We're going to get started so that y'all can go home early. You guys are awesome for being here. You're making my day. Thank you. Especially because this is not like a shiny, happy topic, so being the last slot on the last day, it's kind of a bummer, but it's okay, it'll be all right, I promise. So in terms of disclosures, is this really loud or is this just me? Okay. I feel like I'm shouting. It could be the emptiness in the room, except for the cool people with water bottles. So this is my funding, I do not have any financial disclosures, I'm not going to be talking about medicines. And I hope, especially with this size group, that a lot of what I'm saying is really preaching to the choir. So these are things that you have heard potentially reshaped in a different perspective. So just in terms of outlines, I'm going to talk a little bit about the current state of disarray for child mental health. And I also want to reframe the phrasing. So we keep calling it a child mental health crisis, I really think it's a child mental illness crisis, or a lack of child mental wellness, but that's a whole phrasing and language thing that I also think is really important. I'm going to talk about the historical contribution of violence and racism and structural inequity as the foundational roots of where we are and why we are here. And I'm going to present some biological and psychosocial data on the effects of violence and racism, some really important implications for treatment and how we think about this in terms of our next steps, and then really outline what I think is an important call to action that uses some public health-based models to outline what I expect is going to have to require transformational and just stepping out of all the boxes we've spent a lot of time in. So as many of you know, the AAP and the ACAP and the Children's Hospital Association of America all set out a joint, hello, there's a mental health crisis. And you can see that the leading cause of death is now firearm-related injuries, and the third leading cause of death is drug overdose and poisoning. So we now have one in three, as opposed to, you know, not being in the top five. And the shape of these curves is not good. So the scope of the problem is that rates of suicidal ideation, sadness, hopelessness continue to increase in the pediatric population. We have a national boarding crisis where we have hundreds to thousands of kids sitting in ERs, which is not a therapeutic environment, and in fact, it's probably damaging, awaiting higher levels of care, and this is a problem that is facing everywhere. I will say that at Boston Children's, we are exceptionally good at the boarding crisis, meaning that for the last decade, we've had 10 to 15, and over the last three or five years, we have had upwards of 50 to 60 kids boarding, either in our ED or in our inpatient med-surg units, which is an impressive number when Massachusetts actually has the highest number of mental health care providers per children. So there is cracks and fractures in even our most well-supported system that are leading to these problems. We have a workforce shortage that is now further synergistically impacted by burnout, and this is workforce at every level. It is not a surprise to any of us that this is happening, right? So for anyone who has been in psychiatry, we've said, hey, guys, we don't have enough providers, we don't have enough providers, we don't have enough providers. Even if every training program for social workers and LCSWs and nurse practitioners and child psychiatrists were filled, we will continue to be short with the current rates of child mental illness, which are upward to 30, 40%. So this is no longer a small slice of the population. This is one-third or greater of our pediatric visits to outpatient general pediatric practices, as well as our ED, our now mental health visits. And it's not going to get better, because our world is unstable. So please note, the pandemic didn't cause this. The pandemic might have made it a little bit more apparent. But the roots of instability, of violence, of natural disasters, and even school shootings. So I have this up here, but this is the shootings at school, high schools, since 2000. There's actually a map that tracks mass shootings, and I'll show you some pictures from that. So what I am going to start with is a really not a pleasant conversation. The roots of inequity and violence and racism are fundamentally embedded in our system and our political structure. And you can actually continuously trace rates of violence across every state and every major city in the United States to redlining. The structural disinvestment and the lack of support to create equity at the level of property ownership, schools, taxes, continues to lead to these types of maps. I'm going to walk you through this. The first one, let's see if this works. If you look up here, this is actually the rate of current and violent crime in Boston. And I get to pick on Boston and New Orleans, because that's where I am. But this is the same that you would see in Detroit, in Chicago, Baltimore, pretty much every big city. So if you look at this bright red spot, this is the rates of current violent firearm violence. And the map below, the red areas are the areas that in the 1930s were structurally disadvantaged. It was next to impossible to get home ownership loans there. And the green areas were areas where it was easier to get loans. It also happens to map onto socioeconomic disparities as well as continual racial disparities. So just like every other major city, Boston has huge racial and socioeconomic inequalities that have been perpetuated by our political structure and the lack of investment in those regions that still overlies our rates of violent crime. In New Orleans, we did the same thing. And what you actually have over here, it's not up there yet. This is our map of violent crime. And what's next to it is our mortality gap. So in New Orleans, we have a 25-year mortality gap. Does anyone want to guess the distance between that number, those two numbers? So this little number here and this number here, in terms of physical distance? It's about five miles. So that's an incredible mortality gap. And when I look at that, that is not due to death by violent crimes. That is due to cardiovascular disease, obesity, diabetes, and other leading major causes of death. So the legacy of racism is present today. This is a red-limbing map of New Orleans here. And this is... I can't read this because it's not coming up on my screen. But one of these is neighborhood violence, one of these is domestic violence, and this last one is actually stop-and-frisk rates. And if I overlay that over our mass shooting index, this is the national map for shootings, mass shootings. And what you'll see is those bright red areas that were created by redlining and continue to exist are the bright red areas for all of our violent crimes, for our stop-and-frisk rates, as well as for areas where mass shootings are occurring. These are fundamentally rooted in structural inequity. So what we're going to talk about now is the biologic consequences of trauma, racism, and violence, both within and across generations. So when I showed you that morbidity and mortality map, I was trying to highlight the fact that there are health consequences to these locations that we have disadvantaged for generations. And we're going to talk about data about dysregulation in the HPA axis, the autonomic nervous system, the hypothalamic-pituitary-gonadal axis, and the cellular stress system. We're not actually going to talk about the immune system, because that would keep you guys here for days. And as much as I know you would like to stay and hear about depressing stuff like this for days, we're not going to do that. But the point of this is that the next sets of