Well, hello everyone. Thanks for coming. My name is Aaron Krasner, and we're going to talk to you today about the youth mental health crisis in some detail. I'm really, really happy to be sharing this time with you, and I wanted to get things started with some introductions. Just of course letting you know that these are Category 1 credits, and you can claim them as such. There's going to be four presenters today in total. Myself, Stephan Carlson, Mayank and we are incredibly fortunate to have a UCSF senior member of ASAP with us, Dan Becker. So I'm going to be presenting the kind of meat and potatoes of today's presentation, the data. And then Dr. Gupta is going to talk somewhat more theoretically about an adaptation to the data. And Dr. Carlson is going to talk to you today about what we're actually doing about the data. And Dr. Becker will join us at the end for a discussion, and we will invite you guys to participate in that discussion too. And with that, I'm going to get going. Welcome to today's talk. I'm imagining you guys have heard the word Zoomers. This corresponds to the generation that child and adolescent psychiatrists have been treating, and also corresponds to the generation that has been contending with the greatest adversity compared to previous generations. That's one of the things I'm going to make a point about today. That's me. I have no conflicts. I think I should have some conflicts for some time. I've avoided them my whole career. I think I'm ready for some conflicts. Okay. There's no way I can talk to you about what's happening to adolescents if I don't tell you a little bit about adolescents. Many of you are probably as familiar as we are with adolescents, so please bear with this discussion. I think it's important to start by asking the question, from a psychiatric standpoint, why do we care about adolescents? We care about them, of course, because they're our children or our friends' children. We also care about them because what happens to them matters in a major way. People are familiar with this concept that adolescence is a time when psychopathology iterates or becomes more clear. I've always wondered why. I've been working with teenagers since I'm probably 20, but I've never known quite why it might be that during adolescence psychopathology really does take root. This article from 2008, a simple phrase sometimes matters to me, moving parts get broken. Meaning, if we look at neural pruning and neural connectivity, changing neurochemistry, that's a lot of opportunity for problems. If we add here experimentation with drugs and alcohol around that time, and I encourage you to think here about the increasing danger of cannabis exposure and the development of psychotic symptoms, and I'm adding a little phenotype here that I want you to take note of, high novelty-seeking boys with low harm avoidance. My guess is you all know at least one of those boys. Also, of course, in adolescence, contemporaneous with all of the development is endocrine change. Of course, there's a finding in the affective disorders literature around the predominance of female gender. Interestingly, that this only really iterates at Tanner stage three. What are we talking about here? We're talking about early, middle, and late adolescence. Throughout this time and these times, you have enormous change. Change that doesn't transpire as such really throughout the lifespan. Physical, cognitive, emotional, social, moral, and values-based changes. I add here a little bit about risk and resilience because I'm going to be talking to you about how to conceptualize risk and resilience among the Zoomer generation, especially in light of the universal stressor that has been COVID. Risk and resilience is a common concept to you, I'm sure. It's important as a basic heuristic in terms of understanding the factors that line up in favor of and against a given individual developmentally. This is a really important slide. It comes from Stanford. I don't know if anyone here is from Stanford. It was a collaboration, UCSF and Stanford. What they did, this imaging group, Gottlieb's group, is they realized that there were some morphological changes in the brain in the longitudinal studies that they were conducting that were not anticipated. Their hypothesis is that related to adversity incurred in the pandemic. What I'm showing here are the morphometric changes that are anticipated throughout the lifespan. Because this group found evidence that there were massive departures from normative adolescent brain development that were incurred as a result of increased stress relating to the pandemic. That's a big deal. This group interrupted their longitudinal study because the brains of the teenagers that they were looking at in both controls and in the experimental design had changed. Think about that. Let that in for a second. This was a statistically significant finding. As I round the bend on the introduction to adolescence, let me just be clear. Adolescent psychopathology is common. It's persistent. It really sets the stage for a lifetime struggle. It's costly, especially affective disorders. This is probably not news to you guys. It's deadly. Psychopathology is associated with risks for despair death, especially for teens. It's increasing. This is what I'm going to be telling you guys about today. The psychopathology rates are really changing. I'm going to show you how and hopefully tell you why. Things for the Zoomers weren't so hot prior to the pandemic. The list of stuff that they and their parents encountered was not trivial at all. 9-11, Katrina, Afghanistan, the Gulf Wars, intensification of domestic terrorism, white nationalism, and escalations in hate crime, financial crisis of 2008, opioid epidemic, mass shootings, climate change, police brutality, and civil unrest, social media and the commodification of humans and human behavior, economic and health disparities that were ever-widening. In anticipation of this talk, I did read two books, one called Fight and the other called iGen. This book, Fight, was really a fantastic rendering of the Zoomers. If you haven't read it and you have an interest, I highly recommend it. Dr. Murthy, our Surgeon