Good afternoon everyone. If this is going to be our group, feel free to come in nice and close, but stay wherever you are if you're comfortable to. We don't bite. Before we start, just want to get an informal poll. How many folks here are child psychiatrists or working with kids at this point regularly in their practice? Okay. How many folks work predominantly with adults? Okay. Cool. So I think we're kind of split then between child and adult folks. How many of you are involved in either working in or supervising school mental health related programs? All right. Great. Okay. Yeah. Well, welcome. So today we're going to be presenting to you about building a school psychiatrist toolkit. And our goal is really to address how to understand and think about issues of anti-racism and structural competency and care delivery and supervision and working with schools. So my name is Aishwarya and I'm going to introduce you to our rock star panel that we have here today. I have no disclosures. I'm a second year child fellow at Duke. And then I'm going to introduce Dr. Sonal Jain next. She has no disclosures. She's a first year child and adolescent psychiatry fellow at Duke. She attended medical school at the New York Institute of Technology, College of Osteopathic Medicine and graduated from Boston University Medical Center for her residency. And she developed her passion for collaborative care and global mental health while she was there. During her time at BMC, she contributed to multiple papers looking at different models of collaborative care and examining the effects of COVID on pediatric patients and their families. Currently she's an APA and SAMHSA minority fellow where she's working on a qualitative study examining South Asian mental health and is hoping to develop a useful toolkit with the data collected to allow for more accessibility to mental health in this population. Next I'm going to introduce Dr. Wajiko Jiragi. Dr. Jiragi is an assistant professor of psychiatry at the University of Pennsylvania Perlman School of Medicine, Associate Chair of Diversity, Equity and Inclusion for the Department of Child and Adolescent Psychiatry and Behavioral Sciences at the Children's Hospital of Philadelphia. And she is also a faculty member at Policy Lab and the medical director of the Young Child Clinic at CHOP. She is a practicing infant and preschool psychiatrist. Dr. Jiragi's research areas have been focused on health equity, diversity and inclusion with a focus on early childhood development and parenting practices. Her core areas of focus have been on prevention, promotion and early intervention. Currently she is focused on improving health outcomes for infants after NICU hospitalization. Her recent work has measured the prevalence of mental health conditions and symptoms in hospitalized infants' parents as well as the outcomes, as differences in outcomes and later utilization for services for both children and parents and cross-cultural differences. She completed her undergraduate degree at Columbia University, attended medical school at Baylor College of Medicine, completed her residency training at the University of Pennsylvania Pearlman School of Medicine, and her child and adolescent psychiatry fellowship at Yale Study Center. She also completed the Harris Infant Psychiatry Fellowship, Klingenstein NIMH Research Fellowship, and Edward Ziegler Center in Child Development and Social Policy at the Yale Child Study Center, as well as the Solnit Fellowship at 0 to 3. She has received multiple research development awards from the NIMH and Eunice Shriver National Institute of Child and Human Development and the University of Pennsylvania Provost Award. She has also received awards for her work in the community and teaching, including the Dean's Award for Excellence in Clinical Teaching at an affiliated hospital from the University of Pennsylvania's Pearlman School of Medicine and the Rusty Turner Memorial Award for Excellence Award from Families as Allies. She is also a distinguished fellow in ACAP. She is active in multiple organizations, including the World Association of Infant Mental Health, 0 to 3 Academy of Graduate Fellows, Society for Research in Child Development, including SRCD Black Caucus, ACAP Diversity and Culture Committee, and Health Promotions and Prevention Committee, as well as ADPERT. She's the deputy editor of J-CAP. She has published many articles in scientific journals, written multiple blogs, and co-edited a textbook, The Clinical Guide to the Psychiatric Assessment of Infants and Young Children, and most recently participated in multiple media interviews in print, radio, and television. You can find her disclosures up here. We also have Dr. Steve Adelsheim joining us today. He is a clinical professor and associate chair for community engagement at Stanford's Department of Psychiatry, directing the Center for Youth Mental Health and Well-Being. Steve's work is focused on early detection and intervention programs for young people, and he leads the effort to bring ALCOVE to the U.S., an integrated youth mental health model which opened in June 2021 in Palo Alto and San Jose, California, and L.A. County in November of 2022, with plans to open in three other California sites over the next few years. Dr. Adelsheim also co-leads PEPNET, the National Clinical Network for Early Psychosis Programs. Steve also co-directs the Media and Mental Health Initiative in Stanford's Psychiatry Department. He has partnered for many years with Native American and tribal partners on expanding early intervention mental health supports for tribal youth. Steve previously spent many years leading school mental health efforts for the state of New Mexico and served as New Mexico's state psychiatric medical director. He is committed to developing the National Public Mental Health Early Intervention Continuum for Young People, from school mental health to ALCOVE community-integrated youth mental health programs to early psychosis programs. You can find his disclosures above here as well. Thank you so much to our panel for joining us today. We'll go ahead and get started with a little bit of an outline. So what you can expect from us is we'll tell you a little bit about the different roles school psychiatrists take in our communities, what some models of care can look like. We'll take a little bit of a developmental lens and walk you through what different concerns can present across the lifespan, and we'll think about some fundamentals and thinking about structural competency and anti-racism in our work, especially amidst an evolving political landscape. We'll have some case discussions and then our esteemed discussants will provide some remarks to close it out. Throughout, we welcome your questions and we would invite you to come up to those microphones there so that you can be heard on the recording for others who will watch this later. All right, did you want to lead us off? You go ahead. Good afternoon. Thank you all for coming. Again, I'm Wajiko Juragi, an infant preschool psychiatrist, and I'm hoping that today is part of the discussion at the end or throughout that we'll talk a little bit about what it means to be under the age of five, how structural racism impacts very young children in early care settings, whether that's with family kith and kin or center-based care, what that means for early school entrants. So again, I look forward to the talk and the