data are really outlining the biological consequences of exposure to racism and trauma, and the fact that we can track it both across individuals and across generations. So one of the models of how racism and violence influence health is through an accelerated aging model. So Arlene Jeronymous actually proposed this in relationship to women of color, and specifically for preterm birth rates and low birth weight, suggesting that the impact of being a woman of color and the embodiment of the stressful experiences of continually being exposed to microaggressions, to both large and small exposures to discrimination, is leading to over-activation of our stress response systems and an acceleration of the aging process. That is all driving the onset of health-related diseases like obesity, diabetes, and cardiovascular disease at an earlier age in women of color. And also is influencing their risk of preterm birth. So what we know is that for certain cellular markers of aging, we'll talk a lot about telomeres because they're my favorite cellular marker of aging. It doesn't mean they're not other markers. Martin Picard has very wonderful data that sort of overlaps a lot of this related to mitochondrial function. These just happen to be my favorite. So telomeres are the shoelace cap at the end of all eukaryotic chromosomes. They're actually highly evolutionary conserved. So they actually exist in yeast all the way up to us. The similarity in sequence between the rhesus macaque and us is 100%. So I can actually amplify and measure telomere length the exact same way in a primate model that I can in humans. They serve as sort of biologic sensors for metabolic dysregulation, ionizing radiation, and physiologic stress response systems. They're actually also trigger terminal differentiation. So one of the things is that in the brain and in the kidney and in the heart, the length of telomeres actually differentiates when our stem cells become sort of their end point. So nephron progenitor cells will turn into nephrons. Oligodendrocytes will enter terminal differentiation based on telomere length. So if we have processes that are accelerating telomere length loss, we will actually lose some of that extra kind of plasticity or reserve that comes with having stem cells. So the first thing I'm going to talk about was actually a dental study. So this was associated with the School of Dentistry. We did that so that we could get spit because if you're getting your mouth looked at, you're going to be okay with spitting. And so we went in to do oral exams and recruited kids just from a population-based measure throughout New Orleans. So if you've ever been to New Orleans, this is actually why we're called the Crescent City. So that's the Mississippi River makes a crescent. And you saw maps of this earlier. So that little gray spot in the middle is actually the Ninth Ward. It's one of our highest areas of both structural racism and violence. And if you look at this figure, this is actually our rates of violent crime. And this was in about 2016, I think, is this one. And so you'll see that our kids very much overlap many of our high-risk areas. We recruited, this was a community-recruited sample of 5 to 15-year-old African-American youth. And we looked at the impact of multiple stressors on tenor length and on cortisol and on psychopathology. And what we identified was a direct effect of neighborhood violent crime. So this is crime data obtained from police reports at the one-mile and five-mile radius around the child's residence. And it strongly predicted tumor length in these kids. And it also predicted acute cortisol reactivity during a social stressor task. So we had these kids come in. We told them we were going to make them give a story and do some math. And we let them sit in a corner. And then we had them come and stand on a stage like this, put a bright light in their face, and took a bunch of undergrads in white coats and put them in front of them and had them start at 14,972 and subtract 13 as quickly as possible. And every time they screwed up, we said, I'm sorry, that is incorrect. Please try again. And then after we did that, we then had them tell a story. I will say that about 50% of these kids could have cared less. And about 50% of my RAs from my undergraduates were really distressed and sometimes cried. So it was distressful for both the people who were performing the TSST and for the people who were supposed to be the stern people making the other people upset. Social evaluative threat is one of the best and most established methods for activating both the autonomic nervous system and the hypothalamic pituitary adrenal access of generating a cortisol response. And so these objective measures of violent crime. So this was both all violent crimes. So this is robberies, armed robberies, gun violence, assaults, as well as domestic violence rates. We're all associated with changes in cortisol reactivity in these kids, as well as telomere length, as well as externalizing disease. And this is actually what you see. So normally when we stress children, we get a very lovely activation. So it's a blue line where you see an increase in cortisol and then a decrease in cortisol during the social stressor task. As we increase the amount of violence in their neighborhood, we flattened that reactivity. Now cortisol reactivity is really important for learning, for attention, for physiologic function, for social engagement. So activation of cortisol allows you to be alert and oriented. For me, it's allowing me to gaze off into the room and see who's still awake and who needs to be like poked to keep awake. And it's also calming down my autonomic nervous system. So my voice is going to get a little bit less shaky as we go along. So the activation is really important. And what this is suggesting is that this objective measure of violence in these children's environment, it's changing that pattern. What is even more important, it was also increasing maternal report of externalizing behaviors. And none of those pathways were mediating, meaning that the alteration in telomere length, the alteration in cortisol, and the elevation in externalizing were completely separate pathways. Why would I care? Because I treat symptoms as a clinician. And so if I treat symptoms and I treat trauma, and I think that the disruptive behavior that sometimes accompanies trauma gets better, but I don't measure cortisol, and I don't measure the autonomic nervous system, and I don't measure cellular stress, I may be fixing one third of the problem and leaving the altered biologic imprint of exposure to violence untreated. I don't have that answer. So there are also more insidious forms of violence. And I will say that they are actually more prevalent in the South, in part because of the ties to different perspectives of parenting. This is actually, Elizabeth Grishoff has done a tremendous amount of work about corporal punishment. And one of the things that we know about corporal punishment is it is the primary pathway leading to physical abuse. And if you look at this, I don't know how well you guys can see it, it's also a primary pathway for predicting externalizing disorders, aggression, and violence as adults. So the use of corporal punishment in meta-analytic studies is bad. It actually decreases executive function, it doesn't correct behavior, and we have two decades of research to support that. Why does it become a problem? Because if we look at parental perspective of the use of corporal punishment as a disciplined strategy, you can see the lovely rates. This is by gender, with orange being male and blue being female. This is across the last 30 years. Even at this point, about 50% of parents endorse the use of corporal punishment as a disciplined strategy. And if you look, there's a difference by age, so greater amounts