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Catherine McClellan, PhD, discusses her role in helping provide psychological support for children experiencing anxiety while receiving medical care.

Bravery Ladder: Tool to Address Medical Anxiety

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Melanie (Host): Welcome to Healing Heroes PDX, the podcast series from the specialists at Shriners Hospitals for Children in Portland.

I'm Melanie Cole. And today we're learning about the Bravery Ladder, tools to address medical anxiety. Joining me is Dr. Catherine McClellan. She's a pediatric psychologist at Shriners Hospitals for Children in Portland. Dr. McClellan, it's a pleasure to have you join us today as a new member of the medical staff team at the Portland Shriners Hospital. Tell us a little bit about yourself and how you came to Shriners Hospitals for Children in Portland.

Dr. Catherine McClellan (Guest): Sure. Thank you so much. Well, I always focused my research and my studies on pediatric psychology, especially surrounding pain for medical procedures. I did a variety of work working with, several different medical populations, including sickle cell disease and cystic fibrosis. I had enjoyed a good period of time at a pediatrics practice here in Portland. And when I saw this job come up in Shriners, I knew it was a very special job and a very special opportunity. So I jumped on the chance to transition over here.

Melanie: That's so cool. So then let's talk about this topic. Tell us about children who experience anxiety in response to receiving medical care. I would imagine that this is very common for kids. Tell us what that looks like. What have you seen?

Dr. McClellan: Sure. You're right, Melanie. Medical anxiety is extremely common and pretty understandable, especially young children. Many youths with medical anxiety, this can start after they have a painful or frightening medical experience, but sometimes just anticipating a medical procedure is really enough to bring on anxiety.

So in medical anxieties, individuals have very strong reactions and fears of medical interventions and treatment. When young children have medical anxiety, it often can take the form or look a lot like a tantrum or disruptive behavior whereas some youth come in with more of the classic signs of fear or anxiety who are very withdrawn or fearful.

Here at Shriners Portland, it is critical that we consider medical anxiety in all aspects of our care. Many youths who we work with have complex medical concerns that will require multiple significant medical procedures and interventions. Helping children learn how to cope with fear and distress early will allow them to feel more confident and in control as they face future health challenges.

Melanie: Then tell us how you help the children. Tell us how building bravery is an important skill to teach, not only to patients, but also to their families and to so many people right now, building bravery is what we all need. So speak about that a little bit and how you work with the families.

Dr. McClellan: Thank you. That's a great question. So the concept of bravery or bravery training is to focus on controlling what you can and using your past experiences to approach something that might be fearful. I always emphasize to families and children that we're not striving to have no anxiety. What we're trying to do is train people to know that they can do hard things and be brave even if they're feeling scared.

Melanie: So what does that look like? Give us some coping mechanisms for those families.

Dr. McClellan: Absolutely. Well, one tool that I use a lot is called a Bravery Ladder. And so Bravery Ladders work through the process of what we call systematic desensitization or in layperson's terms, gradually getting used to something that was really hard to tolerate at first. So with Bravery Ladders, what we do is we help the children and the teens that we work with face their fears, but in a way that feels supported and allows children to learn coping skills.

So when one is developing a Bravery Ladder, you always start by working with the child and the parent to identify their goal such as completing a blood draw. And then we like to break down all the steps in the process of getting the blood draw, starting from the easiest, all the way up to the very hardest and that would be the top of the ladder, and that most likely would be getting the actual blood draw.

So for example, with a youth who's afraid of the blood draw, we look at all the lower rungs below the blood draw as the steps that we need to get to the top of the ladder. So for example, walking into the clinic or having your skin cleaned with alcohol wipes, then we start by asking the child to rate how much fear or distress they have around each step on the letter.

Usually, we use a zero to 10 scale. That way we can have a good sense of where the different items fall on the ladder and what we should start with, because we always want to start by facing the lowest least fearful part of the procedure. That allows children to experience feelings of success and helps them to stay motivated to work on this hard task of being brave.

Then what we typically do, just like any other training, we've prescribed daily homework and practice. So what we have parents do and use is start with, one of the lower feared stimuli, like perhaps just saying the word blood draw or saying the word shot and have the family practice for five to 10 minutes a day, having the child be around that situation or words or item. So might be five minutes a day of just saying blood draw so that the child learns that while they initially have a big, strong fear response in their body, over time, even over the 10 minutes of that practice, they're going to notice that they're not as afraid of the word shot.

And we do this for each rung of the ladder so that the child feels more confident and more able to face their fear because they've been around it a lot more.

Melanie: What have you seen as far as kids adapting and using this Bravery Ladder? It's such a great idea.

Dr. McClellan: I have seen really some beautiful, beautiful results, and that's been a thrill for me. So what we find is youth who practice with their parents and climb that ladder. When they get to the procedure, they're ready, they're still scared, but they are ready for the procedure. And most important to me is how happy they feel afterwards, how happy they feel that they were actually able to face this challenge that was really hard for them.

Melanie: So how would a parent who's coming there for their first time with their child? And the child is very fearful and the parents probably too. Just tell us as we wrap up, Dr. McClellan, how do the parents find you? How do they find out about this ability, this program, this Bravery Ladder?

Dr. McClellan: What a great question. So I am integrated into the clinic, so that means I'm part of the medical team. So when a family might come here for a fracture clinic or something like that, we're doing screenings to check for behavioral or emotional health concerns. And any time there's concerns that parents might raise or a physician might observe or something might come up in the screening, I'm called in to consult with the family.

Melanie: And do you have any final thoughts for parents about helping their children with that medical anxiety? Because it is so common as we said, and it's a pretty scary thing for kids. Give us your best advice and final thoughts.

Dr. McClellan: So one of the things that I think we don't pay enough attention to at times is how parents are feeling about the medical procedure. It's really hard to watch your child go through something that might be painful or scary for them. So having parents make sure that they're taking care of themselves and that they're able to be as supportive and as calm and cool as possible for their child will really make a difference as children always follow their parent's leads.

Melanie: Thank you so much, Dr. McClellan, for joining us today. What great information and so important for families and children to hear. What a great program you have. And please visit us online at That concludes this episode of Healing Heroes PDX with the Shriners Hospitals for Children in Portland. Please remember to subscribe, rate and review this podcast and all of our other podcasts. I'm Melanie Cole.

About The Speakers

Catherine McClellan, Ph.D.

Catherine McClellan, Ph.D., is the on-site pediatric psychologist at Shriners Children's Portland, and she works closely with care providers and the behavioral health team to provide emotional and behavioral support for patients. Dr. McClellan joins the Shriners Children's Portland team after her time at Metropolitan Pediatrics in Beaverton, Oregon, where she provided a broad range of assessment, triage and therapy services for pediatric patients.

Dr. McClellan is a licensed clinical psychologist who has worked extensively in health care settings as part of a multidisciplinary team. She graduated from Reed College, earned her doctorate from West Virginia University and completed her internship at Children’s Hospital of Orange County in Orange, California. Dr. McClellan completed her fellowship at University of South Carolina/Richland Children’s Hospital, Columbia, South Carolina.

Learn more about Dr. McClellan

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