Hi. Good afternoon, everyone. Thank you so much for coming. I know that we're competing against postprandial experiences, as well as the sunshine in San Francisco, which you know is a beautiful thing when it arrives. So thank you so much for choosing us. I have the pleasure of starting with this plenary presentation, and I am honored to be here with my dear friend and colleague, Dr. Tammy Benton, president-elect for the American Academy of Child and Adolescent Psychiatry, as well as many other many important things. And I'm pleasured to be here. My name is Warren Ng. I'm also the president of the American Academy of Child and Adolescent Psychiatry. We're really grateful for Dr. Brendel, president of the APA, as well as Hal Levin, in creating the space for us to share perspectives across our organizations, particularly highlighting the experience of children's mental health in our nation. So thank you so much for coming. We've titled this talk Sounding the Alarm and Strategies for Youth Mental Health. We're naming it that because Dr. Benton was so very wise to author really a commentary specifically on the children's mental health emergency with our fellow co-author, Dr. Wanjiku Jurage, so really acknowledging the importance of this issue affecting all of our children in this nation. So with that, so on behalf of Dr. Benton and myself, we have no financial disclosures, except to acknowledge that it's been over two decades since our former Surgeon General, Dr. David Satcher, acknowledged that there's no health without mental health. And yet we know that we continue to struggle to integrate these important parts of ourselves in order to be whole, and particularly for our children and adolescents, how to best support them in integrating their experiences in order to keep them healthy and well. So as a part of our presentation today, I have the pleasure of starting, and then I'm going to hand off to my wonderful successor, Dr. Benton. So I'm going to talk about some of the key social determinants of mental health. And as we all know, 80% of all health outcomes are determined by our social determinants, yet there are many issues that affect how each child and adolescent in our country experiences that. Then we'll also highlight some of the youth disproportionately impacted during the last few years, as well as then focus on some targeted strategies that Dr. Benton will illuminate us with. I love our quotes, and I shared this with our wonderful Director of Training, Carmen Thornton, in terms of be the rainbow in someone else's cloud. And so really acknowledging that all of you, can I see a show of hands? How many of you take care of children or adolescents in your work? Thank you. And how many of you are child and adolescent psychiatrists? Wonderful. So I just wanted to express my gratitude on behalf of myself and Dr. Benton and our CEO, Heidi Forde, for all of the incredible work that you're all doing in terms of doing this work, because it has been incredibly challenging. But however, I think no matter how difficult it is, similar to how we celebrate grit and resilience in children, we can forge ahead together. And so I really acknowledge and champion all of your efforts, and also put a plug in for caregiver and provider well-being. So it's really important, given all of these things, how important you are to helping their kids and adolescents and families. So the global scope is that we know that about a quarter of all of our world's population are children and adolescents. And yet, they make up 1.9 billion children in the world. And yet, we acknowledge that about 13% of them are struggling with a mental health or developmental issue that is affecting their well-being and ability to thrive, as well as contribute to the societies that they're in. And we just appreciate that mental health conditions impact about 86 million youth, ages 15 to 19. And we know that there are important times in a young person's life when they're going to start experiencing potentially behavioral health issues. However, I think we all appreciate where the American Psychiatric Association meeting celebrating not only our children and adolescents and children of all ages, but also our adults and our caregivers in our community, and just acknowledging that the past few years has a disproportionate impact on all of us. And in terms of the caregivers for our young people who celebrate, if you are privileged to have a child and adolescent in your life, then you're able to best support them. And yet, at the same time, we know that parents, families, and communities are struggling as well. So just acknowledging the scope of the issue in terms of in this country, about 53 million people are needing mental health services, less than half of them are receiving them. So there are always three parts of every story. So I'm going to start, and I'm going to talk a bit about what are we inheriting as we're arriving in the moment, and it's really acknowledging before the pandemic, because a lot of us are in the pandemic, because a lot of the challenges that we face currently, as we're emerging from the public health emergency, is also the issues related to the foundation and the infrastructure and the determinants of what health is. And then also talk a bit about some of what we've learned and experienced during the pandemic, and then some of the strategies, and hopefully being wiser and stronger, emerging into the future. So I love this Maya Angelou quote, is that, you can't really know where you're going until you know where you've been. And that's really acknowledging and understanding all of the challenges that we face, the new challenges, as well as the ones we've inherited. So we appreciate that there's been a silent pandemic of children's mental health well before the pandemic, and about one in five children and adolescents have a mental health or behavioral health or developmental disorder. And yet, 50% of all adult conditions that are behavioral health start before the age of 14. And these are all things that we know as truths. However, how are we not necessarily disproportionately putting the resources where they are most impactful, which are children, adolescents, and supporting families. We also appreciate, in terms of this nation and our scope of the mental health issues, that 73 million children under the age of 18 live in the United States. And as you can see, there are about 7.7 million, this was an earlier estimate, that have a treatable mental illness, and less than half of them are receiving any kind of care. We know that that access to care is going to be more difficult for communities of color, as well as those that are youth that are minoritized or marginalized. We also appreciate that 11% of all 8 and 11-year-olds experience severe impairment, impairing enough to interfere with their education, as well as their well-being, as well as their mental health and physical health. We also appreciate the age of onset is different for different mental health conditions, and just appreciating that many of these challenges face children at different ages. And we know that there are a lot of people children at different ages, and we know that in working in child analysis and mental health, we face comorbidity all of the time. So we're often not facing just one issue, we're often facing two. And sometimes it's prodromal in one sense and fully developed in another. So it's really trying to tease apart the many different diagnostic considerations as we're thinking about most effective treatment strategies. Now, before the pandemic, we appreciate that, you know, there's actually been an increasing rate of children and adolescents coming to our emergency department with mental health and behavioral health conditions. And if we're looking at 2015 to 2020, we appreciate there's been an 8% increase in mental health and behavioral health conditions, compared to 1.5 of other medical conditions. And so we're appreciating that, you know, the crisis that we arrived at during the pandemic had already been building, so that's why we refer to it as a silent pandemic. And really understanding that we didn't sort of respond to some of those issues, and that part of it is the challenges of how do we advocate for children, adolescents, and mental health, particularly when children and adolescents don't vote. So they depend on us as the grownups, the caregivers, the parents, as well as the providers to advocate on their behalf. The other things that we've seen in the five years before the pandemic is really increasing rates of anxiety, depression, about third to about 27%, as well as behavioral issues. So we were seeing some of these trends even before the pandemic struck. But the one thing that is important is that in the survey, they were also looking at caregiver well-being, and caregiver well-being was going down at the same time as all of these issues were going up. So there's not only a crisis of children's mental health, but what is happening in the homes, what is happening within our families and communities, and how can we better support them if we're really going to take this challenge. This was also a really important acknowledgement of ringing the alarm. So Representative Watson Coleman, who is a leading, a leader within our country, but really championing how do we approach mental health issues. Sometimes it's not just within our health system, it's sometimes within our political, social structures that we can best advocate. So through the Congressional Black Caucus, really being able to ring the alarm in order to acknowledge that there's a disproportionate impact with suicide with Black youth and adolescents at that time, and how do we best acknowledge that. And in this graph, you can see actually it's the, I would say that the turquoise, 11.8% increase in Black youth suicide that was disproportionately higher than other racial and ethnic groups. Now we appreciate that suicide is the second leading cause of death for young people, 10 to 14, as well as now I think 17 to 24. Acknowledging that these are really startling statistics. If this was any other medical condition, we would not necessarily have to ring the alarm or sound the alarm. And I think that that's sort of some of the challenges that we face in mental health and behavioral health issues is that how do we advocate for issues that are very stigmatizing and or have challenges in terms of how we can best articulate the fact that we do have effective treatments and that children and adolescents, when they don't receive care, when they need it, it has both long-term and short-term mental health and physical health and social outcomes. So when we think about the other, other pandemics that are also occurring, we can also appreciate that we are facing a crisis with firearms in this country. And I think as we're thinking about children's mental health, we also need to think about injuries and deaths. And so as you can see on this graph, the blue line is really for young adults, 20 to 24, and the increase in firearm-related injuries and deaths in children and adolescents, particularly in the years 2019 to 2020. And the yellow line, which is also going up, is really ages 15 to 19. So in adolescent deaths and injuries. Now when we look at race and ethnicity, the turquoise is actually American Indian Native Hawaiian, a Native Alaskan population, so our indigenous communities, and are disproportionately impacted by firearm injuries and deaths of children and youth. And you can see the line underneath it is white, non-Hispanic, and the red increasing in 2019 to 2020 are black, non-Hispanic, as categories utilized in this study. So we can appreciate that there are also emerging trends, and it's putting the story together as we're appreciating the impact on children and