General, has sounded the alarm for the youth mental health crisis several times. As part of the call to arms, he has offered some important data. I'm going to be showing you data throughout this talk. A lot of the data corresponds to pre-pandemic prevalence and incidence assessment and post, meaning how do we know that there actually is a change in the rates of psychopathology. When we look at 2009 to 2019, there was a pre-pandemic increase in affective disorders, 40 percent among teens, suicidal ideation increasing, suicide plan increasing, behavior health care utilization increasing. And there were, you know, unfortunately, many, many suicides. Of course, that's really why we're here. We're talking about psychopathology because it's a risk factor for the loss of life. And most of us are doctors and we would like to help people. More trends here. These are pre-pandemic percentages of high school students who experience persistent feelings of hopelessness, blah, blah, blah. You can see those trends. It's self-evident. I include here a little slide around Dr. Mary Kangas and Kessler. They're fantastic epidemiologists. And I wanted to just note here that one thing that they said, this is the state of the art comes from about 2016. And they say, although there is substantial variation in the findings based on methodologic characteristics of the studies, the findings converge in demonstrating, and here's what I want everyone to remember. One-fourth of youth experience a mental disorder during the past year, and about one-third across their lifetime. That's a lot. Anxiety disorders are the most frequent disorders in children, followed by behavioral disorders, then mood disorders, and substance use disorders. Girls have greater rates of mood and anxiety disorders, and boys have greater rates of behavior disorders, whereas there is an equal gender ratio for substance use disorders. Psychiatric epidemiology is interesting, and I spent a lot of time reading psychiatric epidemiology. I've read more of it in the last sort of six months preparing for this talk than I had read maybe in training. So I got back into what it means. It's important to identify the goal. The goal is to identify the problem. And it's not so easy to do that, actually. It seems like it should be easier. There's two ways we think about problems and count them prevalence, which is amount of problem per time and incidence. And just to remind you, a lot of these studies are case-control studies that are looking at risk, disease, and trying to account for co-founding variables. This slide I've shown you here is—oh, you can see that. Cool. Oops. This is another slide that is illustrating, in the pre-pandemic, the increase in affective disorders. Pre-pandemic, females were disadvantaged. LGBTQIA, BIPOC youth were disadvantaged. And parents were disadvantaged. I want to comment briefly on the overwhelming, repetitive finding that young girls in the pre-pandemic era were faring worse. I want to pause here. I'm going to pause here again and again. This is a very, very important finding. In the pre-pandemic period, young women were disproportionately depressed, suicidal, and self-injurious. It started in the wake of the release of the iPhone. Famously, Steve Jobs—does anyone know what Steve Jobs said about whether or not he would give his kids the iPhone that he made? He said he wouldn't. Turns out, when this study controlled for other variables, it was a particular alchemy of social media at night with emotional investment in the social media that was messing up sleep and as part of this, they found that 86% of adolescents sleep with their phone in the bedroom, often under their pillow or in their hand. It's pretty compelling. It was the cluster of insomnia, emotional stimulation that was, in this study, very clearly correlated to the increasing prevalence of depressive disorders in this population. According to the CDC, hospital admissions data shows the number of teenage girls who've been suicidal has increased 50% nationwide since 2019. Sophia Jimenez was one of them. I remember crying every night and not knowing what was going on and I felt so alone. Sophia and her friend Nina Hughes were in eighth grade looking forward to high school when COVID turned their worlds upside down. I've always been a super smart kid and I've always had really good grades and then as soon as the pandemic hit, I failed a class. When I was virtual, I had no motivation to do anything. I would just sit in my room, never leave and it was like obvious signs of depression. My mental health got really bad, especially my eating disorder. I was basically home alone all day. My parents, while they noticed that I wasn't eating, I would refuse to eat so then they ended up taking me to the hospital. Sophia had to stay in the hospital for two weeks before a bed opened up at a psychiatric facility. Your generation like got hit with this in what's for speaking of a fun carefree time. What was lost? What did you guys lose during the pandemic? Myself. Yourself? Yeah. I would definitely say there were big pieces of myself that I were definitely lost. I lost friends because we wouldn't see each other. We couldn't go to our first homecoming. I couldn't have an eighth grade graduation. I know that doesn't sound like that big of a deal. It's a big deal when you're in eighth grade. Yeah. I feel like if the pandemic hadn't happened at all, a lot of my like sadness and like mental problems would not be as bad as they are. It just made everything worse. That's it, right? It made everything worse. According to the CDC. Resulting from the quarantine and mitigation strategies to manage the threat of infection, 90% of students lost in-person school. Families have experienced, and I read so many of these articles, so I just grabbed one, a couple of quotes. Families have experienced enormous stress due to seclusion within households, social isolation, concern about the health of family and friends, disruptions to school and childcare, and the need to make new health-related decisions in a context of uncertainty. My guess is you can all remember some of those decisions. What do we do about the groceries? What do we do? Such stressors