We have a nice intimate group here, so this will be fun. We're going to have it, part of this will be talking, and then we're going to have an interactive experience. So we have tables set up in case there was a big group, but we'll all gather on one table later on. We'll tell you when, so we can get this experience together. So just to introduce ourselves, I am Paul Rosenfield. I'm Associate Professor in Icahn School of Medicine at Mount Sinai at the Morningside West Campus, and I have with me two of our former trainees in the residency program who are now Chief Fellows in Child Psychiatry. Arafat Zadeh is at NYU, and Susan Kim is at Mass General Hospital. So this is work that we did together with Tomas Restrepo-Palacio, who is unable to be here because he is living in Thailand currently, and couldn't quite make the flight over. But a lot of the inspiration and work that went into this project is his effort and time. So this is called Life in ACES, an interactive training experience, and we want to give some background to this concept, and then we're going to talk about how we utilize this as a training experience for our residents, medical students, and actually faculty development as well. So our objectives are to demonstrate the relevance of learning about ACES and social determinants of health within a biopsychosocial framework, and tell a little bit about some of the research work that we did in understanding ACES within our context, within our clinic, and then introduce this interactive experience created to raise awareness and knowledge about the impact of ACES and social determinants on patients' illnesses and life course, to really help us both gain an empathy for our patients' experiences, and help improve our ability to formulate their cases to enhance their treatment, and hopefully achieve better outcomes and understanding. And then we want to, you know, have discussions here, thinking about other strategies to help address social determinants of mental health and counteract attitudes that can happen where we feel helpless and demoralized about our patients' life challenges. So I'm going to turn it over to Dr. Zaidi to talk about ACES. So, I'm sure most of us know, ACES stands for Adverse Childhood Experiences. And CDC defines them as potentially traumatic events that occur in childhood that are linked to chronic health problems, mental illness and substance misuse in adulthood, and also have a negative impact on education and job opportunities. This is the ACES questionnaire. It's a yes-no questionnaire that encompasses things like physical abuse, emotional abuse, witnessing domestic violence, separation from caregivers, and sort of other, you know, alcoholism and substance use, and if anyone, any caregivers were incarcerated, for example. So this is the ACES questionnaire. And the goal of our study is to learn about our patient population at Mount Sinai Morningside, which is in Manhattan, on the Upper West Side, and to encourage a structural competency in our staff. We wanted to be able to implement better and more effective trauma-informed treatments for our patients. So we'll be talking a little bit about the insights that we were able to gather from our ACES study in our hospital-based outpatient psychiatry service, and that's an adult psychiatry service. And we'll also talk about the investigation of PEARLS in our inpatient pediatric psychiatry unit, and that's sort of an adaptation of the ACES questionnaire, which Dr. Kim will tell us more about later. And ultimately, our project, which is ACES in Life, this innovative training strategy to help engage and inspire medical learners to understand the impact of the social determinants of health and ACES. So we'll get to experience that a little bit later. So I wanted to talk about our outpatient psychiatry service and the data that we gathered about ACES from our practice. Basically our intakes, the process included the ACES questionnaire, and we looked at about 318 intakes and did a retrospective chart analysis to learn about the prevalence of ACES in our patient population. Our primary endpoint was to determine the prevalence of ACES among the new intakes in our outpatient clinic. And this sort of shows some raw data about how people responded on the ACES questionnaire to the various specific ACES questions. So these are the number of positive responses for each category. And these are our results, which demonstrate the percentage of the number of ACES that we saw in our intakes as compared to a national average. So as we predicted, ACES are quite prevalent in our outpatient psychiatric clinic, and in fact, more so than the national average. So in a more broad patient population, in a psychiatric population, we saw that ACES are more prevalent, and there were a significant number of patients that had four or more ACES or seven or more ACES, which we know are very much linked to negative outcomes. And we also were able to gather vignettes from specific patients and found these stories very powerful, so I wanted to share some snippets from those as well. This 57-year-old female who has an ACES score of 9 says, I started drinking when I was 9, my mother was an alcoholic, and all there was in the fridge was beer. That's why my fridge is always full of juice boxes, I don't want my kids to go through the same issues I had in my childhood. This is another quote from a 20-year-old male who has an ACES score of 9, I wasn't able to sleep with my girlfriend, she broke up with me because of that. But every time I think about what he did to me when I was 9, I get scared. I can't hurt her like he hurt me. And this from a 30-year-old female with an ACES score of 5, my father was an