adolescents. Now when we also look at the gun deaths associated with youth, there's been an increase of 50% between 2019 and 2021, which was very alarming. And I don't know if you all remember during the pandemic that gun sales skyrocketed when everything else, liquor stores were open and everything else was closed, but firearms were increasing. And I think that that also represents access to firearms and also lethal means in terms of how do we safeguard children and adolescents. And in this one study that looks at suicides, we're accounted for more than half of the US gun deaths. So now we need to think of not only gun safety, but also thinking specifically about lethal means and also how are guns implicated, particularly in the suicide deaths of young people. And when we think about gun deaths among US kids, it's greater even among homicides, 60%, and about 32% of them were suicides. But when we look at adults, it's quite the reverse. So we're also acknowledging that there is very severe implications. And if we're going to create a safer environment, we also have to acknowledge those other contributors to some of these deaths. And when we take a look at the 10 leading causes of death among Black, non-Hispanic young people, we can also see that the 10 leading causes of death, as we look at the ages of 15 to 24, homicide is number one. And as we mentioned, that so many of the gun deaths are related to not only homicide, but also suicide. So unintentional injury number two. So we can just appreciate that suicide within the age range of 15 to 24 is number three in terms of cause of death. So as we're looking at cross-racial and ethnic groups, we can also appreciate what are the risk factors. And I think we need to be intentional about looking at data to best understand how we can best have strategies. And I also love this Maya Angelou quote, do the best you can until you know better. Then when you know better, do better. And so I think part of it is how can we use the science, the data, as well as the knowledge and wisdom that we have emerging from the pandemic to best inform how we can best care for our children and adolescents going forward. Now, during the pandemic, as all of you have experienced personally, as well as professionally, there's been a real disproportionate impact among different communities. And it relates to many of these social determinants, which we understand is having a large impact on health and mental health and well-being. So racial disparities, racism, systemic and structural, as well as food insecurity, disruptions in our family environment. And we think about the ACEs as yet another indicator of how do we understand risk when it comes to children and adolescents, but also housing instability, which is really key. How are we linking our mental health interventions with creating safe environments, such as housing and food? So the basic needs. And it's really acknowledging that all of these things contribute. Yet these were incredibly impactful, particularly during the pandemic, but across racial, ethnic, as well as socioeconomic status, disproportionately impacting communities. So when we think about economic stability, neighborhood or physical, environment, education, food, community and social context, and healthcare system as only being one part of that, at least picture, we can appreciate how important it is to be able to embrace, I think, from a mental health and psychiatric perspective, that our lane is all of these lanes in order to best promote health and well-being. Now, when we think about the educational impact, and we know that the pandemic has also had a great impact on schooling, because many of our youth and children were not in school for the first year, bless you, but also acknowledging that there's also been a disproportionate impact on Black and Latino, as well as low-income, rural and urban environments. So appreciating that even though there's, on average, five months of loss with regards to math, as well as four months in terms of reading, that the numbers of months lost to Black or Latino kids was greater than that. And there's also been a difference in terms of their socioeconomic status. So we understand that not all kids had access to Wi-Fi, as well as equipment that allowed them to do remote schooling or to remain in contact with their world during the pandemic. The other thing is housing and food. And I think that this is a really important reminder of how much these things influence and impact our children and adolescents. When the fact that half of lower-income parents worry that they didn't have enough money for food or housing, and 52% of lower income for food or housing, and 38% for child care. And we understand that all of these things are really important determinants when it comes to children, adolescents. When they took away the child tax credit, well, when they had the child tax credit, that was the most important thing we could have done as a society to promote the health and well-being of our future generations. Unfortunately, it went away, but we could see during its impact that it decreased poverty in our country significantly. And those are some of the strategies that we need to think going forward of being inclusive, of advocating with our families and communities to really ensure that kids and adolescents have the food as well as the housing they need to best promote their health and well-being. When we think about risk and resilience, we also appreciate the fact that there are many challenges that children and adolescents face, and families as well. And being able to tip the scale so that we can support their well-being by providing higher quality of care housing, food, as well as safe schools are also parts of those equations. Now, part of that equation is also the fact that Medicaid is the provider of over 50% of all of the children, adolescents, mental health services in this country, and yet there is sometimes an intentional withdrawal or decrease in terms of funding for Medicaid recipients, which are many times children in CHIP programs, and understanding that when the kids don't get their insurance or their Medicaid coverage, they're not able to access care appropriately. And we're just appreciating that now that there's mandatory re-enrollment for Medicaid, sometimes those strategies are really in place to try to have kids and adolescents fall off of those enrollment panels so that they don't receive the care that they need. So those are additional advocacy opportunities for all of us. And I think this wonderful quote by Dr. Reverend Martin Luther King, of all forms of inequality and justice in healthcare, is the most shocking and inhumane, and we all acknowledge that. But in terms of taking action, I think part of our action is not only in terms of the treatment that we can provide in our offices, but also the importance of advocacy that we can also provide as we're speaking to all of these other social determinants issues. Now we've lost so many lives and so many loved ones, as well as no one's life has been untouched by COVID-19, and over 1.1 million Americans' lives have been lost. However, it has been disproportionate in terms of its impact on communities of color and children of color. So when we think about 220 now thousand children in this country who've been orphaned, who've lost one parent or caregiver, about 70% of them were kids under the age of 13. And we can imagine the impact and the devastation caused by that, when a third of all households in the U.S. are single-parent homes. So really just appreciating the scope of that. But when we're looking at disproportionately racial and ethnic groups, 3.5 times greater risk of losing a parent or caregiver if you're American Indian or Native Alaskan, and two times higher if you're Black or Hispanic, or 1.4 times higher if you're Asian American. So really appreciating that the scope of the impact is also disproportionate, depending on the communities. Now intersectionality is really important. I love this Audre Lorde quote, is that, there's no such thing as a single-issue struggle, because we don't live single-issue lives. So it's appreciating all of our full dimensions, and sometimes those dimensions, or their intersections, are supportive of one another, or sometimes they actually increase our risk, as it relates to sometimes issues related to racism, sexism, homophobia, transphobia, et cetera. Now one of the things that's important is that, now speaking about during the pandemic, there's been a 51% increase in ED visits, as we've known for adolescent females, 31% increase in adolescents coming to the emergency department. And we know that it wasn't just the numbers, it was also the level of complexity. So during the pandemic, we saw among female adolescents that for the successive year, there was an increase in terms of psychiatric comorbidity. So in 2020, it was eating disorders and tick disorders, and we all know that tick-tock phenomenon that occurred. But also with regards to the role of social media in many of these contributing factors. There's also, in 2021, the following year, an increase in terms of depression, as well as OCD. And we've continued to see increasing complexity, not only severity and acuity in our emergency departments. The other thing we've seen are overdose deaths. So we've seen in the CDC reports, really looking during the pandemic, that there's been an overdose increase, about 65% of young people aged 10 to 19. And we definitely know the dangers of the fentanyl-laced compounds, particularly with some of the synthetic opioids that are so deadly. And sometimes you don't have as much of a warning before some of these kids are exposed to sometimes some of these compounds that they can either access online or within their communities. But the important thing is about 40% of all these overdose deaths had a mental health disorder in terms of these adolescents. So there were opportunities to intervene. And how do substance abuse disorders co-occur with mental health conditions? And how can we really sort of sound the alarm in terms of all of us who are taking care of kids, whether or not it's through our substance use issues or whether or not they're mental health issues, to ask about both? And also the drug overdose deaths have not been equally distributed. So if we're thinking about the disproportionate impact on Native and Indian as well as Alaskan Natives, they're the highest. And they usually represent our highest rates for suicide as well as risk factors. And then secondly, in terms of the next one, is the Latinx. So really thinking about overdose deaths as it relates to adolescents across racial and ethnic groups. And what's encouraging is that we're moving forward. Having more sort of race and ethnicity embedded within our understanding of the demographics and statistics will be very important, thinking about targeted interventions. The other thing is that during the pandemic, I don't know if you'd heard that, there was this sense that suicide rates had decreased. And there was this sense of, well, maybe if people were together more, maybe that decreased the risk for young people and the whole population, and maybe it's really that sense of togetherness. Unfortunately, that ended, and suicide rates have continued to increase during this year. And I think one of the things that we're also seeing is the disproportionate impact on black youth as well as youth of color. And so really understanding that there are increased risks among youth of color, but also with our gender diverse youth, our LGBTQ plus youth. So acknowledging those statistics. Now the Youth Risk Behavior Survey is a wonderful survey that is done with high school students, really giving us a pulse of what's going on in this country. And these studies