discussion thereafter. Thanks. So I get to be here for my colleague, Dr. Joshi, who actually ended up getting pulled into another presentation today, and I'm really honored to be on the panel with everybody here today. You know, I want to just say that right now, it's an amazing time in this country for school mental health. As someone who got involved in this work back in the early and mid-90s, you know, the idea that we would see this much conversation, support, and funding for school mental health is pretty unbelievable, and there's a sense that we have this very brief window of opportunity to create models and infrastructure and programs that support our young people through these early intervention structures with schools that really is unprecedented, but there's a sense we need to be able to think about how to do it well, and so I think it behooves all of us to sort of get the skills we can to also think about the systemic issues, and as we're talking today about the issues of really providing clear, culturally appropriate support for our young people, there are, you know, there are many issues to think about. I'm someone that came to school mental health from more of the community side, and when we think about school mental health programs, you know, it's important to think about them on a continuum, really from the roles of the school health and mental health professionals that are based in schools to, you know, the whole issues around how we develop supports for young people with disabilities, whether, you know, through Section 504 or IDEA, you know, if they also need those additional services and supports, and the roles of schools in terms of child find as well and how that happens, and then there's the whole world of community health and mental health providers coming into schools, often from the HIPAA side of the system where there are different issues around informed consent and confidentiality, and thinking about how and providing those services, one is really taking on a little bit of a different role than when one is really more often employed or doing child psychiatry consultations for a school district as well, and so thinking about that entire continuum and the different tiers, you know, that we often speak about becomes really important in thinking about, you know, how we provide this care and support in pretty important ways. You know, I would just say that as we frame this discussion, being able to think about if you're interfacing with schools or going to, you know, what is the cultural background of the administration of the school, the teachers in the school in relation to the students in the school and in the community, and thinking about the issues that are there, what's the capacity of families within this school to give input about schools, programs, and procedures becomes a really important piece, and frankly, the voice of the students in terms of how services are happening and meeting the needs of the students within the school setting also become very important, and what is the training culturally for everyone involved in the school in appropriate ways, you know, and I'll just, I'll stop and one story I would just share, for example, is I worked actually in school-based health centers for many years in New Mexico before moving to California, and in that work, I spent four years working in school-based health centers that were in Native American communities, and there was one school I worked at that was about 35 miles outside of Albuquerque that was a Native American school, and it was the, it was a school that was mainly supported by mostly white teachers, and because it was in a different school district from Albuquerque public schools, which required students when they retired to leave the school district for a year before they could return and become teachers again, it was a school where many of the teachers would drive the 35 miles to teach in a separate school district to start collecting their retirement, and then after being there a year, they could go back to the Albuquerque public schools with their retirement and start working again, and so you had many teachers that were coming for a year to be able to work with these Native students so they could spend a year there and then go back to their home school district, and as you might imagine, the motivation and interest in supporting the educational needs of those students was not as strong as one would hope, and so as a result, there were lots of cultural problems. There were lots of issues around suspension and expulsion because of the lack of awareness, understanding, and thoughtfulness around addressing the cultural issues within the school, and it was frankly hugely problematic, and so there was a lot of education that needed to happen, a great deal of support for the students and families, and so it's important, I also think, to think about the schools we're working in and the kind of supports the families have, the schools have, and what are the connections with the community and with the people providing the care and education within the schools, so let me leave it there. Thanks. Before I get started with the presentation, I have one more introduction to do. Dr. Ashwari Rajagopalan is a second-year child and adolescent psychiatry fellow at Duke. She completed medical school at Philadelphia College of Osteopathic Medicine, where she graduated the Leonard Finkelston Dio Award for Compassionate Concern for Patients, was a member of the Gold Humanism Sigma Sigma Phi and Omega Beta Iota Honor Societies. She completed general psychiatry training at Harvard South Shore, where she served as a chief resident and helped develop the program's anti-racism and structural competency curriculum for residents. She also served on local and national committees for diversity, equity, inclusion at VA Boston and through the VHA. At Duke, Ashwari is the chief fellow for the Pediatric Consultation Liaison Service and chief fellow for the Psychosocial Treatment Clinic, where she helps supervise first-year fellows in their longitudinal therapy cases. She's had the opportunity to participate in the expansion of the North Carolina Psychiatric Access Line to include school-based consultation and to participate in consultation calls with primary care providers. She looks forward to learning about many ways in which she can serve children and families as a child and adolescent psychiatrist and has been a great mentor for me as well. So just to give a little bit of background as we start, kids are struggling. That's a matter of fact right now. According to the 2021 CDC data surveying high school students, nearly 42% of students felt persistently sad or hopeless. 