suggest that it's okay to do in two to four year olds than it is to do in teenagers. I would suggest the reason it's bad to hit teenagers is they're going to hit back. But it's bad to hit everybody. And it's in training in people that violence is a way that you deal with behaviors you don't like. And it's also in training in the heads of young children that it's okay to hit people that you care about, that are supposed to keep you safe. None of which is a good perspective. When Kathy Taylor did a bunch of work looking at this as a social norm, she asked families, where do you get advice about discipline? And the vast majority said either the religious leader or pediatricians. So she promptly surveyed pediatricians about their perspectives about does spanking lead to negative outcomes? And so most pediatricians in the study in the late, it was like 2017, 2016, agreed that it had negative consequences. The problem is that about 30% didn't think it had negative consequences. So two decades of meta-analytic work suggesting that corporal punishment has negative consequences, primary source of people suggesting it's okay or whether or not it's okay are pediatricians. And 30% are saying it's okay. It doesn't have any negative consequences. And then when we look at does spanking lead to positive outcomes? Again, most pediatricians agreed with the evidence base, which it doesn't. Like it's not a great behavior strategy. And yet 30% of pediatricians think that it does. It does have positive outcomes. So even within the population that is supposed to be providing information to parents about the use of corporal punishment, we in the United States are still having 30% of our pediatricians endorse it and 50% of our parents endorse it. This is a global map of all of the countries that have banned corporal punishment. It's actually a World Health Organization initiative to end corporal punishment across the world because it's bad to hit children. What I'd like you to note is all of the yellow countries have full prohibition against corporal punishment. And the dark blue, permit it. This is a map of the United States documenting the 19 states that actually legislate how to beat children in schools. In Louisiana, we actually document what you can use to hit children with, how you document it, and distinguish it from child abuse carefully, parish by parish in Louisiana. In 2016, it was a huge accomplishment because we banned beating children with developmental disabilities in schools. Yeah, that's great. That's where we go, Louisiana. Yes, we got it. What I also want to point out is if you were to look at the map of mass shootings in 2022, and you look at that bright orange-red area in the Gulf South where I live, there's a lovely overlap between the increase in mass shootings and the areas that are legislating how to beat children. Now, this is correlation. I'm worried that if I were to study this long enough, I would end up with causative pathways. This is a huge thing to be aware of, that we talk about neighborhood-level violence, but if we have meta-analytic data saying that the use of corporal punishment leads to more aggressive adults and are more likely to use aggression as a means as adults, in the areas of our own country that legislate how to beat children in schools, we're seeing greater numbers of mass shootings. So, what is the impact of racism itself on adolescent health? So, first of all, let's talk about the population problem. Black youth are exposed to more weapon-related violence. They are more likely than white to be threatened by violence, more likely to be victimized by white children. They are more likely to be exposed to multiple types of violence, so neighborhood-level violence, violence within the home, and violence in the school setting. And 61% of black youth in a national population study experienced one ACE compared to 40% of white children and 51% of Hispanic. So, children who are of color in the United States face huge increases in exposure to every type of violence. And that's not including racism. And so this is Sanders and Phillips' conceptual model of the impact of racial violence on child development. So, children of color are exposed to racial discrimination, and it changes over the course of development. For girls, the two highest time points for girls in terms of exposure to racism are pubertal development, when African-American girls are treated and more adultified, so they are considered, because of their physical development, to be more adult, and so therefore exposed to a substantial amount of discrimination from that perspective. And the second-highest time is during pregnancy for women of color. For male youth of color, it is in that adolescent transition and young adulthood. So, we are taking huge, really important developmental time periods and overlaying increased risk of exposure to racism and discrimination. The effects of biologic things, so perception of threat, fear, and hypervigilance, so always being unalert. So, racial socialization is a method used by families of color to learn to do things differently. So, if you are a youth of color in Louisiana, you are taught to keep both hands on the wheel when you see a police officer. A very good friend of mine's son was playing with squirt guns in a parking lot in Atlanta, and the father almost tackled him and said, you don't get to play with squirt guns, because he is much more likely to get shot. So, this idea that this changes how these youth interact with the world is incredibly important. It can contribute to loss of self-efficacy, loss of self-esteem or hopelessness, and certainly increased anger, frustration with the world around you, depression, and anxiety, all of which we know influences the physiology. This is going to be buffered by parental interactions as well as community support, and that will influence the outcomes that follow. And this is actually work by several of my colleagues in Louisiana, so Samantha Francois and Kat Theo, where they looked at the impact of exposure to racism on externalizing and aggressive behaviors and the moderation by civic engagement. And so what is important to see here is that, so this is looking at the direct effect of racism stress on aggressive behaviors, and so we don't see an impact of racial stress, of how much you are bothered by it, on your risk of aggressive or externalizing behavior, but we do see aggressive behavior being predicted by exposure to direct exposures to discrimination, and that that is moderated by the amount of civic engagement. Why is this important? Because when I think about solutions, one of the things in my head is to create peer networks and peer mentoring networks. And so if civic engagement can buffer the impact of racism on risk for aggression and externalizing behaviors, this may be an even more impactful approach to helping protect children of color. What about, so at the beginning of the talk, I talked that we'd say the effects of racism and violence within, so we've talked about the effects on the HPA axis, on the telomere length and on externalizing behaviors within generations and buffering by social engagement across generations. So this is a study done looking at the impact of a mom's experiences of discrimination in pregnancy. So remember that I said earlier that women's risk of being exposed to racism are highest during pregnancy. So what this is showing is that discrimination during the second and third trimester of pregnancy is one of the most predictive factors for social-emotional development of her child at six months of age. So mom's own exposure to racism and discrimination is influencing the social-emotional development of her child. And so then we wanted to look at this in terms of the effect of mom's exposure to adversity, discrimination, both prenatally and preconceptually, and how that influences