I hope everybody's doing well. My name's Justine Larson, and I'm the Medical Director for Schools and Residential Treatment at Shepherd Pratt in Maryland. And today, the title of our session is, What is the Role of Child Psychiatrists in K through 12 Schools? Here are my disclosures. So first, I'm going to be talking for the next 20 minutes, just to kind of give an overview and to get you thinking about the role of child psychiatrists and what the different roles can be. And then we're going to hear from Dr. Sunny Patel on federal initiatives. Dr. Patel is a child and adolescent psychiatrist serving as the Senior Medical Advisor at SAMHSA's Center for Mental Health Services. And his portfolio is focused on the mental health of children, youth, and families, and mental health financing. Before SAMHSA, Dr. Patel was appointed as a White House Fellow and served at the Department of Homeland Security as an advisor to the Secretary and Deputy Secretary, where he focused on issues at the nexus of immigration and public health. And then we're going to be hearing from Dr. Heather Gotham on the topic of resources and models in mental health in schools. Jessica Gonzalez also helped to develop these slides, and she is the Associate Director of the MHTT Network Coordinating Office, which is through the School Mental Health and Education Initiative. And Heather Gotham is a licensed clinical psychologist and clinical associate professor at Stanford University School of Medicine and Director of the MHTTC Network Coordinating Office. She works to improve access to effective care in the public health, mental health, and addiction treatment systems. Her research uses implementation science to assist behavioral health providers in utilizing evidence-based treatments at national, state, and local levels. So today, as I said, for the next 20 minutes, I want to focus on considering the role of CAPS in the landscape of mental health services and supports. And we're going to be talking about some of the resources and frameworks to support mental health in schools. And then we're going to be looking at federal activities as well. So probably if you're here, you already have a sense of some of the benefits of school-based services. But I think there's becoming an even greater increased awareness about the importance of school-based services. So I think fundamentally, providing services where kids are is incredibly important. About 53 million youth in the U.S. are attending school. There is a great deal of data supporting the benefits of school mental health programs. So data showing improved academics, improved social skills, improved self-awareness. There are also ways in which schools can collaborate with community partners for mental health services. And there's data to support success with those with decreasing truancy, decreasing discipline rates, increasing high school graduation. So bottom line, I'm a believer in school-based school mental health services. And there is data to support there that they help. So what I thought I'd do is I'd just kind of give you guys a little flavor of a case. This is a person, a real case that I have, that I'm working with currently. And what I want to do is to think about what could be someone's role as a child psychiatrist in this case. And so just to start, I'm calling her Madison. She's a 15-year-old adopted female with a past diagnosis of MDD, PTSD, intrauterine exposures. And she was actually recently discharged from a 15-month residential stay. She has three previous psych admissions before that. And the way that I came to meet her was that a school staff came to my office basically saying that she had come to them with a self-inflicted wound on her leg. So what is your first step? So the first step, of course, depends on your role. And there are a lot of different roles you can have as a psychiatrist in a school. So your next step depends on your role. So I just was thinking about sort of what are the roles of CAHPS. And I listed some of them here, and I'm hoping that by the end of the time together, we might even have come up with some other roles that we have. What consultant? So obviously, individual case consultant. So evaluating the person, figuring out what services they should have in place. How could the classroom and staff better support her or him? Systems consultant. So how do you structure the classroom? How do you structure the services, the systems that the school has in place to meet the needs? Educator to staff and family. So how can you help the family navigate the IEP process, for example? How can you help staff to respond to specific challenges like self-injury or what, you know, when they're kind of dysregulated themselves, you know, knowing that a child is cutting themselves, how do you help them to figure out how to respond to the child? And then psychiatric provider to follow her over time, perhaps. And advocate. And there's a lot of ways in which we as psychiatrists can be advocates in schools in a number of different areas. And from my experience, I'm going to talk a little bit about some of the areas where I found advocacy to be important, and maybe you have other areas as well. So she's a new student at the school, one of the schools where I work, which is a non-public school. And in Maryland, I don't know if, basically, this school is funded by public and served, we serve across many school districts. And they pay us to take kids who have sort of gone beyond the scope of what the school, the public schools manage. So that's, she's a new student at the non-public school, started several weeks after her 15-month stay. Upon discharge, she made several new friends at the non-public school, but began to smoke marijuana and stay out late pretty much immediately with the new friends, because she was very eager to sort of connect with other kids. She had one cutting episode, which was the one that the staff member approached me about. But she denied any suicidal ideation. I mentioned a little bit about her past medical history and previous med trials. The parents basically were emergency foster care parents, and she was placed with them at 20 months old, apparently very dirty, had a lot of, had experienced a lot of neglect, was really not able to vocalize much. And there was a lot of evidence that she had been probably either, definitely physically abused and neglected. So just thinking about her, but just in general, as an individual case consultant, this is an important role. You may literally be one of the few people getting any history from the family and the student, which, you know, I still, it's always hard for me to believe this, but even some of the counselors working in schools don't necessarily, you can't rely on them necessarily even taking a full history. So you may actually be one of the few people in the school who's read the educational records, talked to the family, gotten the history. And so that is very important as you're relaying the information to the team that you may be the only person who has this information. So this is important because it obviously helps teach the staff about the best approach. Just an example, this girl ended up having a lot of processing issues. Her testing had revealed that, but like many kids, she's able to mask that. You wouldn't know that her, the level of her cognitive challenges. And so I did talk with staff a lot about kind of the way that you present information to her and the speed at which you present information, you know, is important because her cognitive challenges are more than, than, you know, she presents. In terms of a systems consultant, so here's some examples of ways that you can be a systems consultant. So obviously IEP consult, consultation, and there are some good resources out there for you to learn more about IEPs and the process and all of that if you feel like you want to beef up your knowledge there. Another example of a systems consultant that we recently did at Shepard Pratt was really beef up our threat assessment process. As you know, you know, there's a lot of worries, of course, about threats of violence, you know, a lot in the media about the shootings. And I do think as a child psychiatrist, even though many of us didn't really get so much training on this necessarily, it's very important to be able to guide staff and to talk to kids who are making violent threats or, you know, threats to shoot up the school, those kinds of things. So I can talk a little bit about that. Suicide screening and assessment is another example of ways that you can advise the schools and supporting staff in response to threats, which is part of the whole threat assessment process. Just briefly, in terms of the legal aspects of education, I won't go into detail too much about this, but to say that there are some good overviews available. There is the practice parameter, the ACAP practice parameter, which you can, which is a little bit old, but it has some good information in it. There's also the systems of care training module, training toolkit module, which has a really nice