29 experienced poor mental health. And of that, 22% of students seriously considered a suicide attempt while 10% attempted suicide. Going further, diving further deeper into those statistics, there's disparities in these data as well. So LGBTQ plus youth are more likely to report having seriously considered a suicide attempt. That's 45% of youth. And among historically marginalized racial groups, black youth are the most likely to have considered a suicide attempt. So we're really working with some pretty severe numbers here. And then thinking about schools in general, why are schools important? For a lot of different reasons. Children and youth spend most of their awake hours there. Their social learning, academic learning, and it can be a major place where, or the only point of healthcare access for kids. And so this is a place where we can really intervene or help out. The problem is, and I'm sure we've heard this before, schools are understaffed and under scrutiny lately. Per the U.S. News and World Report, more than half of public schools in the country reported being understaffed in the 2022 and 2023 school year. Additionally, content of learning has received nationwide media attention, particularly with themes around racism, anti-racism, sexual and gender minoritized identities. So as much as kids are able to get all of this learning and such, they're still struggling with these very real consequences. And so this slide is just to highlight some of the headlines lately that have been happening at schools and related to schools. So as I mentioned, teachers and staff shortages are more and more increasing. Teachers are overworked and underpaid, and so burnout is contributing to understaffing. And then we have these bills and bans going on where in Florida specifically, there's the DEI spending becomes official as DeSantis enacts college reforms. Tennessee is having this book scrutiny bill. And these are just a few of the headlines that are going on within the country. So moving to a role of a psychiatrist in schools, how do psychiatrists work in and with schools? And this is a question for the group in terms of kind of what your experience is or what you imagine, how do psychiatrists work in schools? Feel free to call it. If anyone wants to just shout it out or stand up near a microphone and just let us know. Psychiatrists tend to collaborate with schools, like contacting teachers, I think I saw it as well. Yeah. Trying to do an email, a phone call, giving them a cell phone, a T-text, just to kind of have a collaborative approach to get through the headlines. Absolutely, absolutely. I would second that. We're just always trying to collaborate and have that conversation, right, with teachers and the school system. At times, I've been able to be a formal consultant to the school and the nursing and the health clinic. Sometimes that happens. Yeah, thank you so much for sharing that. Anybody else want to add? Yeah, no, exactly. Some psychiatrists are embedded directly in the school, seeing patients directly at school, as mentioned, consultants to the school, reviewing cases seen by school social workers or school psychologists or other providers. And then we're all embedded in the community too, right? So whether it's in the hospital as a CL psychiatrist or primary care or private practice or just a community provider, there's lots of ways of collaborating with schools and an important part of the kid's full picture. So in our capacity as psychiatrists, we may be called to render diagnostic evaluations for children. We may be asked to recommend accommodations for children to make education more accessible. And then zooming out, we may be asked to weigh in on psychologically pertinent topics as well. So bullying, community violence, developmental frameworks for curriculum development or youth mental health crisis, which is very top of our list these days. And those are just a few of the roles that I can name, but there's plenty of other roles that we have. And so making this a little bit more real and pertinent for our discussion today, we wanted to bring in a case discussion. And so over the course of this presentation, we'll walk through different elements of what our role may look like and how anti-racism and structural competency can play into the assessments we conduct of children, families and communities in these contexts. So our case is gonna look at a 12 year old female. She's referred to you by the school counselor after allegedly sending text messages with inappropriate language in them to peers. The parents of the other children report these messages to the school. When the child was asked about these text messages, she was oppositional and hostile and was suspended out of school for one day. You are asked to clear the child to return to school. So another question for the group, what additional background information would you want to help with your formulation? And same thing, call out, can go to the mic, whatever you guys prefer. Yes, absolutely. Yeah, 100%. I'd like to know some background information about this individual. You know, is this a person of any sort of sex or any kind of gender? Yes. It's a female? Yeah, yeah. So wanting to know a little bit about who they are, whether this is something that's happened before and kind of what are their individual circumstances. Great, okay. So some additional background information. Allison is a neurotypically developing 12-year-old black natally female child using she, her pronouns. She lives with adoptive mother and father and younger brother. Parents are separating. Has a history of adjustment disorder with mixed disturbance of mood and conduct. She saw a psychiatrist two times for medication evaluation but family declined SSRI initiation. She started individual therapy in a training clinic. She's been doing CopingCat with focus on anxiety. As Allison reported, her primary concern is feeling overwhelmed. Furthermore, she's an excellent student. She typically earns straight A grades, advanced beyond grade level in mathematics and reading. She's a competitive athlete, competes on a traveling gymnastics team and is projected to be recruited by collegiate gymnastics. She has an older brother and a younger brother. Both are bio children of adoptive parents. Her preferred activities include playing board games and card games with family, spending time with siblings and taking care of younger brother who is two years old. She's never had any prior disciplinary action or behavioral concerns reported at school. Now there may be other questions that we didn't kind of allude to that are important to understand and constrain the child but we can keep going and kind of dissect as far as the information that we have. So how do we really think about this child in this case? So keeping that information in mind, we're thinking about developmental milestones. And so I'm just gonna do a quick aside and talk a little bit about each milestone for each kind of schooling age. So preschool milestones. Major themes we wanna think about at preschool is learning to share cooperative play, imaginative play and gender identity development. And so common concerns in preschool are impulsivity and aggression, difficult to settle and separation anxiety. So that's kind of what we're hearing more about in that age. In elementary school milestones, that's a time of tremendous growth for kids. So they're building friendships, they're learning to sustain friendships, learning from mistakes, growing their personality a bit, recognizing to peers and teachers, developing their identity and evolving to seek more praise and appreciation and some influence of peer pressure. Common concerns in elementary school, academic concerns. So difficulty with specific subject matter, difficulty with organization of material, attentional concerns, mood concerns, anxiety concerns and aggression and bullying. Middle school milestones. We're thinking, I don't know about you guys, but for middle school was tough for me. So that's a difficult time for kids. It's puberty's starting, there's more responsibility, increased social concerns, more adaptability, trying to fit in, not