alcoholic, he used to beat me up all the time. He also used to hurt my mother. I left home as soon as I could live with my boyfriend. He was the same as my father. He was always drunk and tried to hurt me too. And I'll have Dr. Kim tell us a little bit about our inpatient pediatric study. So I'll be discussing a study that we conducted in the inpatient pediatric unit at Mount Sinai, where we utilized a modified version of the original ACES questionnaire called PEARLS to assess for the presence of trauma in the unit. But before doing so, I just want to delve a little bit into how I was personally inspired to learn more about ACES. And as a child and adolescent psychiatry fellow, I will say that there is a subset of individuals who pursue child psychiatry because we're, how should I say this, very young at heart. And I say this with caution because Dr. Zadie is also a child psychiatry fellow herself. But this opportunity gives me the chance to continue to talk about Disney, which I'm a huge fan of. And we see in the very popular movie Frozen, we see that Elsa, one of the protagonists, isolates herself for many, many years because she is holding onto a secret. And I hate it when people give spoilers, but I think it's safe for me to say that her secret is that whatever she touches will turn into ice or snow. And basically, she shuns herself from her kingdom, from the rest of the world, even her family, which serves as a form of trauma for her. This is also another very popular Disney movie, Encanto, which explores familial generational trauma, where the characters have this immense pressure to live up to these lofty expectations set by their ancestors. If you've seen this movie, you will know the song, We Don't Talk About Bruno. But today, we will talk about Bruno and we will talk about his trauma. So Bruno is a character who fails to live up to these expectations. And in the process, he isolates himself, similar to Elsa, from his family, and he disappears for years and years, which again serves as a form of trauma for him. Going back to the movie Frozen, we see that an act of love, an act of compassion, in this case, Anna, her sister, helps crack years and years of trauma and helps her to finally start that healing process. So most recently, Disney has been delving into the backstories of the villains who we loved to despise while growing up. And what we learned from these newer studies is that these villains actually have a history of trauma themselves. They have a history of hardships, and their way to protect themselves from the world is by using maladaptive coping strategies, even maybe a little bit of evil along the way. So in the PEARLS questionnaire, which I promise I will go into in a minute, it asks specific questions that are very relevant to the pediatric cohort. So one of the questions that it asks about is whether there is a history of a caregiver or a parent passing away during their formative years. And this has always been a very important and relevant topic for us to consider when working with the pediatric population, but even more so during the pandemic, because in the U.S. alone, more than 200,000 children have lost either a primary caregiver or a parent. And going back to Disney, we see that more than half of the Disney leading ladies have a parent who passed away. So let's bring the topic back to PEARLS, which I just realized I didn't tell you what it stands for. So it stands for the Pediatric ACEs and Life Events Related Scale. And this questionnaire has two parts. So part one is very similar to what you would find in the original ACEs questionnaire. The one difference is that in the original ACEs questionnaire, the questions are directed directly to the patients themselves. However, in PEARLS, the questions are directed to the caregivers. So part one is comprised of the original 10 questions. Part two is what makes the PEARLS questionnaire unique. So this part goes into topics that are very relevant to the younger population. So it delves into whether there is any history of bullying, discrimination, housing or food insecurity, being separated from a parent, being under DCF custody, having a parent or a caregiver who had a chronic medical condition or who deceased during their formative years. And we are still in the process of analyzing the results from this study. And what we find is that there really wasn't much of a correlation between the ACEs or the PEARLS score to some of the things that we measured, which included length of stay in the inpatient unit, number of psychiatric medications at the time of discharge. However, we did find a statistical difference in the presence of ACEs and also the presence of a medical condition, such as history of asthma and also history of allergies as well. So we're very excited to be publishing the results from the study very soon. So it's very important for us to think about ACEs when we treat our patients because presence of ACEs can lead to disrupted neurodevelopment, social, emotional and cognitive impairment, adoption of high-risk behaviors such as substance use, promiscuity, disability, disease and social problems, and even early death. However, the presence of ACEs does not mean that one is inevitably going to lead a challenging life. Many studies have shown that the presence of a protective factor can really change one's trajectory. So a protective factor would include having a loving grandparent or an aunt, distant relative, having a caring teacher or a counselor, receiving therapy, receiving psychiatric treatment if indicated, voting for a politician who cares about mental health treatment and social determinants of health. Which then leads us to our next topic. I'll