective factors in the social environment. So the biological systems, looking at those physiological responses to stress and how they get supports in the environment to help them navigate through those involuntary physiological responses to stressors. The single-most influential factor for building resilience in children is supportive relationships with adults. So that kind of leads us to highlighting that VI services need to be safe containers where students experience protective factors to process the toxic stress they might experience in their environment. And specifically to visual impairment. Because we have already seen there's a high rate of bullying and visual impairment can intercept with many -- you know, if children have a history of other ACE factors. Disability has not been identified as an ACE factor but what has been specifically identified also is that when we look at ACEs, that community factors play a role and when there's systemic discrimination or systemic treatment of a group in the way that child participates in, that can also function as an ACE factor. So what we're going to look at next then is the -- using the polyvagal ladder. When I talked in the beginning about stress and trauma and the mechanism of those, I said we would talk about it as an onion. We first introduced it as kind of how the physiological response works, how we complete the stress cycle by shaking off kind of that. Dr. Porges developed the polyvagal theory. My understanding is you had him as a speaker in recent history. And Debra Dana is a social worker who worked on -- collaborated with Dr. Porges to create a framework that would make it easier to apply the concepts within polyvagal theory. It looks at the autonomic nervous system from the perspective of the vagal nerve that runs through the body, that main nerve that connects -- expresses the physiological changes that occur, control them, that occur in our body, and response to stressors. And so they provided the metaphor of a ladder to kind of differentiate among stressors and the impact that it has. So the ladder starts off at the top. So at the top we have ventral vagal activation. We're going to talk about how we apply this to our students in a minute but I'm going to share the framework first. I don't think it's important that we use the fancy terms, understanding the framework is really helpful and I love that the ladder is an easy one to kind of apply. So the ventral vagal activation is when we look at a baseline of being safe, social, and engaged. That's why we want to function. That's where we can be connected and we can handle -- we're in a zone where stressors aren't overwhelming us. Then down the ladder, the next rung in the middle, we think of that, if we think of a traffic light or we think of, you know, the green space and we have the yellow space and the red space. The green space is that safe, social, engaged. We can carry on in our life, feel good. The sympathetic activation is when we become mobilized, agitated, and frantic. This is where we might use the words of like feeling anxiety. Then further down the ladder we have what's called dorsal ventral and these relate to specific places with the vagal nerve. But I don't feel like we need -- I don't want to get caught in the weeds of it. I want to convey the framework. With dorsal ventral, this is where we have feelings of being numbed, collapsed, or shut down. I have links and I feel like I have links on all the slides that have kind of a framework or an activity or the video. So you can kind of go to it for more information. But now let's transition to using the ladder. So the ladder works kind of three principles. We look at hierarchy. So throughout the day we can be moving up and down the ladder. If we're starting at a baseline of safe, social, engaged and something happens that makes us anxious, we might feel mobilized, agitated, frantic, anxious. But then if we do an activity that helps us shake that off, we can move back up to ventral vagal. However, we also can be further down the ladder, numb, collapsed, shut down, maybe some criticized us publicly and we really shut down and we're going to have to do more work to get back up to that place of safe, social, and engaged. For kiddos who have experienced ACEs, their baseline may not at all be, depending on what they've experienced, may not be safe, social, engaged as their baseline at all. Their baselines, when we have like a diagnosed mental health condition like anxiety or depression, those kiddos may be -- their baseline is always sympathetic or shut down, if a kid is struggling with depression. So those are important things to think about when we're working with children and students, like where are they on that ladder. Then we have neuroreception and the idea is that the nervous system that we're involuntarily scanning for cues in the environment about safety. The story follows state is used to describe that we feel first a threat before we have a story to go along with it. So our physiological body makes an imperceptible shift. When we have these nervous system shifts with the shortened breath and increased heart rate, they happen before we ever even notice them. We do get to places where we notice our heart racing and our breath being short but the system has already been activated well before that. So what story are we telling ourselves about the threat that we're feeling? A lot of that has to do with our prior history. And then we have co-regulation, which is emotional regulation that relies on reciprocal relationships. We talked about how, for children, supportive relationships is the number one influencing factor on how children process through stressors. And so co-regulation occurs actually between two people, the theory on it is that two people will -- if someone is escalated and you come present as calm, your calmness will help regulate that person come deescalate. And it's that concept of as humans we need reciprocal relationships to feel closeness with another. When we feel closeness with another when we're activated, whether it's sympathetic or dorsal that helps us feel better and that helps us deactivate. So this can apply -- the ladder can apply to making VI services feel safe. Some ways we can think about this is having awareness and empathy that the act of pulling kids out for classes may be experienced as a stressor. So we have to think about the scanning for cues and what's happening. So when we go to meet a student, the idea that when we're meeting that student, their nervous system might have already been activated or the mere fact of leaving their classroom and feeling different may cause their nervous system to be activated when they meet with us. Another way we can think about making VI services feel safe is having awareness and empathy that the skills and tools, the content of our lessons. So what the student is anticipating in coming in to work with us might make kids look or feel more different. Using a cane, optical device, using assistive technology in a way that others aren't. And it may also increase their risk for experiencing bullying, bullying that they might not be talking about. So those are things that we have to kind of keep in mind. That's why having this framework can be really helpful. Also a way that we can think about the ladder is attuning. So that means observing and responding with empathy to body language, tone of voice, a level of engagement for cues to where a student might be on that polyvagal ladder when you meet with them. It's not just the whole history of what they bring in with them at that moment but it might be the actual events that happened five minutes before, earlier in the day, and they haven't had a chance to deescalate yet. So I'm going to talk about activities to do with students