stick out too much. Common concerns in middle school. So similar to elementary school, there's more increase in mood related symptoms, social media related concerns. We got TikTok and Instagram nowadays, probably more, I don't even know. Consider role of substance use and community concerns. So violence, suicide, events presented in the media. And then we get to high school. High school is a time where you're working towards graduation. There's peer pressure to know what you wanna do in that time. Academic advancement. There's the development of romantic or intimate relationships. Interpersonal conflict and complex executive functioning. You're learning to drive, you're transitioning to manage your own life. At 18, you're considered an adult. So all of those things are like added elements. And then the common concerns in high school kind of related to what I'm speaking of. There's more consumption of media. There's preparation of transition, often out of the home and those mood related symptoms, which could be thought related concerns or related to substance use or separate from that as well. And so what do we wanna consider along with all of those developmental milestones depending on the age of the child? We're also thinking about where does this kid come from? Who lives at home? Like family of origin and current family. Who lives at home? What is the structure of the home? What does the identified patient get support? Is it from mom, dad, someone else in the family? And do they have access to basic needs, including food, shelter, healthcare, psychological safety? And the availability of caregivers. Who's at home when the kid gets home or when the child gets home? Or when do they see their caregivers? And then there's the systemic stressors that we wanna consider as well. So systemically marginalized identities. Do they belong to racial ethnic minoritized identities, sexual or gender minoritized identities, the neurodevelopmental differences or disabilities, and psychiatric diagnoses or chronic illnesses are all important to consider when we're thinking about the whole picture of this child. And then we wanna consider the strengths, right? So we're thinking about one part of where this child is coming from, but then also what the strengths of the child are. So what does the child have that brings them that strength? And then there's caregivers and child. What strength do they bring together? And then the school, what strengths do the school provides for the child? And then kind of zooming out even further, who else is in that village for that child? So are there other clinicians involved? Pediatrician, therapist, family therapist, other ancillary therapy services such as physical therapy, occupational or speech therapy. And then community leaders. Those are super important to consider as well. So religious or spiritual affinity leaders, cultural or heritage-based organization leaders, extended family, local and national organizations. They all can be part of the strengths for this child. And then we wanna name the systemic racism and structural inequities. We really wanna keep that in mind and that a lens part of when we're looking at children and trying to see what's going on at the school. So what are some examples of systemic racism and structural inequities you have seen in schools? And again, you can shout out, come to the mic, whoever you prefer. Yeah. Yeah, you said disproportional punishment. Disproportional diagnoses, yeah. What kinds of resources? Sure. Right, disproportionate word choice, right? Some racially-laden terms. Yeah. Absolutely. And so yeah, exactly. Some things that we talked about, like hostile, aggressive, oppositional, usually are used to describe black children, which is really unfortunate. And then there's the tropes about children from different Asian backgrounds with regards to anxiety. Automatically, it's assumed the pressure is coming from parents or that's what, that's why they're so anxious. And then aggression without context. So policies that lead to immediate action without considering the circumstance. And so I know I threw a lot of information out at everyone. And so bringing it back to Allison and our case, the words oppositional and hostile, like we talked about, were used to describe her behavior without a description of the behavior. So what happened? Additional information revealed that this was the first time she had sent text messages with inappropriate language. So how did we arrive at immediate suspension? And why is psychiatric clearance needed for return to school? What factors do you guys think may be contributing to the turn of events? Yeah, you said race? Yes. Yeah, yeah. What did you say? Current sociopolitical climate. Is that what you said? Yeah. Political climate. Do we know much about the makeup of the school in terms of the racial makeup, in terms of the school or the administration or anything like that? So I think that's actually one of the factors to consider, right? And that's sort of intentionally left vague for that purpose, right, is that? Okay. Going back to systemic factors, again, what are the resources that the school has that they have resources to do an evaluation or provide non-suspension services to figure out? Exactly, yeah. I was wondering about the parents and their advocacy of standing up for the school. Do you have the time? Yeah, that's a great point. And where does one learn how to have those interactions with the school system as a primary caregiver or a parent? I mean, what about the potential mental health diagnosis issue and, I mean, one of the things that it sort of raises is questions about how irritability may be interpreted within the context of a school setting potentially as well. And in the context of her race. And potentially in the context of her race. Absolutely. And that it wasn't described at all. So it's unclear to the psychiatrist who's receiving this information what exactly happened. So was it truly irritability? You know, was it a child trying to reason? And since we weren't there, right, we're only left with sort of what's described, which was hostile and oppositional. And so we've done some of this already, just in our discussion here, so translating naming into action. So we've named some of those concerns already, and then identifying underlying contributing factors of concern and question, which we also did just now, some of those things such as race, and underlying diagnoses, and thinking about the family, and all of those things are important to understand for this child, and for any child. And then proposing a plan of action for addressing the concern. So what does that include? Does that include collecting data, changing policy, incorporating additional stakeholders, and who will be the accountable parties? So those are the questions that we really wanna be asking ourselves when we're thinking about cases like this. So in the question of Allison's return to school evaluation after a suspension, many issues may be tied to structural racism, as we have noted. So utilization of out-of-school suspension, right? What are the other resources that are available rather than just a school suspension? Racially coded language, this is hostile and oppositional. And then requirement of psychiatric evaluation to return to school, like what is the utility of these things? So as a psychiatrist, what steps could you take to address any of these? I know we've