hand the mic over to Dr. Rosenfield. All right. Thank you, Susan. So just a quick question. How many people here actually use the ACEs questionnaire with their patients? Have you ever done this? Yeah, a couple of people? Okay, great. Yeah, I think what Arfa was saying about our clinic was with the study, we actually introduced the ACEs questionnaire for all new intakes, partly because we wanted to study this, and this was a way of making a quality improvement project, and we were able to ask all of our patients coming in and get a sense of this to then inform our treatment better. And what we also wanted to educate our trainees about is social determinants of health. So ACEs are sort of an important part of social development, but the social determinants of health, which I'm sure many people have heard about and talked about and learned about here at this conference, are described by the WHO as non-medical factors that influence health outcomes. So these are the conditions in which people are born, where they're growing up, they're working, they're living, they're aging, and the wider set of forces and systems shaping the conditions of daily life. So as a picture here, all the artwork is by a wonderful artist, Joe Ryu, just very evocative and wonderful. So yeah, if you're living near a power plant, or if you are in a run-down neighborhood, or if your school system is broken, those are all different social determinants that can impact your health outcomes. So this is a wonderful sort of table by Ruth Shim and Michael Compton in their writings and book about social determinants of health. And what we want to look at in the middle, if you can see, are sort of different domains of social determinants. Experience of homelessness, food insecurity, poor access to health care, adverse built environment, meaning the neighborhood you're living in is run down, or there are a lot of abandoned buildings, or there's neighborhood disorder, crime in the neighborhood, pollution, climate change impact within your neighborhood. And then on the bottom left, early life experiences, discrimination and racism certainly impact people's health, exposure to violence, the criminal justice system, you know, the inequity in how black populations in particular are incarcerated and the laws and enactment of criminal justice system is quite inequitable and can impact people's health. And then also low education and unemployment, poverty, income. So these all lead upstream to people having perhaps more difficult, you know, reduced range of choices, risk factors like Susan talked about, stress responses that certainly impact our physical and emotional health, psychological stress, and those lead ultimately to adverse mental health outcomes and there's data on, you know, increased risk of a whole range of mental health outcomes as well as physical health outcomes in response to these social determinants. But what's the most important piece is the underlying, the bottom of this table, which demonstrates how public policies and social norms drive this inequity, right? If you have a policy of redlining and not selling to, not allowing black families to purchase a house in a neighborhood or get a mortgage to live in a neighborhood, you're going to create segregation and inequity and an inability to build capital in a family and sort of drive a system that is grossly inequitable. And social norms, whether they be sort of certain prejudices and biases or expectations of, you know, how you pull yourself up by your bootstraps and not understanding the underlying inequitable policies that can impact people. So this leads to an unfair and unjust distribution of opportunity and therefore all these social determinants stream out of that. So I just want to ask you a little bit before we jump into this interactive experience, sort of a couple of you used the ACEs. I'm sure people have thought about social determinants and have learned about this. How do you integrate this understanding into your work currently? And if anyone would like to share, either come up to the mic or raise your hand and I'll repeat it for everyone else because we are recording this session. Thank you. And just say your name and where you're from. Absolutely. So I am Aaron Van Dyne. I'm a psychiatry resident at Naval Medical Center Portsmouth. We've started talking about the Aces a lot, in part because our population, primarily 18, 19, 20-year-olds, still very much adolescents in many regards. This is their first job out of high school. And unfortunately, a lot of them who we see coming in, difficulty adjusting to being away from home, difficulty adjusting to being in the Navy. One of the things that I've been working with some of our team to kind of figure out is how much of that is maybe related to adverse childhood events that they experienced in childhood. Certainly, one thing that we spend a lot of time considering that's related is how supportive of a family network they have at home and those sorts of things. And so definitely something we're increasingly thinking about, just because the recognition that the Navy's always been a place where people went maybe to get away from challenging things at home. But increasingly, I feel like they're bringing some of that with them, some of that baggage with them that ends up affecting their service in the Navy. Yeah, great. Yeah, thank you. So on the one hand, if there's greater adversity in childhood, they may be more at risk for PTSD and other outcomes related to their service. But the military service could also provide a really supportive environment of bonding and common purpose and mission that could also be protective. So yeah. Yes. Hi, my name is Birgma. I'm