Thanks for joining us this early in the morning. So this is a graph that I took from a research paper that really highlights the boarding crisis that's really taken place and exploded in the last few years. From early 2009 to 2019, the number of patients actually presenting to a psychiatric emergency department for children actually skyrocketed about 300%. And it's even more drastic when you compare it to the volume changes that have actually occurred in normal ERs. So basically, while normal ER volumes have stayed the same in the pediatric world, psychiatry patients have gone through the roof. And it's been causing a lot of major issues for placeless in the emergency departments who really can't handle what to do for boarding. It's even more problematic from the CDC data of deaths. Suicide is the number two leading cause of deaths from ages 10 to 14. The third largest is 15 to 24. And it goes back up to the second largest, the 25 to 35. In addition, in this last most recent morbidity mortality stats, suicide is actually the 10th leading cause of death in children ages 5 to 9. And that's a new number that actually hasn't been there previously. So it's getting younger and younger and becoming more and more of a problem. And also, people even presenting to the ER, it's suicide attempt or self-injurious behavior has now actually been number nine in people 10 through 24. So people are really presenting for these issues, and it's becoming a problem. And due to that, CHA, Children's Hospital Association, ACAP, American Academy of Child and Adolescent Psychiatry, and AAP, American Academy of Pediatrics, in October of 2021 actually declared a national state of emergency, which really we are still within. And kind of combining in the same round time, 988 was created from the suicide hotline. So these are very important things that have happened due to this growing boarding crisis that's actually happening in ERs. And it's even more important because the patients that are staying longer are our special needs population. So people with autism, BIPOC, and the LGBTQ population are oftentimes staying two times or more longer in ERs. And so we need to actually pay special consideration for that. All right. So here is the BIPOC considerations for the ER. So I have no disclosures. So when we actually look at the YRBS studies, we're seeing who's been feeling sad or hopeless. And this is from the 2020-2021 survey, the most recent one that's out there. And really, there's really no difference in people being sad or hopeless from most of the ethnic and races. When we actually look at seriously considered suicide, we can see that in the black and African-American population, it's actually similar to the national average. But it's actually what's actually bringing everything up, that and American Indians. And so these populations are considering it more. And even more importantly, it's drastically increased when we actually look at, have you thought, have you made a plan to attempt? And so especially in Hispanic communities. And so it's really becoming a national problem. And then actually attempted, we see that the black and African-American community were the ones that actually attempted comparatively to anyone else in their peers. And so this is why we need to address it. And actually, African-Americans are the fastest and only really rising demographic that's actually increasing in their suicide rates. And most of the other demographics are actually falling comparatively. And we can also see that the African-American population is actually seeking medical attention for their suicide attempts. Now, this actually could be much lower, and people probably should be presenting. But these are the ones that actually are presenting. When we look at the same CDC statistics, and we're looking at Asian-Americans, we actually see that suicide is the number one reason for presenting to the ER in Asian-Americans in ages 10 to 14. And it still remains at number two for 15 to 24, and increases again to two for the 25 to 35 age group. And so we often think, we don't always think about Asian populations and needing mental health, but this is actually becoming a huge issue. All right, so I'm going to play this video. New this midday, May is Mental Health Awareness and Asian-American Pacific Islander Heritage Month. And today, we're talking about what some experts call a mental health crisis in the AAPI community. ABC's Reena Roy explains why seeking help can often be stigmatized in the community, and what some are doing to try to change that. Growing up in a South Asian home, Dr. Dimple Patel of Chicago says she never knew much about therapy or mental health. I didn't understand what depression looked like, or what anxiety looked like, because mental health was never really talked about. Like, oh, you're fine. But she realized she was struggling after a car accident forced the then 21-year-old to take a step back from her college courses and stay home to recover. I didn't know that I was experiencing anxiety. I wasn't eating, I wasn't sleeping, my heart was constantly racing. So she secretly started seeing a therapist. I was so afraid of being judged what other people are going to say. Speaking openly about mental health can often be considered taboo in the Asian-American community. Stigma is definitely a really big issue. Some of that has to do with cultural values and privacy and mental illness bringing shame to oneself and one's family. Another big contributor is the model minority stereotype. This stereotype portrays Asian-Americans as effortlessly successful. As AAPI, we can internalize that stereotype and start to believe that we need to be perfect. Patel's mother battled that stigma herself and never got the help she needed, dying by suicide in 2011. 41% of Asian-Americans are currently experiencing anxiety or depression symptoms. And 62% of those diagnosed with mental health conditions need help accessing services. AAPI right now are hurting. We are experiencing three crises at once, the mental health pandemic that's happening right now, but also the rising tide of anti-Asian hate crimes, as well as sort of longstanding problems in the mental health system that don't meet AAPI where they're at. Dr. Jeffrey Liu says there's a lack of translators and cross-cultural training in the mental health industry. Patel now doing her part to help bring more representation to the community as a therapist and advocate herself. That's why I shared my story and my mom's, so I can raise the awareness of things like this do happen. And we need to talk about it. And it's OK to ask for help. Rena Roy, ABC News, New York. So that's just one of examples, just really highlighting what actually is happening for a lot of Asian-Americans. Next, I'm going to go to a case example. So there's a 12-year-old male who presents to your emergency department with aggression. With this, this can mean many, many different things. It could be physical disease, like pain, delirium catatonia, intoxication. It could be a psychiatric illness, anxiety, psychosis, mania, PTSD, sensory issues, like noise, sound, intrusive things, physical issues, like just being hungry, or relationship triggers. So fear of strangers, parental distress, these are just some examples of what aggression can be. And really, aggression is just a symptom. However, race plays a large part in what the patient will be diagnosed with and where in their mental health journey they'll present at. So the majority of Asian and African-Americans actually present to the ED as their first time seeking mental health treatment, usually because they're in a huge state of distress, which actually is really disproportionate in terms of actually seeking out mental health later. And they're not able to actually find someone that resembles them to get treatment. And this really highlights who is actually using mental health services. So compared to whites, African-Americans are 25% less likely to use mental health service. Hispanics are 25% less likely. And Asian-Americans are 51% less likely. So a huge disparity with this. And a lot of this has to do with stigma, but that's not the only thing that's playing a role. And then also, when we ask these minority populations, hey, do you think you would have received better care if you were different race or ethnicity? And 15% of African-Americans said, yeah, I would have if I was white. 