Welcome. Thank you for coming this afternoon to spend some time with us as we talk about child and adolescent mental health. The title of our talk today is Meeting the Demand, Meeting Children, Adolescents, and Families Where They Are. I'm Michelle Durham. I am a child and adolescent psychiatrist based out of Houston, Texas, working at the Meadows Mental Health Policy Institute and also with InStride Health, which is an online virtual program for kids struggling with anxiety and OCD. I'm happy today to be with my colleagues here who I'll introduce shortly. I also just want to make sure that everyone knows that we don't have anything to disclose regarding commercial interests and don't plan on discussing unlabeled or investigational uses of commercial products. So today we have a great panel of presenters and I'm going to introduce them now and then I'll do a little bit of a background about the child mental health crisis and then I'll pass the baton on to my three different set of speakers to talk about meeting this demand in crisis care, or I shouldn't say crisis care, before crisis care for kids who need mental health services. So as we go down the table here, Anita Morris is the project director for Team Up for Children and the director of research strategy and process improvement for Boston Medical Center Health System. She's a certified family nurse practitioner whose locus of clinical practice has always been in the safety net, working in community health centers with historically marginalized populations. Ms. Morris joined Team Up in 2016, guiding the development and implementation of a comprehensive integrated behavioral health care model within pediatric primary care settings that has demonstrated positive impact on children and families. As director of research strategy and process improvement, Ms. Morris supports the growing research portfolio across the BMC Health System. Prior to coming to Boston Medical Center, Ms. Morris provided consulting services on various topics, including clinical model design, health care payment reform, and workforce development. I also had the pleasure of working with Anita Morris for eight years or so when I was at Boston Medical Center prior to moving to Houston, Texas, so I'm really happy that she accepted my invitation to speak today. Luanne Southern currently works at the University of Texas system as the executive director for the Texas Child Mental Health Consortium, which was created by the 86 Texas legislator in Senate Bill 11 to address gaps in mental health care for children and adolescents in Texas. Luanne most recently provided strategic consulting services to the Texas Child Welfare System as a senior director for Casey Family Programs, a national operating foundation focused on improving and ultimately preventing the need for foster care. She previously served as deputy commissioner for the Texas Department of State Health Services. Luanne has many years of national, state, and local experience in health and human services with an emphasis on policy and practices that address the behavioral health needs of children, youth, and families. Ms. Southern has an MSW, master's in social work from the University of Texas, and a bachelor's in social work from Goshen College in Indiana. Next is Laura Avila. She's a part of Central All Cove Team Youth Advisory. Laura is attending University of California in San Diego. She began her mental health advocacy work four years ago and founded the mental health organization within her district. She's also part of the California Department of Education Student Mental Health Policy Work Group where she learned about All Cove. As a youth advisor for the Central All Cove Team, she continues voicing the needs of young people and works alongside other young leaders to improve equal opportunities and resources for communities across the state. And last but not least is Mac Chakowsky. He's part of the Central All Cove Team Youth Advisory. Mac is a student at Stanford University. He has been involved in Sacramento's mental health sphere for the past four years, participating in different forms of activism ranging from local community focused pursuits to larger statewide projects. His passion for destigmatizing mental health and starting conversations brought him to Central All Cove Team Youth Advisory Group where he's been able to come together with other youth across the state who are equally passionate about mental health. It was very intentional for us to put a panel together of not just child psychiatrists but everyone that can be a part of the system for kids and making this better for them, their health of themselves, but also their families. And I want to encourage us all who are other psychiatrists in the room to really think about this team-based model of care and not to forget youth voice and when we're designing systems of care for youth. I think Mac at the last time we presented this said it very eloquently, what are you doing if you don't have young people at the table? And so I'm leading with that but I just want to make sure that it's noted that it's very intentional of thinking about we have to do this work with everybody and not just with MDs at the table. So for those of us that are seeing kids in our work, we know that there's a huge crisis in mental health for kids. There's about 2.7 million plus youth that are experiencing severe major depression. About 6 in 10 youth with major depression don't receive treatment. About 42% of high school students experience persistent feelings of sadness or hopelessness and about 18% of high school students made a suicide plan this past year. These are just some of the staggering statistics that we're seeing nationally and probably in many places and depending on where you are, probably feeling a little desperate for how do we help folks when there's not a lot of services for kids in some of the states that many of us are sitting in. I was lucky to be in Massachusetts for a big portion of my career and now that I'm in Texas I'm glad folks that like Luann are at the table and we're trying to do something to improve access for mental health care but there's a lot of work left to do. I think why and I know why Alcove at the end of our table will present a little bit is how do we start on this other end of the continuum around prevention and promotion and not so much in a desperate need in crisis intervention which has been the narrative since the pandemic. I think a lot of thinking about crisis services and let's have more inpatient facilities and but how do we think about building up community and kids and making sure that they have what they need early in that trajectory and not when families are in crisis. The other thing before I get to this slide I wanted to also say is there's this recent book sort of the anxious generation of thinking about young people that I have started listening to on audible but many of us who are probably sitting clinically and seeing folks are realizing that a lot of teenagers are feeling quite lonely and that's probably going for adults as well and the Surgeon General talked about that in his mental health report but the book gives a really a lot of data to support and extrapolating that pre social media Instagram tick-tock and everything to now how much kids are really suffering and that even though they're more connected online they're very lonely and so it's a very interesting read for those who want to read that book but it's a it's really talking about this impact that we're seeing in our offices of a lot of suicidality a lot of depression a lot of anxiety and adolescent across gender across ages and in young people. The other thing that we're battling right is this mental health professional shortage there's about 10,000 child psychiatrists in the in the United States about one in four child psychologists so there's about 4,000 psychologists that are consider themselves child focus therapists and there's about 70% of US counties that have no child psychiatrist at all and so when we look at this this is you know why we put this panel together like we have to think of other innovative ways to reach kids and families because there's not enough of us and there won't be enough of us as a former training director for a general psychiatry program there are not a lot of people going into fellowships these days either and so this just is gonna get worse and worse if and so I don't mean to be doom and gloom but I also want us to think about other ways to reach kids earlier and to meet them wherever they are because there's this huge demand for services but we don't have a lot of people necessarily specializing in child mental health. Last but not least I mentioned the US Surgeon General's report that came out and Dr. Vivek Murthy talked a lot about loneliness and and what we need to do about this youth mental health crisis but I love this particular couple of few sentences that that I'm gonna just go ahead and read out loud to be sure this isn't an issue we can fix overnight or with a single prescription ensuring healthy children and families will take an all of society effort including policy institutional and individual changes and how we view and prioritize mental health. Our obligation to act is not just medical it's moral. I believe that coming out of the COVID-19 pandemic we have an unprecedented opportunity as a country to rebuild in a way that refocuses our identity and common values puts people first and strengthens our connections to each other and we can say this is likely true across the age spectrum for all of us but not to forget that we are all part of this work to advocate for improved services even if the majority of your week is sitting taking care of patients that you have a lot to say whether it's locally and your region or nationally about how do we improve care for families overall. So with that I'm the I'm going to introduce or ask Anita Morris to come up to talk a little bit about how are we meeting them kids and families in the clinical setting. Anita. Thanks Michelle. Hi how is everybody doing? Do you mind just watching my time? Thank you. So thank you so much for coming and joining us today. I think all the things that Michelle said just to frame our discussion are kind of wholeheartedly true and I think really core to our work both the importance of a very large table when we think about how to kind of address and improve the services and that children and families receive and that we have to kind of think out of the box that we need to think about kind of longer term strategies both to promote