the physiologic development of incomes. So this is a study that we completed about five years ago. We recruited women of color prenatally. We basically tracked down every pregnant woman we could see, and we would say, hey, you want to be in the study? I've got all this cool swag. It had turtle logos and all those things. And we interviewed moms prenatally. We collected birth outcomes data. We brought the children back at four months, 12 months, and 18 months, and then ran out of money because NIH didn't refund it. But we wanted to go further. And at four months of age, we measured autonomic function during a stressor that I'll talk about with Ben. And we measured telomere length across the first year and a half of life. At 12 months, we did the strange situation procedure, so a measure of attachment, but it's also a stressor to the child. So during that, we measured cortisol. And then we measured life events across, as well as behavioral problems at 18 months, using the ANSI, which is the Infant-Toddler Social-Emotional Assessment, developed by Margaret Briggs-Gallon, and up in Connecticut. And then we also looked at the CBCL scores. And so the first thing that we found, thanks to my doctoral student who went in the middle of the night to collect a bunch of placentas, was that maternal mom's exposure reported prenatally to her own adverse childhood experiences was significantly predictive of shorter telomere length than the placenta. So the placenta is like this accelerated aging organism of the baby. It's both maternal and child, but the side that we measured with baby side. So across all tissues on the fetal side of the placenta, we saw accelerated aging in the form of shorter telomere length. And that accelerated aging in the placenta actually predicted the infant's autonomic reactivity at four months of age, suggesting that mom's exposure to adversity prior to pregnancy and prior before the age of 18 accelerated the development and aging of the placenta, which then accelerated the development of the autonomic nervous system. So there's a lot of vascular signals and other inflammatory signals that go back and forth that could attribute or account for this pathway. So at four months of age, we had the mom and baby complete the still phase. So this is the baby equivalent of the Trier social stressor test. So this is a way to look at the dyadic interaction. Mom and baby play together for two minutes. We have mom look away. And then mom looks back at the infant with a neutral expression. And baby doesn't like it, because it's neither do you guys. It's OK. And so that is a way to activate the baby's mechanisms to try to get mom's engagement. So the expected still phase response is the baby gets all excited, moves their arms around. Babies can get very upset. And then mom turns back and re-engages. What we expect to see in terms of autonomic response is that they start with high parasympathetic tone, so higher RSA. And then when you activate the stress response system, you drop parasympathetic tone and increase sympathetic tone. So you see a decline in RSA. And then you, did I get that right? Yeah. I was like, wait. And then after the mom comes back and re-engages with the child, we expect to see it increased. So what we saw was that in females, whose mom had more exposure to ACEs, and this is over here, you see a much more robust response, meaning that there's a little bit more advanced development of the autonomic nervous system in infants whose moms were exposed to ACEs. So this is building upon that aging model that we were talking about. The autonomic nervous system is one of our first stress response systems to develop. We actually see changes in heart rate variability during pregnancy. So if you sing to your baby, or if mom eats something baby doesn't like, we can actually see co-regulation change of the autonomic nervous system. And so what we see, at least in girls, whose moms were exposed to a higher amount of ACEs, was that there was a increased response in terms of the autonomic nervous system. I will say, boys, we're doing something. They're different. We don't understand what's happening in boys. It also could be that they are later developing and we missed the time window. But what's important is that this effect was above and beyond the effect of prenatal stress. So there was a different impact of mom's ACEs. So while these two were correlated, mom's prenatal stress and mom's adverse childhood experiences, they were not identical. This was actually replicated by Sarah Gray and her postdoc in a group of preschoolers. So these are now older kids, ages three to five. They were put through many more stressors, but they were also, in this case, looking at the sympathetic nervous system response. And so what you'll see in this path analysis is that the primary predictor was actually mom's ACE. It was not the child's own trauma exposure, and it was not... I can't remember. I can't see what the other one was. I know it was not the mom's exposure or the child's exposure to violence. It was mom's preconception exposure to adversity in a second cohort was strongly predictive of the autonomic nervous system during a series of tests designed to stress the system. So this is a replication in an older cohort. We subsequently looked at this pathway in terms of that cellular marker aging of telomere length. So telomere length was measured by buccal cells at four, 12, and 18 months. And what you see is that maternal ACE score predicted a greater decline in telomere length over here, so higher ACE score leading to a more rapid decline or more accelerated cellular aging. And if you look over here... Whoopsie, sorry. What you'll see is that it was maternal ACE score and not prenatal stress that was driving this accelerated aging. That same accelerated aging and that interaction with telomere length was actually predictive of increased externalizing at 18 months. So mom's adverse experiences coupled with accelerated cellular aging were driving a pathway of increased externalizing behaviors at 18 months of age. We subsequently wanted to better understand how this might be transmitted. So one of the things that we have in this is that we did dyadic interactions, so we have the ability to look at caregiving sensitivity. So in my head, right, so we have adversity that would influence whether mom's a good caregiver and how sensitive and responsive she is, and that would lead to elevated risk for the offspring. Unfortunately, that is not the case. So what we see here is a direct path of mom's ACE to 18-month externalizing behaviors, and this is measured through the ITSE as well as the CBCL. We see a direct effect of mom's ACE on maternal socioeconomic status. Mom's SES is actually predicting more sensitive caregiving. What was really striking, and I actually am fascinated by, is the fact that the higher the mom's ACE, the more sensitive her parenting and caregiving were during our dyadic interactions. So in my head, I would have expected the opposite. This is why it's good to do science and be proven wrong. We then looked at the pathway through attachment security, and so we see a lovely relationship, which we would predict, which is sensitive and contingent caregiving at 4 months of age predicted secure attachment, but that had nothing to do with behavioral problems at 18 months of age. So there is, again, a separate pathway that is not going through parenting that is leading to the elevated risk of externalizing in these kids. And we do see that there is a 4-month autonomic pathway towards confidence, but that's the only one. So what this is suggesting is that my primary model is wrong, which is good because that keeps me going and makes me do more research, and that while there is an important component of caregiving and maternal sensitivity that is driving attachment security, when I am thinking about the relationship between mom's exposure to violence and adversity and the risk of increased externalizing in the child, there are other factors that are involved. It's not going through SES. It's not going through sensitive parenting, and that is a gap in our knowledge base that we're going to be looking for and trying to fill. So in this study, we also measured mom's exposure to racial discrimination. So we used the experiences of discrimination, which captures a range of different exposures. So this can be employment exposures, it can be day-to-day regular services, and unfairly stopped and frisked. And this is sort of the list of being unfairly fired, not hired for a job, unfairly stopped and searched, and this is the N in the percentage. I think it's important to note that in this community recruited cohort, we had 44% of our moms report that they had been unfairly stopped and searched. So we're not talking about something that is a rare occurrence. 