have the potential to disrupt basic processes within the family by overloading the lives of caregivers who are faced with the challenges of both providing and taking care of the family. So what did COVID do in addition to age the brains of those that were in Gottlieb's study? Well, there was a massive increase in psychological distress. If we look at 2018 to late April, and the best review was a pediatrics review, and I'd be happy to send you the article, where they pooled data from, what is that, 80,000 youth, and the findings are quite striking and incontrovertible and clear. The prevalence of depression and anxiety symptoms during COVID doubled. And, of course, moderator analyses reveal that the prevalence rates were higher when collected later in the pandemic, i.e., after more morbidity associated, in older adolescents, and, of course, again, in girls, because from an epidemiologic standpoint, when the prevalence rate is higher prior in the pre-pandemic, we would expect there to be a perpetuation of that. So why? Well, here are some of the risk factors. Lots and lots of challenges. People actually worried about getting the disease being one of them. Now, here's something interesting. There is a pretty strike and repetitive finding that substance use disorders dropped for the teens, and I think I know why. They couldn't get any drugs. And, interestingly, this is a study from Iceland, where they did a very rigorous population-based assessment. It was the thought of this very strong epidemiologic group in Iceland that this was a harbinger of bad things. Finally, in addition, youth living under the stress of parental substance use because parental substance use disorders increased. Family dysfunction and domestic violence could predispose the later onset of substance use and violent behavior, and that is the expectation among several of the research groups that I encountered on this topic, that this is a forthcoming problem. But what about the adults? One in four, worsening mental health. One in seven, worsening behavioral health for the kids. One in ten say both. Very, very interestingly, a PTSD study looked at adult respondents, and those who, for 86% of them who responded positively for PTSD, said their kids also met that cutoff score. So this speaks to the traumatic influence of the pandemic. There were elevated levels of adverse mental health conditions, substance use, and suicidal ideation among adults. Anxiety disorder, depressive disorders, and suicidal ideation all increased when controlling and looking carefully at the previous periods. And, of course, these conditions disproportionately affect at-risk people. Now, I'm going to start to move into a discussion about relationships and families, and hopefully this is where I can teach you guys something if you're not familiar with it already. I'm starting with this slide because it's a little bit stark. This demonstrates increases in interpersonal violence or domestic violence during the pandemic. And here I'm showing corresponding rates of change for teens and parents, and I want to draw your attention in particular to the disparity as it grows in the category of worse. So here, can everyone see this little marker? Yeah, okay, good. So here, these are people and families that did better in the pandemic, and some did, and I have an explanation as to why. Here's people who stay about the same, and in both of these you have either nominal higher scores from the parent or mostly higher from the kid, both sides. But when we look at where things did worse, there's clearly a signal in terms of the rates of parental psychopathology and the rates of child psychopathology, meaning a leading variable, as I am analyzing this data, has to do with parents more than kids. In this study, as the parents did worse, so too did the kids. And that leads me to the next section where I want to talk to you about teen and parent interactions, i.e., the family. There's lots of ways to think about families. I'm going to tell you about two. One is the circumplex model, and the other is the ecological model. Most of us are familiar with the ecological model. It's Bronfenbrenner from the late 70s, and it's straightforward. It says, that which transpires at multiple different interacting levels systemically throughout a society filters into a significance for the child. It is less about parent-child interaction and more about the cumulative risk factors in society as they iterate and manifest problematically for families. These are typical ecological models for the impact of adversity on kids. Now I want to talk to you about a more dynamic model. Just by a show of hands, has anyone ever heard of the circumplex model for parent and family function? Okay, good. I'm teaching you something new. It's old, though. It's a model from the 80s. It was developed by a guy named Olson, or Olin. What I want to explain about it is... Before I explain this and the language there, I'm going to see... No, I don't have that. Okay, good. I'll do it right here. Here's the concept. If we look at this graph, across the top is the matter of cohesion within a family, and going up and down is the matter of flexibility. Cohesion corresponds to a sense of meaning, purpose, and understanding in teens and family members. That's the concept of coherence in a family. Flexibility corresponds to the either slavish or hopefully less slavish fidelity to role that we find ourselves in in our families. So in a family with high rigidity, all of the roles are static, with very little flexibility. In the coherence metric, we talk about whether or not that's really where enmeshment lives. The reason I like this model... First of all, a third thing that is a part of this is communication, and they study communication carefully. So basically what's happening here is in higher-functioning families, there is more coherence and more flexibility. In lower-functioning families, there's less. Duh. I wanted to identify here, if you can see it, that at the bottom end here is what they call less balanced. These are the more enmeshed and rigid family structures. Then up here, there are the more balanced ones in white, where you can see structurally