from Iceland. I'm a child and adolescent psychiatry resident there. And right now, I'm working at an acute team where we are assessing suicidal risk and psychotic. Yeah. And in that, when we meet the children, we ask, OK, how are the situation at home? How are the social status? And what are the trauma history? We don't have, but we should maybe have the ACE questionnaire. But we ask these questions to everyone because to know where can we start from. Because if they're in a fight and flight response at home all the time, there's nothing to work with. We have to, we're really aware of making stability before we can do more work. So that's how we do it there in the acute setting. That's great that you're asking about it and really integrating that into your understanding of patients. And one advantage of doing the ACEs questionnaire is that people can fill it out by themselves and then give it to you. So sometimes, they can be more open and honest, actually, on the questionnaire. Because sometimes, trainees have difficulty. They might say, well, have you had any emotional, verbal, or physical abuse? And people say no. But they haven't really asked in depth. So teaching them to ask in depth and really take time with understanding, but also using the ACEs questionnaire, both can really enhance your awareness of what's going on. If you have anything to add. Yeah, please. Hi, my name is Sophia Yoon. I'm a PGY-2 psych resident at Jamaica Hospital Medical Center in Queens, New York. I'm interested in pursuing child and adolescent psychiatry. And I found your talk to be very insightful. One question I do have is, you mentioned that positive experiences could potentially negate ACEs. I was wondering if there's a certain number or quality of positive experiences that can reverse a certain number for ACEs, or if it's entirely dependent on the individual. Because I know that people who have four or higher ACE score, they're considered particularly at high risk. So I just wanted to know if you had any comments on that. There is a recent study, actually, 2023, that looked at positive childhood experiences. And so having an adult at home who was supportive, or you would listen to you when you were upset, or took care of you, and the more of those PCEs instead of ACEs you had, the less risk of having negative mental health outcomes. Mental health outcomes, depression, other mental health outcomes. And so we try to quantify this. And so there's some relation to the quantity of positive childhood experiences. But there's a qualitative aspect to understanding people's lives, because even two people who have experienced this emotional neglect may have taken that in very differently. And even two people who had a positive grandparent experience, there's still qualitative differences in how that impacted them. So it's hard to say for sure how they will each impact someone. But there is evidence of PCEs mitigating the effect of ACEs. So yeah, do you want to add something? Yeah, and we, yeah. And we include that in our interactive experience that we'll talk about. We incorporated, we call them resilience factors into it. So hopefully we'll have a little bit of an interactive understanding of how they might integrate, these positive resilience factors might integrate into adverse childhood experiences. And I think that also, just to add, I think that one of the. things with the ACES questionnaire is that it's a yes-no questionnaire, and it's sort of like you get a point or you don't get a point, but certainly, you know, there's discussion about is the impact of witnessing domestic violence the same as, you know, emotional neglect or however broad range that might be, and like how broadly it might affect people or, you know, sexual abuse, is that really the same, should that really get the same number of points as a different type of adverse childhood experience? So, you know, I think quantifying it is pretty difficult, and doesn't really capture the gravity of everything, so that's probably like one of the drawbacks. ACES doesn't capture the nuance. Yeah, I think it's a start to the discussion. It sort of gives you a sense, there's some data about how many ACES, but then it's more of a discussion and exploration with your patients, so I'm really glad we have some trainees here, and I'm sure, and some faculty, so this is something that I think we are, think is important to teach and, you know, integrate into the work that our trainees are implementing, and also, of course, in all of our work. So, let's jump on into this experience. So, we are, it's called Life in ACES. This started when Tomas Restrepo, who I mentioned at the beginning, was a resident in our program, and I was talking with him about how to teach about social determinants of health, and he said, why don't we make a game from this? And so, he set about creating this really wonderful experience with a board, different characters, and the characters roll the dice to see how many ACES they have in life, because our lives are not, you know, it's luck, how we're, what family we're born into, and what our circumstances are, right? It's not out of our own merits in any way, right? So, we roll the dice, and then we become the character with a variable number of ACES, and then through the process, we pick cards that are different social determinants of health, different experiences in your neighborhood, or of education, and even getting, you know, having a mental health disorder, or getting treatment. So, we're going to go through this process. We're going to set up two tables, and so we can split, be at the back, and we'll explain all the cards and stuff to you, so please don't take them out yet. And