corresponding to the three areas on the ladder. So when your student is in ventral vagal activation, which is the top of the ladder, they are regulated, they are social. They are engaged. This is a really great time to establish some rituals that can help develop closeness. So participating -- so a way we can do that is by creating a check-in. We want to teach a new skill when our student is not activated. So creating a ritual is a way to do that. And so one aspect of that is focusing specifically on how things are going with respect to visual impairment. Because there might not be any other safe spaces that they student has to talk specifically about their experiences of visual impairment. And one way we can help normalize that is by sharing a vulnerability that we're experiencing. Of course it has to be age appropriate and professional. But that we can model nerve system regulation. So, you know, if I was meeting with a student, I might share with them that before this presentation my videos weren't opening and I wasn't sure what was going wrong. And I certainly felt myself escalating. There are small little things that we can do to share but our language and our willingness to be vulnerable and our willingness to be self-reflective invites students in to that space. One of the activities that I really enjoy doing, really with kids of any age because it's hard not to laugh at poopsicle. I was talking to my friend who was doing the low vision conference on Friday and she and I had visited not long ago and we were talking about this. Poopsicle, popsicle, and dream sickle. I remember one time I was working with a student and I start our sessions -- I'm working with this kiddo online and we start our sessions with, okay, what's your poopsicle related to low vision this week? Or today. What was something that really kind of just stunk? And what was your popsicle and what's your dreamsicle, what was something you would really like to see happened. A lot of his personal experiences had to do with disability and he had to advocate for himself. He was in a situation where there were some issues with some accessible materials. He was sharing about how he was navigating and advocating for himself and what that felt like. His mom responded -- she was on the calls. She was like after we kind of finished she sent me a note and actually she's like he never tells me this. Of course we know that it's a different relationship with parents a lot of times but what I found that the container of poopsicle, popsicle, and dream sickle creates a fun life space that we can stay in the shallow end of the pool and talk lighthearted or we can also go into the deep end. I have a link there. A dad shared this and that's kind of where I found it. But it's the same principles as feelings and trigger scale. A lot of schools use this so students are already familiar with it. Going with something that is familiar is great but sometimes it's fun to have a little twist. When we were prepping for this -- Kaycee was like is that a typo? I was like, nope. It's poopsicle. When your student is in sympathetic activation, which is middle of the ladder, and there is -- they're mobilized, agitated, your strategy can be to invite your student to participate in down regulating that -- so you can have them when they need them. The link at the bottom has a whole bunch of resources. I just love this. It's very teacher friendly. I got all three of these from this activity. Belly breaths, where you put your hand on your we had. A grounding technique where you clench and release. And then I thought this was fun. It was a mindful hand massage. You have a little bit of lotion. You give it to your kiddo, they do a self-hand massage, which kind of feels special and has a sensory component for those kids who might like that. Then I'm looking at the time here. When your student is in dorsal ventral activation, they are numb and collapsed. You might invite your student to sing or hum with you. You might have selected songs in advance that you can use from your phone but the actual act of humming and singing creates that sort of positive kind of arousal when someone is really collapsed. It's a soothing sort of experience. When you hum with another person or sing, that's a way of co-regulating. I have a link there for a video that shows how to do this. Also journaling or doing a written or memo or drawing are other ways to get that creative expression going and energizing in a positive way. I have an article there that talks about turning triggers into glimmers. I had a client who called this Gliggers. Or a walk in nature. Sometimes taking five minutes talking as you do it, helps someone settle into being more productive. If a student is in the middle of the bottom part of the ladder, our teaching is not going to be as effective anyway. I have here, as the last item, a link to a video. I don't know that we have time for it. I just wanted to add this on. Where a student, Amy, she's a teen from RNIB. She talks about three strategies that she uses for regulating anxiety. It's raw and I love how raw it is and she uses three strategies and it's really beautiful. They are not the three strategies that I mentioned in the presentation because I wanted to do something extra for you to look at but I thought it was really cool. I think having students share and doing videos work for them is a really great strategy of building that coughs. Lastly, the part I want to return to Leslie's story is one thing that I didn't tell you from Leslie's story is that when she was in sixth grade she lived in a neighborhood in which there were gangs and she was bullied and one day -- she never told anyone. She was told they were going to find her after school. She ran home and she got in the door she had a panic attack and so her mom of course was like -- well, her mom was responsive and took her to school the next day and went to the principal's office but while she was waiting, another child came in who was bloody from having been bullied and so her mom walked out of the school and told her -- she had her family move from that neighborhood that day. Leslie had already had a protective experience of her mom standing up to power and supporting her and that helped her have her voice for when she stood up to her principal. She then told me after standing up to her principal she got the courage to write her library to say she wanted them to have large-print copies of an encyclopedia. This is in the '60s. I thought it was a beautiful way of tying together as we address and support our kiddos, they become resilient and that helps them be advocates for themselves. If you would like to talk about this further, I'm planning on thinking about toying with doing a newsletter on mental health and visual impairment. So mental health at the intersection of low vision and then also little groups for discussion. So you can reach out to me if you might be interested in that. And as I look at some of the questions, I saw a question about early how does lack of access to information affect the mental health of children? For example, does lack of sensory information manifest similar to neglect from the child's perspective? I don't know that there's a lot of research on this but from looking at the frameworks, what we have to do is look at how can we compensate or -- how can we compensate for lack of visual cues through tactile and other sensory to develop that closeness. The number one factors are supportive relationships. From a child's perspective if there's a support relationship, even if there's sensory -- lack of sensory cues, the supportive relationships can compensate for that and that's why it's so important to help train parents how they can connect and bond with their children in other ways that aren't primarily visual.