45% reported that they had been treated or received poorer service than other people at restaurants or stores because of their color, and 40% reported that people had acted as if they thought you were dishonest. So half of our moms in this community recruited, very diverse SES cohort, were experiencing these discriminatory acts during their prenatal period. And so when we looked at the relationship between the development of the cortisol response in infants, so we had a 4 and 12 month cortisol response, we wanted to see if there were differences in black versus white in this same cohort. And what we found was there were, but the reason that there were differences in the development of the cortisol response system was almost entirely explained by mom's exposure to discrimination. So physiologic differences that are being driven by mom's report of her own exposure to discrimination that is leading to a flattening of the cortisol reactivity pattern in youth of color and a difference in 4 to 12 months. So we then wanted to say, okay, well how are these adverse experiences which have these biologic effects related to discrimination? The first thing is in the A, you see that mom's exposure to discrimination is significantly correlated, although not 100%, with mom's own exposure. We then looked at baby's own life events, so we captured baby's life events using the preschool age psychosocial assessment or the PAPA life events scale for 12 and 18 months. And so then we said of the infant's life events, how does that relate to mom's ACE exposure? So this is a relatively established finding is that moms who are exposed to more ACEs, their children tend to have more exposure to ACEs as well, so we see the same thing. And then we also saw that the infant was more likely to be exposed to more of these adverse life events in the first 18 months of life in relation to mom's own exposure to discrimination. So very much an intertwined pathway between mom's ACE exposure, discrimination, and infant's life events. However, when we looked at the biologic outcomes, what we saw was that mom's exposure to discrimination is not influencing RSA. So remember we looked at that earlier, we showed that mom's exposure to adverse childhood experiences influenced RSA, but mom's exposure to discrimination during pregnancy did not. We saw that telomere length was influenced by mom's ACE, but maternal exposure to discrimination was not. And similarly, NC competence and externalizing behaviors were really all driven by mom's ACE score and not by discrimination, despite their high correlation. What we did see was that infants' own exposure to life events, which was also correlated with mom's exposure to discrimination, moderated the relationship between telomere length loss and mom's ACE score, and mom's ACE score and ITSE, suggesting that infants who have additional exposures above and beyond mom's own ACE exposure, we see a moderation based on their, so it's a cumulative effect of mom's ACE score and child's life events influencing telomere length and externalizing. So what about intergenerational effects in older children? So going back to that same study, that dental study that we looked at, it was 125 black youth ages 5 to 15. The moms were 20 to 60 years of age, 92 percent were black, and this is their average household income. And in this case, we actually looked at the co-activation of the hypothalamic pituitary adrenal axis and the HPG axis. And the reason for this is that there is a theory that during stressful or challenging times, both your cortisol levels and your testosterone, even if you're a girl, are brought up. And the thought is that there is a coupling of the HPA axis and the HPG axis that allow you to co-regulate. And basically that the HPG axis, when it goes up, will down regulate and kind of smooth out your cortisol. And similarly, your cortisol, when it goes up, will kind of even out your testosterone. So there is an inverse coupling. And this positive coupling is associated with better outcomes in terms of behavior and social-emotional competence. And so we looked at this in both stress, so this is that same TSST pattern where we would expect to see co-regulation of cortisol and testosterone during that, as well as diurnal patterns. So diurnal, we collected eight time points over two days from the home, and looked at the relationship between testosterone and cortisol in these youth, and mom's own report of her exposure to discrimination. And so this is a complicated slide, but what I'm going to do is highlight that when it says police encounter, so this is mom's exposure to being stopped and frisked in her lifetime, and her exposure to police treating her unfairly. And so what you see is that in kids with high testosterone, so having a more reactive pattern of testosterone, there's a decoupling of the HPA axis and the HPG axis. So mom's exposure to police-specific discrimination is, in a subset of kids, driving a decoupling of the HPG axis and testosterone. So a physiologic effect that is a function of mom's exposure to discrimination in the face of law enforcement. It didn't work with sort of day-to-day experiences of discrimination, and it wasn't present with experiences of discrimination in terms of employment. And so this is suggesting that there are a subset of kids that are more vulnerable to the physiologic impact of mom's discriminatory experiences, particularly with law enforcement. So in terms of a model, there's a tremendous amount of evidence that there are intergenerational and really multigenerational effects of racism and violence. And this is something that has been demonstrated in preclinical animal models. Certainly it's been demonstrated in multiple different at-risk minoritized populations. And when we think about multigenerational exposure to violence and discrimination, we have multiple populations within the United States. So indigenous Americans, children of color, and we are now increasingly seeing effects with those children who are emigrating or coming into the United States seeking asylum. So this is an increasing area of concern for this exposure to generational inequity and racial discrimination. And so we see a few effects through epigenetic pathways over here. So we talked about telomeres as part of this. There are definitely effects in terms of other markers. So there are micro RNAs that have been found to be changed, mitochondrial function. Those are influencing both the gamete itself over here, but also the prenatal environment. And so the maternal fetal prenatal unit is influenced. And we see changes in mom's own physiologic stress response, which then influences this further. We do think that there is a buffering effect of the prenatal environment or the postnatal environment, right? And when we do have dads over here, I haven't talked about any data with dads. It's a huge gap in the