Hello, and welcome. My name is Dr. Lisa Fortuna, and I'm a professor and vice chair of psychiatry in the Department of Psychiatry and Behavioral Sciences at the University of California, San Francisco, or UCSF. I'm pleased that you're joining us for today's Emerging Topics webinar series, which is titled today, The COVID-19 Pandemic and the Child's Mental Health Crisis. What do we do now? Okay. So the Emerging Topics webinar series are designed to help you stay up to date on important topics and trends impacting psychiatry by participating in APA's new Emerging Topics webinar series. These activities are free of charge for all members and presented by specialists across the field. These monthly webinars will explore a range of diverse pertinent topics and offer a chance to interact with peers and subject matter experts, and hopefully encourage some discussion. In terms of continuing education credits, today's webinar has been designated for 1.5 AMA PRA Category 1 credit for physicians, and credit for participating in today's webinar will be available until November 20th, 2022. So please make sure to do that. You can also download the handouts for this presentation. They're available in the chat area of the attendee control panel, which is depicted here on this slide. Please click the message bubble icon to open the chat function, then select the link to download the PDF version of the slides. Please feel free to submit your questions throughout the presentation, and all you need to do is type them into the question area found in the attendance control panel as well. We'll reserve 20 to 30 minutes. We'll see where we end at the end of the presentation for Q&A. And again, my name is Dr. Lisa Fortuna, and as mentioned here, I'm at UCSF. I am an adult psychiatrist and child and adolescent psychiatrist. I am part of the APA Council on Children, Youth, and Their Families, as well as an active member of American Academy of Child and Adolescent Psychiatry, where I chair the committee on systems of care and child-serving systems of care, and public health and mental health is one of my areas of expertise, as well as trauma. So I'm hoping to integrate how do we think about the pandemic during this time, and how do we need to think about that in regards to public health and policy, as well as our clinical practice? Again, what do we do now, right, in terms of where we are in the pandemic and the mental health crisis? These are my disclosures. I do not have any conflicts of interest to disclose. I do receive funding from NIMH, which I'll talk a little bit about, a project that we're kicking off that has relevance to today's topic. And there is some artwork that are youth murals in the Mission District of San Francisco, where San Francisco General Hospital is, and they're my personal photos, not copyrighted. And some of those photos are interesting to see what is on the minds of youth during these times, and I'll point that out as we see them. So the main objectives today are that we want to discuss some of the root causes of the child mental health crisis that we have all become very aware of in the last couple of years, and how that crisis or those mental health needs that were already increasing, were exacerbated by the pandemic. This will not be a comprehensive sort of complete explanation for the crisis, but I'll try to point to some things that I think we need to think about in what might have been some of the root causes and what we need to address. And then in that regard, we'll try to look at strategies. So hopefully you'll be able to specify at least three strategies for addressing mental health needs faced by communities disproportionately affected by the pandemic. Describe some evidence-based options for optimizing use of telepsychiatry, which we know has grown tremendously in use, technology, and other clinical innovations. And then try to think about a framework or discuss a framework for how do we integrate community priorities and advocacy for addressing child mental health needs during this time. And I really will emphasize the importance of that, increasing importance more than ever of including community in coming up with solutions. So this is a statistic that is very well known. You've probably seen this to a large degree, that mental health needs before COVID-19 were already a challenge, that one in five children need mental health services and among children living below 100% of the federal poverty level. Yes, more than one in five have a mental health or developmental disorder, but we know that most young people do not access mental health services and that Latinx and black children are less likely to receive adequate evidence-based mental health services. And the barriers and disparities were exacerbated by the COVID-19 pandemic. So what are some of the things that are underlying some of the difficulties in accessing mental health services? One thing that I want to emphasize here is it has been a stress system of care, the mental health systems of care for quite a long time now. What we know is that half of the counties in the United States do not have a psychiatrist or an addiction medicine specialist. Even in child psychiatry, we know that there's between 8 to 9,000 child psychiatrists in the nation to serve millions of children who may need mental health services. The shortages have disproportionately affected low-income consumers, as nearly one of four behavioral health providers did not see any Medicaid beneficiaries in 2020. The lack of behavioral health providers essentially has created a desert of mental health services throughout the country. This has also involved short staffing and often ill-equipped emergency rooms to deal with acute mental health problems. Patients are typically staying in inpatient settings when they do get there longer, as outpatient facilities also struggle to find workers to be able to have people step down to outpatient services. Health systems have scrambled to fill short and long-term staffing shortages, which were worsened by the COVID-19 pandemic, which I know many of you are probably well aware of. If we're looking at social media, if we're looking at some art to get a pulse, this is an anecdotal experience of a person trying to access mental health system and something that they put on Twitter, author unknown, trying to access the mental health system. You're either too well for us, apologies, this is the experience, or you're sufficiently unwell, we'll put you on the 12-month wait list, apologies, or you're far too unwell for us, off to the ED for you, apologies. And this is just really someone's depiction about the frustration that many consumers and communities are having, where they cannot get the service that they need at the right time, at the right level of care, and expeditiously. And this is something that many of you probably are well aware of. If we think about the narrative stories, what I would really want you to think about are, you know, if you're a mental health provider, a psychiatrist, a child and adolescent psychiatrist, the