health and wellness prevent issues as they emerge and then also to build the workforce and be ready for kind of a better day in the future. So a lot of that is core to team up as Michelle referenced is to acknowledge Michelle's contributions to team up. Team up began in 2015. We had the opportunity to work on it together and so I'm just going to talk a little bit about the model and kind of our approach to how we're trying to integrate those core components. So team up is now about eight years old. We began at the end of 2015. It is an initiative run out of Boston Medical Center. That's where I work but really designed to create kind of co develop and create a model of integrated behavioral health care in primary care settings. So we work with a number of different primary care settings federally qualified health centers across the kind of Boston region. Since 2015 until now we have really developed this model of scale the model to additional clinics and there's a large kind of evaluation arm of team up. So we've done a lot of research to figure out kind of what seems to be making a difference. But at the core of the model is the fact that it is really an integrated care model. So looking to try to utilize the opportunity of primary care where if you think about the first couple of years of life kids are coming in for well child visits up to six times a year. So really utilize that opportunity of primary care to be very attentive to and incorporate behavioral health needs as well. Team up was intentionally designed to be responsive to the needs of structurally marginalized communities. So intentionally our plan was to be working with federally qualified health centers really around developing the model with the true assumption that a model that works for folks who oftentimes are experiencing many barriers to receiving services will also work broadly for our whole community. These are just some statistics on the kind of the population of kids that are served at the seven community health centers that have the team up model right now. In total there's about 40,000 kids who are seen annually at one of these seven health centers and by far the two thirds of the population are at or below the federal poverty level almost a little bit more than a third of the population prefer to receive their services in a language other than English. So very diverse population this is our mission and aim statement and I think really the thing that we always like to focus on here is that we really see access to behavioral health services as a social justice issue. As Michelle slides noted at the beginning many kids I think it's it's a majority of kids don't actually receive behavioral health services when they when they have symptoms or need those services. Imagine any other common diagnosis imagine if 50 percent of kids who had diabetes actually just never received care for that. It's really astounding to think about it in that perspective. So I had mentioned we began back in 2015 when we started we started with three community health centers and through a first phase of work that lasted about four years developed the majority of what you see here which is what we call the team up transformation model or the team up model. The kind of guiding principles for developing the model was that it needed to work and be sustained within that community health center. And the reason why we started with a co-development phase was because at the time there really was not kind of off the shelf model available that was what we call full spectrum. So from birth through young adulthood and actually from promotion prevention through diagnosis assessment reassessment and access to specialty care where appropriate as well. So this model I think you guys see my cursor I don't think you can right. So I'll just kind of visually talk through it. The top of the kind of it's obviously organized into four domains. The top domain is really the clinical model itself. It starts with that promotion so strengthening families. We do what's called a universal touch point where the the integrated team will meet and see the family when there's absolutely nothing going on. So again an attempt at trying to kind of destigmatize behavioral and mental and developmental care is part and parcel of just your regular primary care experience. We also do enhanced universal screening so screen with a variety of different tools at all well child visits. One thing to note here is that Massachusetts is a little bit unique in this area that would not the only state but in the state of Massachusetts it's been a requirement to screen for social developmental and behavioral issues during well child visits now for probably like 15 or 20 years. So there's been a expectation for a long time in the state that that screening is happening at every single visit. It obviously doesn't happen a hundred percent of the time at all visits but we use the SWCC so the survey for of well-being for young children then the PSC 17 and from 5 older and reflex to the PSC 19 if the PSC 17 is positive. So a pretty thorough screening process and also a screening for social determinants of health or health related social needs at all well child visits too. The next part of the clinical model is around enhanced access to care. So our goal is that when a primary care provider identifies an emerging behavioral health issue even prior to hitting the diagnostic criteria to have a diagnosis that that child and family meets with the integrated team actually on the same day of care. That's a warm handoff so that services begin kind of as quickly as possible and are as flexible to align with the family and the child's interests as possible. And then we also do a lot of connection to services in the community or specialty services for kids who need that. So that is the clinical model and I think kind of decided to go through it in more detail just to really focus on the clinical care. Underneath that the next the next kind of part of this model speaks to the organizational changes that need to happen within the department in order for that model to exist and and work well. So things like making sure the electronic medical record works for everybody on the team stuff like that. The next one is the learning community. So what we do at BMC is run a learning community where we support these practices in their implementation of this model. And then the final part of the model is our efforts around leading kind of system level change. After the first three or four years we realized that we could perfect and optimize this model kind of as far as we possibly could and without some structural changes in the payment system and in the kind of organization of the health care system writ large we were not going to get as much of the gain out as we could. So the main things about this model that differentiate it are that it's full spectrum. The team is made up of the primary care provider an integrated behavioral health clinician and an integrated community health worker. I'll talk about that more in a second. And then I had mentioned before we have benefited from an evaluation arm. So from now eight years in have really been able to demonstrate results from the model as well. This just describes the learning community support that we provide. It includes kind of all types of what you would consider technical assistance revenue optimization support things like that and then quite a bit of clinical training for each of those three roles but also for the team together. So the next thing I want to do is just go through a quick case study. I won't read it but we'll just kind of point out the important parts of this. This case study is actually from Emily Feinberg. She is a nurse practitioner at one of the community health centers that Team Up is at and is also a member of our BMC leadership team on the initiative. So Emily described this case a 13 year old girl who came in for a well child visit did have a PSC 17 completed and actually was negative. Had a couple things but didn't hit the score threshold to be considered a positive screener. As is often true that screener really is just the beginning of a conversation. So talk to lean a little bit more about how she was doing and through those questions Lena did disclose some depression and anxiety symptoms and actually that she was cutting herself to try to deal with those symptoms. So at that point Emily brought in the rest of the integrated team the integrated behavioral health clinician and the community health worker. I think one of the things that we have found most effective about our model particularly around prevention and promotion is that role of the community health worker who often represents the community that served by that community health center. In this instance was Vietnamese speaking spoke the language of Lena and her father and was really able to spend some time with her father explain what was going on and and really I think kind of destigmatized that that that her his daughter was experiencing symptoms that would actually improve and would benefit would benefit from care and services. The two things just to call out on this again the first is that warm handoff. So Lena did not actually have a technical positive screener did not hit the DSM-5 diagnoses to be diagnosed with criteria to be diagnosed with depression or anxiety in that moment but was really experiencing some pretty significant anxiety and was starting to cut herself as a response to that. She was able to meet the rest of that team and have a care plan put in place on the same day that that issue was identified. And then the second part to call out is just again that role of the community health worker. So now I will go over some of the outcomes sorry these are running through. So as I mentioned before the research arm of team up we do a wide variety of different activities. So part of the work that we do is through data sets that come out of the electronic medical records. So it's looking at all the visit data everything that happens in visits. A second part is staff surveys. So we survey all of the staff in the health centers at the beginning midpoint and end of their time with team up to understand the impact of the model on actual their wellness. So how they're doing and how they think of their ability to provide care within this model. And then the third part is looking at system level indicators. So again a little bit unique in Massachusetts but they're the state runs a database of all of the claims data across all of the different payers. It's always at least