literature. We need more data. And I also think we need more data in bi-parental households that are not sort of male and female, right? So I think there's a lot of really important information that we need to embed in the system when we think about discrimination. And we think about populations that are facing more discrimination. So certainly same-sex couples or non-gender conforming couples are exposed to a different type of discrimination and certainly different rates. But I think it's going to be really important to really pay attention to that. So dads are up here. We need more data on dads or other parent figures. And where we really think racism is having an effect is on the physiologic systems that are both regulating mom. And they're more apparent during pregnancy, because for any of you who've been pregnant, it's a physiologic stressor. It is actually a huge biologic pain. And I'm not going to curse, but it's a lot of work. And it's actually a huge physiologic challenge on your cardiovascular system, on your immune system, on all of those same stress response systems. So we think that one of the reasons we're seeing it more predominantly with that prenatal period is both it's a time of greater exposure, and it's also easier to detect because it's a more physiologically stressed system. And so that is influencing what the baby comes into the world with. The hope is that that early caregiving environment will be able to buffer some of that effect. When I originally made this model, I was super excited. And then our data is suggesting it may not be as impactful. And so really starting to think about what are those other factors that might be buffering and certainly modifiable in that environment. And so the last part of this really gets it, now what? Right? Because this is kind of depressing. And I wanted to highlight this meta-analysis that came out that psychotherapies, so evidence-based psychotherapies, were actually less effective in communities with higher levels of anti-black racism. So there are measures of sort of national levels of anti-black racism that you can get, so objective measures of it, and community levels. And so what this meta-analysis found was that if you looked at the communities where these evidence-based studies were done, and you looked at children of color, that the greater the amount of anti-black racism in those communities, the less effective our evidence-based treatments were for youth of color. And I pause there because I think it's really incredibly important. We have this biopsychosocial model when we think about treating kids, right? And we have increasingly over the last decade been paying attention to the social determinants of health. I have not yet assessed the presence of anti-black racism when I think about my evidence-based treatments, but I think it is now another component of that assessment of the psychosocial environment that we need to integrate into our treatments. Most likely, we need to start having conversations with families of color about what might be impactful either additively or modifications to these evidence-based treatments to really drive effectiveness. I will say that far too often our evidence-based treatments are piloted in middle-class, bi-parental, very stable families. In general, they're predominantly white. That is not the cultural milieu of all of our families, and certainly when I think about the percentage of families and kids that I treat that are trauma exposed, that is very often not the population I am caring for. And so I really think it is important that we as an organization start saying that we need to be more intentional in ensuring that our evidence-based practices are built in a culturally informed way and built in collaboration with the families and communities we are serving. We have to dismantle all of the places that structural racism exists if we want to stop generational trauma and create equity. It's a cornerstone of that pathway, and I am going to point out that our highest rates of suicide and suicidality are in our indigenous youth, our LGBTQ youth, and our youth of color. So this problem is not going away. It is going to get worse unless we are absolutely intentional, and we call it out, and we say this at every time and point that we can, and that we do our own internal work to understand how we are contributing to this and the perpetuation of it. I've spent a lot of time with public health people, which is good and bad, because they like really high-level assessments and not super detailed ones with a lot of people, and I like really detailed assessments, so we have a lot of tension in developing our studies. What I really think is important is, as we all seek to be impactful at addressing the current mental illness crisis, and I'm going to say from adults as well as for youth, is that we have to be pushing at all of these levels. And I will own that I have not been as much of an advocate at these higher levels as I could have been over the last two decades as a child psychiatrist. I feel confident that I've done a lot of strengthening individual knowledge and promoting community education, and certainly in training, but we really have to be fostering collaboration across different organizations and communities. We have to be saying, does this work in your community? Your community is different than my community. Maybe we need to be readapting, rethinking, having conversations about that. We need to be challenging our organizational practices. So I have an outpatient practice that is not reflective of the diversity of the community that we serve, and so now we are digging into that, like what is happening? Why are we not serving the population that we're supposed to be serving? And then really influencing policy and legislation. We have all known that mental health has been this carve-out, that it has not changed as pair rates forever. I encourage you guys to change your language. Every time someone presents data about mental health and physical health, tell them to stop. Mental illness is rooted in the neurobiology and physiology of the body. It is no different than cardiovascular disease, diabetes, hypertension, cancer. It is a biologic process. How we treat it has both psychosocial factors as well as pharmacologic factors, but it is a biologic condition. Are we great at measuring that? No. Do I absolutely believe it is rooted in the neurophysiology and the brain and the body and the connection between neurons? Yes. So every time someone says behavioral health and medical illness, I correct them. It is all medical illness. When a child is boarding in an ER for a psychiatric bed, it is equivalent to a child in respiratory distress not getting appropriate asthma treatment or respiratory support. It is dangerous and detrimental to that child's brain, just like the hypoxia that is associated with not treating asthma effectively. We don't let kids with asthma sit in the ER without treating them. We don't let diabetic kids sit in the ER without giving them insulin. We have thousands of kids every day sitting in ERs without any treatment, and that for me is not treating a medical illness. And I encourage you guys to share that language with your own organizations to correct it every time someone feels the need to separate it out because it's not okay. I want to encourage us to think about a cultural shift around mental health. So all of us work way over here. We are continually treating the sickest individuals, many of whom in the case of child psychopathology have had symptoms of somewhere between 8 and 12 years before they ever have contact with a mental health professional. Now if you believe in neuroplasticity, that is 8 to 12 years of the development and strengthening of aberrant circuits in the brain. No wonder it takes us so long to fix, right? It's a terrible thing to