stories that you may have been experiencing about families at the start of the pandemic and now. A lot of the families like Clarita, a pseudonym here, but sort of depicts a little bit about the story, is, you know, a single mother who was working as a home health aide for clients, and in the middle of the pandemic had to figure out how to help her kids do their schoolwork, how to find family support, care, like childcare, and actually had to make a decision, Clarita, to leave her job because she was, one, afraid of catching COVID by working in people's homes and bringing it back to her children, and also she needed help in being able to support her children who were having to stay at home and having to do schoolwork, which caused a tremendous amount of economic or financial difficulties for her, and it was very challenging for her children, who at least one of them had a special educational plan to be able to actually, you know, help them in terms of their special needs. There was a lot of stress in the family. They had people who passed away in their family due to COVID, and so there was grief, there was a tremendous amount of stress, and now they're back in school, but the young people are still having, her children are still having problems with anxiety and stress. The school is overstressed about being able to support them, so this is just sort of an ongoing story that I think many of you have probably experienced in the patients that you serve, but how do we think about this from a systems perspective and for special populations in particular? You know, Clarita actually also comes from an immigrant family, and here's one of the murals that I promised to show where there was already this ongoing tension around immigration stresses and issues of, you know, communities who might be undocumented, and this was an issue for some families of even being able to access additional supports and services and food hubs because of their concern about their legal status or because of sort of experiencing discrimination around their immigrant, that they were immigrants, and so this was something that was also exacerbated and contributes to mental health during the pandemic. So if we sort of focus on some of those special populations, we know that approximately 5.5 million children in the United States have at least one parent who's undocumented. About 1 million are also undocumented, the child themselves, but 4.5 million are U.S.-born citizens, so most are U.S. citizens, and approximately 9.5 million people live in mixed status families, which include people who both are documented undocumented in one family unit. We know that immigration status, including undocumented families and children even before COVID-19, had met many, many challenges, but COVID created long-term detrimental effects on finances, housing security, food security, fear, and vigilance. Parents less likely to engage with teachers or be active in school or health services, that was already a concern, but even more, and there always has been a risk of even U.S.-born children of immigrant families being less enrolled in public programs and supports that they are entitled to. And then the pandemic only created more issues. I think, you know, this particular set of data are things that, again, people may have seen in their communities locally, people on the call, on the webinar. In the Mission District of San Francisco, which is the historically, the cultural center of Hispanic cultural communities in San Francisco, was disproportionately impacted by the pandemic. There was a study that this reflects between University of California, San Francisco, and communities in the Mission District, including support from the Latinx Task Force of San Francisco, that did a major sort of testing epidemiological study of the rates of COVID in the Mission District, and 45% tested Latinx, and 95% who tested positive were Latinx, so the majority of individuals who tested positive were of Hispanic or Latinx background. And the study further ascertained that congregate living, multiple housemates, which are indicators of financial stressors of people needing to congregate because of being able to afford housing, and then people sort of living together and therefore getting more infected, asymptomatic and sick contacts who had not been tested, and people who had to continue to work and couldn't sort of shelter in place, not eligible for unemployment benefits nor assistance from the coronavirus aid relief, and people like Larita, the story that we heard earlier, who had to sort of leave their jobs anyways for multiple reasons, including family and child care, who were then disproportionately impacted. And then that's not to even sort of state that increased rates of deaths throughout the pandemic in communities of color. And we know that, you know, Latinx minors even made up 70% of the cases in California, despite only 50% of the state's population, 50% of the state's population of children, so even the young people who had COVID. And this is sort of a graffiti, again, in the Mission District, please, please bless my family and friends and the entire global community, let no harm come to them. Gracias. So, you know, people, different surveys have started to, you know, sort of look throughout the pandemic and currently to sort of see what are some of the things that are still, you know, affected families and children throughout the pandemic. And then also, you know, currently, but if we look at the America's Promise survey that they did in 2020, what they found is that more than one in four children reported sleep problems due to worries, feeling unhappy. We know that the young people had a lack of peer contact and reduced opportunities for stress regulation and proactive and pro-social activities throughout the pandemic. But we also know that the pandemic, because of the stressors that were part of that, including the financial and loss and death and increased tensions and pressures on families, that that increased the risk for parental depression or domestic violence and child maltreatment. But even if we just think about parental depression, which definitely increased and is very related to child and adolescent mental health, based on their parents' mental health, we know that our services going forward need to look at this more critically about how do we support family mental health, parental mental health in our systems of care. Things could have been worse and were worse for a lot of children with disabilities, including learning disabilities, that may be continuing to have significant delays and struggles now that they're back in school. I think a lot of the school systems understand that there has been a lot of regression in learning and development for young people across the board, but most definitely for children who have learning disabilities. And then children who already have pre-existing trauma experiences, pre-existing mental health problems, migrant background, low socioeconomic status, we know that this was just sort of an added, the