have really been very helpful in understanding trends. The only problem is that the trend's going in the wrong direction. So whether or not it's really asking about persistent feelings of sadness or hopelessness, that's really increased. And as you can see on the far right, all of the red means it's going in the wrong direction over the course of 2011 to 2021. And it's really appreciating that when two-thirds of all adolescent girls are acknowledging that they have persistent feelings of hopelessness and sadness, what does that say about our communities and our society? So that's why I'm really excited to hear from Dr. Benton, what are some of the strategies? Because I think that there are several, and how can we bring those many things together? The other thing that's important with the Youth Risk Behavior Survey is that they kind of broke down not only race and ethnicity and gender, but they also looked at sexual orientation, sexual behavior. So there's sometimes a difference between how you identify, whether or not you're homosexual, whether or not you're bisexual, whether or not how you identify yourself, and then separately your behavior. So I think one of the things that's really helpful with the Youth Risk Behavior Survey is that you saw that there's actually increased risk for those young people who acknowledge having sexual contact with the same sex. And they may or may not identify with regards to any specific category, but it's really based on their sexual behavior. And we understand that we sometimes link identity to behavior, and we have to also acknowledge that there's a difference between those two. So really understanding risk factors related to behaviors, not necessarily to just identity. Even though, as we see from the Trevor Project's really wonderful surveys, really looking at our LGBTQ plus gender diverse youth, that the suicide rates are about four times higher, and about 45% of LGBTQ plus youth seriously considered attempting suicide in the past year, and about 14% attempted. And I think that that really highlights all of the trends that are going on in this country with some of the really negative, hateful legislation that has targeted our trans youth as well as our gender diverse youth as being a continued challenge in how young people perceive their world as being safe and welcoming, and a world that they belong. And so one of the things that this highlights, the continued challenges, but I think one of the things that's most important is that some of the protective factors that we're also focused on is really connectedness and a sense of belonging. And there's that wonderful quote, and actually Dr. Benoit who gave a wonderful lecture yesterday really acknowledged this. And there's this Dr. Seuss quote that says that, to the world you may be one person, to one person you are the world, and for our young people that is so true. So being seen, being heard is so important, particularly when you're struggling and you know that you're not alone and you're not isolated. And parental monitoring, which was as simple as, do your parents know where you are, and I don't know if you remember that public service announcement that would go on at 10 p.m., do you know where your children are? And so, and I was like, people don't know where their children are? Like that's not a good thing. And so really thinking about like, do your, you know, whether or not it's the level of them being aware or involved in your life, but the important thing is that someone knows where you are and someone hopefully cares and is taking care of you. So there are definitely risk as well as protective factors. I'm going to say that, I'm going to end with this wonderful quote, the time is always, the time is always right to do what is right, and I think Dr. Reverend Martin Luther King definitely led the way in our efforts to bring justice to everything that we do. So with that, I'm going to pass it off to Dr. Benton, who is going to talk about all of the solutions. So thank you, Dr. King, for that excellent presentation. So what I want to talk to you a little bit about and follow up as part of this discussion is, so what are we going to do about all this? It looks like the news is all bad, but the news is actually not all bad. It's actually, we have solutions to these problems, and we have for a long time. We have hundreds of psychosocial interventions that work, but only about 1% of people ever get them. So the question becomes, how are we going to respond to what the needs are right now? And there's some basic guiding principles that should help us get there. Looking at prevention, which is cheap, it's inexpensive, and we know it's effective. There have been hundreds of studies that have pointed out the benefits of prevention, early identification, early intervention. We have opportunities with school-based mental health. What is the role of the psychiatrist in a school-based mental health setting? We also know that there are greater opportunities in integrated behavioral health in pediatric primary care, but not just pediatric primary care settings, also family practice, subspecialty practices, all the places where children and families receive their care. We also know there are opportunities to diversify our children's mental health workforce. And we also have opportunities for advocacy and negotiation around payment and parity. So there are some clear steps for us to take. Telehealth has many potential advantages. We have to be aware of the potential disadvantages of telehealth. But telehealth actually in many ways provides access to others who otherwise would not have access to care. And we also have an opportunity with crisis services. There's been some major gains recently with the SAMHSA 9-8-8 line, a little more work to do, but a lot's been done. And so there's opportunities there. And there's opportunities for us to intervene with justice-involved youth. So there are places where child psychiatrists appear to be absent. I think we're present, but I think there's opportunities for greater presence. That's actually my great-nephew. But anyway, there are effective strategies for prevention and treatment of mental health conditions. I got permission to use the photograph. So prevention. Prevention can occur in all the settings I just identified, primary care, school settings, and other community settings. And interventions in those settings have demonstrated effectiveness. We know that parenting interventions are available to prevent the onset or relapse of many mental health conditions, because we actually know that many of these mental health conditions are generated by social determinants and exposure to adverse circumstances. And we also know that we have hundreds of psychotherapies that one can use to obtain remission for many mental health disorders in children. And we have pharmacotherapies that are effective. Not as many as there are of the psychotherapies, but we actually do have treatments that work. And we also know what risk and protective factors are for young people as well. We know that there are some things that you don't have to pay for that can happen in communities that improve mental health. Positive physical development and activity, recreation, teaching young people to regulate their emotions. Actually, starting with teaching young people to recognize their emotions. And many of you may remember, well, for some of you are old enough to remember, well, actually, the ones of you who are young experience this, but you won't remember. It used to be a time that pediatricians actually talked to parents about prevention. What's normal? What's normal development? Sometimes I think it would change the quality of my life if sometimes someone would just say to a parent, your two-year-old actually is not doing this to provoke you. They're just two, and they don't know. But parents don't necessarily get that kind of anticipatory guidance anymore. But those are opportunities in those settings to give parents tools that they need. We know that good coping skills and good problem-solving skills, supportive relationships with families, feeling good about yourself, high self-esteem, and as Dr. Ng just mentioned, connectedness and belongingness is really important and protective of mental health. And another thing that's often neglected but very important in supporting the development of minoritized youth is we know that positive racial and ethnic identification is protective of mental health, and it's a tool that's highly underutilized. The other thing we've talked a lot about lately is resilience, which I think is a great concept, but I think it requires a little bit of clarification. So there's this idea that if you're resilient, you don't have to worry about your mental health, and that's actually not true. Resilience is a tool, and we used to think, well, actually, I don't think we thought this, we used to say this, that it was an individual quality, right? There were resilient people, as if people live in a vacuum. And so it became a quality that you either had or you didn't have, and we know that's not the truth. We know that resilience requires a resilient support system, and you may remember the diagram that Dr. Ng just showed with the scales. That's what it is. You need to be in an environment that supports that resilience. You need communities, you need family structures, you need other things that allow that to happen. Now we know there are individual factors, right? There are biological vulnerabilities, there's your ability for emotional regulation. All those things matter, but it's your communities and the resources that are around you that will contribute to your ability to foster resilience in your family. So it's important to recognize that it's a tool and a means towards mental health, but it is not mental health all by itself. And we certainly know the top diagram, the top picture is not the way to get there. So this statement by UNICEF really resonated with me. You know, we actually have a unique opportunity right now, and I think most of you are aware of that. There has been no time in my career of 30 years that I have seen the level of national and international attention to children's mental health that I have experienced recently. And I think this is our opportunity to make change, to make transformative change. We have an opportunity to have a level of dialogue about children's mental health that I've not seen during my career. And I don't mean just doing the same old, same old, right? Getting paid more time for our treatment plans and using the same old treatment plans is not the way we're going to solve the problems of children's mental health. We have to do more. And I think we have an opportunity at this moment in history to make significant change that really fosters the mental health of all the children, not just in our country, but in the world. But how are we going to get there? And the fragmentation has made it really, really quite confusing. But I think that we actually have a roadmap. And a lot of the discussions that we've had in the last few years, particularly the discussions we've had after declaring the children's mental health emergency, I think has given us a roadmap for how we can address the challenges of children's mental health in our country. But there's one thing we have to accept. In the words of Barack Obama, change isn't going to happen if we're waiting for someone else to do it. It has to be us, okay? We are the change. And we may feel like it's an overwhelming task, but it's actually not if we think about how we're going to work on this together. If we believe that the solutions are all going to come from the psychiatric community, it will feel overwhelming. But that's not where the change is going to come from. But we