have to spend years fixing. And so what we need to be doing, Is shifting the curve. We need to get out of our clinics and our academic worlds. We need to be embedded in communities. We need to be having conversations with community organizations, with churches, with child care places about early signs and symptoms of emotional distress, of behavioral disruption. And then we need to be building the early intervention programs to treat it before they've had 8 to 12 years of problems. The time period when youth of color are expelled from school the most is what age? No, it's pre-k. It's preschool. And I pause there because that's how early we have to be thinking. So if you are a youth of color and you have been exposed to one or more forced school changes, your odds of being involved in the juvenile justice system are exponentially increased. In the state of Louisiana, the primary predictor for incarceration at the age of 23 is third grade reading level. So this is an early identification of behaviors that are disruptive behaviors that are often trauma related and we have to be doing the education and early identification in schools, in child care, in churches, everywhere we can so that we are preventing that pathway. And, you know, really shifting an entire system. That's my plan. Currently, the vast majority of our work is intensive services. We do specialty services, so consultations. There's an increased school consultation system, certainly primary care consultation, and that's up here. But specialty services, so our own practices, right? So where we see kids in child psychiatry. To really address the embedded problems of racism and violence and social instability and this current mental health care crisis, we have to shift the whole model. We will always have a need for intensive services. The state of Massachusetts did this really interesting thing with the pandemic and the increase in boarders and they forced the opening of 40 new inpatient beds and did nothing about intermediate care. So you know what that did? It created this lovely cycle where kids came in and out of the ER and then had nowhere to go and then came right back. But it did not address or change the rates of boarding or the time of boarding. And particularly for children with developmental disabilities and comorbid psychiatric conditions, as well as children with comorbid medical conditions, that cycle was even more pronounced. So we need to keep those intensive services, but we need to grow our specialty services. We need to strengthen our consultation services. We need to be in every school, everywhere. And we need to be equally in every school. So in Boston, we have 140 school districts. We have a new policy where you have to have one social worker at a school, but we have some that have 42 social workers. So that disparity has to go away because one social worker can't serve 800 kids. So we have to build equity into the places like primary care and our school-based programs and our early child care settings. We need to do targeted wellness promotion. And I think this is really important. We need to ensure, and I'll say this is a place where the social media kind of thing is a really interesting area to be in. So there are some really great wellness promotion things that exist in the social media world. And there are some really terrible ones. And so thinking about how we can curate those, develop an evidence base, and make sure that they are culturally relevant and safe for kids, I think is an incredible area of opportunity and also a place where it can be kind of risky. And so I think that understanding ways that we can do targeted wellness promotion, particularly in places that are low-resourced, and with an absolute intentionality to doing them in a culturally relevant way and a culturally responsive way. Because what might work for my very well-off white self is not going to be the same for a first-generation immigrant from Syria. And it would be horrific of me to think that I would know how to help that person and their family and their children maintain their cultural identity. What is important to them? Understand that. That is probably not the same as a Midwestern girl who got imported into Louisiana who now lives in Boston, right? So that is a really important piece of this. And then we need to be promoting wellness. We need to be saying at every opportunity that mental wellness is child wellness. We need to be dismantling this idea that there is a separation between physical health and mental health. And I will guarantee you that no child can be physically well unless they are first mentally well. And so if you have somebody that's like, no, we're just gonna solve asthma, I can guarantee you you're not gonna solve asthma if that kid is anxious or depressed or psychotic or traumatized. And so that language becomes very important. So as I said, I was preaching to the choir. I hope that I have given you information that is useful. That this idea of changing our language is something that you think about, even if you're not willing to immediately jump on it. But exposure to violence and trauma is rooted in systemic and structural racism. And the sooner we are all talking that way, the better. Violence across all levels increases the risk for mental illness within and across generations. And so if we want to be thinking, we need to be thinking in terms of two generations and three generations. The biologic and behavioral effects of racism and violence do not follow linear pathways. So we need to be thinking about them as a system. And I think we need to be measuring them. So I am really anxious that I have kids that are getting better, and I don't know that I am influencing this physiologic dysregulation that I know is present. It makes me a little nervous every day. And then addressing the current mental illness crisis is going to require us to all step out of the box. That we are going to have to be pushing for systemic transformative efforts across that entire spectrum of prevention. Building our own comfort level in stepping up that ladder. And helping others to come up with us. So building youth advisory councils that are equally impactful. Encouraging 18-year-olds to vote is a huge thing in my head. Because I think the reason there's not a lot of money allocated to kids is because they don't vote. Right? And no offense to anybody who is elderly in the room, but old people vote. And old people with a lot of money donate to research. Turns out little traumatized kids from poor neighborhoods are not donating millions of dollars for research. So we have to be that voice. We have to advocate for them. And we have to rethink our role as child mental health professionals. And get ourselves out of our clinics, despite them being overwhelmed. And get ourselves into the community. We are the most equipped professionals to build wellness. And to understand the health behaviors and the social connectedness that drive wellness. And we need to spend a chunk of our time doing that. Because I think we know it better than anyone else. And so this is the work of an amazingly wonderful group of people. I will say this is a picture from my 49th birthday, which was Mardi Gras Day. And a super spreader event in New Orleans. So it was really fun. It didn't go well. But, you know, those things happen. And, you know, particularly Sarah Gray, Katherine Thiel, and Bertie Shirkleff and Shannon Moody, who did much of the biologic work with the cohorts in New Orleans. And with that, I will take questions. And you all stayed. I'm so excited. Thank you. I don't know if the microphone actually works. Or is needed. It does work. Thank you for your talk. Very interesting. I'm actually an adult psychiatrist. I work in the Netherlands with adults with PTSD. And also second and third generation Holocaust survivors. So this was