pandemic added to those difficulties. And it's not like it's just going back to better again, right? As we sort of start, hopefully, moving out of the pandemic, that we still need to think about the long-term impacts of these things. I mean, even if we think about sort of the mental health consequences of having COVID, what has been found in those individuals who already had pre-existing PTSD or depression or anxiety are more likely to have sort of a mental health sequelae of a long COVID course of mental health if they already have pre-existing stressors or mental health conditions to begin with. And that we need to learn a little bit more about what that relates to children. So again, what is sort of the substrate or factors that are really getting us to where we are? We know that there is a crisis in children's mental health. We've been mentioning that. And if we just consider though, before COVID-19, to think about what we may need to do now at this stage of the pandemic and afterwards, we know that there was an 104% increase in inpatient visits for suicide, suicidal ideation, and self-injury for children ages 1 to 17 years old and 151% increase in children ages 10 to 14. 50% increase in mental health hospital days for children between 2006 and 2014. Again, this is before pandemic. And 61% increase in the rate of self-reported mental health needs since 2005. Then the COVID-related stats, we know that what we feared came to pass, there was an increase in ED visits even more. The proportion of children's mental health related ED visits among all pediatric visits increased and remained elevated through October. 24 to 31% rates compared with 2019, the proportion of mental health related visits for children ages 5 to 11 and 12 to 17 years increased by that amount, approximately 24% and 31% respectively. And then one in four young children, young adults between the ages of 18 and 24 say they've considered suicide because of the pandemic. So these are young adults, according to CDC data. So that sort of points a little bit of a bleak picture during the crisis. And again, the price has been higher for Black and Brown children, many who receive, again, the wrong services or no services and wrong services if they do receive services and at the wrong time, much later in the course of their need or in restrictive or punitive settings like the juvenile justice system. 81% of the children on Medicaid are nonwhite. And we know that the suicide rate for Black children ages 5 to 12 is two times that of their white peers. And 70% of youth in California's juvenile justicism system have unmet behavioral health needs, as I was mentioning, and are dramatically overrepresented in that. So this is getting us to sort of what we need to think about in terms of what we need to do next, right? What we need to do now part of this presentation is really healing-centered care for all these issues isn't simply a matter of tweaking access or tweaking programs. It requires acknowledgment of the role of racialized stress and disproportionate impact and poverty in the social and emotional health of young people. And it also requires us to rethink how we're providing services going forward across our child and family serving systems of care. And again, this is sort of really pointing this slide into the importance of thinking about the, we all sort of became very aware of the racialized violence as a traumatic experience that became even more visible and paramount during the pandemic, which many people have called the syndemic, right? Sort of this constellation of disasters and trauma, right, between the pandemic and racialized violence that impacted communities and Black families being stressed by witnessing and experiencing racialized violence. It's not that those things were not present within communities and not quite, you know, very much known by those communities, but the sort of the magnitude of the structural racism and the imagery of violence against communities of color and particularly anti-Black racism has been shown in several studies to increase depressive symptoms and PTSD symptoms related to vicarious witnessing of these events like George Floyd and community trauma. So from a community perspective, if we look at communities of color, one of the things that we did in San Francisco is talk to the community and ask them, you know, what are some of the, you know, from the community perspectives, what are some of the priorities that communities have around mental health services? This is just one example, but we did some learning groups online on Facebook, what we call in Spanish, chalas, with the experts, which is what the little photo here shows, that we had on a weekly basis on talking about mental health services topics to help people throughout the pandemic. And we also talked to promotores or community health workers about what are some of the priorities that they saw in their community as they served them throughout the pandemic. And they were many of the things that I've been talking about that came specifically from them, and they're related to some of these social determinants of health in terms of financial stress and unemployment. But child mental health was really at the top of their priorities. Even some participatory action researchers in the community found that mental health was the number one topic followed by financial issues and interrelated with financial issues. Depression and anxiety, substance and alcohol, COVID-19 recovery, special education disruption, family conflict, and suicidality. So even from the community, what we see in our largest statistics, these were the priorities that they identified as well. So in terms of solutions, what are some of the things that the community felt were needed as solutions? And one was need for accessible and culturally appropriate care. That there has been inadequate finances for safety net settings is some of the things that we found that had to sort of be able to provide increasing services and mental health support for communities. Financially struggling community-based organizations that had to take up also a lot of the weight of supporting families, but that are under-resourced. I can give a very specific example of this, and you may have some in your mind as well. One of them was the mission hub. And again, in the mission district of San Francisco, this is a community organization that's a constellation of actually community organizations. So it's a hub where they've, throughout the pandemic, got funding and massive amount of volunteerism to be able to provide food, donated food, fresh produce on a daily basis to families who were struggling and not being able to put food on the table because of all the sort of unemployment or not being able to work throughout the pandemic. And so they were able to sustain that throughout the pandemic, as well as increased case management, mental health services that are integrated into the hub, but they're currently finding that they're not going to be able to sustain that funding to be able to continue some of the