have to be part of it, and we have to be in the thick of it, and we have to understand what our leadership roles are in moving children's mental health forward. So the changes started a long time ago, but the attention to these issues were really highlighted when together we made the joint declaration of the children's mental health emergency. I have to say, honestly, in my career, it's the first time I've seen the Children's Hospital Association, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry do anything together. And this is a historic moment. This is a historic moment. It's historic because people moved beyond their guilt issues to focus on what was going to be in the best interest of our nation. And it's a historic moment that we have to capitalize on because it's created a momentum that has allowed us to move things forward in a tremendous way. And I'll share with you later some of the progress that has been made around these partnerships. Another major component of this joint declaration with these other organizations was an opportunity for us to start to have conversations about shared priorities. So what is it that's driving the challenges that we're seeing in children's mental health right now? And we can all agree it's the same issues. And Dr. Ng put this slide together. I have to tell you, it really reminded me that Dr. Satcher was the Surgeon General how long ago? 1999. We still have the same challenges. Since 1999, he articulated the challenges for us that long ago. It's now 2023. And the issues he identified were all the issues we know contribute to poor mental health in children. It's the social determinants of health. It is poverty. It's exposure to violence. It's adverse childhood experiences. It's financial neglect. It's fragmentation of our payer structures. It's families not having the support that they need. It's disasters and trauma and all the things we've experienced. These are the things he identified as the tasks for us in 1999. So in 2023, I feel pretty comfortable that we have a roadmap for what we need to do to make change. And for us, I think the next steps are fairly clear. It's schools. It's us being in the community and in the places where children are. So it's in schools. It's in healthcare delivery settings. It's in community-based organization, child service agencies, and with families and in the community. And what's the role of the child psychiatrist at all those places? So every lane is our lane. And we should be in all of them. So we should be in community settings, schools and primary care, the ambulatory clinics that we already serve, more acute services like partial intensive outpatient, emergency and crisis settings, and inpatient. We have opportunities to improve this continuum because there are many organizations that actually don't have a continuum. My organization didn't have a continuum until, well, we'll have a continuum in January of 2024. But the reality is that we can do even better than these services that we're offering. Telehealth has been an enabler. And it's allowed us to think differently about how we provide care. And many of you may remember, we've been trying to get paid for telehealth for years. And then COVID came along and suddenly we could get paid in a day. And so I think that really just speaks to what the capabilities really are. The other thing that's been a real enabler is expansion of mobile crisis services. And so when we get the 988 line working at the top of the 988 line performance potential, it will really make a significant difference because people can get crisis services immediately if they're suicidal, but also you want to be able to have mobile crisis teams who can actually meet people in the community. And then ideally, we have more opportunities for health promotion and prevention. And if we are able to create a system that provides these things, it will make a significant difference in the mental health for children and families. And schools is a good place to do that. Schools provide an opportunity to do all of those things. Schools provide us with an opportunity to do education for prevention. It allows us to identify kids at risk so we can develop targeted interventions. It allows us to provide care for kids who actually are already struggling with problems. And so it provides an opportunity for us to interact with communities in many different ways. Other opportunities, the collaborative care models. And I'm sure, how many of you are working in collaborative care models now? That's pretty good. How many people want to work at collaborative care models? Okay, that's even better. We can get there. There's a lot of work happening in this area. So with the collaborative care models, it's an opportunity for us to support pediatricians who actually are seeing the majority of the kids with mental health concerns, and they have the least amount of training. But there's opportunities for us to educate them. It's an opportunity for us to create a system that allows the support that pediatricians need to provide care in the setting where they work with children they've known most of their lives. And it provides us with an opportunity to expand capacity by providing more education for primary care providers. And we can do this in a multitude of different ways. Doesn't require that you have to be in that practice, but there are other ways to do it. And this is one of them. So many of you may be involved in ECHO projects. How many people have an ECHO program of some sort? Perfect. We could do more, but it's good that we have a start. And the ECHO program allows you to move knowledge, not the patients and not the providers. So the ECHO programs allow us to educate the primary care providers in an ongoing way so they can provide the care that's needed for their patients. It gives the patients the capacity to remain in their communities. When we start to talk about addressing issues like health disparities, allowing patients to receive their care from the providers that they know and trust is one way to address some of the disparities in healthcare. We talk about what's happening with minoritized youth populations feeling uncomfortable going into these other settings with other non-minoritized providers, but sometimes their pediatricians are the people who have the capacity to provide that level of comfort that they're not gonna get in another setting. So ECHO allows people, it moves knowledge, it doesn't move the people, and it allows people to get the care that they need when they need it, where they need it at the right level. So one of the things that I've been most excited about is what I've been learning about children's mental health from my colleagues in under-resourced countries. And so in under-resourced countries, we think we don't have that many resources. When I talk to my colleagues in places like India, they'll say to me, I've never been able to figure out why you guys can't get it together over there with all those resources. And we feel under-resourced. But I've learned a lot of things from them. And UNICEF, I think, has been visionary in thinking about how do you expand access to care? How do you partner with families and communities? And how do you utilize the strengths that exist within communities to support mental health? And I wanna share some of those things with you because I think that we are gonna need to think about how we can integrate these into our care systems to expand access. But also, I wanna sort of challenge us to think a little differently about how healthcare is provided. So one of the things that we talk a lot about is the opportunities with digital health. And most of us have used some of those, primarily with telehealth. But digital health is more than telehealth. There's also the opportunity to develop peer support for young people to support their mental health. And then non-specialist providers. And many of you who may have been involved with the community mental health movement some years ago may be familiar with the whole concept of using non-specialist providers. But I wanna talk a little bit about that today because I see that as an opportunity for us. So talking about digital health, it's a broad term. And I'm using the Food and Drug Administration's definition. But digital health, actually, it really captures all the electronic platforms we're using for anything that has a digital technology. So it's our EHR, it's our Apple Watch that we use for monitoring our heart rate. It spans a wide range of applications. And so when we talk about digital health, AI's part of that, it covers a lot of things. It covers mobile health, it covers all of our IT applications, all of our wearables, telemedicine, and personalized medicine, which we talk a lot about now. And then there's also a lot of mobile and AI technology that we use now in healthcare that we're not even aware that we use. And so that essentially, a lot of the information that goes into our health record is actually used to generate algorithms around treatment. That's happening across the medical field right now, even though we're not necessarily aware that we use those things. The purpose of these technologies is to actually enhance care delivery. And I think that we have some opportunities in mental health to use some of these applications to enhance healthcare delivery. But one of the challenges is that everybody doesn't have access. And we learned this during the pandemic. So there were significant disparities in who had access to just thinking about telehealth during the pandemic. We also learned, if you think about it, the majority of the world closed their schools. There were a few people who remained open, but most people closed their schools. The estimates are about 90% of the world's population, but about a third of the people who immediately switched to online platforms for education had no access to those platforms. And so essentially, they received nothing during the pandemic. We also know that a large number of kids, approximately 2.2 billion children under 25 years of age, have limited or no internet access. And so if we talk about digital opportunities, we're gonna have to address those things as well. And then there's also the concerns with social media. And many of you may have looked at the Surgeon General's report on social media that was just released, was it today? So I read it today, actually. I was really curious. And it was really interesting because the data on social media is actually conflicting. So there's definitely some data that demonstrates some benefits for social media use in adolescents, particularly in select populations, because it can decrease social isolation for some. But there's a lot of data that suggests potential harms of social media. And what the Surgeon General's advisory actually recommended today is that we actually start to look at it and examine it in the same way we examine other things that we give to young people. So we don't just tell toy makers, make whatever you want and just give them the kids. He's actually advocating for us doing the same thing with social media, that we have to be more critical about what's out there, because we're not sure what all the harms are. We know there's some. We know there's some advantages, but we actually don't know enough to allow this to be freely available to kids. So I would suggest taking a look at it because it was actually really well put together. And we know the potential harms of cyberbullying, the impact of social media on self-esteem for young people who believe all the people who have filters actually look the way they look with their filters. So we know what some of the issues are. We know that young people can spend too much time on social media. And to be quite candid, most of the research