a year 18 months delayed but we are able to get that data and have been able to look at differences between team up health centers and non team up health centers that way. So I'm going to start with the outcomes for children and families. The first thing is that children really are getting screened and identified much better and much more consistently. So at team up health centers the second cohort the cohort that we're working with right now they screened at about 92 percent of well child visits. It's probably impossible to get higher than that. That's really kind of the top of it is anybody who has been a primary care provider worked in a primary care environment that is as close to 100 percent as it's possible to get. That is higher than the state average of 68 percent. So even in a state that requires universal screening the screening rate is 68 percent. And in states that don't have that requirement oftentimes anecdotally we see rates that are lower or certain subsets of the population that are not screened at all. A common one is not to screen kind of early school age kids. So 5 to 12 won't get screened. We'll screen in early childhood and screen in adolescence, but not necessarily in that age range. The second part is that warm handoffs actually really do make a difference. So kids who have a warm handoff are actually more engaged in care and come back for their second visit before a child who's just referred through kind of traditional referral pathways has their first visit. So again, you think back to 50% of kids not receiving services for a diagnosis that they have, this really substantially makes a difference. The second area that we look at is kids' behavioral symptoms themselves, and we did a small cohort study where we followed 60 families over a year, long period of time, kids in those families who were receiving services and saw an improvement in their symptoms, an improvement in what we call health-related quality of life, and I think one that we're particularly keen on looking at further, and improvement in school functioning. So literally fewer missed days of school. So again, those services we know really will create a positive impact. And then the last area that we look at for kids and families is medication use. So we've always been agnostic on whether we want to see an increase or a decrease in medication use. Really what we want is for kids and their families to have the opportunity for medication when it's clinically appropriate and for that decision to happen together with the family. But what we are quite happy to see is a decline in polypharmacy, so a decline in the number of kids who are on multiple medications. So then moving over to the workforce, again we do these surveys throughout our work, our cohort work with each of the health centers. And in the first, with the first cohort of health centers we did qualitative interviews. Michelle actually did a bunch of these herself. And from those results found that the model itself was associated with an increased sense of professional fulfillment, increased collaboration and communication across the care team. So when we think about the impact on the health system, the health workforce during COVID, models of care that really promote a sense of professional wellness by themselves are going to also support the workforce and their wellness as well. And then we've additionally, this is the claims-based data looked at. Let me see if I can just get this up. Looked at utilization patterns across the health system. So looked at, this is claims-based data, comparing team up health centers to non-team up health centers. And what we have seen through this is an increase in engagement in primary care services. So the model is associated with increased receipt of mental health services in primary care both by your primary care provider as well as by other folks, the behavioral health clinician and others inside the primary care environment with actually no impact at all on avoidable utilization or avoidable cost across the system. So by and large, definitely making things better for kids and families, getting those service to them, making things better for the workforce, and also we're seeing good trends across the health system. These are all of our partners. And I will pass it on to my colleague, Lou Anne. »» And just to note that we're going to have time at the end for question and discussion. We're leaving a chunk of time. So have your questions ready. »» Well, let me just first say how impressed I am that all of you are here for the very last session of the day. I know it's probably been a very long day. And so I'm glad that you have a commitment to learning about child and adolescent mental health or you wouldn't be here. So thank you for that. And thank you for what you do every day out in the field. I am here to talk about the Texas Child Mental Health Care Consortium. We were created in 2019 by the Texas legislature. So we are a state legislated consortium. The thing that's unique about us that a lot of people ask questions about is that traditionally in children's mental health, states get financed through a health and human service organization, either a state mental health department or a state health and human service agency to purchase mental health services for adults and for children. With this particular initiative, the legislature learned about a group of psychiatrists who had been meeting regularly that represented the academic institutions with schools of psychiatry across the state of Texas. That group of psychiatrists met to talk about the mental health needs of Texans and what that group could do to improve the service delivery system as a group of psychiatrists. And one of the senators found out about that and thought, wow, that's a really good idea. So they created the Texas Child Mental Health Care Consortium that brings together 12 academic health science centers across the state of Texas that have schools of psychiatry. So they are institutions like Texas A&M University, the University of Texas system, which has quite a few schools across the state of Texas that have medical schools. One of them was here actually at the exhibit hall from Houston, I noticed and met with them earlier. We also have University of North Texas, which is in Fort Worth, Texas Tech, which is in Lubbock, Texas Tech in El Paso, which is on the border of Texas and Mexico. And we also have the Baylor College of Medicine, which is in Houston. So those 12 academic health science centers have been meeting. And we asked others to join in that group. So legislatively, those 12 institutions plus the Texas Health and Human Services Agency, the Texas Education Agency, the Texas Department of Family and Protective Services, which is our child welfare agency, and then we have three other organizations in Texas that represent mental health. One of those is the Mental Health Meadows, Mental Health Policy Institute that Michelle works for. The Hogg Foundation for Mental Health, which is through the University of Texas at Austin. And the Texas Council of Community Centers, which represents all of the local community mental health centers across the state of Texas that receive public funds to provide behavioral health care in our state. The reason I took a little bit to just explain that big picture is because it's a very unique setup. The way we are financed comes through the Texas Higher Education Coordinating Board, which is the entity that finances all of higher ed in Texas. So we are financed through a different arm, a different appropriation than the Health and Human Services agencies are in Texas. We were also formed specifically to increase access to care for children and adolescents in our state. And the last time our group provided this presentation we were asked about our funding. So this gives you an overview. In Texas our legislature meets every other year. So these are biennial budgets. So the first year that we were financed, we were financed at $91 million. And that's a two-year budget. So it was about $45 million a year. And as you can see over the course of time with each of the legislative sessions we've had since, our funding has increased, which tells you that our legislature is very invested in children's mental health, which we are very happy about. We also, during a special session a few years ago as a result of a school shooting that occurred in Uvalde, Texas, which some of you may know about, we received an appropriation of additional funding through federal COVID relief dollars to expand our school-based mental health initiative to try to address the mental health needs of young people in Texas public schools. So we are funded to do these initiatives. And the first one is called the Texas Child Health Access Through Telemedicine. This is, when we think about the continuum of services for children's mental health, all the way from prevention and early intervention to inpatient psychiatric hospitalization and everything in between, our Texas Child Health Access Through Telemedicine program fills the space of early identification, assessment and short-term intervention. It was designed specifically for schools to identify students who appear to be in need of some type of mental health intervention early. So again, we want to address the needs early enough that the young person doesn't get older, that the symptoms don't become more severe, and that they don't require more intensive types of care. So the way this works is that our 12 academic institutions develop memoranda of understanding with the school districts in their region of Texas, and those school districts generally use their school counselors to refer students into our program. And I'll go into our data about that program in a little bit so you can see how we've done in terms of expanding this across Texas. We also have a Child Psychiatry Access Network which links primary care pediatricians and providers of primary care with our behavioral health teams at our 12 academic health science centers to provide CMEs on topics relating to behavioral health and child and adolescence, and also to provide phone consultation when a pediatrician has a young person in their office that has behavioral health needs so that they know they can call our number and access that consult. During the last couple of years with our federal ARPA funding, we've also expanded now to include perinatal psychiatry access so that a women's health provider that has a woman who is pregnant or one-year postpartum that comes to their practice and appears to have behavioral health