module on school-based services, including the history of sort of the legal aspects of education and how to talk to families about IEPs and what's involved with the IEPs. So, you know, one thing that I do when I'm working with a child is I obviously read their, the educational testing that has occurred and also look at their IEP. And one of the things that I was always surprised by, when you read the educational testing, it's important to know how they diagnose something. So just to give you an example, I have a child who has autism, or he, you know, everyone talks about him as having autism, that's how he's sort of formulated by the staff and everything. It turns out, when you look, when I kind of delved into his testing, he never really had testing for autism. He, you know, and so they had given him a diagnosis of autism on sort of just checklists that the parents had filled out, which, you know, actually when you think about it, could easily be, had a lot of overlap with social anxiety, for example. So it ended up that this kid did not have autism after we sort of got the proper tests, the ADOS, and the checklists and things can often have some overlapping symptoms. And I think we're the only people that are really going to do that a lot of the time in the schools. So this here is just, I put up here the different categories of disabilities that people can have IEPs. I think that's good information to have. And then understanding the IEP process, and being a little bit of a detective in that sense, I think is important. So I mentioned a little bit about the IEP, and I won't go into that in detail, but basically these are the potential components of an IEP. And I think it's nice to know when you're looking at an IEP, what's in the IEP, and also what is missing from the IEP. I also mentioned threat assessments, and as another example of a way in which you can be a systems consultant. So I put here some resources. Obviously that's a much bigger and different topic, but this article here, The Need to See and Respond, it's a very nice little clinical perspective summary that talks about the role of CAPS in school threat assessment. We decided at Shepherd Pratt, we ended up doing our training using Dewey Cornell's Threat Assessment Model. There are actually very few evidence-based models on threat assessment. This is one of them. And it gives a helpful sort of process for how to develop a process for threat assessment in schools. Also this other resource down at the bottom we found very useful, the SAVRI, because there is the sort of process for assessing a threat, like triaging a threat, for example. And the SAVRI is one example of a more in-depth clinical evaluation when somebody's making a threat and sort of how serious that threat is. Another example of being a systems consultant is helping to develop suicide screening protocols. And these are some of the materials that we developed at Shepherd Pratt, where we basically started a universal suicide screening for all of our kids, keeping in mind that our kids are already high risk. Again, this is a much bigger topic, but we ended up using the ASQ, which is available online, free. It's a very simple set of questions. There are four questions that you ask about suicidal thoughts and risk. The other one that we use, too, is the Columbia Suicide Scale, which is also helpful. It's a little bit longer than the ASQ, so that's why we went with the ASQ as our screener. This is just more details on the suicide screening. We also have, as part of our suicide screening, the use of safety plans. Some of you may be familiar with safety plans, but they're both a... What I like about them is that it's something that staff can do, because it's an intervention as well as sort of an information gathering process. It's basically working with the youth to develop a plan for, if they're feeling suicidal, what they can do. What's nice about it is there is an evidence base that pre and post that the suicidal ideation decreases after the safety plan development. It's something nice that school staff can learn to do and gives them a sense of empowerment, rather than just sending all of the kids to the emergency room, which, if you guys have worked in schools, you know that that's often a common go-to. Another important role of CAPS is as an educator. We have very important knowledge that a lot of school staff, they have knowledge about other things, and it's important to always be very respectful of that knowledge around the knowledge of how to teach, the knowledge of being an educator, but we have knowledge about things that we can share. Here's some examples of things that I have ended up spending a fair amount of time working with staff on teaching them. The first is impact of trauma on behavior, impact of trauma on the biology of the brain and the behavior. The importance of gender-affirming approaches from a clinical perspective, for example, so ways in which being gender-affirming helps to improve mental health and prevent negative outcomes. When to be worried, how behavior works, so the usefulness of planned ignoring and often kind of understanding that sometimes behavior serves a function. Talking about specific diagnoses such as anxiety and ADHD, and then also some of the more, I guess, softer concepts like counter-transference and how sometimes kids will evoke feelings in us, and that causes us to behave in a certain way, so being able to explain these ideas that staff can then think, oh, yeah, you know, they do push my buttons, and what do I do about that? And boundaries, boundaries are a huge challenge in schools and in the work that we do, and so teaching staff about thinking about boundaries, what causes us, our boundaries to be challenged, those are some examples of things that as psychiatrists we have been trained on to various degrees and can talk with staff about. Also a role of CAPS as advocates, so here's some examples, reducing exclusionary discipline, so thinking about when someone does, when a kid does something naughty, we, you know, how do you respond and how do you help the staff respond? So just last week, a kid was, had an episode and broke a window. He was very upset, and the staff texted me and said, we're thinking about suspending him, but we wanted to talk to you. I was glad that I was able to say, explain, you know, he has a history of trauma, these things have happened at home, he's in the midst of a, you know, mood episode right now, and so we were able to avoid suspending him, but to help keep him there in school and work with him and obviously help him to, you know, not break windows in the future, but also not be suspended. Promoting increased behavioral health workforce in schools is another important area of advocacy, and payment models, which we haven't really gotten into at this talk, but obviously that's incredibly important. So this, I just put this up because I thought that it was, I guess what I wanted to convey was that when you're working in a school or when you have the opportunity to work in a school, I think it's really important to look for those, those potential areas of things that you can do as a psychiatrist, and you may think that something is obvious or you may not realize how much you have to share, but it's important to go ahead and do those things. So look at what role you could have and do it. So just to go back to the case I mentioned, so with, in the school where I work, I have a number of different roles. So I mentioned as a system consultant, we set up the suicidal ideation screening, and so one of the things that I talked to the nurse about was when the patient comes, when the child comes in looking for Band-Aids and then does have a cut, we do, that's one of our triggers for the screening that we do. As you know, self-injury isn't necessarily suicidal ideation, but it is a risk factor. So I think it's worth asking the suicide questions. So because he had been trained, the nurse, in how to screen for suicide, he felt comfortable doing that. As educators, talking to staff about self-injury in adolescence and how to respond. So one of the things was making sure that she wasn't getting some sort of other rewards or that kind of thing. We want to help respond appropriately, but not make it at all rewarding. Discussing trauma-informed approaches. Educating counseling staff how to respond to substance abuse issues in school. So as I mentioned, she was using a lot of marijuana. And counselors, mental health counselors or other staff, they sometimes feel like substance use is a separate thing. And so that's one of my things that we should all be talking about substance use and we have the skills to do it. You don't have to have some kind of separate training or knowledge. It's not, to be able to talk to kids about substance use. As an advocate, to work to increase the availability of ongoing care. So figuring out what she needs. Does she need, she needed a therapist, obviously. She needed more support since she got. So those are just some examples of ways that you could have a role in schools. And