that reflects the harms of social media relate to the disruption to other activities like sleep, which increases your risk for mood disorders and has been linked with suicidal behavior in adolescents. So some of the other opportunities though, that have been posed by the COVID-19 pandemic, in contrast to the challenges, is that the access to digital health can provide you with increased access to mental health and psychosocial services. We saw that during the pandemic. We also know that, and I actually think this is one of the benefits of digital health that I think is actually most useful, is access to educational materials. And you can expand access to education using social media in ways that you can't do with in-person education. And I think we really have to take advantage of that for the dissemination of mental health information. We can also do screening and diagnosis, treatment and care, as most of us have been doing with telehealth, training and supervision of mental health workers. And this is one of the opportunities for us to expand access by expanding training. And then the other thing that's happening now is they're using actually social media to track human trends and behavior. And we'll talk a little bit about that. We're actually learning about what people are doing. We're actually starting to look at social media messages and post as a way to gather information about youth who may be considering suicide. And then the other thing that has been really exciting is the opportunity to expand global health using digital technology for training. And so this is a modality that very much lends itself to educating people across space and time. The other thing about digital platforms is, though we didn't grow up with them, but young people nowadays did. And they find them easy to use. They prefer to use them. They're convenient. They can use them when they want to. They can be anonymous if they need to be. They like information that does not have a lot of text in it. Text messages tend to be short, unless people are fighting, in which case they tend to be long. But most of the time, they're relatively brief. And it provides opportunities for people to connect with peers. And we all know that a major component of adolescent development is expanding their social network beyond that of their parents and their families. But we also learned, and I learned this in a very interesting way, that you can actually exacerbate disparities. So I learned this when I opened an edition of the Orange Journal, and I saw an article about my department in the Orange Journal, written by one of my fellows, who did a study looking at disparities in utilization access to telehealth during the COVID pandemic, and actually compared data from Boston Children's Hospital, and decided, well, not decided, the data showed that we had actually introduced a disparity in care, and that the number of minoritized youth receiving Medicaid received less care when we switched to telehealth than prior to the pandemic. And so I think it's important to pay attention to those things. I had to, because it was published, and I wish they'd given me a heads up, but I also think it was an important lesson, because it never occurred to me that we could do that within my own department. So there are other things that UNICEF is doing to expand capacity, and I'd really like to talk with you about the EMPOWER project. Many of you may be familiar with that, but it's a project we're working on now. So EMPOWER is a project that was started by Vikram Patel, who's basically a community psychiatrist, but also a global mental health psychiatrist based in Boston and India, who decided to do something he called reverse engineering. And with EMPOWER, the goal is to build health system capacity for prevention and care. But the way that they do that is by training non-specialist providers. So what does that actually mean? So what EMPOWER does is it identifies people who are not mental health professionals. They can be bachelor's level people. They can be people who never went to college. And they establish a training using a digital platform that teaches people to deliver components of evidence-based interventions. And one of the things that EMPOWER does is it designs the training around specific diagnostic groups using evidence-based practice. They're able to monitor what's being delivered because they're able to see it. And they're able to provide real-time feedback and supervision for the individuals that are providing it. They also provide tools for measuring outcomes. So one example is behavioral activation for depression. And if you think about it, behavioral activation is not a complex thing to deliver if appropriately trained. You don't need to have a master's or MD or PhD to deliver behavioral activation. And so with EMPOWER, Bikram's group intends to generalize that training. They have a couple of sites here in the United States, one in Texas, and one is my own site, where we're looking at training daycare workers to deliver some of the basic evidence-based intervention to children in daycare centers, particularly related to disruptive behaviors. And those are opportunities for us to expand access by training other people who don't necessarily provide mental health care on a regular basis. There's also a lot of e-interventions. There's a lot of CBT interventions available. Many of you are probably familiar with some of the online programs. And then there's also some really interesting things that are available at websites and games and apps. We have a virtual reality intervention that we use to train individuals with autism to respond to first responders. And we also use virtual reality to teach police officers and EMS workers how to approach autistic individuals if they're called for some kind of emergency. And those have been very, very effective interventions for training. Then, of course, mobile messaging. The text line is a good example of that. Another area of interest has been there's something called web scraping. So you're able to look at social media messages. Now, mind you, I did start to look at Reddit. And there's some, anyway. That's been an interesting learning experience. I'm not even sure what you make of some of that stuff. But actually they're using, for some of the researchers who are looking at social media research, they're actually gathering text that individuals use who may be depressed or may be anxious. And what is the language that they're using around suicidality? And they're trying to take this data and capture individuals who might be suicidal based on what they're posting on social media. They're also doing the same thing for gun violence. And so I think there's some, it'll be interesting to see what this research reveals. But I think there's some opportunities for us to use social media in ways that inform practice. How am I doing on time? Great. So what do we need to do to make this all happen? And I think that we really need to pull together the right individuals and the other leaders and get a commitment to work on this together. And why am I saying this to this group of child psychiatrists? It's because our tendency in medicine has been, we work with other medical professionals. And it's interesting that for us, when you think about that diagram with social determinants of health, only 10 to 20% of what happens is driven by anything that we do. And I'm sure you can relate to this experience I'm about to share with you, because I'm sure you've all had it. You have a patient in your office and you know that that patient is actually probably doing pretty well. And that you also recognize that that kid is actually fine. What's wrong is what's happening around that kid. And no matter what you do in your office, you send them out the door and you have no further control over anything that happens. And it's a frustrating experience. And the question is, so how can we use this children's mental health emergency to change that? And my recommendation and what I'm gonna ask you to do and what Warren's been doing in his presidency and what I intend to do in mine is we have to engage with these other systems of care. So there's a role for us in all those places. There isn't a lane that doesn't belong to child psychiatrists. Many of you may find in your own communities, it's psychologists are in the schools. They're not keeping us out. We could be in the schools as well. We need to be in the schools. We need to be in the community. We need to be in the places where children and families are. And because we cannot do all this work by ourself, and there's more than enough work to go around, we're gonna have to partner with these other people to make this happen. And then we're gonna have to lend our expertise because they don't know all the answers either. I mean, when I think about child welfare, AKA family regulation, they don't know what to do about all the kids in their system. They don't know what, they see these behavioral problems. They don't know what they are. They don't know what to do about them. They don't know that they induce quite a few of them. And so I think there's some opportunities for us to really expand our capacity to improve mental health by partnering more aggressively with these groups. With juvenile justice. Okay, we know that incarcerating kids does not create rehabilitation in any capacity. In fact, we know based on our own science that kids who commit minor offenses, the recommendations are that those children remain in the community. That's not where they are. And with the gun violence, more of them are incarcerated than ever because judges don't feel safe discharging them with everything that's happening in the community. We need to partner with those communities to provide guidance around the things that we know are correct. The other things that we're gonna need to do is educate people about mental health stigma and improve mental health literacy and how people talk about mental health and how they understand mental health. We're gonna have to strengthen and support implementation research. So I can tell you, I do research, I have grants. What I know is that most of the evidence-based intervention, the hundreds that I mentioned, never translate into action for patients. And so we're gonna have to do things to support implementation science research and quality improvement research so that we actually know what's happening with families. And then we have to form partnerships with patients and families. Their voices matter. How do we use peers to support individuals struggling with mental health conditions? How do we support their families in having a voice in how care is delivered? Environmental change is really important. And so when I think about the issues, and I think sometimes we wonder, so what can we do about this? We vote and pay taxes. And so basically, we know that green space is psychologically healthy. You actually don't need a study to tell you that. We actually know that. And so there are things that we can do to shape communities that will make a difference in the lives of children. They need to be able to go outside and play. I don't think we need a randomized control trial to know that that's actually true. And then I think that we have opportunities to work in other settings where families are everyday churches, community centers. And I mentioned child welfare and juvenile justice. And we need to think about how we're gonna expand our workforce so that it's not child psychiatrists doing everything. So what does this look like? And what should this look like? It should look like a youth-centered system of care, and that we should be thinking about how we're gonna provide these resources for children. How are we gonna engage with these other people who form