talked a little bit about a few of them. Anything else that we haven't talked about that you guys can think of? I do think there's a role for psychiatrists, child psychiatrists, for advocacy, right? And education and advocacy in the schools. So I was in Arizona last week. I feel like I've been all over the place. And I was talking about school mental health options, right, that are coming, especially with a lot of the state money and how, you know, integration, right, of issues around behavioral health in schools. And some of the teachers told me that there's actually a movement in some of their districts to remove this conversation about social emotional health and behavioral health in a very similar way to not talking about critical race theory, right? Sort of integrating those ideas about that we're actually doing an analysis of structural racism and how it impacts on our children's outcomes, right, and well-being. And so they're actually becoming an integrated concept around critical race theory and social emotional health and well-being and social justice in schools. And they wanted to ban those conversations, right? And that they can't get federal funding unless they have a school resource officer. So if they have a policing system within the school, then they'll be allowed to get, you know, pass through federal fund grants and that kind of thing. So I think one of the things that as psychiatrists and child psychiatrists we need to do is really have those critical conversations and advocacy about how, yes, we have to do education around sort of our clinical lens and how we're looking at racism and the way that we approach children's behaviors or understand them, but also sort of systematically, right? Like, do we not have, you know, that social emotional support where we do have a officer, right? You know, it sort of criminalizes children's mental health and well-being versus, you know, really thinking about wellness and sort of the justice of all kids thriving, right? And so I think advocacy, I guess, is my bottom line with that in terms of people understanding these, what's going on. Yeah. And so bringing it back to Allison, what would a child-centered plan look like for Allison? We're really focused on her specifically. There's not a right or wrong answer. It's just, you know, if you had infinite resources, right, what would you do in the instance that someone is reporting inappropriate text messages at school? What might you be able to do to get to the bottom of it? I find myself wondering what would happen if somebody knew the child well enough to know if this was a change from the baseline and then to act upon that, and kind of be curious about why did this happen now or what's going on in a much more supportive way? Definitely. I think one of the ideas was incorporating her therapist. She sees a therapist, they're working together, maybe getting them involved. They might know the child better than kind of what's going on here. And just piggybacking on that, assuming that you can do foundations like Talk, Notice, Act in schools, and even like, you know, the janitor or the lunch person noticed this change in her, and identified it as a change. Right. Absolutely. I think looking at this question a lot, we have to evaluate it out, right? Yeah. And so, like, I think some of, and I do a lot of person-to-person consults, and how I mean, there's a lot of creative things. Yes. I mean, there's a lot of research that shows better, but you know, when schools are doing like meditation instead of detention, right, so you know, a great number of improvements in these behavioral conditions. Are we actually understanding the needs of these kids, what their emotional experiences are, teaching them and giving them some insight into that and then helping the adults in their lives navigate those different spaces they live and play in school? Right, it sounds like linking to the various contexts in which our children grow and you know, exist in the broader world to actually understand and individualize. And then also sort of the broader themes too about how do we make schools environments where kids can feel supported in all elements of their growth and development. And so thinking about it, so some of us here are trainees, and so thinking about the trainee experience and at different stages of training, whether medical student, resident, fellow, there's varied levels of comfort in engaging in systems levels conversations. And so how can attending psychiatrists support trainees acknowledging and confronting structural barriers to equity in the classroom and in the community I think are important to kind of acknowledge as well. And so speaking from a trainee perspective, I've definitely had supervisors that have been super helpful in acknowledging those structural barriers. I mean, we think I've, I can speak from my previous hospital experience, I definitely noticed a very concerning, you know, structural racism concern that happened in the hospital with a patient. And I had a great supervisor who I was like, I think something's wrong here and I don't know what to do about it. And I don't really know if what I'm feeling is correct or not. And so having that gut feeling, being able to talk to a supervisor and them validating what I had, they were like, yeah, you're right, this is wrong and this is not okay. And this is how we can go about doing something about it. Especially being in that training experience where you're like, I don't wanna get you into trouble. I don't wanna, you know, I have years to go before I'm somewhere that I can actually speak up. And so being able to have a supervisor who supported me and being able to, you know, help me navigate how to report it in a way that was productive and not punitive, I think was a really great experience, at least for me. And I think I see some folks in the audience who work with trainees or have supervised trainees and would welcome your perspective. I'm not putting anyone on blast out here, but would love to hear your perspectives on how you support trainees when sometimes, you know, we're the first folks who get tasked with having those conversations. If we're on a school rotation or it's an outpatient of ours, what are some of the ways that you think about how to empower trainees who feel a little bit more concerned about how to have these conversations and identify systemic level problems in the care of their patients? Yeah, I want to just repeat this for the recording that including structural contributors in every formulation and every encounter. I have several supervisors who do this in my outpatient clinics and it's been really transformative in the care that I feel I'm able to provide because I think we actually get a 360 degree view of what's happening and it helps to feel a little bit less powerless even when we're amidst a lot of structural concerns that maybe we don't have exactly what we need to overcome but naming it as the first step to and sharing that with a supervisor because it can also feel very isolating when you're the point person for the first time in this work as a trainee but to know there's someone else who shares in it with you and has your back in navigating that process. You know, a couple things that I think about might be important is one within the training experience to ensure that the trainee is embedded enough or has enough exposure to the culture of the school to understand