13% of Latinos said that, and 11% of Asians. So the perception on the community is we are not providing adequate care to people of different minorities. And in one study, African-American and Latinx were more likely to be diagnosed with psychotic disorders and behavioral disorders and less likely to be diagnosed with depression, bipolar, and substance abuse. They were also more likely to be hospitalized. And this was even more pronounced in males comparatively to females. And I've seen this repeated in both adult and children studies, that we really are missing the mood symptoms when we're looking at African-Americans and Latinx populations. So with the case continued, the child was brought in by police for aggression at the school. This is actually quite a common thing that we do see. Police in our ER account for about 30% to 40% of the people that are brought in, and many of them are on mental health holds. And that actually could potentially be damaging for their future if they want to go into the military or if they eventually want to own a gun. And so these things can actually preclude things later down the line. And half the time, they're actually coming in on an involuntary hold is because their parent can't transport them at that time. Or even if they can, because the police were involved, the police assume that they have to put them on this hold, which can actually have long-term damages and effects. In addition, one study was showing from North Carolina ERs that the annual rates of adults transported to EDs by law enforcement increased almost 50% from 2009 to 2016. And I can imagine that's happening not just in North Carolina, but a lot of other places as well. And the most common diagnosis for police transport was mental health diagnosis at 43.1%. And this was then followed by injury and poisoning, and then circulatory conditions. So police are actually playing a large role in bringing kids or adults to the emergency department, which has its own negative side effects from that. And then EMS and mental health. So compared to general medical transports, fewer behavioral health transports resulted in a hospital admission. So a lot of these kids are being transported unnecessarily by EMS when they really shouldn't be, comparatively to their medical counterparts. And among behavioral health transports, persons with schizophrenia were 2.62 times more likely than those with substance use disorders to be admitted. And persons with mood disorders were 4.36 times more likely than those of substance abuse to be admitted. So substance abuse actually is not really getting their due diligence and making sure they're getting adequate treatment, in addition to our other mental health concerns. So when we're thinking about police, though, this actually plays a huge role in the African-American community. And one police interaction from one study did not increase the mental health concerns. But if they had encounters with multiple police, this actually increased the rate of PTSD and other conditions. And we're also looking at intergenerational traumas and George Floyd and social things that have happened, which is a big thing that a lot of parents are coming in and saying, I don't want my kid to be seen by the police. I don't want them to get shot. I don't want them to get murdered. And so these things are actually playing a huge role. When we are relying on police to be our main transport, and it might not even be up to the child and the family making that decision. It could be the school. It could be somebody calling them on the street. And that's how they end up in your ER. But this actually causes a huge, huge concern that can actually worsen mental health issues in general. I'm going to play this video, and I'll lower the volume. 10 rules. 10 rules of survival. 10 rules of survival if stopped by the police. Number one, be polite and respectful when stopped by the police. Be polite. Be respectful. Remember that your goal is to get home safely. Your goal is to get home safely. Your goal is to get home safely. I'm sorry. Number two, don't be afraid to ask questions. I'm sorry. Number two, if you feel your rights have been violated, you and your parents have a right to file a formal complaint with your local police jurisdiction. Number three, do not, under any circumstances, get in an argument with the police. Number four, always remember that anything you say or do can be used against you in court. Number five, keep your hands in plain sight. Make sure the police can see your hands at all times. Number six, avoid physical contact with police officers. Do not make any sudden movements and keep your hands out of your pockets. do not run even if you are afraid. Number eight, even if you believe you are innocent, do not resist arrest. Number nine, if you are arrested, do not make any statements about the incident until you are able to meet with a lawyer or public defender. Number 10, stay calm and remain in control. Watch your words. Watch your body language. Watch your emotions. Remember. Remember. Remember, your goal is to get home safely. Get home safely. So my family has never had that talk with me. But I have actually, this is a very, very common talk that the African-American community has with their family on a regular basis. And I have had this talk with several of my patients who don't understand that. The first time was when I was in fellowship. And I had a 17-year-old African-American male who had high-functioning autism. And I had a 17-year-old African-American male who had high-functioning autism, who had just decided to walk into people's yards in a suburb of Chicago. And we actually played that exact video. And we're like, dude, you can't do that. You might, something bad might happen. And so a lot of times, you being in the ER might be the one having this talk if their parent hasn't had it already. Police is not just a problem in African-American communities. It's also going to be a problem in Latinx communities or other immigrant communities. There's oftentimes that there is a fear of deportation or ICE involvement, even if they are legal and documented. And because they're fearful that maybe they might not be with someone else in their family will be discovered. And this also will lead to less reporting and less reporting of people who are And this also will lead to less reporting of abuse because they're afraid of what might happen if any type of authority figure gets involved and now playing a role in their community. And I've actually have seen it on occasion. And it can lead to decrease in mental health outcomes as well. So with this case, due to their aggressive nature and upon arrival, a patient was chemically and physically restrained. So restraint use in the minority population restraints were more often used in the black population. Restraint use is more likely to be used in public health insurance, which oftentimes is exacerbated in minority populations because of previous red zoning laws or registering laws. And it becomes even more so with those two combined, then it's like double entendre kind of thing. Well, not entendre, but it's making everything much worse. And this is both true for both physical and chemical restraints. And this has been shown in more recent studies in both the adult and child populations. And I remember when I was in this training, they're talking about how that EPS symptoms actually are more likely to occur in African-Americans and young males. But in reality, when you look at that study, these people were given much higher doses. And we already know that higher doses of antipsychotics can actually cause EPS. And so that study in itself and what we've been taught for a long time actually has a lot of racist kind of tendencies in what we're doing to these populations. So it's not so much that they are more likely to have it, we're just more likely to induce it in them by giving them more. And we're interested in looking to see if this is actually happening more in communities that actually do have better representation with physicians are the same color and also having larger minority populations. Because most of these were done in primarily white areas. But I actually believe that this would be similar results in high minority populations as well. So one study showed that in a 10-year period, both mental health visits increased by 268% and mental health visits, health ED visits with pharmacological restraint increased by 370%. So even though we're seeing an increase in our mental health visits, chemical restraints were actually being utilized more. And this can be a huge problem if we're actually restraining and having to do this more, leading to even more prolonged boarding times that we were discussing earlier. And we know when patients are restrained, patients are less likely to seek follow-up services. And like we said earlier, minorities are already less likely to seek follow-up services. So if they're getting restrained and that's their first time seeing mental health, because that's the first time they're really presenting, is in the emergency department, we are basically setting them up for failure in the mental health system if we're restraining and not giving them adequate follow-up. So what some places are doing is really trying to expand the mental health service capacity and making sure that they're really not coming just to the ED, but really providing psychiatric care, regardless of a person's ability to pay. And a lot of the times that's what people will say is, I can't go to get mental health treatment because I don't have insurance. I don't have this. I don't have the ability to pay for it. So