the lives of children to support and improve the mental health outcomes for these groups? It's all of us. It's all of us working together to make this happen. Now, we've had some successes, and I wanna talk a little bit about that. I don't know how many of you were able to make it to the legislative conference this year. Thank you. But we've been able to accomplish quite a lot in these last couple of years since we declared this crisis. And I just wanna remind you of what some of those accomplishments have been, because it's actually been a lot. And I wanna thank all of you, because it's not a single effort. It's a community effort. And people being out there, giving their support, talking to people in their communities has made a difference. So these are some of the accomplishments that we've made over the last few years. The Omnibus Appropriations Act, where there was $5 million provided for subspecialty loan repayment. And many of you may be aware that, even though that act was authorized some time ago, the pediatric subspecialists were not included, which is us, was child psychiatrists. And so now that is the law. The Bipartisan Safer Communities Act has been signed into law. And that's helpful for us, because it expands the loan repayment program. And there's been a requirement now that HHS provides some guidance around telehealth. You know how confusing it had been. And now they have to tell us how we can actually use telehealth and how we can be reimbursed for that. There's also been the Restoring Hope for Mental Health and Wellbeing Act, which passed. And so there's increased funding for integrated care. There's increased funding for the SAMHSA Minority Fellowship Program. And then there's support for parity implementation. So parity has been the expectation and the rule for a long time. It's just never happened. And now there should be some more financial support and people's support to move that forward. And then there's the Omnibus Appropriations Act, Restoring Hope for Mental Health and Wellbeing Act. So there's Mental Health and Substance Use Parity Implementation, integrated models for telepsychiatry, increased funding for GME education for residents, and increased funding for the Minority Fellowship Program and loan repayment. And so those are some of the gains that we've been able to make over the last few years. So I think that just speaks to the fact that together we actually can get things done. And so finally, just to summarize the high points, you know, for us, you know, as we're thinking about the future in the next few years, it's being where the kids are, okay, wherever they are. It's making sure kids get the right care at the right time, at the right level. It's partnerships and collaborations with everyone. And, you know, and I actually think we've been collaborating for a long time. I'm not sure why people don't know we're there, but we need to be there more and we need to use our voices to highlight the work that we're doing. And we need to make sure that whatever we're doing, that we assure equity, diversity, and inclusion of all voices. We have to expand our roles within the system of care. We have to be more present and we have to be more visible. And then aligned with what Dr. Warren always reminds me of, we need to take care of ourselves in the process. And so I want to thank you all for your time and attention today. And I look forward to working with you in the future. Thank you. Thank you, everyone. If you would like to come to one of the mics, if you have any questions, we're happy to invite them. Hello. I'm a psychiatrist in Canada, in Quebec, and I have a question. If you have any kind of emotion course in primary school in U.S. or any kind of class to learn emotion in school? Thank you so much. I think that that also speaks to the importance of prevention and that whole continuum of care. There are really wonderful programs that focus on social-emotional development within schools, and it's really teaching from an early age within schools, which are the normal environments for kids to learn and to grow and to thrive, really how to label their emotions, how to understand them, how to talk about them, so that we can develop the language in order to convey to other people what you're experiencing inside. So there are some very effective schools, and we have a wonderful schools committee within ACAP, and there's also a Center for School Mental Health, and Dr. Sharon Hoover is a wonderful leader in that initiative. So I would say that there are many resources that are available, and as a fellow Canadian, welcome. And I think just acknowledging that there's a lot of wonderful work. I also wanted to plug what Dr. Benton shared, is that schools are really beacons of hope within communities where kids and families converge, and I think that that's a unique opportunity to be able to bring together our educators, as well as our parents and families that might not otherwise seek care due to stigma or other barriers. And so I know that we're privileged to have a school-based mental health program, and what we do is we offer workshops within our schools after the kids have been dropped off so that the parents can actually be available to have workshops on sleep hygiene, or sleep routines, or homework help, or diet and nutrition, and things that we don't necessarily think are specifically mental health components, but are so key to that. Or how to manage social media. Or how to manage social media, definitely. And it is shocking, I don't know for many of you, some of the young kids that I see in my office, and how they have access to phones at such an early age, and I think parents really struggle with how to have those conversations, and how to make decisions, and how to protect their youth. But I think what's really important is what we always focus on, the relationship and the communication. So if there are difficult things, let's learn to talk about them, and let's engage the children in learning. That's it. You've captured it. Is this working? Okay, good. See, my question comes in 14 parts. I wrote it down. I'm kidding. Thanks for your remarks. Dr. Benton, you spoke about a child psychiatrist's role as part of a collaborative team. The team, however, was understandably focused on the care of the child. What I say to my patients, as I'm sure you do to yours, is that children do not exist in a vacuum. I have been doing a lot of family work, and I'm finding that an increasingly growing part of my practice in the community is dealing with parents that have their own mental health issues. Do you have any recommendations as to how we as child psychiatrists can interface with adult psychiatrists and the adult mental health community at large to promote positive outcomes for both the children and their parents without blurring the lines of treatment or promoting unhealthy alliances or seeming like we are taking sides? And then, lastly, as someone who frequently quotes Dr. Seuss as well, it's important to remember that to save a life is to save a world, too. So I'd be curious, because it sounds like you've thought about this issue. I'd be curious to hear what you- Yeah, I would be a little curious to know what you think, but I think it kind of goes back to the partnership issue. The question becomes for us, what should those partnerships look like? Because we have a limited number of us, and we're working on more of us, except everybody doesn't need us in the same way. It seems as though there was a time that we did more consultation with schools that was just a normal part of what happened, but I think as schools have had more limited resources, they actually do less for kids. You may remember when they used to do all the psychological testing, and they used to have psychiatry consultants who would work with the team of psychologists and social workers. Somehow, it seemed to disappear a little bit. I mean, I know it still exists, but it's not the routine anymore. My observation has been what happens is schools find their own special panels of psychiatrists, and then they use those, and then whatever happens, happens. I think that we do need to remember that we are child psychiatrists. We are also adult psychiatrists, but essentially, from my perspective, one of the distinctions for child psychiatrists is that your training fundamentally requires you to work with families. You have to be able to work with parents, recognizing that they're more than just the people who drop the kid off at the appointment and pay the co-pay, because a lot of times I hear ... I talk to some of my trainees, and they're like, well, I'm the child's doctor. It's like, how is that even possible? They don't live alone. Basically, I think that essentially, we have to see it's our role. We are treating that family, and it's challenging, but I think that the idea of us partnering with other professionals in a deeper way and understanding that our role many times ... We're going to be leaders of those teams, and we have to be leaders, because we're the people that have actually been trained in all the pieces that other people do. Now, mind you, I've been trained to do psychotherapy. I will never be as good as my psychologist, because they do it all the time every day, and I see them as the experts, but our expertise is that we have to learn the principles of psychotherapy and pharmacotherapy and family functioning and social systems. We should join teams with that expertise that we can share, because I think that will help to shape a more effective and functioning system, because right now, it's just not working. It's not working for our kids. We know all the ACEs, so we don't need to go through those today, but the problem is that the child welfare system monitors all that. They monitor that for every family. Child welfare determines whether you can keep your kid or not, and so when something's not going well, families are afraid. Schools are required to ... The mandated requirements are stricter than they've ever been, and there's an upside to that. There's also the other side of that, and so families are afraid, and I think that the overreaction in part relates to not having enough expertise, and I think that's where we have a role to play, and I think that's how we'll address all the things that you've raised. Thank you very much. If I can add, I think particularly the family component is ... I don't know if ... For those of you who are child and adolescent psychiatrists, when I went through my adult residency training, and I did my child rotation, and my adult psychiatry resident colleagues were like, oh my god, how could you do child? You have to deal with the parents. You've got two patients for the price of one. Why would you want to do that? I think part of it is seeing the beauty in it, because I think when you're able to help a parent, you can also not only benefit that child, but every child that that parent might have the privilege to take care of, and so you're able to do that, and as a child and adolescent psychiatrist, as Dr. Benton shared, part of it is that we are systems thinkers, and I'm just thinking that Dr. Axelson's over there, and he's an incredible expert in continuum of care, so talk about people who can create continuums within communities, within states, is really impactful, and it's really expanding the idea of the family, outside of just the nuclear family, to the community, and to the world that the young person is in, which is really important, and I do have to give another plug. I'm a family physician by training, so I think I come to it with a specific bias, but I definitely appreciate your acknowledgement of parents, parent work. Thank you. I grew up in a family, so that's why I'm still here. And I ran away from my family, so that'll tell you a