next I'm gonna pass the torch to Dr. Patel. And then hopefully we can have some good discussion afterwards to be able to talk more about what your role could be. Let's see how long this is. I may have to swap. Okay. Thank you. Can everyone hear me okay? So thanks for that, Dr. Larson. And so I'm going to sort of zoom out and sort of provide what the federal government's footprint and thinking around school-based mental health is. And then we'll pass it off to Dr. Gotham who'll sort of provide texture in what does the work look like on the ground as a technical assistance provider and coordinator across the country from all the case examples that they have. And so hopefully by the end of our time together, this will be at least a framework within which to think about school-based mental health. So you know, these are a bunch of headlines that I've sort of culled and I'm wondering if folks have thoughts on when these headlines may have come from. Like is it the last week, month, year? COVID, all right, so maybe in the last couple of years. Anybody else? Week, all right, anybody? One more. Last 10 years. This is like the last 20 years, right? Like I mean, it sort of spreads sort of the gamut of across different types of media outlets. And I think it's, and then this is within the last month. Pretty similar headlines. And what I pulled over the last month has been very local news sources or niche news sources. It's not necessarily the Atlantic or the New Yorker or some large paper that's talking about it. This is very local news sources that sort of have their finger on the pulse of this as well. And I think, so one of the points that I want to sort of put out there is we have called this an acute mental health crisis, a youth mental health crisis, but you know, as physicians, we know it's an acute on chronic crisis, right? Like this is not new. And it's challenging in public messaging because acute on chronic, like it means something to us, but it might not necessarily mean something to the lay public. And it's not necessarily the best comm strategy. And so I think there is an urgency, but it's also to recognize that the kids were not all right before. And it's important that we have dedicated resources now, but just in context. So that's one of the take home messages. So if you fall asleep in the next 20 minutes, like if you hear this, you've pretty much got most of it. And so that's my first point. The second is a key priority, you know, as a federal government, we want to provide and support services where youth spend a considerable amount of time. And for the purpose of this talk and, you know, what we've been thinking about writ large has been around schools and strength and largely around strengthening systems of care. And I think Dr. Larson spoke a bunch about the various players in a system of care. And we could probably do a whole talk on that as well. And then the third is leveraging resources that I think we are at a unique moment where there, at least from the federal government's perspective, that there is interagency support and focus on providing resources for school based mental health. And a lot of that was funded through the Bipartisan Safer Communities Act from last summer. And I'll provide some more context around that. And then the fourth is that there are solutions within reach. And you know, if you've been following and, you know, we'll talk a little bit about CDC data that's come out recently that you may have been following in the headlines. But you know, if two thirds of kids are reporting that they're feeling hopeless or depressed, like we're going to need a public health solution, right? With 10,000 child psychiatrists in this country, like even, and if there's 70 million kids, like if two thirds are not feeling all right, the ratio of providers to kids are, one is not feasible to be able to provide direct care. And then that's, you know, in an ideal world thinking, without thinking about all the barriers in accessing care and all, you know, the workforce issues. So, you know, we need to think about a public health model. And one of them is Project AWARE, which Dr. Gotham will speak about more, in more detail, but I'll sort of provide a snippet and we can dovetail that. So defining the issue, we're going to go through this real quick because we don't, you know, we don't need to belabor and navel gaze on the problem. We know the problem. You know, 20% of children have diagnosable mental, emotional, or behavioral health disorder. And 10% have what's considered a serious emotional disturbance, which, you know, it's kind of an archaic definition, but, you know, but that affects a child's ability to function at home, school, and the community. And we, I think one of the things that we know, you know, if you're an adult psychiatrist or a child psychiatrist, that adults we take care of were children once. And often, you know, mental health symptoms begin earlier in childhood and largely present themselves over the course of adolescence. And so, you know, this is an important time for us to be intervening. And then, you know, the statistics around death by suicide are concerning, given that it's, that is a preventable outcome. And so we have, you know, there's a need and press to be able to address this crisis. We know COVID hasn't made anything better, that like with other sort of ailments that have sort of shown inequities in the course of COVID, that these inequities existed prior. And it was the, you know, the societal cardiac stress test that, you know, showed where the hypoperfusion is happening, right? And so, you know, I think it's important for us to recognize that almost, you know, 300,000 children lost some sort of primary caregiver, like that is a major loss. And if we think about this in context of like primary attachments, like that is a real challenge that kids are facing in this country. And as we're coming out of the public health emergency, I think it's important for us to recognize that these are persistent loss. You know, the death of a caregiver is a lifelong loss and how do we help kids with that? And then we could belabor the statistics for some time, but the various other measures around depression, anxiety have not, have shown large spikes as well. SAMHSA runs a survey called the National Survey on Drug Use and Health, which, you know, there was a data point in 2021 that captured the pandemic and, you know, three quarters, 20% of kids reported that, you know, the symptoms aligned with a past major depressive episode within the past year. And three quarters of those kids had reported severe impairment. And then the other point to sort of highlight has been that half perceived the pandemic to significantly affect their negative, negatively affect their mental health. The other sort of data point is there's the CDC runs a youth risk behavior survey, which has made headlines in the past couple of months of around increased suicidality in teenage girls. And, you know, I think the point to highlight here is that made the headline, but the rates, you know, 10 years ago were also not good. You know, like a third of teenage girls feeling persistently sad or hopeless is, you know, this is a relative 50% ish relative increase, but, or less than 50%, but a 20% increase, but it's, these trends were concerning and the uptrend was happening prior to the pandemic in 2019. So this kind of cross-sectional survey data doesn't tell us, you know, sort of, you can't make claims of causality, but I think it is important for us to recognize that there are larger forces at play that, you know, we're taking a toll on, on children's mental health prior to the pandemic as well. It's not to negate the impact of the pandemic, but I think there, there can be a risk of attributing much of the current ills to, well, COVID just made it worse. And it's like, yes, and things were not all right before. What are the drivers of this youth mental health crisis? I think to this audience, we probably don't need to belabor this because, you know, we probably see this every day in our clinic rooms or in hospitals that we work in, but, you know, social isolation, you know, increased exposure to adverse childhood events, the impact of social media, academic stressors, financial stressors, parental mental health issues, and then just the, all of the, you know, structural violence that kids sort of endure based, you know, and particularly in this current moment with the pernicious sort of LGBTQI discriminatory laws at state, within states. Like I think we are attuned to that in the federal government, particularly with the don't say gay and the transgender, the anti-transgender laws that are being enacted. And I think it's important for us to recognize our role as physicians and sort of taking care of patients who are facing these, who are caught in the political crosswind, crossfire, and then climate anxiety. And I think this is something that's, you know, we see with children and youth as being pretty top of mind. So what's our strategy? It's not all doom and gloom. I think