also very interesting for me. And I actually have a question about your slide about the relationship between maternal adverse childhood events and your proposed pathway to that leading to child disruptive behavior. And I was wondering if you also looked at paternal influences in that. Because unfortunately in my practice, I see a lot of women who have been traumatized in their childhood who now are in relationships where they again meet violence or other forms of situations that might also impact their children and their own parental, their own way of parenting. So I was wondering if you also looked at that and a possible compounder. Yeah. So in that study, we actually tried to. So we actually had a sub-study called What About Dads? Which was really, for me, arose out of a conversation with a father who was in labor and delivery. And I was recruiting his wife into the study during labor. It was just because that was when we had the opportunity to do. And I asked him if he wanted to be part of the study and sort of talked about his importance. And he started crying. And he said, ever since I walked in here, no one thought I was important. If you think about like that process, when you go in, like as a woman goes in to deliver a baby and there's this guy there and they're like, just carry the bags and don't say anything. And so we only had a subset of them. And it turned out that their exposures were very correlated. So Rachel Yehuda has some great work with the Holocaust survivors that actually sees different pathways in terms of methylation of things like FKPP5 in relation to parental versus maternal exposure to the Holocaust, where there was a sort of dual effect, if they both were, that was mediated by whether or not they developed PTSD. So in this study, there's a complete gap. We are currently working on a study with child soldiers in Sierra Leone, where we actually have both parents. In general, one of them was a child soldier survivor. They also both have tremendous amounts of trauma. And so we will be looking at these same pathways. And we'll actually be getting parenting by dads and moms, which I'm super excited about. So stay tuned, but it's a really important question. And in part, the potential for sort of assorted parenting, right? So sort of mating, where there are these shared experiences that may be making you more likely to have a partner with the similar exposures. So it's a really important question, and it was a giant flaw in our study. Thank you. Thanks. Yay, more questions? I have questions. Thank you. The call to actions in terms of getting into community is really important. I'm wondering what's, you know, because we've built a current healthcare systems of how we get compensated, the work is really tied to this direct patient care models with the codings, and that our communities have limited resources. And so when we actually talking to the newer generation of child psychiatrists to do it, I'm wondering what you're thinking in terms of systemic changes of how to actually balance how we value our work by the community who resources are already streamed. Yeah, so it's a super important question. And so one of the, so there's two ways that we're trying to take a bite out of this right now. So one is in relationship to our ability to support school-based services. So right now, the vast majority of school-based mental health, there's a fight between the Department of Education, the Department of Mental Health, for their health and human services as to who owns it, which is really obnoxious. They should both own it and give money towards it. And so there's a fee-for-service model where you can actually provide, you know, the social work and mental health treatment at the school and bill for it, right? That is unfortunately not a system that's going to work because it doesn't address the culture, the community, and all those other pieces. And so what we are advocating now is a reframe of how school mental health is supported so that it is something that includes both direct services and the building of trauma-informed practices and evidence-based practices that address how to provide support for children with mental illness in the school setting in an appropriate way. So that is a policy-level advocacy that we are pushing really hard for in Massachusetts in particular, and that we will then look at that in terms of its ability to prevent kids going and sitting in the ER, which is really my goal. Like, I don't want them somewhere that's dangerous and unhealthy for them. So that is one model. The other model that we are really working on, and we've hired our first person in this role, are building the ability to reimburse individuals who are cultural brokers. So a cultural broker is a translator of language as well as culture. And so in one of our groups, we do a lot of work with refugees, and so they have trained a couple of their family members, a grandmother in one case and a mother in another case, to be there for therapeutic interventions for children. And this person is there to both translate the language, so serving as a medical interpreter, but also serving as a cultural interpreter. And so we have now developed a reimbursement model so that they are being paid, they were hired as like a community health worker within our hospital setting. And so when they are providing the service, we are able to bill for them, because it turns out there is no code for billing for an interpreter, which is a really ridiculous thing, which I don't understand. But when we have them certified as a medical translator, which is a thing, because you can get a certification for it, and just being a native speaker does not qualify you, and there are some problems with how that system is designed, but we can get them certified as a medical translator and have them function as this cultural broker, because there was no job or billing code for cultural broker, we embedded it within the community health worker system. And so what we're going to be evaluating is, can we scale that? With the idea that these individuals will then be in this therapeutic setting, enhancing our ability to provide care, but taking those experiences back to their community. And we wanted to make sure that it was a living wage, right, so that this could be their job. There's actually this really amazing organization that is training immigrant women who are low SES to be medical translators and then getting them jobs. And so what we want to do is sort of capitalize on that and start to really support those women with the idea that we can bring the experience of mental health treatment in a culturally responsive way back to those communities. So I think those are our two current test pilot cases, but I think it's really important. And I think the other place for me is about thinking about having these conversations with the communities early and often about where should we be and who is the we that should be there. I think we have an opportunity to rethink the level of provider providing care, right? I don't think necessarily every child needs a licensed clinical social worker or a child, certainly every child does not need a child psychiatrist. So doing better alignment of that and, you know, can we get these mental health counselors? We have a whole behavioral health response team that has a range of experiences from an RN to just sort of a counseling degree. And so I think leveraging those systems but building them on the community side rather than in our worlds and in community mental health clinics. All right. I'm so grateful you guys were all here. Thank you. Really appreciate it.

child mental health

mental illness crisis

structural violence

racism

systemic inequities

marginalized communities

suicidal ideation

mental health care

historical racism

community-oriented approach

policy changes