how do we make it more accessible? And we really need to make sure we're actually putting a lot of these clinics in lower income areas. That way it's just naturally being there and it's not actually further stigmatizing them. They have to drive or take a bus like 20, 30 minutes away just to get to their health care appointment. Even here in DC, we actually do have mental health deserts, even though it's the largest place for psychiatrists in the nation in terms of what we say we're actually in the good zone. But in reality, there's nothing in the southeast portion of the district, where most of our minority populations are seeing. And we see an even higher increase in our African-American population in terms of their suicide attempts. And we're just having a really medical desert there. I'd like to leave it on one last video. And I think it kind of highlights a lot of what's going on in minority populations in getting mental health treatment. I was always taught to be strong in this world, told to never let my guard down because at any moment I could be attacked without a moment's notice that my skin made me a target. Skin that has persevered through many trials and tribulations from seeing my mama raped by landlords, to my father being beaten and stripped of his manhood, to my brothers and sisters being separated into jobs for this bigger system. My skin has always been under attack. Yet somehow we prevailed through it all, through all the lynchings, literacy tests, New Jim Crows, war on drugs, the gentrifications, police brutalities, food deserts, mass incarcerations. We survived and adapted and pushed to change because our very existence depended on it. Our very existence depends on this, this black strength, strength that has carried us for decades but is undermining an important aspect of our humanity and feeding in on itself. Being strong all the time took away our ability to speak about our weaknesses, our sadness, our mental illnesses. This silence is killing us. On top of that, we lack proper mental health care access and endure mistreatments by medical professionals who cannot relate to us in their practice. On top of that, we stigmatize mental illness to preserve this place of our strength, damaging ourselves and among black children observing a spike in suicide rates because they may feel that their place in heaven is way better than their place here today because when black life isn't valued enough for professional help, adequate housing, or even breathing, Life here degrades in value in comparison to life after. Black bodies. Strong black souls are floating through the wind seamlessly letting go. Strong black bodies are screaming for help but suffering in silence and being socially and systematically being put on quiet. Black souls are strong, but we do need help when we do fall through the cracks. That is why I want you to know that you can patch things up with me. Alright, we can kick it back like it was a drive-thru movie in the 1970s. We can get some help from people who actually understand us, refute our standards of stigmatizing mental illness, and fight against the structures that chronically misdiagnose what this really is. Fight against the racism that brings up our mental health issues and lowers our treatment options, bringing us one step closer to seeing no other option. I want us to see that we have a way to heal this wound that has been widening ever since day one with no means of contracting. I want us to know that the seed that we sow today is the harvest we reap tomorrow. And when we finally reap, we can find peace in these moments. Noticing that the danger isn't gone, but we finally have a place where it feels like it is. The grounding of black bodies. Alright, thank you so much, Dr. Shad, for your great presentation. And here are her references. And so now we will swap it over to LGBTQ considerations. And as I mentioned earlier, our colleague, Mr. Wu, had an urgent concern and wasn't able to make it, I'll record a video and I'll pull that up now. One second. Morning, everyone. Thank you so much for having me here. I regret that I'm not able to make it to the conference this year, but I'm very excited to still kind of be here virtually and I'm very much looking forward to having a discussion with you on building a better psychiatric emergency department. And in this section, we are going to specifically talk about one of the special populations that we identified, which is the LGBTQ folks. So before we get started, a bit about myself. I'm currently working on my PhD in counseling and counselor education at the George Washington University. One of my previous training experiences was around emergency management and psychological first aid. So again, I feel very honored to be included in this part of the discussion and I'm looking forward to sharing some of the articles that I found that are very, very important and pertinent to the care that we want to deliver to the LGBTQ community. So first of all, a little bit about the background. So the APA task force in about 10 years ago, they found in a survey that less than 30% of psychiatrists and trainees reported unfamiliarity with issues with the LGBTQ populations' experiences. And so TGNC here stands for transgender and non-confirming people. So it is pretty surprising that a lot of people in the field are not really competent in their ability to provide care for this specific population. So there's pretty much very limited training that are offered in the education experience and that can actually cause harm to our patients. And additionally, there's a significant level of stigma and discrimination that our LGBTQ patients face every single day that are associated with negative mental health consequences. So a lack of clinical knowledge and experience can be really detrimental to our LGBTQ folks' well-being. And suicidality is one of the themes that are identified in the articles about mental health services in this specific population. Research has shown that they are three times more likely to attempt suicide, which is pretty astounding. And also homelessness and violence and increased mental health disorders are all the mental health consequences faced by this population. And so it is important for us to ensure a safe environment in the emergency departments and to provide understanding and openness so that our patients feel safe. Especially emergency care experiences are the first encounter in the mental health system. So it is really critical that we as psychiatric providers in the emergency room are aware of the gender-affirming care, which I'm going to talk about in the next slide. So what is gender-affirming care? Gender-affirming care, so I am sure that a lot of us have heard about it and probably also have practiced with our patients. But what does that really mean? So defined by World Health Organization, gender-affirming care is interventions can be psychological, medical, social, that are designed to support and affirm an individual's gender identity when in conflict with the gender they were assigned at birth. So I like the definition. So this was found on a website by the Association of American Medical Colleges. They have really, really good resources around gender-affirming care. And gender-affirming care, so we now know the definition of it and what it actually can entail. So it can run a full continuum, ranging from counseling to change social expression, or it can be medications, such as hormone therapy. For children in particular, the timing of the interventions is really critical because we know that they are still in the phase where they are still in the cognitive and physical development. And we also want to keep in mind that their parents may also have an important role in their development. So interventions with children who are in this particular community is really critical. And I like this definition by an author from the American Academy of Pediatrics on gender-affirming care. So the goal of gender-affirming treatment is not treatment itself, but it's really to listen to the child and build understanding to create an environment of safety where emotions, questions, and concerns can really be expressed and explored. So something to keep in mind when it comes to what gender-affirming care really means. So we all know that it's important that we are aware of the resources for our LGBTQ patients. These are some of the national resources that can be very helpful, but it's also very important to be aware of the local resources that are available in the communities where our LGBTQ patients reside. So they may have quicker or easier access to services when they are in need. Again, we want to make sure that we have resources available for our patients. So there are a few articles that I found that I thought would be very helpful for us to have a discussion on. So first of all, this article by Schultz published last year. They were primarily exploring the values, beliefs, and lived experiences of youth identifying as LGBTQ who sought emergency