we are at a unique, we have a unique window of opportunity that's open, and probably that hasn't been open in 50 years. That there is a concerted, focused attention on mental health, and particularly youth mental health in this administration, which I just have not seen action on, you know, probably since the Community Mental Health Act in 1963, like a transformative sort of vision around this. And so, you know, and the president sort of outlined this in his unity agenda, not this State of the Union, but the one prior around what are the three big pillars around creating healthy environments, strengthening systems, capacity, and increasing connections to care. Pretty airy, got to admit, but that's what that kind of venue is for, right? It's not to get into like nitty gritty policy proposal, but these are all the actions under these sort of, the three big pillars. And many of these focus on, have a call out specific to school mental health and youth mental health, and particularly around thinking about public health approaches to addressing mental health, and particularly around promotion and prevention interventions, and upstream and earlier in childhood. The other point to highlight around these actions is, you know, this is probably more detailed than anybody follows, but if you are a C-SPAN watcher, the Venn diagram of following this stuff is probably, you know, quite high. I might be the only one, which is I'm putting it up here. But you know, every time the administration puts out some sort of major policy action, they put out these fact sheets, and so, you know, they put them up on the whitehouse.gov website, and the number, this is just a snippet of the number of ones that have been put out there, and these, that's a lot. In historical context, like this level of attention and number of substantive actions and monies sort of put towards mental health, and specifically youth mental health, just hasn't been the case before. And I think they knew that I was giving the talk, and so like a couple of days ago, they put out a new fact sheet, and so that was really nice of the administration to really think about, you know, having something to deliver here, and one of the specific things that they called out here a couple of days ago is related to sustainable funding of school-based services, and I think that's germane to this talk, because a lot of what SAMHSA does is grant funding, and you know, if you are a steward of a grant, you know that the life cycle of those are generally, you know, three to five years, depending on, you know, the kind of grant, and so what does sustainability look like? And our vision of sustainability is how do we create a system where if, you know, half of kids in America, approximately half of kids in America are on Medicaid or CHIP, that billing through Medicaid is the sustainable path towards making that happen, and notwithstanding, you know, the challenges that might exist, this new sort of billing guide that CMS put out a couple of days ago is one of the, I would encourage you to check it out if you partake in the provision and the delivery of mental health services in schools or are just interested. It's like 200 pages long, but there's an executive summary, so if you're not, if you don't want to get into the weeds, I think it's a really helpful guide. The other place where this is really important is it's part of our strategic plan at SAMHSA, that the promoting and resilience and emotional health of children, youth, and families is a core pillar of our sort of five-pronged strategic plan, which should, this is a, it's in a draft phase at the moment, but it should be coming out, and you know, why this is important is I think these are signals for where our priorities lie and where our focus is, and I think we've come a long way where children have a seat at the table, and I think that's a, and the needs of children, youth, and families have a seat at the table. We have a framework, you know, everybody's got a framework. We have a framework for youth mental health, and it's, we think it's hopeful, and so thinking about health opportunity potential and equity and how do we sort of realize that in the strategies that we sort of put forth related to school mental health. Our friends at the Surgeon General's office, Dr. Murthy, Vivek's like super focused on this, and probably if you look at what all three major priorities of the Surgeon General, they're all related to mental health in some way, shape, or form, right? The three are the youth mental health crisis, which the advisory came out in 21, on social disconnection and loneliness, which came out recently, last week or the week before, and third is on workforce burnout, and, you know, I think these are things that are squarely in our lane for thinking about how do we sort of take action on them, and we have that strategic plan that we sort of put out, you know, has specific actions related to promoting resilience in children, youth, and families, but, so it's on our website, but specifically thinking about how do we integrate behavioral health services and youth-serving systems, and schools are a youth-serving system, how do we think about crisis response and incorporating the needs of children, youth, and families in our 988 rollout, which launched in July of last year, and I didn't include any data on 988, but it is, it's astounding, the uptake that it's had, and then collaborating and working within federal agencies and external stakeholders to increase the capacity to deliver behavioral health services. The second is around implementing and disseminating evidence-based and culturally appropriate services, but in the interest of time, you know, if you've, I don't want to take too much time on this pyramid, because I presume Dr. Gotham has a pyramid in her slides, you know, and students of public health, like, you know, we like pyramids generally, and thinking about, you know, what are primary, secondary, and tertiary sort of prevention services that we can put in place, and how do we think about health for all, opportunity for at-risk youth, and then potential for youth with SMI, SED, or substance use disorders, and making sure that, you know, if we think the kids are not doing all right, that we have resources aligned to be able to reach them where they're at, and, you know, this is a superimposed, you know, Bronfenhunders sort of sociological model, and I think for us, as child psychiatrists, we can sum it up in, you know, sort of one sentence, which is that no child exists in isolation, right? Children only exist in the context of caregivers, or the lack of caregivers, but they, and so they're already embodied in systems, and I would argue that probably all of us are, but I think children acutely, you know, as a conceptual model that they exist in communities and have a broader environment that affects their mental health. And then, so what are the resources in schools? As I was putting the slide together, I realized all of the major federal investments in school mental health have happened in the aftermath of a mass shooting, and that is a really sobering conclusion that there have been three major iterations of a large school-based mental health program that we run, which is Project AWARE, that Dr. Gotham will speak more about, but the 99 Safe Schools Healthy Students with Attorney General Janet Reno had sort of pushed forward in collaboration with HHS and Department of Ed. That happened not because of Columbine, but because of mass shootings that were less prominent in Media 97 and 98. Then Sandy Hook happened, and there was an influx of research that we need to do something, and it evolved into this initiative called Now is the Time. And then, I would say the largest sort of influx of resources have come after the Uvalde shooting last summer in Texas, and there was the Bipartisan Safer Communities Act, BISCA, gave a significant increase in funding to Project AWARE. And so, I can't help but observe that these tragic, horrific events are what lead to investments in school mental health, and yet we have not seen a decrease in that primary sort of impetus that's sort of leading to this funding. And so, I think it's something for us to reflect on as a society around, you know, particularly in mental health, where with these increased resources, we don't think that mental illness is the primary driver of acts of mass violence, and that folks with serious mental illness are more likely to be victims than perpetrators of mass violence. These are pretty well-known facts in our circles, and we also benefit from the resources that are put to bear in the aftermath of this, and it's something I'm trying to make sense of myself. This is not a totally exhaustive list, but as exhaustive as I could put together. All the arrows are specific programs that touch schools in some way, shape, or form, either directly or through some indirect way. And so there are a lot, and I didn't put the arrows on substance use prevention and treatment, not necessarily because it's not important, but because I think