how school systems work and what the different roles are of the different administrators and who does deal with discipline and what are the roles of all the school health and mental health professionals and frankly being able to be in some relationship with them whether it's through doing a presentation at the school or some other kind of consulting role or having an opportunity to even just sit in a classroom or teach a health class or something where one is getting exposed more broadly to the school culture so then when these issues do come up, one is in a relationship and has a sense of even who are the right people to talk to, who are sort of making these decisions and I think those pieces become really important. I think another area really is the interface with the family in terms of support and thinking about how we can, you know, be working with our students and through the conversations with them think about how to help support them and their families as well and understand the situation from the family perspective within the school setting. You know, as we've been discussing, I think we've hinted at the issue of how do families even understand the rights in terms of school settings and I think for us to be sure that our trainees understand them becomes a really important piece and even understand the difference between, you know, what is FERPA as a law in terms of informed consent and confidentiality and what rights do that student have around what's confidential and what is the family want shared with the school around the conversations becomes a really important question too. So being able to, you know, support the empowerment of families to make the decisions they want to make with their student about interfacing with the school becomes an important piece in terms of our training of our trainees as well. Absolutely. And so last but not least, talking about legislative challenges. So as we know, political climate is hot. So curricular bans and limitations, the critical race theory as we've alluded to and book bans are happening all over the country. Acknowledgement of sexual and gender minoritized identities in the school. So there's a lot of bans going on about this as well. And then recent legislative challenges around reproductive justice and autonomy. So really thinking about how that's affecting kids and, you know, who they are and how they're feeling about this. And so we wanted to do a small group activity just to kind of practice what we've learned in our presentation before we move on to our discussants. Just looking at the time. So I think we'll have around 10, 15 minutes to be able to do this. So what this is going to look like is in small groups, we're going to have three different cases. And so the idea is to discuss what information you'd like to know about the patient and how you might obtain the information. Discuss what factors would influence the recommendations you would make to the school and to the patient and family. And discuss how you would identify pertinent structural considerations in the situation and in the recommendations you make. So yeah. Around 10 to 15 minutes. And then one member of each group will hopefully report out for two to three minutes to talk about kind of what you guys have discussed. So maybe we can do case one on this side, case two over here, and case three over there. Does that kind of work for everyone? All right. So we'll put the cases up on the screen. And then for any group, it's going to be a little bit of text. We can kind of move it around to make it easier. All right. So group one, your case is up. If you want to just get a quick skim. And you can also feel free to just riff off of what you see on the screen and make it your own. Just get the general gist of age and presenting concern. And then the rest is kind of, you can run with it. »» And can also take a picture. »» Yeah. Or take a picture and share it with the group. That may help too. »» Are we good? Group one? I'm going to go to group two then. »» Okay. »» Everyone okay? »» Okay. »» Okay. »» Yeah. This one is more you. »» This is group two. It's going to be a good one. »» Okay. And then, is group two ready? Okay. Group three? We'll transition over to you. This is group three. And then if group three is all set, I'm going to go back to the slide kind of for what we need to discuss. All right. So we'll set a timer for 10 minutes and then we'll have you all report out. Yeah, yeah, yeah, of course. It's always good to ask. Yeah, yeah, of course. yeah, yeah, yeah. Are we ready to report out? We'll actually flip things and start with group three. So who's going to tell us what you all decided while we pull up your slide? Yes, we'll have group three go first. people. So again, it leads us back to advocacy through which we can all help with our organizations such as ACAP and others like APA to advocate on behalf of our young children and families and understand that these systems are long-standing, these inequities exist, they impact children and families, but with all of that we have learned some tools today which we can go out and help to change the communities and at the end of the day help children and families. Beautifully said, you know, and all of the issues I think you're sort of raising about how we support families and young people and frankly preschool teachers also apply, right? K-12 as well, absolutely. You know, just a couple of thoughts and, you know, like I mentioned, like was mentioned at the beginning, I worked actually in school-based health centers for many, many years and I will share that I sort of got to know my wife on the opposite ends of a due process hearing where she was the special ed lawyer supporting a family of a seventh grader who was a Hispanic young man in middle school who had been expelled from the school and I was the child psychiatrist expert for the Albuquerque Public Schools and, you know, I just met my wife actually at a due process hearing, I mean, at a community collaborative meeting and then we found ourselves in this situation and, you know, as she presented the situation with the family and with the young person, I was then asked to go back and review and meet with the school district and sort of talk about what was happening and with this young man you could go back to the kindergarten records and talk about the difficulty during transitions and the challenges that this young person was having tracking, you know, the situations in school and really all the way back to their educational record and yet the school district had actually never really even done an assessment around, you know, from a child find perspective around this young person and here he was in seventh grade and they were ready to be done with him and it was, you know, was really striking to me in the sense of thinking about to what degree schools actually one sort of appreciate just the general mental health issues in the first place of our young people, to what degree they actually take responsibility for child find and identifying young people with issues and then particularly when they're developing issues that may be more present a little bit later, recognizing them and then providing that support, you know, and I mentioned this issue of irritability in relation to depression. I mean one of the things that I generally found working in schools for many years was that, you know, schools are very good at talking about