needs can contact again our 12 academic institutions to access perinatal psychiatrists and other perinatal mental health teams to get that consult to know what to do. For example, someone might call and say I have a pregnant woman in my office. She appears to have depression. What do I do? What is an evidence-based practice in mental health to be able to support that woman? What kinds of meds can she be on while she's pregnant? Those kinds of questions. And it's able to link those perinatal experts in psychiatry and mental health with the perinatal providers in primary care. We also have two workforce initiatives, Child Psychiatry Workforce Expansion and the Child and Adolescent Psychiatry Fellowship Program. Michelle showed you the data earlier about how we are desperately in need of more child and adolescent psychiatrists. So we have a couple of workforce initiatives to expand that in Texas and I'll talk about those in a minute. Then we have a very large research arm where all 12 academic institutions have joined forces together to conduct research in the children's mental health area. So this is a map of the state of Texas and you can see this is our active campuses that have developed a Memorandum of Understanding to provide that school-based telehealth program. Right now, if you look at our coverage, there are about 5.4 million children in Texas that attend Texas public schools. In Texas, public schools are not just defined as a neighborhood school or a public school, but also charter schools. So that 5.4 million also includes charter schools. We cover about 3.9 million of those students in the coverage areas that we have, which leaves about 19% of student lives remaining in our state that don't have access to our program. We have about 801 school districts that have signed Memorandum of Understanding with us and that covers about 6,200 school campuses. Whenever I show this data, people are always like, wow, that's a lot. But also, our state is really big. It's a really large, huge population of individuals that live there. In fact, there is a website, our state website, that showed most recently that about one in ten children between the ages of 0 and 18 in the United States lives in Texas. So we have a very large number of children and adolescents in our state. Also just in terms of data, about 60,000 students so far have been referred to our school-based mental health program and about 31,000 have received services so far since we started. Why are they getting referred? Well, the top reason is anxiety. Secondary to that, and I don't know why, but every other line didn't print well. In fact, it doesn't show up at all. But I'll tell you that 42% is anxiety, 30% is depression, 25% for angry behavior, and then attention in school and in class is another 20%. And then you can see disruptive behaviors all the way down to risk of harm. We are not a crisis service when we first started because there's such a need for crisis services. A lot of schools wanted us to do that, but they already should have in place their own crisis response teams and methodology for how to contact individuals in the community when a student exhibits a psychiatric crisis. Referrals by school level are pretty even between elementary, secondary, and intermediate. So that's pretty even. So that's our T-CHAT program. We call it T-CHAT. We like to use acronyms, you know, it's just a thing. And then our Child Psychiatry Access Network, we have about 12,700 pediatric primary care providers that are signed up to be a part of that, to link up with our consultation service. We've completed about 33,000 consults, enrolled about 2,400 clinics and served about 30,000 patients in that particular initiative. Also just to give you an idea about CME topics, a lot of pediatricians call and ask our health-related institutions for details on specific topics. And most recently one of them was how internet and social media use impact child mental health, handling a mental health crisis in pediatric primary care, and suicide prevention. Those have been some recent requests from the primary care clinics that really want to desperately learn about behavioral health diagnoses and evidence-based practices for child and adolescents. Our Perinatal Psychiatry Access Network, we just went statewide September 1 of 2023. So we have conducted about 975 out of 1,000 consultations. And a lot of those consultations are for referral requests, women's health providers who want to know where can they get assistance for their patients that are coming with behavioral health needs. About 45% are related to medication questions for psychiatrists, and about 85% are relating specifically to specific patients that come to the perinatal provider's office. Our Community Psychiatry Workforce Expansion, we are funded to provide child and adolescent psychiatry residents with community psychiatry experience. So we have set up relationships with public mental health providers of care across the state of Texas. We have 39 local behavioral health authorities and about 22 of those have this program where we can place those residents in those entities to get that training and expertise. We also work with six other non-local behavioral health authority providers that are non-profits across the state of Texas. Our hope is that if we give them experience in community psychiatry, they will kind of catch the bug and want to do it and leave school and leave their residency training and come and work for community psychiatry across our state. If they move to other states, that's okay too, but we'd kind of like to keep them in Texas if we can. And so when we're tracking that data to see how many graduates that come out of those programs want to do community psychiatry and end up doing community psychiatry at some place in the U.S. We've also through our funding been able to increase the number of child and adolescent fellowship positions in our state. In 2020 there were 27 first-year child and adolescent psychiatry positions filled in Texas. The number has now jumped to 46 in academic year 2024. And that's a result of our state funding. We're really trying to hone in on increasing those numbers across our academic institutions. We were also able to assist three academic institutions in creating new child and adolescent psychiatry programs. So those are at Texas Tech University in Lubbock, University of North Texas in Fort Worth, and University of Texas at Tyler in Tyler, Texas. We also through our federal funding were able to at the University of Texas Southwestern Medical School in Dallas create the first triple board program. We're very excited about that. It is a triple board in pediatrics, adult psychiatry, and child and adolescent psychiatry. Right now we have four residents in that program. It's a five-year program and we have been told by UT Southwestern that since it started they have more applicants than slots that they can fill, which says a lot about the need for that particular type of a triple boarding program. We also have three research projects. One is focused on youth depression and suicide. One is focused on childhood trauma. And the other one is brand new. Just this year we were funded during the last legislative session to start a new and emerging children's mental health researchers initiative where at our academic institutions, if there are child and adolescent mental health researchers who are so new to the field that they haven't been able to receive NIH funding, we want to fund them to do research on specific initiatives so that they can gain research experience and eventually and hopefully draw down some federal research funding in the field of children's mental health. That program, we submitted a notice of funding opportunity a couple of months ago. And those proposals are due this month. So we hope to get those from across the state. We have a group of psychiatrists from across the country who will be reviewing those applications and then we will be financing those research projects. The purpose of this particular research and all these areas is so that all 12 of those academic centers can work together to identify needs and then hopefully what we are learning in terms of evidence-based work to prevent suicide, to address depression and to address trauma can feed back into our behavioral health care system for child and adolescents so that we can take research and put it into practice in our state. So that is what we do. And I am going to turn it over to our friends from California, from Alcove. All right. We're good. All right. Hey, everyone. We're young people, so this is going to be really fun. My name's Mac. and data and stuff like that. So without further ado, here we go. So this is just a map of the world and where integrated youth mental health services and centers are located. And all of these have in common, they're all integrated youth mental health centers. They're all geared to ages 12 to 25. They're accessible and free to low cost. And so if you kind of zoom in on the US, there's a bit of a disparity between other places like you look at Canada, there's big clusters in Australia, New Zealand, in the UK and the EU. But the United States is lacking a bit, especially for our population and for the amount of youth we have that are struggling. And so Alcove, we're trying to come in and really fill that gap. As a little side comment to the previous slide, something that our advisor says a lot is that Australia has the same or like a smaller population than California as a whole. And they still have a lot more centers than we do. So I think that talks a little bit about the need and how different circumstances lead to different results. And so for ALCOVE, we want to make sure that we have a continuum of care in all levels. So in the middle, we have ALCOVE for sure, but we have young people who can learn about mental health either in their schools or early psychosis programs, maybe even through ads. And so our purpose is to make sure that ALCOVE can serve any type of youth, regardless of what type of level they come into. And regardless of whatever level of knowledge they are at, we can just support them and build off of that. So we want to make sure that regardless of every service that they get or lack thereof, they can come to ALCOVE to just reach out for any type of help that they can get. Awesome, and then just to talk on how this model is unique. First off, we have a prevention to early intervention focus. And so kind of like we talked about earlier, young people do not need a crisis to come receive care from us. We can