initiatives that they started. There's a lack of care coordination across systems. And so when we're thinking about child-serving systems, we're thinking about primary care, schools, behavioral health services, community-based organizations. Again, there's not a lot of coordination across these systems. And there's a technology divide, right, in terms of the amount of ways that people can access telehealth or innovative technology, which I'll be presenting on in a second, as well. And then there's a continued sort of, you know, fight for parity for mental health services and prioritizing that as a benefit for child behavioral health. So that's some of the things that, you know, are on the ground, and many of you may have experienced. And so the thing I'm going to start pushing us into a little bit now is the importance of us thinking about health policy as psychiatrists, as mental health providers, as being well within our purview of interest, because it really is the way to think about sort of how do we transform our systems to having health equity, but also to implement services that I will suggest that when we're moving towards health equity in these ways, we're actually improving mental health services for everyone, right? So that's one way to look at it, not just for communities of color or communities in poverty, but everyone, right? So this is a diagram of how we might think about this. There's this concept, which is implement health in all policies, which is one way to reach health equity. So what does that mean? That means if you have even sort of policies that are thinking about housing or policies that are thinking about sort of employment benefits and that kind of thing, we need to think about how health policy is related to those what might seem not health related, right? They see more other systems, right? Employment, housing, but we need to think about in all of those policies, how do we advocate for things that can have direct impact on health? So, because we know that those things have such an impact on mental health and health, right? And so that's one thing. The other thing is strengthening community capacity, right? So how do we work with our institutions, with community organizations, like some of the ones that I mentioned, like the Mission Hub, other community-based organizations, to be able to improve and strengthen their capacity to be able to provide these services, even if collaboratively with us. And how do we expand understanding of health and mental health and the multiple factors that go into that? And in doing these three things, we increase our social cohesion, we implement health in all policy approaches with health equity as the goal, we expand our understanding of what creates health, and we strengthen the capacity of communities to create their own healthy future. And that really is sort of an umbrella sort of framework for thinking about how do we get out of the mess that we're in, right? And I'll try to give a little bit more examples of that. There have been some additional surveys that show that, you know, schools, right, we know that schools are an important part of that community capacity building, right? And 63% of surveyed parents on this PIQE survey show that parents are concerned about their child's social, emotional, and mental health throughout the pandemic, and more and more data showing that that's even now. Only 36% reported that their schools were providing resources on social, emotional, and mental health supports for students. And this varies by state. I know that at least in California, there's been a lot of emphasis in putting increased funding for, like, LA County School District has increased tremendously the amount of social workers that they have hired that are embedded in schools, putting resources into wellness centers, which are school-based health clinics, and that include mental health services within schools. So these are some of the policies and things that people are trying to do to at least improve school capacity as a community resource and mental health resource to be able to provide for this need that's that's been clearly shown. So when we think about school policies as a legislative focus, some of the things that are out there, if our workgroup task forces on really looking at the data and assessment of needs within schools, increasing legislation that adds to workforce and workforce pipeline, workforce support to be able to provide these services, allocating funding to support school-based mental health services, as I was mentioning, tele-mental health, which is another thing that we can consider of whether, you know, psychiatry, psychology can sort of come into the schools through tele-mental health resources, providing mental health education and resources for students, teachers, staff, crisis hotline. It'll be interesting to think about how to use a 988 legislation around mental health crisis to integrate sort of school supports into that and having a crisis response policy and mental health professional psychiatry school consultation services. So these are all things that have been in several legislations and policy initiatives that we can advocate for as mental health professionals and psychiatrists within our local districts, right? Then there's the whole other issue that I wanted to bring up about the importance of being able to screen young people who may have mental health service needs, right? And it's something that's easier said than done. Only 14% of low-income teenagers, for example, on Medicaid received screening for depression and a follow-up plan, according to the Centers for Medicare and Medicaid Services 2020. And some populations are even less have access to this, right? For example, less than 6% of Indigenous youth received a screening and plan. And the real importance here is for us to be able to identify kids, right, or young people at the right time, right? So going back to sort of several slides back in terms of people not being, young people not being identified, not being provided the right services at the right time or the appropriate services at the right time. And screening is just the first step, but it's an important step. And again, many of you may know that it's easier said than done because, you know, there's several literatures that have shown that there are workflow challenges to screening within our different systems of care, right? Schools, primary care, for example, those wellness centers. And what people know is here are some of the barriers that have been found in the literature. At the level of screening and diagnostic by clinical staff, there could be, and there often can be, staff omission of depression screening. I didn't think the patient needed to be screened, you know, when things are not implemented on a universal level. TDS, PHQ-9, which is a depression screener tool, the workflow is tedious and and you have to sort of, you know, manually put it into the EMR and people miss doing that, you know, so there's a lot of space for omission and error in that step. And then