so, this is all the description, but you don't have to read all this. One other thing is, actually, why don't you split up into two groups, and sort yourselves into the table, two, four, six, eight, ten, twelve, so about six people per table. So, come on up. Yeah, we have, we have chairs set around. Come on up. Yes, so, no, you're good. You guys are good in the back there. What we're going to, we're going to come around and explain it to you. It's worth it. Come on. Come join us. Four is enough for any one table. Great. Alright, so if you look at the board, you'll see there's a spiral, and there's a blue and a red dots. The blue dots lead towards the spiral going up, towards the positive outcome in life, and the red dots lead down to a spiral, which would be a negative outcome. In the, so we're going to start out by rolling our dice, and Susan and Arif are going to sort of guide you on the process. So thank you all for participating in it. Both groups seem to have really gotten into the experience and found it meaningful. I wonder if someone wanted to share just what, so we can share between the two groups, and we have two mics, what feelings came up for you around this? I think the two groups had different outcomes. This group had everyone except one person, I think green on the blue side. So just green ended up on the red side. For you guys, pink and green? Pink and gold ended on the red, and the other two ended on blue. So quite different outcomes. But what feelings, I know you guys have been discussing already, but maybe to share, like what kind of feelings came up around being those characters, and either the one with more advantage, more disadvantage? Do you wanna come up and talk in the mic for a moment? Hi everyone, my name is Ariella, I'm a first year psychiatry resident. I think this game really allowed me to live in, you know, the skin of, you know, someone in the system. Even though I had a positive outcome, I think looking at the other characters, like we all started at the same place, and these social determinants, like, really led us, you know, either up the board or downwards, and I think what was most striking for me is the ones who, you know, were going in the red, basically were staying in the red and continued to go down, and I think, you know, it's a lot to, like, take in, and, you know, I think it left me with profound feelings and, you know, a lot of questions, and I think it was very helpful to take part in this and seeing how interactive it was. Cool, thanks. And, yeah, Jan. So, I'm Jan Wise from the UK, and it raised several points for me. One was the precariousness of success or failure, if I can use those words, but it also drove home that the majority of the change of direction in people's lives is totally outside of our control as psychiatrists, and it behooves us to be involved in the political process for social justice or fairness. Yeah, right, so the social determinants, we can sometimes help someone get, you know, do their application, the psychosocial, you know, psychiatric evaluation for their housing application, but behind that is the whole, you know, is there affordable housing? Do they have capacity to, you know, obtain a job that paid enough money for, you know, crazy rents, for example, in San Francisco, and, you know, what led to someone's homelessness is way beyond what we're dealing with. We're dealing with the after effects of all those things, so, like, the cards with psychosocial treatment helped, and that made a dent, but there's so much more behind that, for sure. So let me ask this question. What systemic changes would you advocate, then, so to change this outcome? So we're here as psychiatrists, where we're, like, trying to help the individual patients, most of us, right? What kind of systemic changes would you think about when we're thinking about, like, these larger, you know, social determinants? Is there anything that might help, yeah? So a better public school system could help bring up the baseline. So one example of that is, like, Head Start. Head Start has been shown to help raise the, you know, a common floor of ability to start learning and reading and all those things for all kids, instead of just the people who have the advantage, yeah. Universal housing? Is that what you said? Yeah. So, like, a right to housing. Even in New York City, we have, like, what's a right to housing, but there's a lot of homelessness still. So people have the right to have to have access to a shelter, at least, but that's not really a, you know, desirable location for most people. So yeah, right to housing or universal basic income is another thing that people have talked about as a way to, you know, reduce level of poverty, yeah. Universal basic income, yeah. So some politicians have advocated for that, and actually, I think, so Matthew Desmond is a writer, a journalist, who wrote Evicted several years ago about the high rates of eviction and homelessness. He just wrote a new book called Poverty by America, and talks about all the different ways that poverty impacts people, adversely mostly, right, and the ways that actually it's not just, doesn't just happen to be that we have many people with poverty, that's the way our systems are set up, that, for example, does anyone know, in the US, I don't know about the, about Europe, but what's the highest funding for housing, like, what, where does the government spend most of its money for housing? The inequity in the juvenile justice system you were saying? Yeah. Oh, yeah, sure, there's tremendous troubles in the justice system in general, like, for example, who can pay bail and not be incarcerated in jail until they can get bail, and how does justice