lot about... I thank you so much, to both of you, you know, ACAP has really given me a place to be able to focus a lot of my passions in advocacy, so I appreciate both of you and your pioneer work in all of this, and I have two questions. So number one, for social media, when they collect all of the data and flag people who may be marked as suicidal, where does that information go? Like, who does that go to? And then my second question is, you know, I finished my fellowship last year, so I'm a new attending down in D.C., and I find in my regional organization, there are a lot of concerns from people about advocacy, because I think there's a general misunderstanding of this is what advocacy means. It doesn't necessarily mean it can mean, but it doesn't necessarily mean you're standing and protesting something, you know, with a big sign or something. So if you have any advice on how to kind of help promote the greater understanding of what advocacy really is for our profession. I'll go first, but first, thank you so much for being our leader as a resident trainee, advocacy leader within D.C. as well. So thank you so much for all of your work, because I think you clearly understand the power of that advocacy work. I would say that with regards to the data within the social media, I think that many of the studies are really within research protocols at this point in terms of where that information goes, and I think it hopefully will inform sometimes the regulation or the industry requirements that we might be pushing for. That's on one side. The other side is that I think a lot of the data is in meta and Google and other things. The challenge is what are they doing with the data, and how can they be proactive with safeguarding what they know already with regards to body image issues, whether or not it has self-harm, and or just the whole manipulative design that is embedded within the social media and social use platforms. So I think that there's a lot of data that does exist, but the question is how to get it if it's not within the constructs of a research protocol. I think within a research protocol that is looking at interventions, they are hopefully using some of those sort of strategies to like pop up safety plans or pop up proactive pro-social comments or texts within that user's phone to help safeguard some of these things, or hey, contact your friend. So I think that there are different studies that are currently going on that will help us inform. The question is how to get them, even when we find what's useful, into the phones and the devices of the young people, and whether or not it's really proactively advocating for that with parents and youth, or whether or not we're expecting industry to do that, or whether or not we have regulatory legislation that will put some of those safeguards into place, which are really key. And then to your second point about advocacy, I think advocacy is an important thing. Sometimes the idea of being political, the idea of having a voice, those can mean so many different things to so many people. I think the question is that there's this wonderful quote that says, you know, our lives begin, or our lives end when, anyways, I'm going to really change that one, but when we don't take action on the things that matter to us. So I'm thinking that no matter what level of action that is, whether or not it's talking to someone else, whether or not it's sharing your ideas, whether or not it's protesting, whether or not it's sort of adding to the advocacy alerts and wanting to respond to write your elected officials and legislators, or whether or not you come to legislative conference and advocacy day, I think that there are all the different levels, and not to necessarily limit yourself, but just think about it as a delicious continuum of things that you can do, depending on how the balance of your life is at that time and what you have available to you. But understanding that that is, as you've already learned, a powerful way, yet another tool in your toolkit in which you can help children, families, and communities. So thank you. The only thing I wanted to add to that is that your question about advocacy, you know, I think that is a, for many people, that just means you're protesting. I think that for us, a lot of it is educating the public. And so being present to educate our legislators, you know, there's an assumption I used to have that, like, they knew all this, and they were just evil, right? They just weren't paying attention. They didn't want to do it. And then I learned they're actually just people with big jobs, and they actually are not experts in every area that we are, and they actually don't understand a lot of these things. And until someone like us, who we do understand these things, it's our responsibility to provide that information to other people so that they can know it, and then they can act on it. And so I see advocacy, I mean, you know, physicians, the root of the word is educator, okay? And so it really is our responsibility to educate, you know, our legislators about the issues that impact young people. And I do realize that's a shift in many ways for many of the professional organizations, but it is a responsibility. And I think we need to educate people about what advocacy is. If we don't teach people, it's not gonna happen. There have been times that I just assumed there were some legislators who could not learn. And a couple of, I mean, because I didn't know, right? So I had all these opinions. And then when I testified before the Senate, there was like one senator who shall remain nameless, who was just really not nice. I mean, you know, got up and made all these racist comments. And I just remember thinking like for the last two years, like, God, he's really awful. But interestingly, recently, he, you know, he like really had this really intelligent, thoughtful conversation about supporting greater funding for substance use. And I was like, when he started to speak, I was like, oh my God, this is gonna be bad. But it wasn't. I mean, it was fantastic. And I think it just really spoke to the power of educating people about what the issues are. It was really pretty amazing. So I am a firm believer in, you know, our role in educating people about what the issues are. And right on the tail of that is my question. I'm a child adolescent psychiatrist in Baltimore. And I have immense amount of concerns. Many of which you've highlighted here, but the other side of it is really kind of the lack of education for the two years. And kids using telehealth, either not having access because of, you know, they didn't have the Wi-Fi or they couldn't pay attention to the screen. And so there was just a desert for intellectual absorption and learning. And then they're catapulted two grades above and the catch up. So compounded on top of that, now that we're dealing with, which I haven't heard a lot of talk about, again, this is an adult conference essentially, but there has not been a lot of talk about this stimulant shortage. And I understand that this is about active ingredient being less available during COVID. And then DEA getting involved thinking about, well, this is similar to opioid. So we need to be really concerned about this. So we're gonna cut down the quotas. And then pharmaceutical companies that are generics are saying, well, if I can't reach my quota, I'm not gonna make any money. So you've got generics dropping out of the market. My kids are getting kicked out of schools, out of daycares. They're actually going into inpatient centers and it's impacting their education again. It's an enormous concern. What is conversation happening kind of behind the scenes with ACAP going and advocating for this? Like speaking of advocating, how do we move? Cause something has to be done. It's a big concern. So I saw a lot of head shaking. So probably a lot of people feel the same way. Thank you. And we're really, thank you so much for all that you're doing in Baltimore. And I think that the stimulant shortage is a crisis on top of another crisis. And ACAP has been very actively responding to and writing letters to the FDA, the DEA, as well as engaging all levels of government that we can have access to. And it is a part of our dialogue. So I think that part of the challenges is that there are multiple, as we're appreciating, we're multiple challenges along that pipeline. And yet at the same time, if we're talking about children's mental health crisis, then that's creating yet more burden. And it disproportionately falls on also more disadvantaged children and families as well as those that have fewer resources because being able to have the time to call multiple pharmacies, to try to find the place that has it, or to even understand adjustment of dose change in medication or kids in the sort of the foster care system with regards to having the prior authorizations, the additional approvals, like they're all huge barriers that are disproportionately impacting some youth and particularly youth of color and low-income youth more than others. So I just want to say that we share your pain. We definitely are advocating on behalf of that. And we are bringing it to the attention of the government, which are in line of sort of legislating and regulating some improvements. So far, it's been a challenge because as you mentioned, it has gotten ensnared with all of the opioid issues and we're trying to really differentiate that discussion, particularly when it comes to children and adolescent mental health. So we won't stop. So just sign up for our advocacy alerts and then you'll definitely see what more we're continuing to do and we'll continue to push forward. I don't know if there's anything else. Hi, thank you very much for your wonderful lecture. We have the privilege to listen in Mexico last year in the Mexican Association. I'm child psychiatrist and I would like to hear your thoughts on this. And maybe it's my feeling or my idea or maybe it's Mexico, I don't know, but how to put this line between the rights for the children, the education, the limits, because for instance, I was thinking when I was a kid, I wasn't able to choose the music on the radio in the car or the TV show, but now my feeling is that many, many parents, they try to respect, they try to say, those are my, the rights of my kid and it's not my role to say anything if my 12 years old girl wants to text or to go with a friend or something like that. And when they come to my office, I wish they come earlier, not in that moment. But I don't know, maybe it's a Mexican problem or it's a everywhere problem. No, no, no, actually it's only a Mexico problem. Children in the United States are not like that. No, no, it's a everywhere, it's a global problem. I just wanted to comment that my observation of families is they actually don't have the support that they need around parenting their children anymore. And so a lot of families move away from their families and if you don't have a sense of, if you don't have a community, you don't really have anyone that can help you know that, actually your child probably shouldn't be doing a lot of things that they're doing. So I think a lot of the parents need more support, which was, some of my comments about the pediatricians, like we used to get anticipatory guidance. And so that was telling us about what was developmentally normal, how you should, there's a strong association between appropriate parental monitoring, family closeness, family structure, and outcomes for young people. So kids need structures, rules, regulations, and parents who are with them overseeing and supervising them. I think a lot of parents are working. You've got two working parents. You have, you know, I don't want to blame social media for everything, but parents