I just neglected the right side of the slide. But all of these are important places where SAMHSA's invested resources. And I think the major take-home point here is many of the programs that we run, state education agencies or state mental health authorities apply for, and so it's not necessarily your local school or things like that, but looking out for notice of funding opportunities that come out, there are many programs that individual localities or schools or districts can apply for as well. So in BISCA, that bill that passed last summer, a lot of money was appropriated to NITSE. Project AWARE got a big chunk of that over the course of five years, and then mental health awareness training, the 988 National Suicide Prevention Helpline, and then CCBHCs, which is a new sort of model of certified community behavioral health clinics, which some of you may either work in or run. The expansion of those over the course of the next 10 years, so taking 10 states every two years to really expand this model of comprehensive and integrated service delivery, which includes children and substance use disorders. And so often that's sort of left out, and so making sure that those issues are front of mind. Top line numbers, this is just shock and awe. There is a lot of money that has been put into the budget. And so SAMHSA's total budget is around $7 billion. It's almost a billion dollar increase within the last year. And then mental health specifically and the programs that we run have also gotten large increases in funding over the last couple of years. I won't speak too much about Project AWARE, because we're going to talk more about it. But really to fast forward to, and we're not doing all this work alone. Our colleagues at HRSA do a bunch of work around workforce and sort of funding workforce programs and school-based workforce issues. CMS, obviously, is the major funder and player in the game. And I think it's really heartening that CMS has their own behavioral health strategy, which includes youth, and that there's work between Ed and CMS to be able to coordinate a technical assistance center to help schools bill services. And so I think that's sort of a needed addition to the field. The Administration for Children and Families obviously runs Head Start much earlier in childhood, but really thinking about how do we sort of coordinate programming in youth-serving systems, and particularly in foster care systems. And then finally, Department of Education has also gotten an influx of funding for school-based mental health services, and then also in providing resources to expand the workforce. So the very last point that I'll make is that this is not just reflected either in sort of pronouncements and sort of funding lines, but also in sort of much more future-looking research strategies and directions. And so the White House put out a report on mental health research priorities earlier this year in coordination with two offices within the White House, the Office Science, Technology, and Policy, OSTP, and the Domestic Policy Council. And schools have multiple call-outs in a place where we need to be, where research focus needs to happen. And largely, this document is highlighting health services research need and intervention sort of effectiveness and efficacy work that needs to happen. We're investing a lot of money in mental health, in school mental health, and we want to make sure it works. And we need to make sure evidence-based care is being delivered. And lack of evidence isn't necessarily lack of efficacy, but we need to invest the resources to be able to make sure we know what works and what doesn't work, because I think there is a risk of harm. And we've seen that with DARE, which was fantastically unsuccessful as a substance use prevention program. And so I think for us to be rigorous, for me as a steward of public money and for all of us as mental health professionals, how do we sort of think about the scholarship we produce? And so priority actions, we want to strengthen the provision of school-linked mental health services. We want to increase training for communities to recognize the signs and symptoms of mental health issues and increase capacity and support mental health workforce in schools. So those are sort of things that are guiding North Stars. So take-home messages, the crisis in context, it's an acute, on-chronic crisis. There is a youth mental health crisis, but it didn't start yesterday or at the beginning of COVID. It's been a long time coming. This is a key priority for the administration, for SAMHSA. And we want to leverage resources from across the US government to focus on this, and we are. And then we want to promote public health approaches to mental health, promotion, prevention, and intervention, because there are just too many kids who are not feeling all right. So that's all I got. And if I can be of help, please write. And I'll turn it over to Heather. Thank you. I'm not seeing any. Oh, there it is. Where did it come from? I don't know. I want to close that. Is that good? Awesome. Thank you. Good morning, everyone. All right, so my role is to go from Justine talking about really from the perspective of a psychiatrist coming into school or providing services for schools. Sonny talked about the overall federal research policy funding for school-based mental health services. And then I'm going to talk more from the schools themselves and looking at both the role of psychiatrists in school mental health, taking from where Justine left off, and then also talking about resources from our network, the Mental Health Technology Transfer Center Network, which is a SAMHSA-funded network that provides training and technical assistance to schools. Just a regular disclaimer slide. These are my opinions and the opinions of the work that we do. So as I said, I want to talk a little bit about school mental health frameworks and the role of psychiatrists in introduction to our network and talk about some resources that we have for folks who are going to be working in schools. So what we hope, this is the ideal, right? The ideal is that schools are able to provide comprehensive school mental health services, that those are a full array of supports and services that promote positive school climate, things like social-emotional learning and mental health and well-being. So not just what we'll talk about as kind of tier three treatment services, but also a full array of supports and services. I think some of what's been missing over time is the mental health prevention and promotion piece. But we have an opportunity to do that now, especially given the increased attention to school mental health and to the issues of adolescents and kids and their mental health needs. We hope, ideally, again, that this is built on a strong foundation of district and school professionals. We know, however, that there is a significant understaffing and shortage of mental health workers in schools and across the board. But we hope that we can build school mental health systems that are and have strategic and strong partnerships with students, with families, with community health and mental health partners, and that we're also able to address some of those social and emotional and environmental factors that impact health and mental health, things like social determinants of health. So again, ideal, comprehensive school mental health systems. And this gets at, what are those core features of those comprehensive school mental health systems? So we want to have a system that has, again, educators and student instructional support personnel that are adequately staffed, that are trained to address school mental health, sorry, student mental health in schools. That we have a strong focus on collaboration and teaming that includes youth and families, but also community health and mental health and other partners. That it works within a multi-tiered system of supports, which I'll talk about in a minute. That things are evidence-based. Sonny was just talking about the specific need for more research and also to use that research in terms of deciding what services are provided in schools. That things are culturally responsive and equitable. And they're based on data. So data-driven decision making, I think Justine talked about that a little bit in terms of using standardized screening for things like suicide, but also that we have data systems in place to understand what's going on at a larger, in a larger sense, across the whole school or across the school district. So these are the core features of comprehensive school mental health services. And here's my pyramid. This is what we call a multi-tiered system of supports and really is an opportunity to look at how we can provide services in schools that go from the bedrock foundation of family school partnerships, professional development, up to tier one, which is the promotion of positive social, emotional, and behavioral skills and overall wellness for all students. So that mental health promotion, mental health prevention piece. Tier two are