there has to be a follow-up, right, which finding hidden screening results in the EMR, missing score interpretation, time consuming to interpret the results, and research patient management options. And if that, you know, that's not always reimbursed in every setting. Provider documentation and charging, incomplete documentation of results and therefore missed opportunity to capture appropriate charges when those are available. So for that reason, this is an area where there's a lot of, there's legislative opportunities here that we can, you know, sort of advocate for around making sure that things are reimbursed and that there are incentives for, especially in primary care settings and schools, to be able to do this screening and have the appropriate workflows and staffing for universal screening, right, because it's the first step. And when we're talking about primary care services, one of the things that we know is, you know, the APA has been very, very strong at advocating for collaborative care, which has a lot of research for adult populations and more and more for child-serving systems. And really what this provides is reimbursable screening, we were just talking about, and planning around behavioral health services and social determinants of mental health. So that's a critical piece, right? It's screening, and then it provides an opportunity for them having a plan. And if we look at this diagram, what we can see is that you have a pediatrician or medical provider who's supported by a psychiatric consultant and a behavioral health care manager that also work with the child and family, have shared registries to be able to look at screening and outcomes and follow-up and plans, and they work together to be able to provide those services within a primary care setting. So this is one of sort of the evidence-based ways to improve access to care, especially in this time where we need to be able to identify kids much earlier and provide the right level of care sooner. One of the things that's happening that I have here around eliminating need for diagnosis that's happening in California is that there is more and more a movement of not requiring, especially in primary care, a diagnosis, access one in the past, access one, so a DSM diagnosis like depression or major depression disorder or anxiety, but that there could be sort of what are more and more called Z codes, which were used to be V codes, which might be things like families experiencing significant employment or housing insecurity or distress, and the youth is experiencing some sub-threshold anxiety or difficulty with school. It also allows for more preventative services in being able to work with, say, a very, very stressed parent with a young child who could benefit from dyadic supportive services within primary care, and that those dyadic services could be reimbursed even without the child having a DSM diagnosis. So these are all things that are coming more and more into the forefront of being able to support families at different levels of care, and then the other pieces, the population health and prevention approach, where it can also happen in these collaborative care teams where the psychiatrist can work with the pediatrician in looking at a panel of patients and seeing that there's a population within the clinic that is experiencing these significant stressors like housing insecurity or depressive symptoms in parents, and then creating sort of plans and interventions for serving that panel of families in a more sort of holistic and targeted way so that you can help that community of patients in the clinic. So those are ways that those things can happen. So when we're thinking about this, we really think thinking about legislating the integration of systems of care so that we can do more of this sort of, I'm going to call it more expansive collaborative care models, right? So moving away from practices and regulations that silo clinics and social services and instead promote these kinds of integrated collaborative approaches. Healthcare regulations and reimbursement strategies should help structure collaborative care and prevention strategies across sectors, and taking advantage of technological advances that can support these cross-sector partnerships. For example, telehealth can help support a collaborative care model either in primary care or let's say in schools, right, where we have someone who is leading the services and you have psychiatric mental health consultation, case management supports, and even sort of interacting with community-based organizations that might be able to provide other family-supporting services. And this is where I, you know, I even here I'm talking a little bit about that, right? The examples of integrated supports, another thing that has been integrated into a lot of programs are family navigators, peer support specialists, case management, integrating substance use treatment, which is another siloed program into mental health services, improving community treatment and prevention programs, and then support around the perinatal continuum, which relates to a little bit about what I was talking about in terms of, you know, how do we move from OBGYN services and prenatal care to perinatal services and postnatal services in pediatrics that follow a family and help them throughout different points of stressors and mental health need, not always needing a diagnosis, for example, but being able to address significant stressors that might have an impact on mental health and functioning and child development. So, a lot of these examples that I'm talking about are sort of being pushed more and more in the legislation of my integration and continuum of care, right? Earlier access and prevention being more of the focus and being able to use a diverse workforce, right? Working together that stems from physicians and primary care doctors to case management to paraprofessionals and peer navigators and family navigators, all working together, right? So, what I want to end us with is a little bit about, well, how do we think about some of this innovation as clinical interventions, which are inclusive of some of these practices that might help? So, research priorities is one thing. I've been talking a lot about some important innovations that might be in the forefront of our minds, but there are some definitely research priorities that I think have emerged from COVID-19 that, and some of these have been listed in a recent article in the Journal of American Academy of Child and Adolescent Psychiatry, which really, which I put as a reference later for you to be able to review more closely. But one important thing is the importance of documenting the impact risks and protective factors through epidemiology, surfaces, surveillance, biomarkers to understand how the COVID-19, in terms of children, has impacted child mental health, cognitive development, learning over the long run. You know, who are the children who are at most risk? I gave some examples of some indicators of who might be, but we need to sort of have some