care for suicidality. And in their research, they emphasized the role of suicidality in LGBTQ patients' mental health, and they identified some barriers to non-confirming care, including a lack of focus in medical school education. Again, this ties back to what we were talking about earlier, where there's a lack of training in working with LGBTQ communities and a lack of familiarity. And also, we all know that a lot of surgical care is not available and that a lot of surgical care options, unfortunately, are not covered by insurances. So the cost incurred can be a huge barrier for our LGBTQ patients to receive the care that they need. And also, the general discriminatory experiences, social biases within the healthcare system can really deter our patients from getting the care that they need. So how do we provide training? How do we foster the self-awareness of ourselves in terms of our perceptions of the LGBTQ community? So these four themes were the themes that they identified in the peer review process. So first of all, affirmation, acceptance. We want to make sure that we foster self-acceptance in our LGBTQ patients so they feel empowered and validated to advocate for themselves. And this theme also emphasizes the importance of using the correct pronouns in clinical care so they feel affirmed about who they are. Strength, it is important to cultivate resilience so that it can offer as a buffer for the daily stressors that our LGBTQ patients are confronted with. Approach and intervention is another theme that was identified. So timely responsiveness to the needs of our LGBTQ patients was a salient intervention. So making sure there's always someone available for them was found very critical to our LGBTQ patients' treatment outcome. So self-referrals and drop-in counseling can be very important in this sense. Safety, psychological distress. The authors identified that a lack of family support or social support are associated with psychological distress. And also homelessness and suicidality are highly positively interacted with each other. So how do we make sure we identify these risk factors so we can refer our patients to appropriate care? Another article by the same author last year also explored lived experiences of youth, again, who identify as LGBTQ and sought emergency care for suicidality. And so these are also the values that these researchers found that were important and meant a lot to the LGBTQ patients, youth patients that they interviewed with. So I'm not going to go over these as thoroughly as I would like to because of the time we have, but feel free to look at this article if you're interested. So another article that I would like to share is the guidelines by the American Psychological Association, where they published this guideline to assist psychiatrists and other mental health clinicians in providing culturally competent, developmentally appropriate, and transaffirmative psychological practice with TGNC people. So the care that is delivered is respectful, aware, and supportive of all identities and life experiences. I really like this article because all the 16 guidelines, there is a rationale under each guideline, citing the research, showing why that guideline is important and pertinent to gender-affirming care. And also there's application parts for each guideline. So you can actually see how each guideline can be actually adopted and applied to a clinical case. So it's a really, really helpful resource, especially when it comes to working with LGBTQ patient population. So I'm just listing a few here. But again, the article has all the very comprehensive information that you might find helpful. So how are we doing with time? Okay, I think I still have just a couple more minutes. So let me discuss this last article that I found very quickly. So this article by Fadas, a few years ago, they found that, so I like this article, and I put this slide as the last slide before the references because I feel like this can be a good overview of the information that we talked about today. So gender-affirming care is the major theme. So these are the skills and things that you may want to keep in mind when you work with LGBTQ patients in the emergency room. So you want to have inclusive and affirming communication skills. Make sure that their preferred name and pronounces are used. When we communicate with our staff members, we want to make sure that if there is a legal, if there's a difference between the legal name and the preferred name, how we reflect it on the medical record. So very important, and there's also suggestions where if you want to interact with your clients, perhaps you want to be aware of their preferred pronouns and also if you don't, if you're unsure, just ask the questions what you prefer. And sometimes also using electronic medical records can avoid some communication barriers. So something to keep in mind, there are various ways for sure. Culturally competent history taking and risk assessments. So according to the article, these factors can be really important to help us identify any culturally appropriate and relevant risk factors. And whether or not they're out, if they're not out, what's the risks that they may be faced with in their family or interpersonal relationships, so we can make sure safety and acceptance is there. Culturally competent treatment environments, again, very important. Make sure that every staff member has the knowledge and awareness of gender-affirming care. LGBTQ-specific discharge planning is super important because we know that the emergency services usually are pretty short term. So we are responsible to make sure that the care that our LGBTQ patients receive after they are discharged are LGBTQ-friendly, inclusive, and not LGBTQ-phobic. If you refer them to a faith-based treatment program, we want to make sure the faith is not against non-binary heterosexual standard, things like that. So we want to be aware of the resources specifically that are LGBTQ-friendly and supportive. So these are all I have. And thank you so much for your attention. And again, if you have any questions regarding anything I have discussed this morning, feel free to reach out to me. My email address is in the slides. And if you would like the slides, please make sure to reach out to one of the presenters today. So, yeah, again, I appreciate your feedback and your attention. Perfect. So we thank Mr. Wu for recording the video. Now we will shift over to Dr. Vamsi who will talk about neurodivergent patient concerns. All right. Hi, everyone. Let's see how high this mic can go. All right. So I see we're at the 45-minute mark now. Energy is probably a little bit low, so I'm going to try to bring the energy level up a little bit. All right. So what's next here? Yeah, so I'm Vamsi Kalari here from Hopkins. I'm the director of the Ped Psych Service there in the emergency room and I also do some outpatient work in our autism clinic and our neuropsychiatry clinic, so a little bit of everything. As discussed earlier, life is pretty simple, So it's a pretty brief talk, but essentially we're going to go over four main domains, a brief introduction, some background information about terms, some relevance as in why you should persevere and continue to listen to this presentation, and that does involve a very engaging Poll Everywhere event, so have your devices ready. And then kind of the meat of the talk, role of a psychiatrist in working with this population, and then ending with one or two case examples. That's kind of the plan here. So starting with background information here. So the title of the talk is Neurodivergence in the Emergency Room, which kind of leads to the question of what does neurodivergence mean? So it's a somewhat new term and essentially it's an inclusive term that refers to people who have brain differences that affect their functioning and that effect can be both a positive and a negative. It's not necessarily a disorder per se. It's more so seen as a difference and it is a non-medical term and essentially the intent is to prevent people from being labeled normal and abnormal. So we're talking about differences here. And just to kind of expand on the terminology here, the opposite of neurodivergence would be neurotypical, in which case we're referring to people with more typical brain functioning. So examples of neurodivergence include people with diagnoses of ADHD, learning disorders, and autism, and autism is going to be the main focus of this talk here today. And within autism, there's obviously a huge spectrum of symptoms and functioning levels and I'm going to be focusing more so on kids who have pretty limited skills, limited receptive and expressive abilities. So continuing with the background, this is always a commonly used figure, but just very briefly touching on autism. So as I'm sure a lot of people know, it's a highly heterogeneous constellation of symptoms and the kind of two main components of autism are impaired social communication abilities, so we're talking about challenges