supports and early intervention services for students who are identified through needs assessments. These are kids who are at risk or who have been identified as early in their needs. And then tier three are targeted interventions for students with serious concerns that affect daily functioning. Again, ideally, schools will have this whole multi-tiered system. They're not just providing services to the kids who have already been identified, but they're able to do some early intervention pieces and some of those tier one pieces as well. There are three other frameworks that are important that you might hear about if you're working in schools. Three other kind of similar to multi-tiered system of supports. And the arrows aren't meant to show that these three systems interacted at just those three tiers. So PBIS, which you may have heard of, is Positive Behavioral Interventions and Supports. This is a system of providing services across all three tiers and is kind of a particular brand of providing multi-tiered systems of supports. Interconnected Systems Frameworks is something that's very similar to PBIS. These are all, again, kind of particular brands. And then Social Emotional Learning is really more on that tier one level. It's a foundational way of and framework for understanding social determinants of health and really kind of the basic building blocks of social, emotional, and behavioral skills. So some terms you might hear as you're working within a school. Oh, there we go. So two examples of how this multi-tiered system of supports can work. This is a district example. The Boston Public Schools use a three-tiered system. It's a comprehensive behavioral health model. This is a model that was developed first at the Massachusetts state level and then came down to the Boston Public Schools. It's built on this, they call it the lighthouse, so they have a pyramid as well. And it's a way that they're providing comprehensive behavioral health services within schools. This is also something that was built on some SAMHSA funding. And then a state example, Wisconsin's School Mental Health Initiative. So Wisconsin received three grants in the early 2010s. And they were able to braid the funding across those three grants to provide services and train up 100 schools in what they call the state school mental health framework. So again, they have a, everyone's got a pyramid here. But here, again, they're looking at providing services within schools across all three tiers. This framework also provided technical assistance and training to these 100 schools so that they were able to really develop these services. So going back a little bit to where psychiatrists fit into this model, we want to stress the idea that we really need strong community partnerships. I think oftentimes schools feel isolated and that they may or may not have school mental health folks on board. Sometimes there's one social worker or one counselor in a school or especially in a rural school district. And they feel like they don't have good connections. I see people nodding. They don't have good connections out to those communities, to the partners. And so I think this is a key place where psychiatrists might need to step in and build those relationships with schools. But we also need schools to step out and seek those relationships as well. These kinds of partnerships really can augment the abilities of schools to address barriers. They can help to provide a broader array of supports and really improve access to mental health care. So again, I just can't stress enough how important it is to build these community partnerships and that they need to come from both sides. So we talked about the multi-tiered system of supports. And Justine talked about a number of roles. So I just wanted to kind of go back to that and think about how those different roles could interact with this MTSS model. I think we talked a little bit about the advocacy role. And let me find my other notes here. The advocacy role, I think that that is important. The advocate can be for the school, for the child. It can be an advocate in terms of providing professional development and support for a healthy school workforce. Psychiatrists can also serve as educators to staff and family. Psychiatrists can also serve as educators to staff and family. Psychiatrists can serve as the psychiatric provider of record. And that, I think, falls in at tier two, but also into tier three. And they can also serve as consultants either at the case level or at the systems level. I think we frequently think about the psychiatrist only providing those tier three services. But I really appreciate Justine's conversation and how we can think about those services across the whole MTSS model. Now I want to talk a little bit about some resources that we have developed through our network for school-based mental health services. So I represent the National Coordinating Office for the MHTTC network. We are a SAMHSA-funded network of right now 12 centers that provide technical assistance and training to the behavioral health workforce. We are a regionally-based system. So we have 10 regional centers that cover all the states and territories. So I would invite you to go onto our website and, based on your state, find out which regional center covers your state or your territory. We're really there to help behavioral health providers accelerate the adoption and implementation of mental health-related evidence-based practices. So we have resources that we develop and disseminate. We provide training and technical assistance. And we deliver workforce development opportunities across the mental health field, all free, mostly virtual. We have tons of resources. We've been a network for the last five years. We have one more year of funding before, hopefully, there's a new version of us. So I really encourage you to reach out to your regional center. We currently, right now, also have two national area centers focused on Hispanic and Latino populations and on American Indian and Alaska Native populations. And those centers will be, in the next funding in October, becoming large national centers of excellence. So they won't be within our network, but they'll still be there providing really important services for those particular populations. We are really fortunate within our work to have a large school mental health initiative. So we have separate funding for our network to provide school mental health-related services. And these are services that each of the regional centers provide within their regions, again, focused on awareness, disseminating information, providing technical assistance specific to mental health services in schools and school systems. This is just a little smattering of some of the work that we've done. We really provide a range of services from a one-time webinar on a particular topic to an in-depth learning collaborative. We work with states. We work with districts and schools. And we work with individual mental health and addiction providers. I wanted to call attention to a few of the larger products or foci that we've had over the past five years. This is the first large project we did in concert with the National Center for School Mental Health at the University of Maryland School of Medicine. This is our implementation guidance modules for states, districts, and schools. So this is a presentation that we did with the National Center for School Mental Health. This is a training package that really focuses on how do we help states, districts, and schools both understand the components of comprehensive school mental health, the things that I've just talked to you about, as well as engage in a planning and implementation process. So what are the modules that you use to plan these services in your district? They're based on the core features of effective school mental health initiatives that I've just been showing. And they're really intended to be used by teams. The modules have been downloaded like 2,000 times over the past few years. And each of our regional centers are using these modules in learning collaboratives and learning to help states and school districts implement these services. Another of our, I think, shining stars of work that we've done over the past few years is called Classroom Wise. So a few years ago, SAMHSA requested that we develop an online training package specifically for educators. So our primary audience has been behavioral health providers. But this was specific for educators and school personnel. And it's really a mental health literacy program. Again, we worked with the National Center for School Mental Health at the University of Maryland to develop this three-part training package. So we have a five-hour online course. We have a video library. And we have a resource collection all put together on a website. So Classroom Wise is really focused on basic mental health awareness and literacy. We've had over 16,000 people complete the training thus far. And again, all of our regional centers are working within their regions to try to