support them at whatever level they are and connect them with the resources that they need at that point in their life. Also, we're designed for youth by youth. I mean, we're here right now. It's true, there is youth feedback in almost every part of ALCOVE, which we'll talk a little bit about later. But we are built on youth feedback. We also have two different types of youth advisory boards that I'll describe a little bit more later. But we do everything from design the center and how it looks like in the furniture and the cute pillows to hiring staff to implementing services and specializing based on communities as well. And also the idea that we're communal. So we have a lot of connections with youth serving agencies as well as just the young people in ALCOVE itself. And so together we have a lot of youth focus. And our idea is just to create a non-clinical atmosphere. We want it to be welcoming for every young person that comes in. And on top of that, just become a safe space for open conversation. So to talk a lot, well, a little bit more about like why this model is unique, we have the six core services that ALCOVE has to have in order to be an ALCOVE basically. So I'll just talk a little bit about what each one represents a little bit. So our main focus, of course, is mental health. And this means that we give psychiatric care, psychological, something to mention is that it's mild-moderate. So after that, we do like the warm handoffs that Anita mentioned, and hopefully have youth continue their services somewhere else. We also provide physical health services, including sexual health. So I know this, I'll talk about this like in a little bit, but it can be a little bit limited because we serve youth from 12 to 25 years old, or at least that's our aim. We also provide family support. So talking about the warm handoffs, it's also important to make sure that young people have a support system. If they don't have one, it's a relapse once again, and it's starting like from the bottom all the way up again. So for us, it's very important to make sure that the family knows how to handle a youth or support them when they're going through mental health services. And also for them to be educated and learn alongside them. We know that it's a difficult time for everyone in their families, and so we want to be able to support that. Another thing that we really have worked on the last couple of years is peer support. So it's just youth helping each other, basically. And so what we try to do is that we expand this program, we educate our peer support specialists, and we allow them to be able to connect with youth, for youth to be able to talk to each other and not have the clinical aspect that Mac mentioned. It can be really overwhelming for a youth who hasn't gone to reach out for help before, to go into a super clinical space. So peer support is there to avoid that. And last but not, oh, well, substance use is also part of the services that we provide. Usually these, it's, again, we start with the introduction of it, and then we do referrals out and do a warm handoff there. And then the last one would be supportive education and employment. So aside from providing all these health services, we also want to make sure that youth can get support for resume building, job applications, even college applications. I know a lot of youth stress out about that, and so we want to support as much as we can in that aspect as well. Great, and then just touching on the youth advisory groups I mentioned earlier, we have two types. So at every Alcove Center, we have a youth advisory group, or called a YAG, that is representative of the community that the Alcove is in, and so very diverse lived experience. And their job is to make sure, along with those six core services, that the needs of the community are met within those services. And so they can supplement, they can add services specific to whatever's going on in their community. And so it's really important that the youth that are represented there understand their community and know what's going on. And then more clinical and higher level support is our Central Alcove Team Youth Advisory Group, or the CADI, which Laura and I are a part of, which kind of overlook all of the centers we have and make sure and provide high level guidance to every Alcove Center, and make sure that our model is actually being implemented in each center. And also just to bring community for our 150 plus young people across Alcove Centers to make sure that, you know, an Alcove in Palo Alto knows what's happening, and an Alcove in South Orange County, or you know, stuff like that. We want to make sure we're all connected in like one big community. Yeah, and talking about connectivity, a little bit about our history is that our first two centers were open in 2021. This initiative goes all the way back to, I believe, 2018. However, because of COVID, that big pandemic thing, you know, we had to slow things down a little bit. So construction was delayed a lot, but the YACs were still able to meet through Zoom. It was more about, let's plan this, let's plan that, let's look at like probably, I'm guessing they had like just little post-it notes or like online share spaces, and they would just plan out what they wanted for when the center would be open, they could get all the planning stuff, they could implement it, have the windows down, the couches, whatever they wanted, right? And so our first two centers that opened up was in Northern California, which was San Jose and Palo Alto. They opened in June, 2021. And then after that, we've had a bunch of other centers, which Mac will talk about, but the Stanford Central Alcove team provided technical guidance and facilitating sharing knowledge between each center. Now that we have around like five centers opened, we established the YAC network. And so our purpose for that is for each center, once again, to know what each other is doing, bounce off ideas. We have a meeting, I believe, once a month now. And so each center has like a representative or two who just report out what they're doing. They just say, okay, well, we have this. How about we do this instead? We should have this event. We should have funding for this other thing. And it creates a sense of community too. A lot of youth have expressed that it's hard to be leaders in their community like this because no one else does it, right? So the discouragement comes sometimes and they feel like they're just fighting a battle by themselves. By having this sense of community, they know that they're not alone and that there's people all across California that are to support them as well. Yeah, and then kind of adding on that, we are growing, which is so exciting. And so our first two centers, like Laura mentioned, opened. And we had our third center, which was Beach Cities, opened in November of 2022. And then we had San Mateo just opened recently this January. So right now we're up to four open centers, which is really exciting. And then we have South Orange County and Sacramento are projected to open later this year. And then we'll get into a little later. We have six more centers that recently got funding to open during 2025. So we're very excited about our growth and we're really kind of hoping to keep it sustainable and accessible, because that's our goal. And as we grow, we want to make sure that evaluation is key in this. That's why we don't have a lot of data because this is just, it's new, right? We have at least like two, three years. And this whole model thing is over-complication of what basically is, let's just test it out, see what works and fix up what doesn't. And that's the easiest way I can put it. We want to make sure that, you know, we get feedback. We don't just want to be throwing something out there and hope it works, right? These centers, the purpose of having just six core services is just that, that there's just six and then the youth can decide, all right, we need maybe a kitchen. San Jose, I know, had a kitchen because their youth wanted to learn how to cook, right? So they would buy the stuff, they would teach them how to cook. They could take meals home. And especially for homeless youth, that was very, very useful. So we want to make sure that each center is malleable and that they can adapt to the community. We don't want the community to adapt to the center. And so by implementing these feedback forms or survey, I guess you could say, we want to make sure that we get the feedback that we need. Mac and I were part of the evaluation group. This is, it's called DataCode now. And so we reviewed the questions, we figured out like what language should be changed, where should each thing be located, should there be a disclaimer talking about, suicide and talking about like eating disorders. And so we, as the youth, spoke out about it, we gave our feedback, and now it's being implemented in two centers. Refinement, once again, once we get that feedback, we want to make sure, okay, what are we doing right? What are we doing wrong? Or what are the challenges that the centers are facing and how do we support them with that? Especially since we're both in the central CADI team. And again, we continue to expand. We want to make sure that in every single ALCO, the same services are being provided. And maybe there'll be such like a little bit, like there'll be more events in this one, maybe because of this other thing, there has to be like relocations, maybe it's done somewhere else, you know? So at least we want to make sure that those six services are being provided and that we're doing it well. So that's basically how I can explain this the best way that I can. Awesome, I just want to talk a little bit about sustainability and funding, because I know a big question we get is like, this all sounds great and awesome, but where's your funding at? How are you going to keep it going? And so I'm going to try to answer that a little bit. So first off, just the general about our funding is we were a part of the first international initiative to bring centers like these. And so our seed funding was provided for a four-year pilot in Santa Clara County and also seed funding for the five centers that are going to be open at the end of this year. And so that was kind of our short-term plan. And then our long-term plan, which we're kind of transitioning to, is where centers like the Stanford Center and the MHSOAC, wow, that's horrible. We're going to explore these public-private partnerships to make sure we can guarantee more funding. And also just our goal is to take all