with social reciprocity in terms of being able to engage in a back and forth conversation, challenges with nonverbal communication, eye contact, difficulties, difficulties understanding facial expressions, picking up on various forms of affect, and then being able to establish and maintain social relationships, that's the other consideration under the social domain there. The other kind of big hierarchy is the restricted and repetitive behaviors, and that's kind of more things you think about with autism, like people who have very restricted interests in certain topics where they spend inordinate amounts of time researching and honing in on their knowledge of these topics, and the sensory sensitivities or hyposensitivity, sensory differences that you often associate with autism, so that's kind of the big picture here, obviously there's a lot more we can say about what autism is and all the flavors that it comes in, but that's not really the focus of our talk here. And then also in this slide, we have a couple of conditions in terms of the various etiologies and comorbidities that come with autism, so fragile X is a common genetic cause of autism, and then notable medical comorbidities include seizure disorders and anxiety disorders, and there is a significant amount of, there are a significant amount of people with autism of intellectual disability, especially in the population that I'm specifically talking about here. Anything else to mention here? Not so much, okay. So moving on to relevance, why should we be here talking about this, why should you care about this talk? So this is, oops, next slide. So this is kind of the deciding factor here, so I want to know from the audience here what thoughts and emotions come to mind when you imagine a child on the autism spectrum coming to an ER in crisis. We have our URL here, polev.com slash autism slash my first name, last name, 067. And if everyone has very positive things to say that they're happy, they're comfortable, then we'll kind of just stop the talk and wrap up. So let's see what the results are. So is this open? I'm not sure if it's open. Overwhelmed, I agree with that. So I'll share my thoughts as well. I kind of work and see this every day, and it's a lot. Overwhelmed this one. For like another minute. I know we are late into the talk, so. I'll start talking about some things I feel. So definitely overwhelmed is one of them. Challenging diagnostically, definitely, especially in the emergency room setting. I often feel sad because it's kind of, you know it's not the ideal place for these patients, and you know that they're often here as kind of a last resort. Communication, definitely. Terror, yes, I see that. I feel that sometimes. Okay. I will say that I also feel optimistic at times. Overwhelmed, yes. That is, this is kind of exactly how a lot of people feel, including myself. There is some optimism that I feel because I think that often these kids really do get passed around. The bug kind of gets passed, and I think in the emergency room is sometimes an opportunity to kind of reset things for the family, the outpatient team, and kind of bring some stability and then kind of reset things before you leave. But yeah, thanks for participating in that. Trying to see if I missed anything else. Diagnostically challenging. Much hope. Overwhelmed. Okay. Alright, so last slide about relevance, and I think this is sort of self-explanatory about the big picture here, why we care about this topic. So kids with ASD are distinct, like quote-unquote high utilizers of ER services. This isn't good for kids. Kids shouldn't be in ERs. This isn't good for families. When families are in ERs, they miss work, they miss taking care of other kids, and it's not good for ERs to have these kids there all the time. So that's an overall negative. We know that kids on the spectrum are up to nine times as likely to present to the ER for psychiatric concerns as neurotypical kids. So this is something that's happening much more frequently for these kids in terms of interacting with the ER for psychiatric reasons. And then more seriously, and I think this has come out in the past ten years or a little bit longer than that, is the higher risk of suicide for this population. So there's a three times higher risk of suicide for people on the spectrum, the neurotypical people, and the first suicide attempt is often years earlier for this population than the neurotypical population. So many reasons to be talking about this topic and thinking about it. I mean, one caveat to mention, though, with a lot of these studies, and our studies that are ongoing at Hopkins about these topics are that a lot of them are based on chart reviews and the diagnosis of autism being present in the chart when kids go to the ER. And with ER charting the way it is, often those sorts of diagnoses don't make it to the chart. So that is a limiting factor in a lot of the evidence and a lot of the studies we have. But if anything, that really means we're really under-reporting the number of kids who are coming to the ER as a comorbidity or kind of their main presenting challenge. But anyway. So kind of moving on to the more salient points of the talk. So what can we as psychiatrists do to help these kids when they come to the ER? And I'm not here to talk about a magical medication that fixed everything or a magical therapy approach, just kind of laying out some guidelines and some pointers in terms of big picture things we can do. So I think first and foremost, like with a lot of our patients, our main role in this situation should be that of an advocate. So ERs really strive to push their flow. Like the point of an ER is to see people who are high-acuity, stabilize them, make sure they're not acutely dangerous and then get them out. And these kids really just interrupt that flow and can lead to frustration to the ER. And it's just not really what they're set up to do in some cases. So a big role that we can play is that ensuing that the behavioral and communication challenges that these kids demonstrate don't kind of overshadow the medical workup that they need and deserve when they come to the ER. Patients who come to the ER and don't have a medical workup often end up having more complicated courses. And it ironically can prolong their course, which is kind of the exact opposite of what the ER wants. Because often if a kid comes in, say with aggression, there are a lot of kind of simple explanations for that. Often it's constipation. Sometimes it's something as easy as hunger or thirst or a headache. We have seen more serious things where kids are having kind of more subtle seizures or kids even have broken bones that are overlooked and then they're kind of passed over to psychiatry. So a huge thing that we can do as psychiatrists is advocating for like a real thoughtful and thorough medical evaluation for these kids. And it's really in everyone's best interest because it results in fewer complications down the road. Another layer of advocacy beyond the individual patient level is to kind of work with the ER to help them better understand the population and really kind of understanding the limitations of this population, why they come to the ER with these complaints because their system is relatively broken. And kind of developing that empathy for this population that also kind of allows them to get better care. Similarly, advocating to hospital administration to provide more resources or at least making them aware of the unique subsets of populations who are coming to the ER in terms of these kids. This is something I spend a lot of time doing to try to get more resources for these kids, be it either sensory rooms or policy changes to help make their stay more streamlined and less cumbersome for the ER, less cumbersome for the family and the kid. And there's some simple things that we can do in terms of having these kids in rooms that have lower sensory exposures, like not right in front of the nursing stations, not with a patient who has like a beeping cardiac monitor, limiting room changes. Often we see kids who have settled into a room for a couple of days get moved and then they really start to regress a little bit. And then bending some of our very rigid rules that we have for psychiatric patients in the emergency room in terms of taking shoelaces away, taking every possible dangerous object away. We recently had a kid who has a restricted interest in spoons. And as per hospital policy, the spoons were felt to be dangerous. But the kid was getting very dysregulated without having his spoons because that's what he spends hours per day kind of looking at and playing with. And by running through some hoops and making some correspondences, we were able to get him his spoons. But simple things like that can really change the course of the case. And then this is a little bit provocative, but I always encourage families to voice displeasure, be it to hospitals, the medical system above the hospital, or kind of state and national leadership. Because