build the capacity of educators and school personnel to understand really basic information about student mental health so that they can really be good partners with folks like you who are providing services. We've also been excited that several states have incorporated this training into required professional development for school staff. So again, really trying to start from the bottom and build up that capacity for understanding. Something that we've heard about Classroom Wise when we've gone into schools to see if they're interested in adopting it is a concern that educators have that we're trying to kind of train them to be mental health providers. And so we want to be really clear about what their role is. Their role, they know the kids the best, obviously. They know when there's something wrong. And I think that building their mental health literacy can help them look at those behaviors in a bit of a different way. Maybe understand a little bit more where those behaviors might be coming from. So there's pieces in Classroom Wise about trauma-based services and trauma-informed care. Again, I think some of the things you were talking about, Justine, when you have a particular issue in a school when a kid acts naughty or acts out, how can we help educators to understand other reasons why that behavior might be occurring so that they're gonna pull in the mental health resources and maybe not start with thinking about an expulsion or a higher-level consequence like that. So we're really excited about Classroom Wise. Recognizing that cultural inclusiveness and equity is so important, one of our regional centers built a companion training to Classroom Wise. It's called CIE Wise. It's a two-hour online course. Also has some really great videos with it. And have educators learn how inequities in education impact school mental health. Talks about implicit bias and its relationship to mental health. And then provide some really concrete, culturally-inclusive strategies to support student mental health. So a companion to our Classroom Wise piece. Both of these were built with educators and with students. The video packages we put together are just brief, like 30 seconds, one minute. Either students talking about what's important to them with their mental health. Educators talking about how they try to bring mental health into the classroom. There's little quick demonstration videos for how educators can bring mental health into the classroom in a way that makes sense. So again, great resource. We've also done a couple implementation projects with a total of almost 30 schools and districts over the past two years. This is work that my office has done. We know that if you build something like this, a training package, you build it and no one will come unless you try to really get out there and show people what it is and why it's important and of benefit. So we're working with these school districts to understand what help can we provide to them to implement something like Classroom Wise. Something else that Justine spoke to briefly that I wanted to highlight in work that we've done is just a few months ago, we collaborated with the SAMHSA-funded Center of Excellence for Protected Health Information. They go by FOCUS PHI. You should check them out. They're amazing and awesome. We worked together with them, with Steve Adelsheim from our group to put together a two-part learning series about how those federal privacy laws apply to student mental health information. It's hugely complicated and is hugely complicated in each specific state. So we kind of only scratched the surface with this but really brought to light some important things for folks who are providing mental health services in schools to understand or at least to be aware of. And we discussed common scenarios involving student mental health information through some case studies, especially in that second part of the learning series. So check it out there. You can access the materials from the series, the recordings, the slide decks and more information there. Additional school mental health resources can be accessed on our training and events calendar and in our products and resources catalog on our website. Another thing I wanted to call out is that SAMHSA asked us in this current year to put together a white paper on threat assessment. Again, dovetails with something that Justine mentioned. But over 20 states have mandated that threat assessment be used in schools. And although there is some research base for threat assessment to be used in schools, I don't think it's at the level that we would want it to be at. And there are a lot of concerns from advocacy groups related to how threat assessment is used. Is it equitable? Are there cultural considerations? The issues about bringing law enforcement into schools, especially in situations that might be mental health situations or situations where kids have an IEP and have some kind of learning disability. So we're working diligently on a white paper that we're hoping will be ready in the next couple months. So more information, that'll be out on our website when it hits. So just to summarize, I think important to know schools really range in their understanding of mental health. Again, from schools that are really under-resourced and may have no mental health folks, may not even have a school nurse, to places that have a school health clinic, which may include behavioral health services, could even include substance use services. So that's important to understand when you're kind of going into a school system or a school to do work. We hope that we're able to get that multi-tiered system of supports as a framework that really can help enhance comprehensive school mental health systems. And we're really thankful to SAMHSA in particular for providing a lot of funding for projects like Project AWARE grant funding that supports states and local educational areas to implement MTSS. Really highlight the partnerships between schools and community psychiatrists. These are so critical in supporting student mental health. And to have folks be aware of ways that those partnerships can be built. And hope that you've gotten the message from all three of us about the important and different critical roles that psychiatrists have in school mental health. A little bit more about us and our network. Again, the website and Jessica Gonzalez, who unfortunately wasn't able to be here today, is our school mental health lead. And feel free to contact her if you have any questions. Thanks very much. I think we have 10 minutes for questions. Yeah, this was being live streamed, or is. And so there's two questions actually from online. I'll take one of them now and then I'll do some in-person ones. The first question I thought was really relevant to some of the things that Dr. Gotham spoke about. So basically the question is, we as the speakers are assuming the schools and teachers are gonna be receptive. And this person was saying, what do you do? So how can we ask the teachers to take on more is basically what this person is saying. And especially when they're so demoralized and burnt out. So one thing I was gonna say is that I, in my experience with the individual teachers that I work with, they will engage with you if they feel like you can help make their job easier. I mean, one thing, they care about kids and they went into the field because they want to help kids. But then when they see a kid who is either oppositional or so dysregulated that they can't focus or being aggressive and disruptive, if you can demonstrate to them that what you can do can help them make their life easier and help them feel better about educating their kids in their classroom, then that is the way that you can sort of hook them. And then from then on you have a partner. And so I have in the school where I work, I walk around and I've had several occasions where basically teachers are sort of on the verge of tears and they're saying, this has been a horrible week. And then we talk about the kids and we try to kind of develop a strategy. And I think that's, then you have a partner. And so that's one way to sort of really work with teachers and really engage them. Because they want to teach their kids. So do you guys have any more comments about that aspect? And then I think some of those materials that Dr. Gotham presented are also really, really could be potentially useful. I really think it's about the role. It's helping educators understand what their role is and that you're not trying to make them a mini psychiatrist or psychologist. You're not expecting them to be the expert. But you're giving them tools to help them, I think, feel more, understand more what their role really is and help them feel more engaged and self-efficacious. Perfect. So let's see, why don't we go to, do you want to go ahead? It's a question, yeah. Hi, thank you. My name is Flavio Cassoi. I work for the New York State Office of Mental Health, which is the New York State regulatory authority for mental health. And this is a question about