the data that we're analyzing at these ALCOVs, be like, hey, this is really benefiting these communities, and then push these public and private partners to invest and really show their model sustainable. And in these, it's also really important to look at reimbursements, because we really want to keep our services, like the goals here, free to low cost. And so we have to work with our partners to navigate through people who are uninsured, people who are on Medi-Cal, Medicaid, or even people who are our private payers. And so we want to make sure that we have reimbursement strategies and even cost-sharing strategies as well. And so right now we're working through some of those hurdles but we're making significant progress. And part of this data collection like DataCOV is going to really show these partnerships that, hey, this model works, and we really want to continue this and make the communities better. Yeah, so a little bit about our growth. So we have about six new partners coming up just for 2024. This is probably going to grow as far as we know. But we have these six new centers from Half Moon Bay, Watsonville, Castro Valley, Humboldt, Marysville, and then San Gabriel Valley. So we have all of these new centers there. Some are located in already established like wellness center areas. Others are going to be brand new. And once again, this is a collaboration between the MHSOAC. I don't like acronyms. So I just wrote it down. It's the Mental Health Services Oversight and Accountability Commission. And then we also have the CYBHI, and that is the Children and Youth Behavioral Health Initiative. And that is run by the California Department of Public Health. It's around $5 billion to invest into mental health services. And so this is just one initiative that that thing supports. There are many other initiatives too that are out there and they're doing amazing work. So this is just one big step into improving mental health in California at least, but hopefully we want to get out of California and grow a little bit more, maybe bring it into other states and also other countries like Mac is going to talk about. Yeah, and then kind of bouncing off of that, our successes. So in our about five years of work, also like two years of implementation with our centers being open, we've learned some things that have gone well. And these have been one, like I've touched on a lot is Youth Voice, which is incorporated into every touch point of ALCOVE. Also just supporting other organizations and our partners and other corporate entities into incorporating Youth Voice into their organization because it is so important if you're working or developing services that are for youth that they're actually going to serve the youth well. And also we've co-developed these structures and processes that have been shared with our ALCOVE partners and our actual ALCOVE centers as well. I think we'll mention some of those in the next slide. Also just developing a learning community. So we want to make sure we're able to train people that we have, want to make sure we're learning from young people's experiences and connecting through our partners. And kind of on that, like the part of the international partnership. So you saw the cluster in Australia, which is Headspace, who we work with really closely, and also in Canada, which is Foundry. And so we work really close with these partners, take their learnings and try to implement them into our services. Also, we have outreach and interest throughout the US and Palau as well, which is a small island nation. In fact, I think next week I'm meeting with people from Palau who have interests. We're gonna go tour an ALCOVE center in San Mateo. And so it's very exciting how we're getting all this interest and we're really hoping to expand really soon. Also, just lastly, relationship cultivation. Not even through own ALCOVE youth advisors, but our partnerships and anyone who we're interacting with and our clients, our patients. We want to make sure that there actually is a genuine connection there, like the warm handoff. Want to make sure it's as accessible and as safe as possible. And to talk a little bit more also on the realistic side, there's many successes and there's always challenges. So I'm gonna talk a little bit about those. One of them is physical health stream. Because of laws, we know that, for example, sexual health is you have to be 12, 15-ish, depending on what state you're talking about. Otherwise, you have to get parental consent. And so that is one thing that is very limiting sometimes and we have to be really careful as to who we offer it to and how. Physical health is the other one. There's only a certain amount of things that we can do at a center without it being a doctor's office or a clinic. And so we're trying to navigate that aspect. Space and location also has to do with this point. And it's just that state requirements for licensing and facilities are very specific. We asked our advisor what the specific reason was and surprisingly enough, it's water supply. That's what she mentioned. In order to have physical health services, you have to have sinks, you have to have many different things. So that is one thing. And the reason why this is important to us is because we want the Alcove Center to be accessible to the youth. We don't want them to have to be able to, I don't know, walk miles and miles just to get there and then miles back to get home. I can say at least for my county, we're super spread out. In order to get from my high school when I was there, it was a 30-minute bus ride to get there and then 30 minutes back. So how are we supposed to put one center that's supposed to be right in the middle with the requirements from the state, with transportation, with everything else? So that's where it becomes a little bit complicated. Co-branding is something that we're barely learning how to do. Once again, it's two-ish years of us having centers open, right? We want people to know what Alcove is and we're still trying to figure out how to work around that, especially with Stanford and all the university. And last but not least is sustainability, which is financial reimbursement. We wanna make sure that we continue having funding for the next couple of years and hopefully not have to worry about that anymore in the future. Growth areas would be ensuring Alcove is accessible, once again, and the reason why we mentioned this is because of cultural adaptions and racial bias, right? Unfortunately, we know that it has to do with a lot of things, racial stereotypes, the way that people think, stigma within ethnic groups. We want to be able to support youth regardless of any stereotypes or ethnic background that they come from. And so Access is one initiative that I believe Prior Caddy, yeah, right? It was like a Prior Caddy that they developed about racial bias. And so it's a model that they created that's implemented and trained at every single Alcove in order to make sure that they're trained and know what to do in many different situations. And we also want to culturally adapt. I know that we've thrown around the idea of creating different models as to how to support youth from different ethnic backgrounds. So we were talking about like, oh, let's have this training about African-American culture, about Latino culture. Let's talk about this, let's talk about that. That way we have knowledge all around and know how to support individuals on a personal level. And once again, growth areas, funding. Funding is very hard. I know we barely understand it. I know that it's very hard to get. And especially considering that Foundry and Headspace from Australia and Canada have universal healthcare and we don't. That makes it really, really complicated. In the US we have private, Medicaid and Medi-Cal. And I can tell you that Medicaid is very difficult. On my end, I was not able to get a vaccine just because my doctor got fired at some point. So that just comes to say a lot, right? It becomes very difficult to get the services that you need in a timely manner and not in like, oh, like in eight months prior or after you need it. So those are a little bit of the growth areas and challenges, but once again, we're trying to tackle one by one and hopefully at some point we will be able to have these all the way down. Yeah, and then just kind of quickly wrapping up. These are links, we're usually on Zoom, so I apologize you're not gonna click these. But if you just search these in the search bar, the first link pops up. So it's the Sanford Center for Youth Mental Health and Wellbeing. Our media and mental health initiative, which is an initiative Alcove has led and are good for media as well. And we also have our social media links if you would like to follow us. And then here is, we have our Alcove info email. So if you wanna get connected with Laura or I, just email that email and then put our names in the subject line and that'll get directly to us. We also have a director, a program director, implementation manager and youth development manager emails as well. If you wanna get in contact with us, we would love to answer your questions and respond to you. So again, thank you guys so much. I'll go ahead and pass it off. Thank you all. So now we're gonna open it up. I hope folks have some questions. We have a good at least 20 minutes or so for questions. Is anybody, if not else, I will start, but go ahead, excellent. Hi everyone. Thank you guys for such a great presentation. And my question is, what advice would you give me? I would love to start or find initiatives in my home state of Tennessee that might be similar to what you guys are doing in Texas and Cali and Boston. Great question. Who wants to go first? I think part of the reason why we're all struggling is actually because of how fractured the system is across different states. So we have started in Team Up, we've started to look at kind of different environments, different states. We're doing a little project in Rhode Island. And the one thing I think that has been the biggest piece of learning is how different each state's system is set up. So not just like, you know, the different types of how the Medicare system, the Medicaid system works in that state, but also like how are the different entities within the state organized? Are they organized through the Department of Public Health? Are they organized through the Department of Mental Health? Are the clinics kind of clustered around hospital systems? Are they freestanding? So it's like, I mean, this is perhaps not a very like useful or helpful