we do interact with a lot of families who are disappointed in their care or upset about their care. And I honestly feel that way as well, that there's a lot that we can be doing that's better. And hearing from families is always helpful for hospital and kind of higher up leadership. So that's something I encourage as well. I should probably speed up a little bit. So kind of stemming off advocacy, being supportive and fostering good communication is something else that we can do as psychiatrists. Kind of going back to our ER colleagues, there's definitely a balance to strike between advocating for our patients, sometimes pretty forcefully, but also supporting these colleagues. Because really they're kind of the safety net. Their ER is the safety net for these patients. And they essentially have no training in how to treat or interact with these patients. So they're in a tough spot and kind of acknowledging that and supporting them through that process. People respond in different ways, but acknowledging that they're in an uncomfortable position and supporting them as best we can through that. Similarly, parents, we often kind of meet them at their worst when kids are kind of no longer safe to be home or have destruction at home or personal physical injury to parents. So similarly being supportive of parents, but also acknowledging that often they're the true experts in these patients who are very complicated, have very subtle traits that we might not be familiar with, like the kid with the spoons that I was referring to. We could have assessed him for hours and spoken to him for days and he would have never told us anything about spoons because he can't communicate with us verbally. So acknowledging that parents are the true experts. But then also kind of supporting parents through the various changes in the treatment plan that they might go to. Often parents come in saying certain things about expectations for treatments or being able to take the kid home or leave the kid in the ER and then they get cold feet about a plan or change their mind. So kind of being open and supportive to that stance and understanding where they're coming from and guiding them through those conversations. Leveraging community resources is also vitally important. Kids spend a huge chunk of their time in schools, so communicating with schools and seeing what services schools can add on, changing level of schools, school locations. Not something we can usually do in the ER, but at least getting that process started for the family. And this again is maybe a little bit controversial, but CPS involved. We do a lot of kind of like joint amicable CPS reporting where parents are like this kid is not safe at home because I cannot take care of this kid. I'm not getting any support with this kid. So then we get CPS involved with the parent's blessing and sometimes that can help expedite services in the home. That can be risky. We don't really see this, but sometimes if CPS feels a certain way, they might then be changes capacity if they really feel that it's not safe at home. So that is a risk, but that is something we do in terms of leveraging CPS to try to expedite things or get more resources at home. And then lastly, staying in close contact with outpatient treatment teams. If the patient has an outpatient treatment team. So if the family is kind of the primary expert in the kid, the outpatient treatment team, especially if they know the kid well, is really probably a secondary expert that sometimes has years of experience with the kid and might have a treatment plan in mind that they might want you to execute. So I think it's a mistake to kind of treat these kids in isolation. You should always be working with the family and the outpatient treatment team. So the other thing is, I think that honesty is honestly the best policy in this case, as it is in most cases. We're pretty open with families that there are limitations to what we can do in the ER. It is kind of a safety net setting. It's not a very therapeutic setting. And to that end, we're always clarifying goals of care, like what do we want to accomplish here? At what point would we feel comfortable sending this kid home? At what point would you feel comfortable taking him home? Because sometimes parents come in with very different expectations. And if you don't have that conversation early on, and you have it like a week or two later, that can be very disappointing for families, understandably. So setting expectations. And I've honestly found that if you go about it in a tactful way, families are understanding. And then, again, with honesty, as a psychiatrist, sometimes it's difficult. But medication is really not the solution to a lot of these problems. So there is a role for active pharmacological management in the emergency room, be it acute aggression and also kind of underlying mood anxiety disorders. But in a lot of these kids, changing like risperidone to Abilify is not going to change the picture for a family and make it safer for the kid to go home. And being honest about that with both the family and the ER staff is important, because sometimes there is pressure from the ER staff, like can we change medication? Can we add another medication? And then the kid can go home. So being open about challenges and limitations. And similarly, behavioral therapy is also not the entire solution. Sometimes our behavior plans can get very theoretical and sound very good on paper, but then when the family tries to implement them, it needs to be something that's consistently realistic for them to do. So sometimes we have things in the ER that we can do in terms of setting a timer, reinforcing every five minutes, but then when the kid leaves the ER and it's just the kid and the single mom at home, that's something that's tough to implement. So kind of trying to keep those behavior plans realistic and oriented towards discharges is something that we also try to be honest with ourselves and the families about. And then lastly, this is sort of an interesting one, but maintaining focus is important. Sometimes these kids can be in the ER for a lot of time, for a long time, and initially there's kind of a burst of agitation, there's a burst of counter-transference from the ER team, from our own team, and then the kid calms down, the team calms down, and then things can kind of just reach this steady state where like, okay, this kid has come today, that looks good, parent still isn't ready to take them home, let's see how tomorrow goes. But that can be dangerous because this is not evidence-based, but in our observations we do see that there's kind of a plateau that we find with a lot of these kids where things get a little bit better and then us and or the families are like, can we make things even better, and then there's like a sudden regression with kind of just being in the ER longer, being deprived of things they have at home, being deprived of interactions with family members. So it's important to always be actively thinking about what you're doing with the day, what your goals are in terms of how you're going to get closer to discharge because otherwise you can actually find yourself in a worse place than where you started. And kind of lastly, redirecting from interpersonal strife. There's a lot of counter-transference that happens sometimes, parents do come in kind of very frustrated, very overwhelmed, and sometimes people on the team can be affected by that and it's important to kind of maintain like a neutral composed in those situations because if you lose the parents, then it's really hard to kind of rectify that relationship and work towards a common goal. So maintaining focus on those small things is important. I've completely lost track of time. Keep going? Okay. All right, so case examples. So I have one very long case and then one briefer case, but we can go through this. So the first case here, so just a heads up, this is sort of a tough case, but it does demonstrate kind of a lot of the points that I made. There's a lot of specific information here, so I tried to leave it vague in some ways as well. So this is a teenager with autism spectrum disorder and a couple of medical comorbidity, bilateral renal cysts, cyclical vomiting, had a G-tube in place, and a seizure disorder. And this kid has pretty limited expressive and receptive language abilities, but receptive better than expressive to some degree. Speaks in about two-word statements intermittently, but generally just does a lot of vocalizations. So he was brought in, chief concern of Psyche-Val, and he was essentially increasingly withdrawn at home, kind of not getting out of bed, not really going to school, just not engaging much, and then enter the space of being more aggressive, biting his caretaker, kind of destroying things at home. Has a family history of psychotic illness, actually, and then completed suicide amongst a family member, and like a really serious and sad trauma history that I'm not gonna get into because it's very specific