get meted out to people of different backgrounds? Just on the housing question, does anyone know what the largest government funding goes to in housing? Jail, oh, housing people in jails, no? But yeah, that's a good thought. Section 8 housing, I wish, that would be great. So the highest funding goes to the mortgage interest credit. So you get a deduction, people who have houses pay a mortgage, and the taxes on that mortgage are allowed, you can deduct them from your taxes. So the biggest government benefits go to the wealthiest people, the people who have houses and are paying a mortgage, way bigger than Section 8 or any other public housing or programs. Matthew Desmond makes the point that poverty doesn't just happen to be, it's coming to the advantage of the wealthier, who have more political power, and the disadvantage of those who have less political power. Yeah, I wonder if the child psychiatry fellows here agree with that perspective or have a different… Could you just repeat what you had said? Oh yeah, sorry. The comment was that one helpful intervention might be to remove children from their families sooner if there's abuse in the family and put them in the foster care system sooner to help protect them. Do you have a thought about that, Arfa? So I am a child psychiatrist at NYU, and we work with Bellevue Hospital, which is one of the New York City public hospitals. We are located right next to what is called the Children's Center, and that's where children who are removed by the foster care system, they go into that holding area, and we frequently get kids from there for various reasons. I'll say that there's a lot wrong with the foster care system as well. Often kids are abused within that system, and I think truly that separation from their caregiver and those initial attachments, you know, if we do look at sort of like primary attachment figures as parents, that separation ends up being really traumatic for them, and in fact I think that system perpetuates that trauma. So certainly like kids who are in abusive situations need to be removed for their safety. I think that we think that the best sort of outcome would be if there was another family member involved, but I think that the foster system itself is also just riddled with abuse and misgivings, that it doesn't end up being, it ends up being sort of its own adverse. You don't have to have an attachment. Oh, at all. No. So you're saying there's no foster assistant, isolate. Yeah, there's like a system, but it's not like you take them away and put them, like, it's not like that. Yeah, I'm not really, I don't know everything about it, but I've only been working for a month at the hospital, so I'm not sure about all the social. I think in the, oh, Susan, do you want to make a comment? Do you want to come up? Well, actually, I just want to say, I feel like there are many issues even within this system. Yeah. Yeah, right. We could improve the foster system, but I think that at least in New York, there's been a move to remove children less frequently because you're separating them from their parents who may be loving towards them, even despite there's also abuse going on at times. The foster care system is not necessarily a positive experience, and people get a lot of abuse in the foster care system, and so, like, providing more supports for a family that's struggling might be a more effective way. So I think that's been a move in the last, I don't know, 20 years or 10 years even in the US to try to support a family rather than removing the child as the first step. Yeah. So I agree there are plenty of issues about the quality of staff looking over, after children in whichever place you put them into, but I'd remind us about that distribution curve, blood pressure, and you have ACEs. A systemic intervention just reducing everybody having one or two ACEs will produce a much more positive outcome than focusing resources on a very small number of people. We've got almost every box ticked. Right. So one, so actually another thing in this book is the earned income tax credit is a benefit for poor families on their taxes to get money back, and many poor people don't know about it, and that, and actually there's also a child tax credit that was passed for several years and now is just reversed. It helped reduce poverty tremendously, so like a larger systemic intervention like that brings down the level of poverty, decreases the risk of ACEs for a huge number of people because, you know, they're not as stressed and they're not having to leave their kids alone without any supervision and, you know, all kinds of downstream effects of a more larger system solution, and that can be helpful. Yes, I mean, there are certainly kids who may need to be taken out of their families and hopefully that can be a helpful thing, but we've just seen how much, you know, that can also backfire. Kids in the foster care system experience a lot of trauma themselves. Great. So I think these are just sort of some further questions to think about, and maybe we can just share any takeaways that we have in terms of both challenges in addressing these and what you want to do to help avoid demoralization. Sometimes we can feel demoralized from all these challenges and our patients are struggling and we don't, you know, know what to do, and we can also encourage our institutions to advocate for policies. So I wonder if anyone can share any takeaways from, you know, sort of thinking about these questions and what you want to take away from this session going forward. Yeah, you had a comment if you want to. Hi, my name is Balcozar Adam. I am a child psychiatrist with the University of Missouri-Columbia and Rural Behavioral