answer, but it's a question of like useful or helpful answer. But I think the first step is to figure out how things are organized and where the, you know, like you can always find primary care and you can always find, well, normally you can find the Association of Federally Qualified Health Centers. Each state has kind of a network of all of the federally qualified health centers. And they often are connected to what's going on in the community. And because they're often living on a shoestring, they're trying to piece together like, you know, different options across a lot of different initiatives. So like I listened to the description about Alcove, I can totally see how that public private partnership would occur because everybody is looking for their, you know, their the right hand, they're looking for their left hand to figure out where to make that connection. I don't know if Tennessee still has this or not, but the governor of Tennessee used to have a state council for children and families that reported directly to the governor. And I know when I did some work in Tennessee, when I was living in the District of Columbia, I don't remember but it's like a cabinet. It's a child and family services cabinet that was associated with the governor's office in Tennessee. If that's still in place that would be a great place to start and a lot of states have those. They are cabinet level positions that report directly to the executive leader, the governor of the state. I would also say that there are for the child psychiatry linkages with pediatric primary care and the perinatal linkages between psychiatry and perinatal providers. There are federal funds through HRSA for those programs and many states have those programs in place. There is a network of those specific types of programs too. I would say Massachusetts was the leader in creating those and Barry Sarvitz who is a psychiatrist there. I wish I had his contact information but he would be a great person for any of you who are interested in creating those types of programs to get in touch with. Do you happen to know, I'm trying to figure out how to get a hold of Dr. Sarvitz but that would be a great place to start. He is with UMass. I'm trying to remember the name of the program but you could probably just Google Dr. Sarvitz, Barry Sarvitz. I would definitely call him and say I've heard that you guys started one of the first programs of these types and what can we do to do something like that in Tennessee. I have a question about prevention and early intervention. Actually my company is working with a Japanese university to make a meta-virus system to prevent children and adolescent mental health. In that time we had a little bit of difficulty to find a moderate risk of the patient because those patients don't have the very severe risk so it doesn't come to our place. In that case, what is your tip for those things to find an early intervention or moderate risk patient for the Texas and California case? I would say that for the earliest type of intervention, so my son's 34, I'm old, but anyway when he was a little child and for many of us as parents when we first have a baby or we have a young child, the pediatrician is that first point of contact. Linking with your pediatric providers early on to talk with them and inform and educate them about the importance of infant mental health and well-being, maternal health and well-being. There are some very good programs like the Nurse Family Partnership is one that the U.S. has done across the country. I think there's federal funding for that program. There are other early intervention programs. There's one called Parents as Teachers, which is another evidence-based early childhood program. Also there is funding through the Families First Prevention Services Act, which came through the Administration on Children and Families, to really focus on prevention and early intervention to address families' needs and support families to prevent referrals into the Child Protective Services area. There's a lot of evidence-based practices that can be put into place for that early age, the zero, I always call them like the zero to fives, to five-year-olds to really emphasize the focus on the family and the focus on thinking about the overall health and well-being of families and how important that is for child development. I don't know if that answered your question fully, but I'm sure that you probably have some other resources that you could think of. Yeah, I agree with everything that Luanne was saying. I think that I would always try to think earlier than what you think prevention is right now, because oftentimes what you think of as prevention, it's only come into your vantage point because something is actually already happening. Real prevention is 100% well, and you're taking steps to support continued wellness. The same types of strategies are going to work, but I think the broadest part of it is attention to connection and relationship. The basis of early childhood care, what the programs are that Luanne is referring to, they focus on what's called relational dyadic approaches. It's helping young caregivers understand the impact that their behavior has on their child and the impact that their child's behavior has on them. That is going to be applicable 100% of the time, regardless of whether something is going on or not. There's a lot of evidence showing that even children who experience significant trauma, if they have one caring adult in their life, that is a protective factor and will help that child actually fare better throughout their whole life after that. I think the other part of maybe what you're asking, though, is prevention in older kids. Not just in early childhood, but prevention in adolescents, in school-aged kids. I think that gets back to the quote that Michelle showed at the beginning. It's connection. It's not being isolated and lonely. The root of that connection, certainly in the Team Up model, is the primary care practice, because you're going to show up there at least once a year, hopefully, if you're coming in for your well child care or your physical exam as you get older. That in and of itself is an opportunity to put it all on the table and say, what is going on? What do you need, even if there's not an identified issue that's going on? I don't know if Mac and Laura have something to add to that, because I think what all COVE is doing is mild to moderate, thinking about that critical time in adolescence, the tweens through young adulthood and trying to prevent. I've said my two sentences, but I really want you to talk about that piece of the prevention work at that age. Yeah. I think on that, our goal, I think very similar to the connection part and the building relationships, is go directly to the community. I think that's going to be the most effective way to not only de-stigmatize mental health, which is in helping reach that preventative to early intervention care, because if mental health is normalized, then more people will receive care or be more inclined to receive care. Also, their mental health in general will just be better if they understand that, hey, this is normal, I'm not lonely, and I'm not alone, as we talked about earlier. I think that our goal in a dream world, I know we talked about Australia, I think they have 250 centers, and they have half the population of California. In an ideal world, we would have 500 centers in California, which we're really hoping to get to. Right now, our goal would be go straight to the community where they need it, where they need it, be as accessible as possible for a young person to literally just walk in, receive care. I think throughout that process, if you let it happen for a long time, communication between people who go to Alcoves, communication between young people in general, then that'll lead into the early prevention and early intervention and break that down a little bit. I think to add to that, I know realistically, sometimes it's very hard to reach everybody that you need to reach. I know, for example, Sacramento is going to have a center. I live in El Centro, California, so it's two hours east of San Diego County, super tiny, right next to the Mexican border. I know for us, my county cannot afford to have an Alcove center, so what do we do there? It's honestly the idea that's been thrown around through another initiative. It's called the Brain Trust with the Children and Youth Mental Health Initiative. They're throwing out the idea of creating a digital resource. I think the key here would be to think of how is this any different than all of the other resources that are available online. I think what we need to think about is let's create something that it's easy to digest with youth in mind, not just like, oh, here's information, here's what you have. You Google something, I'm sad, and then immediately you're depressed. According to Google, that's what you are. It shouldn't be that way. I know for us, it's very different. For example, this is the second time that Mac and I have actually presented together in person. We've been connecting online. He's all the way in Sacramento. I'm all the way south in San Diego. Using the online resource, it's very useful. We're able to practice present. We can just talk about random things. Utilizing it to our favor is really great. I think ideally, we could have an internet or an online resource become the prevention instead of thinking of it as an intervention. What that would do is, for example, the younger spectrum, now that at least in California, they're throwing out the idea of elementary schools also having mental health education implemented and not waiting until high school where it's actually required. If we were to do that, students could potentially be exposed to mental health beforehand and we wouldn't have to be super concerned about the stigma that we, our own generation faces right now. They'd just be used to it. It's just a regular conversation. I think that while it is great to go in community as much as we can, it's also vital for us to use the resources that we have and use them correctly, not just say that we're doing something just for the sake of it, but actually mean and actually do things behind it. I think that's the best thing that I can say about that. Thank you. I'm a guidance counselor in high school. I'm now retired, but did it for decades in New York City, inner city students. Your programs sound wonderful. My problem was not the kids, it was the parents. When I had students, be it suicidal ideation, and thankfully I'm