really clear data to be able to, again, funnel or focus our attentions to those young people. What are some resilience factors, which I think are based in the community? Clinical services access and equity issues at this stage, and what are the outcomes of that? And then it's around developing and testing interventions, prevention and services. How do we create prevention and community interventions? How do we create clinical and service systems interventions that relate to all these things that I've been presenting? And then how do we sort of even support even more school interventions, which is also a very stressed system. In California, at least, or even in a locale in San Francisco, there are some school districts that are down 100 to 300 teachers, right? Which is an overwhelming thing because that's another workforce that's a great loss of people coming into the workforce and also leaving the workforce. And then, you know, you probably have heard a lot about sort of the importance of telepsychiatry, right? and digital interventions. And one of the things that I noted even before the pandemic, and I'm trying to pay attention very carefully when we're thinking about disparities, is I had a PCORI-funded grant, and what we found is that there was real issues in equity of families who are Spanish-speaking or who there was a belief that they had a digital, lack of digital access. We tried to create a digital CBT intervention, Cognitive Behavioral Therapy intervention, that could be used even asynchronously as another supportive tool and extension of mental health services where a provider, a therapist within primary care, for example, could do some coaching, but also provide this asynchronous intervention that families could do together around Cognitive Behavioral Therapy, anxiety management, depression, anxiety, and as an extension of things that people could do at home as well as get support in the clinic. And the clinicians were not so sure families could successfully participate if they were Spanish-speaking or if they felt that they did not have acceptability of digital asynchronous CBT, that they have computer technology challenges, and that they required high levels of literacy for families to be able to do that, right? And so one of the things that we did in research is talk to families about how we could make this tool, this resource, at least available to them, right? And what this, and then again, sort of research that asks families and communities, how can we do it? They said that they needed a technology orientation and support. And if they got that, they could do the intervention that was digitally offered, right? It had different modules that they could do around anxiety management, what's anxiety, for example. If they got orientation, they felt they could do it. Patient family check-ins with the therapist prior to starting using the digital tools so that everyone was on the same page and the therapist knew how to coach them throughout it. Workflows assuring that the same therapists did the intake and the coaching so that there was this continuum of care, even if they were doing things alone. And coordinating between English-Spanish versions with language support and dyads. That was the one thing. There was a Spanish version and an English version of the asynchronous intervention. And they sort of, the families kind of worked with us on how to work with, if the parent was more Spanish-speaking and the child was more English-speaking, how they could use the tool together. And we came up with some creative ways to do that. But that's just to sort of say that there is a way to do these creative interventions with communities that people think may not be able to do so if we work with them, right? And throughout the pandemic, I sort of checked in a lot with my families that were Spanish-speaking and how they were doing with telehealth. And this is just one quote. We're fine. We've had so many losses, but we're still here. When I first heard about telehealth, I wasn't convinced. Once we had to do it, I tried it. I'm starting to think it's good. We have a tablet, like an iPad that we share. We take good care of it. My daughter is getting better. We learn together as a family. This is just in Spanish that I wanted to represent the same quote. And so when we were doing even the telehealth intervention and with this asynchronous modules, parents were saying they're feeling more knowledgeable about their child's anxiety, feel more empowered in them coaching their child. They liked the family-based approach so that everyone was learning and benefiting from the stress management skills and the CBT, and there's a randomized trial underway. But it's just sort of a way of sort of thinking clinically about how to sort of bridge what might seem sort of deficits of families being able to use interventions and working together with them that I think we need to do more and more. And I won't get into this too much, but I think one of the ways that we're thinking about sort of this quality improvement, both in research and in quality improvement and just in clinical services, is using sort of frameworks that help us work with families and communities around implementation, maintenance, reaching and effectively adapting interventions and asking questions with our providers and our teams and our patients. How do I incorporate the intervention? How do I reach the target population? How do I know my intervention is effective? How do I develop organizational support to deliver my intervention? How do I ensure the intervention is delivered properly? And these are sort of questions that we go throughout with all of our stakeholders at each level of sort of creating our interventions and quality improvements, even like screening, right, to be able to sort of do that. And so one of the things I want to end is with a little bit of a concrete example. We got a digital, we got a grant from NIMH that's a transforming disparities grant and led by here at University of California, San Francisco and UCLA with colleagues there who were working with the LA Unified School District and Cheryl Cateopa is my co-PI in LA. And we're basically, you know, this is sort of a busy diagram, but it's just one example of how we're creating a digital navigator app, which improves around sort of screening, provides, it's sort of being co-designed by youth, with youth and as well as clinicians in schools and in primary care here in San Francisco, where we're getting community leader input, youth navigators that we're hiring input, family navigators and multi-stakeholder advisory groups to be, you know, sort of co-developers of this app that will provide different tiers of behavioral health. So going back at that right care at the right time helps with the screening process and the workflow, helps with having a navigator or peer who's helping you navigate through the tool, has a lot of wellness and prevention interventions that are gonna be created, as well as sort of tiering up young people who might need more attention from a clinician