Health. This experience really opened my eyes how people from different life experience background were able to move forward or move backward. It was really something that I can, like, feel it, not just read about it and imagine it. It was a very good experience to see how things and, like, getting medication, taking therapy, having support, having income can help you move forward and be successful in life, and how other life experiences and social determinants of mental health can affect you in a negative way. I would like just to share one thing. The APA have an online resource that was developed by the APA Council for Children, Adolescents, and their Families on Social Determinants of Mental Health, and it's about children and about their experience and the upstream and midstream and downstream interventions. And also, there was vignettes that were described there about different people from different backgrounds, including, for example, immigrants and refugees. So, I just would like to share that this could be a good resource for us while working with children and their families. Yeah, that is a wonderful resource, the APA. There's a general social determinants of health committee that I was on, and there's a document that was created from that, and then the child one was really excellent as well. So, yeah, I think that's a great recommendation. And thank you for, I'm glad this was meaningful for you. Yeah. If I can say one thing, that Ted Rosling, a Swedish professor of statistics, used to go around the globe when he was alive, pointing out that 100 years ago, Sweden was a third world country. Every determinant of health has improved. Infant mortality, maternal mortality, life expectation, literacy, they have all improved over the last century. It's not where we want to be, but it's improving. And it's just, to paraphrase the movie The Martian, you get there by putting one foot in front of another and just keep on doing it. Being demoralized, moral injury, avoidance occurs with framing it wrong. Every step is an improvement. Just contribute to that step. Amen. There are, yeah, Steven Pinker and Jeffrey Sachs write about, you know, that there is a, our society, you know, there's lots of improvements. Poverty is way lower than it used to be. There are lots of opportunities for progress, but the disparity is also growing in our country and, yeah, so there's lots to work on. Yes, Susan. So, I played this game several times, and I will say that whenever I get assigned a character with the many aces, I actually go into learned helplessness mode, especially when I'm just going down the spiral of red. And I think it's important for providers, for us to know how protective factors can really change our patient's trajectory, because sometimes, even as a provider, sometimes I can also feel helpless at times. But when our patients feel helpless, I think it's important for us to know that with effective treatment and with systems, like, improvement, that our patients can get better. Yeah, thank you so much, Susan. And Arafa, final word. I think that Susan saying that, I was also sort of, we were talking about this at our table, that sometimes it feels like we're not doing anything, and it's just like, ugh, like we're not moving the needle. And we were talking about how even staying on the start position, our characters were like, oh, phew, like I didn't move at all. And sometimes I think that we put a lot of pressure on ourselves, or we expect a lot, and I think we underestimate the power that our stability and our effort can put in. But I think our presence actually is really, really meaningful. And judging our patients or their progress based on how we feel like they ought to do, I think oftentimes we don't take into account the fact that maybe the fact that they're on start or that they haven't moved is actually a really big deal for them based on where they come from or what their races are. So I think that there's a combination of our patients are actually doing really well and not underestimating how important care is for them and how important the work that we do is can help us from not becoming demoralized, even though it's really, really hard sometimes. Yeah. What I reflected upon when I was doing the game is the importance of early intervention because we could see when the most negatively charged of our characters had the opportunity of psychotherapy and psychiatric treatment early on and then her fate changed totally. And that's what I think we can do because what can we do about safe water and stable income or universal health care as clinicians? We can advocate and we can vote right and hope that that works. But in our everyday work, we can have early intervention programs that will change the fate of the children. And I think that the perinatal period is one in which you can make small interventions like keeping a mother protected from violence or making sure that she's not depressed during pregnancy, improving the delivery itself, the quality of the delivery so that the baby's brain will be better, making sure that the first year of life the baby is not subjected to a child maltreatment. There are interventions with some evidence that will help you get those goals. And I think that's what we can mostly do to improve the fate of the next generation. Well said. Thank you. Well, thank you all for participating today. Really great to be with you and to have you get to participate in this and to take away all these insights. And so thank you.

Adverse Childhood Experiences

social determinants of health

Life in ACES

childhood trauma

health outcomes

systemic changes

policy interventions

early intervention

healthcare advocacy