financing. So we found in New York that our Medicaid program covers school-based mental health, but not every child in every school is enrolled in Medicaid. So the school-based programs are fiscally unsustainable unless you can get commercial insurance to also pay for school-based mental health. And Governor Hugo's just most recent budget does require that for New York State regulated commercial plans. But my concern, and my job is to oversee parity enforcement and managed care, is that the federally regulated ERISA self-funded plans don't have to do this. And there's a lot of kids on their parents' insurance, obviously. And it's very difficult to have nonprofit agencies operate these programs if a sizable chunk of the children they're serving will not lead to payment of the staff. So I'm wondering, I guess, Dr. Patel, is SAMHSA working with the Department of Labor to make sure that these ERISA plans are gonna cover school-based mental health? And kind of what is the discussion, I guess? I'm curious for other states and at the federal level on how to fix this sustainability. I mean, Medicaid is easy to require, right? I think states can require their sort of small commercial markets to pay. But if it'll fix these federally regulated plans, I don't think any of it gets off the ground. Yeah, I think that's a really good point. And I think the making the dollars work is sort of the magic bullet in making, our ability and hinges on the success of being able to scale school-based mental health intervention and programs writ large. And to your direct question, we partner very closely with Department of Labor and meet at regular intervals to talk about coverage. Coverage of services within plans that they regulate and that they oversee. And so, this is a particularly good flag and we'll keep that top of mind for our next meeting. Do you wanna go ahead? Sure, thank you for the excellent talks. I'm curious regarding school-based violence. How do you advise schools on a systems level to approach and navigate the looming fear and anxiety particularly among young children? I now work for the US Department of State and we're overseas. My kids, very young kids attend international school there. The security is like getting into the White House. I feel very comfortable. They have such great security measures. And by contrast here, I'm from Southern California. And recently there were bomb threats on social media. My friends with kids there, they have to keep their, recently had to keep their school kids home sporadically because of these threats. And I'm just wondering on a systems level, how you advise schools to approach that and the impact it has. On one of your slides, the ideal concept that school should be a safe haven for kids. And I'm just wondering what is your advice on how schools can both implement the safety training like active shooter training that goes on and balance that with addressing the anxiety that kids I'm assuming are developing with these increasing events. Yeah, I'll start and then you guys can talk more. So I think one of the things to do is kind of for us to learn so that we can spread the information and educate others that schools remain a very safe place for kids to be. So, but because we hear so much about the shootings that occur that it starts to feel unsafe, right? But sort of statistically school is the safest place for a child to be. And so I think kind of emphasizing that point. I think the other thing is that in terms of research, there isn't evidence that some of these safety hardening the schools really makes them safer. So like metal detectors or that kind of thing, we don't have evidence to say that those actually help make the school safer. But again, it's sort of this feeling of it feels better or it might, maybe it feels better. And so kind of, I think the importance of trying to get the facts right and getting more research. So another example is the active shooter trainings. There is some, I've seen some data that they do increase anxiety. Do they make people safer? I don't think there's good data necessarily to support that. So what is the best way to prepare? To prepare the school, to prepare the kids for something like, for one of those really extremely unlikely events to occur but one that you want to be prepared for. And obviously we need better training and protocols. But there are, the Dewey Cornell one for example, it's through UVA, so you can find it on the UVA website. The school is called the Center for School Violence I think is what it's called. But I think that, and they have some really good materials on just kind of about the statistics, about the fact that schools are a safe place to be and things like that. But I think ongoing need for really studying what is gonna help make, what in reality is gonna make us feel, make us safer, not just feel safer instead of stressing the kids out more. So I don't know what you think. Do you guys have anything to add there? I think you covered it quite well. Okay, okay. All right, and we do have a couple more questions online too so I'll do those after. And then we'll probably have that. Mine's hopefully a little briefer. But first and foremost, with respect to the pyramids and the tier-based systems, what typical grades and ages per tier are children being enrolled? Can you give me a little bit more about your question? Yes, so is it typically the younger goes tier three first and then it's later in years when they get moved to tier one? Or is there any sort of trends? Yeah, so the tiers aren't, kids aren't categorized into the tiers. The tiers are just a way to think about the services that are being provided. So, and it's based on a public health and prevention model where ideally there are services and supports that are provided to all students. So these could be things like social-emotional learning. It's one of the frameworks that I talked about. Those are services that are provided across the whole school and then if kids get identified as being at risk for a particular issue, then perhaps the school has some kind of early services, early intervention services that might be like a group for kids who might be at risk of truancy or some mentoring that is kind of in a, not, I don't wanna say, not super intensive but something that might be provided even in a small group. And then for kids who are identified as having a mental health issue that is at a higher level or is at a more acute level or a more intense level, then they would get in school or services like mental health counseling from a school psychologist or might be something where we're pulling in a psychiatrist or there's a reach out to a community behavioral health clinic. So that kids aren't placed in tiers. It's just a way to think about what kinds of services are being provided. We're mindful of the time and just to lump a couple of questions that came up online and then Dr. Larson can close us out. I think there was a question around what do we mean by promoting resilience? And I think that there's a whole suite of different types of interventions that promote resilience. Many schools have implemented like mindfulness, sort of programs and teaching around that. And it would take some time to be exhaustive in what that looks like but I think the bottom line, the piece is it's not necessarily targeted towards a specific disorder or symptoms but largely helping children and youth sort of regulate their emotions, identify what they're feeling and be able to sort of manage the stresses of everyday life. And so there's a whole host of things that sort of fit into that. And then there's a specific question around programs and addressing the inequities and disparities around in American Indian and Alaskan Native communities and we know that the suicide rates are really high in these populations and particularly around school mental health, we have specific AWARE grantee and maybe Heather might want to speak to this but in support that we provide for AWARE grants for Native Americans. Yeah, I would also say to that question that our National American Indian and Alaska Native MHTTC Center provides through our School Mental Health Initiative a lot of resources. They do trainings, they do technical assistance specific to Native schools and that's both for folks who are working in Native schools as well as for people who are working in urban centers or other places that have a population of American Indian and Alaska Native students. So lots of resources again, mhttcnetwork.org and then you can get to the National American Indian and Alaska Native Center. Great, well thank you so much for being such a great audience and asking questions and being engaged and I'll be around here for a bit if anybody wants to talk before we, but thanks again for coming and keep up all the good work. Thank you.

Dr. Justine Larson

Shepherd Pratt

Maryland

child psychiatrists

K-12 schools

mental health services

school-based services

academic improvement

social improvement

community partners

SAMHSA initiatives

funding options

mental health programs