behavior and, you know, when I was wearing sort of often a state mental health hat, behavior was described as mental health plus substance abuse related intervention but behavior in schools has a whole different definition and I think it's often really important for us to understand even the meaning of words in the context of the different cultures that we're working in and there were many students that I worked with who were maybe having their very first fight or their very first battle or yelling at a teacher back for the very first time and when one had a chance to talk with them, you know, they were developing a depressive kind of issue and really for the first time it needed all kinds of support and the school needed help understanding there was an underlying mental health condition that, you know, for which that person needed support and even on the times when I was able to intervene and meet with young people who had brought guns to school and they were about to send them to the Juvenile Justice Center but, you know, someone said but, you know, as long as you're here maybe you get to talk with them first, you know, on multiple cases those young people that brought guns to schools were having early psychotic experiences, were very paranoid and were really struggling with their experiences in relation to other students or with teachers and when one could help the school understand what was happening we could at least get that young person to an emergency room or to a hospitalization as a first step rather than into the juvenile justice system and so I think for me there's been a bias that schools are often very well-meaning but under-supported and particularly now as teachers are so stressed and anxious themselves, you know, and needing additional support to be able to do their jobs it seems even more important for us to find ways to support everyone in the school system and support our families and support our students in a way that has never been truer than it actually is right now and so I think we have sort of great opportunities to do that but again we still have really tremendous challenges in terms of being able to build that support and so for me having opportunities for students to really understand what's happening within the context of the school system sees even more important and for families to really even understand that much more what their rights are and I find in the systems that I've worked in in training our students still don't often have the opportunities to understand, you know, this big circle of the Americans with Disabilities Act and what 504 means inside of it and what IDA is within the context of that in terms of the impact of that disability on someone's ability to benefit from their educational program and, you know, without being able to do that it's really challenging then when we go out as practitioners in the community to know how to advocate as well for our families without, you know, having those experiences or knowing who to even talk to when you figure out you're supposed to call the school. Well, who do you call to talk to with the school about the student that you're working with and so those training opportunities become really critical and important as well and I think just one final comment around advocacy. I think knowing where sort of we end up wanting to draw the line for ourselves and our trainees, you know, does become really important and and trying to have a sense of where one needs to then take the step to sort of change things within the context of a school system and, you know, I worked in one middle school where we were on our sixth principal in five years and, you know, our school-based health center team was sort of the continuity, you know, within the school over time and, you know, here was the student and family I was working with and, you know, we had a young man who we were waiting for their student assistance team meeting to happen around the issues of was there some underlying mental health issue and they were all backed up and it was two months then three months and four months we kept asking when's the assessment gonna happen and in the interim the student got in a fight, yelled at somebody, and they were gonna expel him from school and so then the question became, you know, well what do we do with that and one, you know, there was the issue of educating the family around what their opportunities were and in terms of the possibility for their rights and then when they wanted to go ahead and sort of fight that and were dismissed by the the school leadership, you know, I think I had a decision to make about whether I was going to sort of stay with that or not and the principal really felt very clear, this new principal, that it was time to lay down the discipline within the school and at the end of the day I sort of went over them, made a complaint to the school district, and then was summarily kicked out of the school, right, and it was the only school I've been kicked out of and I sort of knew in terms of taking that complaint forward that it was gonna happen but there was a sense of needing the broader school administration to know that there were real problems with how things were happening at this school and a sense that if I didn't do it it wasn't gonna happen and and I think those are really difficult questions and decisions we need to make on behalf of our students and families, you know, we kept working with the family outside of school and tried to help with their transition to a new setting but I think, you know, these are challenging times and even more so now and, you know, I was listening to a podcast the other day about a transgender young man from Texas who was really struggling with his school and the family made a very difficult decision to allow him to to leave and go live with relatives in Rhode Island because things were just too painful and difficult in his school and, you know, he was talking about, you know, his first week at school realizing, you know, and after in Texas they had removed the safe space things on the school, you know, windows and then as he moved to the new setting where there was the LGBTQ plus club at his school and, you know, the network of other students and all the safe spaces and all the other programs he can get involved in just even from a safety and health perspective a sense that really he could start to breathe again and when you think about what our teachers are dealing with and our families and our students with these changes that are happening nationally being able to to think about how to be of support across all these issues just, you know, seems so critical right now so our role is, I think, even more critical than it has been. So, thank you. Thank you all. We'll open the floor for any questions that you may have or any remarks from the audience and if there aren't any it looks absolutely beautiful outside so maybe you wish to soak up a little sunshine. Thank you so much for coming. I was just gonna ask about a slightly fickle question of kids that are homeschooled and where I come from in Scotland there is a kind of social policy infrastructure to support and not lose those kids and some might have a good experience being homeschooled some might not at all and, you know, I'm just curious to know if you've encountered any difficulties with it how to actually identify and support mental health needs address systemic barriers for kids