and it's not a good thing. That was very salient. And essentially at this point, he's cared for by his grandmother, and they live alone in a private home. So this was kind of all going on between him and his grandmother. So it's a tough situation that they came in on. So in terms of brief chart review for him, so he is seen at the Outpatient Autism Specialty Clinic. He's had sporadic ER visits for aggression and for dislodging his G-tube, but has never really had a prolonged ER stay, and he has no in-home services. This is kind of just on a couple of wait lists. So where are we going next? Okay, so he proceeded to stay in our ER for a little over 800 hours. He was started on low doses of SSRI, and actually had pretty remarkable effect for him. He was much more engaged, brighter out of bed. So that was really nice, honestly. Behavioral psychology worked with his grandmother at length, both in terms of training her, in terms of how to defend herself, kind of by releasing from hair pulls, and implementing a token reward system. And then behavioral psychology also worked with nursing to kind of work on behavioral activation stuff for him, and behavioral planning token reward system in the ER setting. He was put on the wait list for a specialized neuropsychiatry inpatient unit outside of Hopkins. And really, we tried, but we really didn't make much progress in bolstering his outpatient services. So that we were kind of waiting for that specialty unit to come through, and then grandma was like, you know what? Like, I think I'm feeling okay about this. We're feeling good with this behavioral plan. His outpatient psychiatrist is on board. Let's go home, see how things go. Two months later, he is back, unfortunately, this time for a almost 1,200 hour ER course. Staff are pretty frustrated that he's back, and also his prolonged stay. He was quite agitated when he came in, but he was profoundly constipated as well. So once we cleared that out, he was doing a little bit better. But grandma was very skittish at this point. It was kind of a resurgence of the same picture of biting physical destruction. We referred him to the same neuropsychiatry unit, and interestingly, they rejected him for his G-tube, which they didn't the first time. So we worked with GI about getting rid of that, and he hadn't used it in a long time. So that was actually taken out to make him eligible for that unit. Kind of continuing with our behavioral psychology supports. Again, not much success in bolstering his outpatient services. And he actually did get admitted to that specialty unit, and we were all very excited and proud of ourselves. And then six weeks later, he had a 500 hour ER course, and there was frustration now becoming despair that was happening amongst our team, including myself, honestly. He did have, so essentially he was admitted to that specialty unit for about a month, and did quite well there. But then was discharged with not many outpatient services, and kind of went home and lasted about a week or two. He did have a seizure at home, so we did have an EEG to see if there were any changes in terms of ongoing seizure activity that really wasn't contributing at that point. And at this point, his grandmother was quite fatigued, not really able to work with behavioral psychology so much anymore, really worn out by this whole process. Been multiple meetings with his outpatient team and his school to try to bolster social supports. We made the kind of joint CPS report that I talked about, and he was discharged home with home services one week away, in-home ABA. And then two weeks later, he's back. The in-home services didn't really pan out. There was an insurance authorization issue, and grandma was like, I can't take him home this time. So that was actually last week. So when I get back next week, we'll see what's going on. But that's unfortunately kind of a lot of what we see. So that's one case. I know we should probably stop. But the second case was much more of a success. It's a kid who came in, who was actually traumatized at school, had kind of an abuse incident at school. But we were able to kind of work with the school and make some medication adjustments to help him be calmer and get a change in his school placement. And he was discharged pretty quickly and hasn't come back in a couple of months. So that's kind of a happier ending. But this first case really sticks with us as a demonstration of kind of what we should strive to do. But even when you strive to do all the right things, sometimes outside factors make it difficult for these kids to succeed at home. So that's kind of essentially where we are. So it's kind of a, it's a fraught area, but we're trying our best and hopefully sharing some of those big picture tips and how to approach these cases is helpful. I think we're out of time, right? Okay, very good. All right, thanks everyone. All right, well, thank you so much to Dr. Kalari for showcasing what that experience is like, treating our patients on the spectrum. Here are his references. And we will go through some of the program exemplars pretty quickly, because I do want to make sure that there's time for you all to ask questions, because you have these two experts up here who are ED psychiatrists. So let's go through. So, you know, in thinking about this, we talk about it from a prevention and environment aspect, a staffing aspect, early interventions, urgent care and aftercare services. So when we're thinking about prevention in general, we know that, you know, getting people behavioral health before they get to the ED is ideal. So for, of course, for our children, one of the things that both APA and ACAP have been advocating for is school-based mental health services. And for our adults, we recognize that most of the behavioral health care is gonna be from the internal medicine offices. So working toward collaborative efforts. And there are a lot of different programs and models that showcase that and the benefits of them. When we think about environments, so, you know, Dr. Kalari was mentioning how, you know, there's benefits of sensory rooms and benefits of being mindful of space. As you think about it, like our medical EDs in which we are taking care of our patients really aren't always ideal for people with behavioral health emergencies. So one model that was mentioned in the roadmap to an ideal crisis system by the National Council of Mental Health Wellness is the MPATH programs, which stands for Emergency Psychiatric Assessment, Treatment and Healing Unit. And basically in these units, there are typically like recliners, everybody's, all of the patients are collective in a centralized area. Then there are no fishbowls, so you have staff, social workers and nurses all collectively together and immediately available should people need some de-escalation or any supports. And then the other key point is that people see the psychiatrist as quickly as possible versus in a lot of the more typical models, it's a huge delay. And one of the things that they find is that, you know, in this model, typically there is a decreased use of restraints and a lot of times people wind up not necessarily needing an admission because it's about a 24-hour observation. And as you can imagine, when you come into the ED, it's typically one of the worst moments of your life. You might be tired, you might be intoxicated, but you know, after a bit of a tincture of time, things get a little bit better. And then with more observation, you can have better data to really determine whether somebody needs to be admitted versus the admit by default. Then I wanted to talk about staffing. So of course there are multiple folks that make the, make our behavioral health EDs really, really well. But one of the things I wanna highlight is the importance and benefit of having full-time psychiatrists in the ED. So one such exemplar is actually Children's National. So back in 2015, or between 2015 and 2019, there was about a 900% increase in ED boarders. One of the things that they did was they basically hired ED psychiatrists, they created a new inpatient unit, and then they wound up drastically decreasing those boarding times. And then one of the other things is it allows for direct integration into medical services. It allows for a person who is directly, you know, able to talk with the CPS groups and develop relationships with the school systems, among other things. And if you wanna learn a little bit more about emergency psychiatry in general, I suggest the American Association of Emergency Psychiatry, which is a wonderful resource. Then I wanted to just briefly mention urgent mental health care. So recognize that, you know, a lot of times when folks present to the ED, some of the things are urgent, but not necessarily emergent. But the ED has become the de facto place to get services when you need it most. The Colehen Northwell Program actually has both a urgent mental health care and a psychiatric ED. And in that model, basically people can just walk in from nine to