married to the psychiatrist, and he told me different things to ask, so I learned what to do to ask about, are you making a plan? Are you giving away your special items? Things like that. But when I had students who had mental, emotional problems that I encountered in talking with them, and I wanted the parent to take them to, not a guidance counselor, but to go up the scale to eventually possibly psychiatrist, the parents in the city, inner city parents, were so afraid of labeling their child, that nothing happened. I, as again, I had my spouse who could help me help them, but I don't know if other people have, if the psychiatrist, if the parent is willing to come, like the young lady, the case study where the young lady was cutting, and Einstein has a program for that, and I would speak to the person who was in charge of it, but you know, my hands were really tied. So that's one thing, and the other thing, an unrelated or a different issue, that for example, in Texas, where you might have a young person who gets pregnant, and is having mental and emotional problems about however she got pregnant, and she doesn't want to be pregnant, and other states, some other states, what do you do? I'm in New York City, it's not, you know, I had quite a number of students who became pregnant, and could handle it, and could deal with it, but now a lot of things have changed, so I leave the answers to you. I want to address the parent part. So our services, our school-based telehealth program, when it was created, there was a big concern about stigma, and that a school would somehow be interfering if they identified a young person in need of a mental health service, right? And so we had to make certain that when the school was going to identify a young person, or did identify a young person that might need our early intervention service, they had to talk with the family to get the family's consent to make a referral to us. And then we in turn have to get parental consent to be able to work with that young person and their family. I can tell you that there is stigma, but I've been in this field for 40 years. My first job was at a state hospital 40 years ago, and in that amount of time, the history that I have seen from what stigma looked like in the 80s and what stigma looks like today is completely different, thank God. And part of that is because I think post-pandemic, one of the unintended consequences is that so many of us are experiencing anxiety, depression, you know, loneliness, as Michelle alluded to earlier. Just yesterday, I saw on the news here in New York City that Miss USA has decided to remove her title because of mental health needs. We have Olympians who decided that they needed to take some time off because of their mental health. We have football players in the NFL. We have movie stars. We have rock stars. We have famous people that kids, youth, families, all of us see every day coming out and saying, look, I have a mental health issue and I need to take some time off and I need to take care of myself. That makes mental health much more of a priority for everyone. It makes it more normalized. It makes us more part of the conversation. I will also say, though, that it's also generational. So a lot of parents, like I think young people are much more open. I've talked to lots of young people. They talk about mental health and they want to be involved in student mental health on their school campus, which I think is very cool. They see it as a priority, but I think for a lot of parents, there is still that, oh my gosh, you know, the school is referring my child for a mental health need. What does that mean? All of that kind of thing. One of the great linkages for that, and I know you talked about this earlier, is the use of community health workers, the use of parent, peer support specialists, family liaisons. Some schools now have family liaisons where they are parents with lived experience who have tried to navigate these complex systems of ours to help stand in partnership with a family to help them navigate through and make it not seem so scary when you get that call that your young person and your family might need an intervention. And so I think those are things now that are available, that are helpful to be able to have a family feel less worry and less concern if they can link with another person who's gone through the same thing. And just to add to that last point, I mean, a lot of, there's so much that happens before they get to us as a child psychiatrist, and so community health workers, guidance counselors like yourself, other folks, teachers in the schools, I think we need that support of families to get them to come to us through the door, right? I mean, that's part of the point of this talk a bit too, like I'm not seeing every kid. One, there's just not enough child psychiatrists, but two, there's just so much that could be done prior to even seeing me as well. But then that goes to the point I think Luanne is making, is that we need to sort of demystify with parents, maybe less so with kids these days, of what does it mean to come see a psychiatrist? I would definitely finally get people in my clinic, probably because they were mandated at some point to come to see me. And one of the first things, even in 2024, is I'm not crazy, like don't lock my kid up. And there's real things, whether inner city or other folks, there's real reasons for them to be scared about coming to see one of us. And so we need to legitimize that aspect of it, that sometimes they do get locked up, sometimes they do get reported. There's a lot that happens to folks for why they don't want to come see us. And so we do need to make sure we understand that piece of it, and then how can we support the parent to support them through that whole process. And I had sometimes people come to the clinic with maybe a guidance counselor or a therapist or a trusted someone in their family or community that they trusted because they're worried about what I'm going to do when they get there, not knowing who I am or what's going to happen. And so just like anything in a journey to mental health, I think that people just need support along this journey, and parents and caregivers are no different. Fear of the unknown is a real thing, and it brings up a lot of anxiety. And so as much as we can partner with everyone that's at this table, but everyone that's just coming into contact with a kid or parent, and help them understand what does it mean, and that if I'm not the right fit, if I'm not the right fit, that they actually can go to someone different, too. Yes, it may take some time and all the things in this environment, but at the end of the day, if a provider isn't the right fit, we should also support them in saying, we can try to navigate getting you someone else that you feel more connected with to get you and your family better, right? So it's a complicated thing that I know guidance counselors everywhere kind of go through, but then there's the other side of it, of the fear of what might happen, or how I may be treated, or how my family or children may be treated as well. So real things that they're sort of battling while thinking about getting their kids some help. Any last question or thought or even comment for the panel? Can I just say one thing? Thank you so much for your work as a guidance counselor in schools, because really, I mean, we work with schools every day, and we also get asked not only to provide support on different topics relating to child behavioral health, but also to the teaching staff and the school personnel, who are really overwhelmed, have really, really hard jobs, and they ask us, can you please help us with our own well-being and our own wellness, and what can we do? So I just want to recognize that that is a very difficult role, and I appreciate your service in public schools, seriously, because it is something that, especially since COVID, we've seen a lot of teachers leave and a lot of guidance counselors leave, because it's a big job, and it's a lot of responsibility. There were many times when I would say to my husband, save me a session at the end of the day. Thank you. Thanks, Luann. Thanks for saying that. Hey, David. Hi. Hi. I came in here to charge my laptop so I could make it home to see my kids tonight, and I happened to see my program director from residency. I said, oh, I'm going to totally stay in this room. I'm an addiction psychiatrist, so thank you for letting me stay in here, but I'm training motivational interviewing, and I was really impressed after doing addiction psychiatry fellowship, I'll try to keep this brief, at BU, and then kind of going other places and treating general psychiatry, using it in general psychiatry, how effective it was there, and I kind of, you know, we focus a lot on stigma, which I kind of think is like the defense, but it's good to have a good offense, too, and it just allows you to connect, to build rapport, and it's amazing. People will just suddenly be willing to accept interventions, willing to, you know, go with referrals. There's even a book that's pretty popular called, oh, I always butcher the name, How to Talk to Your Kids so Kids Will Listen, How to Talk. Yeah, people, if you google it, you'll find it, and this is, yeah, so, I mean, this is for families, right, for families to learn how to have these conversations with their children and teens, the teen versions, too, so very effective intervention. It just hasn't been widely rolled out and implemented over the last two decades, even though it's been proven to work, so as much as we focus on reducing stigma, I would also just, you know, really encourage people, from my experience, if nothing else, just that I found motivational interviewing to be extremely helpful intervention. Thank you. Yeah, thanks, David. Good to see you, but yeah, a valid point, and sort of what, you know, talking, rolling, as am I, I love the rolling with resistance, right, and ambivalence, and that we have to do a lot in the work we do, people wanting care but not sure if they want care, do they want to do this, or want one aspect of treatment, so it's just part of the work that we're doing day in and day out, but good point. I want to thank you all for staying till the end of our talk today, and another round of applause, if you will, for our great panel.

mental health crisis

youth

child psychiatrists

integrated care model

early intervention

primary care

telemedicine

holistic services

community engagement

youth voice

destigmatizing mental health

peer support

collaborative efforts