and helping to sort of, you know, screen and triage what higher level of care that they might need. But the main thing it's embedding screening tools, it's embedding stakeholder selected apps and interesting wellness pieces and prevention pieces and an algorithm for triage of prevention, treatment and maintenance. So it's a way of sort of implementing this kind of model of integrated care as well as community engagement and collaborative work together through digital supports and working with families and communities to do so. So we have a once in a generation opportunity to address the crisis, right? That was already present before the pandemic. A lot of the public opinion policy maker agendas, some of the things that we've been talking about are aligned, at least in California, there's a new administration has stated, the administration has stated a focus on children's wellbeing and it's expressed interest and willingness to engage. Community knows they do not have enough mental health providers to serve local needs and are part of the partnership and advocacy for that. There's emerging consensus and consciousness of the impact of adversity, structural racism and the pandemic on the social, emotional health of children. So I think, you know, my sort of urgence is to take advantage of this moment in time to embrace the critical need, to reform our financing and delivery models that they're more healing, they're relationship centered, they're collaborative and adapt a concurrent but aligned paradigm shift across child serving systems so that these kinds of models are intersecting across the systems, schools, community, primary care, behavioral health, where kids are served. So the main takeaways are we really need, how, what do we do now? Part of the intervention of the presentation, you know, interdisciplinary multi-sector collaboration, trauma responsive, comprehensively promote child and family health, multi-level implementation strategies, systems of care that account for clinical, organizational, social structures, relevant to child mental health that we need to transform, need to empower community stakeholders, address their needs, build capacity for community and academic partnerships for innovation, promoting parenting competencies, positive peers, caring adults, positive community environments. And again, that sort of piece that I talked about earlier is the health policy development with health equity as a goal. That really helps all people, right? When we do that. So these are references that you have in your handouts. It goes a little bit more into detail about technology delivered interventions, impact on communities of color, ways of implementing stakeholder collaborations, issues of inequities, the research focus that we need to have right now and how to implement sort of advocacy around these policies. So I think we have time for questions and answers. So I was told to make sure you've been submitting questions or submit questions now, if you have them, because we have a little bit of time for that at this point. All right, well, thank you, Dr. Fortuna for an amazing presentation. Everyone in the audience, my name is Ben and I work at APA. And so what I will do is pop off mute and facilitate the Q&A section. So if you all have any questions, please feel free to submit them in the questions area. And Dr. Fortuna, we'll just jump right in. So someone actually asked this question in the chat. The question is, where is the behavioral health provider in the collaborative care team? Ah, yes. Okay, so that's a good question. So in the collaborative health team, you're right. Often what is part of a collaborative team is the integrated care part, right? So there's two elements. There's the integrated behavioral health services and then the collaborative care. And so often the thing that makes things work the best is when you have embedded behavioral health clinicians within primary care that work with case management and the primary care provider within the primary care context to provide services. And it can have the, obviously the psychiatric MD consultation, for example, but when you have an integrated care model where you can actually provide brief interventions and supports right in the school, I mean, right in the school pool in the school or in the primary care setting, that's where the behavioral health clinician is. We have some of those in our clinics. And I think increasingly so, having the embedded behavioral health clinicians right in that setting to be able to provide brief interventions. Awesome, thank you for that answer. Well, one comment that I am seeing is it's nearing the top of the hour. So folks might be jumping off and you have several people saying great presentation. So I just wanted to point that out. The next question is, it's a bit of a long one. So with 63% of parents surveyed concerned about the lack of socio-emotional support, can you speak to the experience of educators who are facing pressure from other parents insisting that the schools remove socio-emotional education from the schools entirely? And then the comment, it's concerning that at a time of such need, there's some actively advocating for removing these services. Yeah, it is alarming, right? That people are advocating for removing these services. And I don't really understand what the impetus for it is. I think, you know, what we have found, which is sort of embedded in the question is that teachers are facing tremendous amount of pressure and stress themselves, right? And don't want to, for example, have to be the providers of mental health services on top of everything else that they're doing, which is why I think there's some legislation that's trying to look at, you know, what are the mental health services needs in schools right now? And what are the people that have to be implemented at least in wellness centers and providing direct mental health services to youth within schools, including tele-mental health as being an option. How to sort of build additional resources, right? I think that's where the legislation is going within schools because they're completely stretched. I think there's still a need for social-emotional education to sort of support teachers in their everyday practice, as well as sort of the school environment. That's more of a public health intervention. But I know there's a need to build more resources and advocate for that around actual mental health services within schools. It's hard for me to understand the rationale for wanting less of it. But that's all I can say. There's need for more resources. All right, the next question is, do you believe the integrated support models and working with community also helps with any stigma any of these families may hold? Yes, so some of the things that we have found is that as we integrate behavioral health, for example, more so into primary care or wellness centers, we do find that it tends to de-stigmatize it. People are much more willing, we find, to be able to get those supports from their primary care setting, for