three. People could actually call and reserve their place in line and be able to stay at home for the maximum amount of time as opposed to coming in a little bit earlier. And from that, they're able to give the support folks need, and then also decrease the boarding in the ED to see a psychiatrist. And all of the folks are seen by a child psychiatrist. And then finally, one other one that I wanted to highlight is actually one that Dr. Kalari would be aware of, and that is the Bridge Program at Hopkins. So one of the things that we, there was an initial pilot that got created because we recognized that sometimes people would be ready for discharge, but then we just need something to happen in the interim to help support folks. So they basically created a bridge clinic from the ED to for folks who need to go to the day hospital or intensive outpatient, but there wasn't an immediate admission date for the inpatient to the day hospital and then the day hospital to the outpatient. And in it, you have psychologists who offer individual and family psychological services. And then they can help with the safety assessment and continued planning. Because as you can imagine, when you're in the ED, when you're in the inpatient unit, sometimes you hear the information, but there's a benefit to somebody who can reinforce that with you. And then there's also some medication management consultation options. So, and from that, they're able to decrease inpatient admissions, decrease ED boarding, and help move people to an appropriate service when they are clinically ready. So I now want to just shift it over to questions. So please come to the mics so we can get it recorded and then we'll go from there. Thank you so much. Thank you very much. Just a couple of questions or comments regarding the first presentation about people, patients that are black or ethnic minorities seeing having difficulties relating to the clinicians because they don't, those clinicians are not black like themselves. I do agree with that as well. In a recent presentation I did where I work, it was regarding that same matter. So like in, I work in, I'm from Canada, and the number of, percentage of black people in Canada is about 4.7%, but the percentage of doctors who are black is about half of that. And one thing that I feel, or people are saying will help, is that trying to encourage people from that community to go into medicine. That way patients can relate in a way better of or have some place they can culturally agree with their clinician, with that clinician. Secondly, for patients who are black, having more increased risk of restraints, chemical or physical or hospitalization. You did point out various risk factors, but from, and also from my experience, I see social determinants also come into play in terms of them reaching out for help or following up with help when it's offered. For example, with housing, unstable employment, finances. There are some patients who come from the black community that don't have benefits, for example, for psychotherapy. And that dissuades them from reaching out because we refer them for free counseling. It takes a very long time to get them to come to us. Very long time. Or sometimes they don't get the same consistent clinician. That also dissuades them as well. And there's also the impact of substance use, like the substance use is overrepresented amongst that community. So especially things like alcohol, cocaine, methamphetamine, people who may come in intoxicated to the ED, they are more likely to be presenting with agitation that could also impact on use of restraints and hospitalization. And some staff as well who may not be able to culturally interpret certain symptoms, they might also see those as a pathology, whereas it might just be something from the individual's background. I recently had a patient who was, came in with unspecified psychosis, but she also like a Pentecostal Christian. But because she was like trying to pray at night, some staff saw that, and like speaking tongues, some staff saw that as she's having visual hallucinations. But because I share certain, because of my own background, I just knew that that's not a pathology. This is where she's, this is like from her own culture. And she may be more fixated on it than normal, but just trying to tease out what is pathology and what is not. And lastly, regarding the children in the ED, in the presentation it says, I saw like the case example, whereby the patient was 1,000 plus hours in the emergency room. I was very surprised, you know, because like you said, the ED is more like a safety net, rather than, it's not the most therapeutic environment. We have similar challenges where I work, especially when you are keeping children in the ED, and how do you separate them from the adult population? We had an incident whereby a child was unfortunately sexually assaulted by an adult patient while they were waiting in the hallway. The child was waiting for an inpatient bed. So I wonder, like in that example, the patient was waiting for a specialized neuropsychiatric bed. Could, was there the possibility of them admitted to a general children's inpatient bed rather than the specialized unit? And, you know, we know resources can be very challenging in, especially in children population. Well, thanks a lot. I think you're, I think you're definitely right. We need to increase the workforce of, and one of the ways that we're doing that is actually by having the minority fellowship, the Stansted Minority Fellowships, which actually they're not here because they're in breakfast, but he's one of those standouts from that. And it actually, and really getting to see long-term pictures of like debt and everything else, because med school, at least where I'm faculty at, is like 70,000 just for tuition in DC, which is one of the most expensive cities in the nation. So when, even though I'm doing interviews for med students, like a lot of them need 100% financial aid in order to actually make it feasible. And so we need to break down like barriers of like previous social determinants of health or redlining and all these other things that are still like coming back and impacting who is being able to treat who and serve who. So you're absolutely right. We need to have that change. Is this, okay. Yeah, so with regard to the patient that I presented a thousand hours plus is definitely out of the ordinary for us in terms of ER stay. We definitely do try to send kids to general inpatient psych units because the longer the kids are in the ER, it's just not good for everyone, as I implied. The thing is most units, including our own at Hopkins, requires kids who can, what's the wording, I think meaningfully participate in groups. And this kid, by virtue of his limited language abilities, just could not. So that's often a hard exclusionary criteria. And often most units, including our own, look for an acute modifiable psychiatric illness that can be treated as like a criteria for admission. So there are all these kind of roadblocks that present themselves. There are kids who we get who might have also similarly limited verbal abilities, but then it is clear that they're having a mood episode that that's not sufficiently treated in the ER. Or some kids have some sort of psychotic symptoms as well. And then we can kind of get buy-in from the inpatient unit to accept these kids. But generally it's kind of a treacherous territory. But I'm in 100% agreement that a 1,000 plus hour ED course is not good for anyone. I think in our space it is a standalone children's ER. I mean, that sounds horrific what you described, the incident that happened. But thankfully in our space this is a separate area and we do have like a locked, secured psychiatric area with three going on four beds. So that's where this patient was for the vast majority of that course. But the huge downside is that area doesn't have windows. So that's a huge limitation. But we do have some ability. We have like a recreational area that's like closer to the rooftop where we would take this patient just to get like natural light, fresh air, humane things. So there are some things that we tried to do out of the norm that was like a big lift administratively because there are a lot of limitations and regulations about taking kids there. But this kid stood out as kind of an extraordinary case. So we were able to get some rules to be bent for this kid. But definitely not something we do regularly or enjoy doing or should be done on us. Does that answer your question? I hope you, okay. Well, perfect. Thank you so much. So we're at time, but our panelists and our speakers will be up here. So feel free to come up and thank you so much for your attendance. Thank you.

child psychiatry crisis

psychiatric ER visits

youth suicide statistics

national state of emergency

autism ER stays

BIPOC challenges

LGBTQ mental health

stigma cultural barriers

minority underrepresentation

mental health disparities

school-based services

anti-racist practices

MPATH model