that are homeschooled and not part of the school system. I only have anecdata since this is, you know, year two but you may have more experience. Well, you know, I guess I would say, right, it's, you know, really different experiences. I think there are some parents that, you know, of homeschooled students that actually come back into the school district for additional supports and thinking about how to help them has been really important and I've also worked at times and settings where homeschooled students then also come together as groups of homeschooled students to get some other socialization and support as well and I think those opportunities have been important ones to connect with those groups to sort of enhance the ability of the young people to have opportunities to be together and learn how to support each other. I think though the isolation sometimes can be really challenging for young people and so encouraging those families to create those other opportunities for their students to interface and interact through other sort of extracurricular kinds of things within families has been important. I think that's as much as as much as I could say. I think at times it challenged Dr. Benton. One of the challenges that they have faced as their children have progressed through those programs are resources. So that in some homeschooled communities they don't offer a place. They share resources. They bring students together. But if you're in a homeschooled community or district, you don't necessarily have access to those resources. And then the other thing that they're challenging, and I think it's that better and more homeschooled, homeschooled kids are going to college, is the college resources more available. So that if you weren't connected to a community, a school community with a lot of resources, you didn't necessarily have access to the same resources. So I think there are some structural barriers. And I think that they're linked to the structural barriers that exist in the school system in the first place. Lots of families have had a way to, I mean in religious communities, they've found a lot of ways to work around I don't know why my family decided to do that. But it's been really interesting. Some of them actually aren't in college now. So it's been an interesting experience. I think another factor when you think about just homeschooled homes, So it became a general optimist for a lot of people. Also, when there may have been kids who have behavior issues, they have repeated suspensions over and over again. Sometimes schools may have made the decision, hey, you should put the school to call. to come back for the interactive transfer schedule. It takes away from our, I mean, the thing about a school is sort of practice for life. For kids, you know, going forward, all the things you have to do is interact, engage, and be present on time to deal with it. Thank you. Yeah. Thank you. All right. All right. Thank you, everybody. Hi, my name is Manath. I'm a medical student at University of Virginia. I'm just starting to touch the brink of the iceberg of child adolescent psychiatry, so I don't know much about everything. But yeah, thanks. I just have a question. Glad you're here. Thank you. I just have a question about, especially about preschool and elementary school. I imagine that, when I imagine a very small child being brought in for a consultation, I imagine the parents having a lot of knowledge about psychiatry already and being in a very privileged position in terms of finances and time, being able to do that. I just wonder, I don't know how many preschools are able to have the connections to a psychiatrist and are able to make sure that children get assessed in elementary school as well. Because I know in middle and high school, there's a lot of counselors and more resources. But I was intrigued about very young children getting that support. Yeah, so one doesn't have to be wealthy to get care for children of the age of five. I think it really is a couple of things. One has to have access, so there has to be someone in the community that feels comfortable in talking with families who have very young children and talking with whatever setting in which their child is currently spending their day. And I think it really is, time is a thing. Because again, the parents have to be able to come to the clinic. And most of our clinics are during day hours. So for many families, that can be a challenge. For young child work, it's also sort of the typical routine that we see children multiple times over multiple weeks, which again can be a challenge for all families. And if you're under-resourced, it's an even greater challenge. We are all, all of us who see very young children are flexible and nimble, like our little people. And so we try to work with families to make sure that we can meet families where they are. But again, the assessment really is having a better understanding of the parents' concerns. Many times, they're sent to us by other family members, by their pediatrician or primary care provider, sometimes by the schools. We aren't necessarily in the schools, like some of the folks who treat big kids. But we are, and there are folks in the schools who can be a resource. Not every child who has behavioral challenges needs a child psychiatrist. I think that's partly what our little first Allison case was all about, was that sometimes, it really is just getting a sense of what is going on with the family. And in that case, the parents are getting separated, right? And so that seemed to be something that had sort of been missed by everyone. And same too for the little ones, right? There can be something that's going on that has upset their routine. So sometimes it's just having the time and space to be able to talk with families. Many times, they're just, as we talked about already, everyone's under-resourced. Everyone is stressed, everyone has pressures. And sometimes, many early care providers and early preschools aren't able to do that. And that's how we get involved. Again, this is when advocacy comes into play. I mean, if we had a magic wand, right? It would be a lovely thing, first of all, for there to be universal preschool. So all children would have a place to go that is safe, where they can learn for what they're gonna need for a big school, where the teachers have the time and space, where they're well-paid, where there is parental leave for all of those things we know really impact very young children. And so really, his part and parcel of what I do is not just treating the child, right? Because that's one child in one family we've made up, and maybe one school we've been able to talk to, so they can think a little bit more broadly about early childhood development, but we have to think bigger than that, right? And that's where advocacy comes into play, where we can actually change systems to ensure that not just that one child who makes it into my one clinic in Philly, at CHOP, gets the services they need, but that all children around the country and around the globe get the care and services that they need. Okay, and so we are over time. I'm waiting for them to come in at any moment, but thank you all. Thank you.

psychiatrists

school settings

anti-racism

structural competency

systemic racism

student development

school interventions

advocacy

mental health

legislative challenges

cultural issues

Dr. Aishwarya Rajagopalan