will tell you, their kids see all the things that other kids have and it becomes a source of tension at home. And then, and they don't necessarily have the level of community support that they used to have. For people who have faith-based communities or strong school communities, where kids are really included in places where there is more parental monitoring, the outcomes are better. But I actually think that we have an opportunity ourselves to really, you know, sort of consider that parents don't necessarily have that structure and support anymore. And sometimes we have to, you know, help them understand how to set up an appropriate structure for their kids. I tell people to go to church, they were like, oh, Dr. Bitten, I didn't know you were so religious. It's like, I'm not. I think you need a, I think, and you don't need to be religious either. You know, what you really need is a community of people who, you know, have shared principles and goals. But I feel like that's a way for us to get more community support, but I do think we also have the opportunity to do some anticipatory guidance ourselves and some education for parents. Yeah, and I echo that. It's more than Mexico. And so definitely Canada as well. So we're going to go continental. But I think that the idea that one of the slides that I showed that even prior to the pandemic, that there was a 29% increase in anxiety and then 25% increase in depression. But that one thing that was quite striking was that the caregiver wellbeing was going down. So what we are seeing is that I think parents nowadays feel awful. I mean, they just see, you know, they're overwhelmed. They're stressed out like all of us in terms of doing the best work that we can. And the question is, is that what's giving them a break when there's a breakdown in terms of the family structure, the family support network, and many individuals are not necessarily living within a context where there's additional multigenerational family support or others, depending on their situation. Just appreciating like who's helping to set the many different limits. And I think parents are making choices based on survival on what they can or can't do. When they come to us, I think one of the things that we do, like Dr. Benton was saying, in terms of anticipatory guidance, is that just acknowledging that sometimes structure, expectations, and limits are a part of caring and loving. And being able to acknowledge that you're not taking away your giving. You're giving them that sense of security. Because without that, it's hard to seek that. And they're not gonna get that anywhere else. And utilizing your trusting, loving relationship, hopefully at home, with your parent is one way to do that. Or expanding that circle of saying, our nuclear family went nuclear. There isn't really any such thing. And you have to create intentionally that support network for both your kid, but also for yourself. And really helping to align having those discussions about what each individual child is gonna need. And I'm also going back to the wonderful comment from our colleague from Baltimore, and thinking about our ACAP, our presenters are going to the AMA meeting in a couple of weeks. And a part of those discussions also have to do with prior authorizations and the other things that take up a lot of our times as physicians doing this work, in terms of trying to deal with that in addition to the stimulant shortage. So many of those dialogues, we'll also continue to have within the House of Medicine with our other partners in medicine to come together in coalition. Because we find that when we're doing that, it is more effective. So we'll continue to update you on that. But I think if you're talking to any parents or caregivers, I usually approach them with gratitude and compassion. Because I'm just like, OMG. And I know, you know, and we know as child and adolescent psychiatrists and those working in children's mental health, when most parents come to see us, they're already feeling like they're gonna be blamed. Like it's gonna be their fault. And I think that sometimes that's a hard place to start from. So I usually try to acknowledge that you're doing the best you can. Let's see what else we can do. Because it's not fair to you that you don't have all the support you need. Thank you very much for these great presentations. I just arrived a little bit late. But I am also a adult psychiatrist from Mexico as well. But what I am now seeing is very young adults coming to my practice that they are, somehow their mental age is a little bit different. They are not the same age as they used to be. So they are now 18, 19, but in that it's legally adult in Mexico. But then they behave very younger. And then also what I saw because of COVID is that some of these patients, they come sometimes with depressive symptoms, but also the depression that characterized normally adolescence is not the same as now. And I was wondering, what is your experience with that? How you handle that? Do you have seen that trend and how you're handling them? Bienvenido and welcome to all of our wonderful colleagues from around the world and Mexico in particular with our two wonderful questions. I think one of the things that I, one of my slides was really in the loss of educational years when it comes to math or to reading. But the loss to educational years in terms of social emotional development and peer relationships and social skills. And I think that that's really been challenged. And I think we do not know the full impact of that over time but when you're thinking that those are formative years if you're in your preteen and teenage years and your peer relationships and normalizing. Also your contact with your extended family members, like many kids didn't have exposure to their grandparents because they were also wanting to keep them safe. And so you had the loss of some of that love and support and all of those things. I think that we're only appreciating and I think as we're sort of emerging out of this period, what are the long-term impacts of that global sort of period on child development during that time? It isn't just loss of educational years which we understand is having a loss of fiscal impact. It was estimated that because of their loss of education of four or five months of reading or writing that there was going to each one of those young people was gonna have a loss of $50,000 in terms of their ability to be generative in a monetary sense. But I just think about in terms of a social sense and a psychological wellbeing as well as social emotional development that I think, I don't know if you remember when people started coming out of the woodwork after at least some of the public health emergency periods, like people had forgotten how to interact with each other. And it was just people, their social skills, like it just took a little while, a hot minute to sort of get back on track and some people never did. And if you're a kid and you never learned then I always worried about how are you negotiating the world now when you didn't necessarily develop those skills and those kids were anxious, depressed and are having other limitations already had a hard time learning then are having a hard time catching up and the world has moved on and they feel left behind. So I'm just mindful of how we're addressing some of those gaps, which we'll continue to see. We'll probably hear about the last generation at some point. Hi. Hello, thank you all for doing this lecture. I'm a child and adolescent psychiatrist and I have definitely been wondering about not just the short-term impact of COVID on our young people but the long-term with the, and also I've actually been wondering about, do you all know if there are currently any epigenetic studies that could maybe more longitudinally track the impact because as child psychiatrists, the next five to 10 years we're gonna be taking care of the generation of toddlers who may be have born in such a high stress time within our world not just nation as a epidemic. So I was just curious if anything's kind of in the work related to epigenetics and the stress of the COVID pandemic. Yeah, there actually is actually quite a bit of study. So there's some large studies looking at pregnant women during the COVID pandemic and they're following the infants for a couple of years. And so they, it's actually, it's happening in Philadelphia at my location. There's this infant psychiatrist, Dr. Wanji Gujaraghi who's an ACAB member, who actually is leading a large study focusing upon the impact of COVID stress on the development of the infant during pregnancy and then the mental health impact of that stressor on the mother and the father. And they're being followed longitudinally over four to five years. So there actually is quite a bit of work and some of the studies suggest that there is a modification in the children's temperament once they're born postpartum in the early months that they're noticing that the kids, at least some of the preliminary data suggests that they're more anxious and that the parenting is much more anxious. And so I think you're gonna see more studies. There's been some other studies that actually surveyed pregnant women during the pandemic. And then there's been other more survey data because during the pandemic, everything was shut down, but there is data on the impact of the COVID pandemic on parenting for toddlers. And there's a literature out there. And what they're finding is that some of the differences that you see are based on what the socioeconomic circumstances were for the parents. So for, if you look at some of the European countries where there was more access to outdoor space, the mothers did better and they were less anxious. Their parenting was less anxious compared with some of the data on the inner city. So I'd be happy to connect you with Dr. Jawagi's team is doing that work. But there is actually quite a bit of literature really emerging around the impact of the COVID pandemic on parenting for young children and what happened to pregnant families during the pandemic and how that's affected their children. That's an excellent question though. That is great. And Dr. Jawagi was one of the co-authors on the Sounding the Alarm article that Dr. Benton led. So the other thing is that there are also studies that are more long-term looking at long COVID in terms of the pediatric population, which is separate from the epigenetics as well as the mental health sequelae, but looking at the neuropsychiatric, so as well as the medical outcome. So I know that there are multiple sites around the country. I know Columbia is one of them as well, so I'm familiar with that one. But I think one of the things that they're definitely seeing is that from post-viral syndromes, they're really learning a lot about it being really much more complex than because we know that COVID-19 was multisystemic. It wasn't really restrictive in terms of its impact. So we'll have to see. But I know that we suddenly have gone over time. So... And I'm so impressed with all of you because you have limited your vitamin D exposure today because it is sunny in San Francisco and you know that that's kind of golden. So, but we wanted to thank you all for coming. We thank you so much for all of the service to the kids and the families and the communities. And please take care of yourself. Get some vitamin D, take a walk. Nature is healing. So is each other. So thank you for all you're doing. Take care. Thank you.

youth mental health

societal pressures

COVID-19 pandemic

social determinants

racial disparities

economic instability

fragmented care systems

anxiety and depression

LGBTQ+ youth

mental health access

integrated care

policy advocacy

digital health

telehealth technologies