example, than to immediately say, okay, go to psychiatry, right, or behavioral health services. When we do integrated support models within community-based organizations, which we're trying to do more, and the community is asking for it, to have wellness groups or depression groups and that are culturally relevant and integrated within the things that they're doing to support the social needs of families, that is much, much more acceptable and not seen as just psychiatry and for crazy people. And people take on to it very well. All right, this next question is specific to San Francisco, where you are. So how are San Francisco emergency departments implementing mental health services to children and their caregivers presenting with a mental health crisis to decrease stays in the emergency department? So this is a big issue, it's a big problem. Increasing use of emergency departments is a thing. I mean, one of the things that the city, I know, is doing is trying to increase the capacity for mobile crisis, crisis stabilization units, intensive outpatient programs, partial hospital programs. I mean, anything that's sort of a lower level of care than inpatient services, because we have very little inpatient services. And we're trying to create more beds for that, for inpatient child and adolescent services. But even with that, I think the thing is to really sort of build out more of these sort of crisis, community-based interventions, so that kids don't have to take the emergency department as their go-to place, as well as sort of these brief, crisis units that can sort of follow kids for a week or two and stabilize the situation and then connect them to outpatient services. So there's more and more funding going into that, sort of move people into that, sort of move people away from the ED as their resource for crisis. Awesome. And this next question pivots a bit to the clinician burnout topic. So there's a concern that distancing psychiatrists from direct patient interactions through models like collaborative care or telepsych can actually increase the possibility of burnout. So how do we utilize our psychiatrists in the systems while not burning them out? Yeah, I think, and I know exactly what you're saying, like, you're sort of doing all these consultations from afar and just writing your consultations into the portal that you're providing your recommendations in telepsychiatry after session after session and not having that sort of patient-human engagement, which I do think is important for us as mental health providers, right, and as psychiatrists. I think the best way to utilize psychiatrists is, and this is what I try to do in my faculty and people who work here, is you have to make it variable, right? Like, I think all of us can take a certain amount of sort of telepsychiatry, but I feel like it needs, and most of the faculty and staff that we have here like to have a balance of, but I also have some in-person sessions, right, where I'm actually engaging with families still and having that balance, as well as having some hours where I'm providing, you know, maybe a consultation online or sort of some telepsychiatry consultation. And then also, if we can work as teams, I find that a lot of psychiatrists who are working in these new models like the idea of having multidisciplinary teams that you can talk about cases and support one another and actually have that sort of direct contact as well. I think the more we sort of just automate like what we're doing and from a distance, there might be more burnout, especially with more and more sort of documentation. I think you have to create a balance of like work activities and meaningfulness for psychiatrists. And I think the more and more they're engaged with community members too, who are also working towards improving this, or again, there's multidisciplinary teams, I think it becomes a supportive team for everybody, right, in being able to be successful. So I think it's a balance of not having too much of one thing, right, and having that human contact, I agree. Thank you. All right, the next one is, what are your thoughts on the research direction? So what needs to be done? What needs to be done more? And then what could be some of the challenges for researchers? Yeah, so I think, you know, as I was mentioning on that one slide, we need to still have sort of, some research has to be continued epidemiological surveillance of what is really happening with youth mental health within schools and within primary care and behavioral health services, emergency department, like we need to keep our finger on the pulse of that sort of rates and epidemiology and patterns of care need and diagnoses so it doesn't just wander off on us. And then I think the other piece is more research on these innovative interventions and cross-sector interventions, right, that we need to sort of de-silo around mental health. And, you know, it's challenging because we are not, our mental health, our health services, this is a challenge, are not structured to be de-siloed, right? Like we have reached our system. So there's legislative stuff and policy stuff that sort of can facilitate those kinds of programs that we need to push. The good news is, is that like the National Institute of Health actually is putting a lot more of these requests for proposals that are these kinds of systems of care, innovations, technology innovations, digital innovations, that's becoming more and more an area of interest for NIH. They just put out another call that was called Compass that is actually funding for community organizations to lead research and innovation in collaboration with academic partners. I think there's a lot to be gained from these new opportunities. I do think where we're hit the most challenges is do our systems of research and clinical services, can they flex and bend and change in their structure to be able to encompass these new ways of working together with communities and other agencies? I think that's where at least I'm finding some challenge of bending those structures enough to be able to have these creative approaches. Wonderful, well, the remaining comments are comments rather than questions, just saying thank you for an amazing presentation. So Dr. Fortuna, thank you so much. That's it for questions. I'm not seeing any others submitted, so I'll pass it back to you for any final comments, before we wrap up. Great, so thank you, everyone, for your participation and hanging in there. And I do think even though I had a lot of negative statistics, I do think that there is an opportunity for doing things better, not just going back to normal, but doing things better. And your ongoing persistence and advocacy, all of us together, is really critical. So I just want to, with an ending mural from a young person in the mission again, thank you.

Dr. Lisa Fortuna

COVID-19 Pandemic

Child's Mental Health Crisis

APA

Emerging Topics webinar series

impact of pandemic

mental health services

disparities in care

behavioral health providers

integrating mental health care