separated, etc. Flexibly connected. Obviously, we all want to be kind of up here, and not down here. This model is a sensitive one in terms of stress. The more stress that infuses into a family system, the more likely that there is decrements in flexibility and cohesion. The reason I'm introducing this concept is because I repeatedly found that what drove the youth mental health crisis is the parenting and adult mental health crisis. I'm going to say that again. What I found repeatedly is the leading variable for adolescent psychopathology was adult and parenting psychopathology. That would, of course, matter in the interaction between parent and child. That's why I like a more dynamic model, such as this circumflex model. Turns out that the variable that matters the most for families is the co-parenting unit. Co-parenting refers to the task of aligning with, communicating, and partnering with a parent in the running of a household, as it relates to children. This is a simple schematic that starts to identify the centrality of co-parenting and our thoughts about our partners as we are attempting to raise children. When we look at parents, and I think many of us spend a lot of time working with parents, especially if we work with teenagers, depressed parents or disillusioned parents have less energy for parenting. This is not rocket science, right? When parental self-esteem or work-home balance or a sense of strength to be conscious about one's role as parent, when that's mitigated, it is very easy to default into problematic parenting. I think problematic parenting would happen predominantly when responsiveness is low and demandingness is also low. But it would also make sense that low responsiveness and high demandingness, as in the authoritarian parent who sets a limit and then doesn't care, is problematic. We would be curious about factors that would allow us to feel authoritative as parents. And it sounds easy, but it ain't. It would appear that the problems, as I've begun to lay them out for you, have predisposed an epidemic of loneliness. Loneliness turns out, it's another book I read in anticipation of this, a guy named Dr. Jesti, I don't know if I said his name right, I think he's at UCSD, wrote a phenomenal book about loneliness. Who knew? Loneliness was a neurobiological construct. I had no idea. It is common universal human experience involving feelings and cognitions that reflect emotionally from perceived deficiencies in social relationships. I believe loneliness was at an all-time high when we were all cloistered together with our families, feeling estranged from one another. And that certainly was the case for many, many people during the pandemic. Loneliness is associated with physical health problems, depression, anxiety, etc. And loneliness is also in dialogue with another metric that I had known relatively nothing about, called subjective well-being. Has anyone here ever heard of this as a metric that is followed in psychiatry? Okay, good, then you guys are smarter than me. I didn't know anything about it. So I was glad to read about it. And I found, I learned something really important. Subjective well-being is probably best articulated as a blend of hedonic and eudaimonic pleasure. Hedonic pleasure you could think of as embodied pleasures, pleasures of senses, maybe you could think of it as sex, drugs, rock and roll, kind of, right? And then eudaimonic pleasure, coming from the Greek, right, eudaimonic, is the value of a life well-lived, is the value of a virtuous life. And one thing that wasn't clear in the literature but became clear as I thought about it was the blend or balance between hedonic and eudaimonic pleasures. It would make sense to you all that depressed people and people with untreated psychopathology probably would be more curious about hedonic pleasure, even though anhedonia is one of the core criteria for depression, or perhaps more importantly because of that, people who are anhedonic would be seeking pleasure, duh. However, it also might not be a shock to you that a monomaniacal pursuit of hedonic pleasure might backfire. In fact, I think it does in addictions, and I think it did throughout the pandemic when people were, I think, seeking and seeking pleasure and relief in whatever way they could all the time. I think it had a very dulling effect on pleasure. However, it's a hard sell to say to someone who is depressed and seeking hedonic pleasure at their own detriment to ask and encourage them to cultivate a life worth living that is virtuous because I don't think that the return on investment feels the same when people are more depressed. However, when we look at larger studies of subjective well-being, it would appear that a predominance of eudaimonic pleasure over hedonic pleasure is the win. So I'm presenting you with, I think, a crisis that many people lost time, energy, and effort to, seeking, seeking, seeking hedonic pleasure at their own expense. Okay. I'm probably not the best math student, but here goes an equation. Pre-pandemic trends plus pandemic stress, I'm going to call that all risk, minus available treatment and family resilience, which would include resources. Now I'm going to call that resilience. So risk minus resilience equals the youth mental health crisis. This is where we are. We are in a perpetuated state of adversity and debit because the risk has predominated at expense of resilience, and there is marginally little resilience in our system. Oh, I'm going backwards. Am I going to be stuck here? Oh, yay. Is there any good news? Am I going to offer you anything positive here? Yes. I think tele-mental health is a thing. I think it is a way to transcend certain barriers of access to care. It was inaugurated and largely tolerated, and there are studies that are looking at efficacy, and I do believe that this is a valid change and a provident one for our field. Now if that's not been depressing yet, now I'm going to really bum you out. You guys, the mental health system for teenagers is pretty poor, and I'm now going to tell you why. How do we screen for adolescent psychopathology? The answer is variably. How do we offer outpatient treatment? We don't have much outpatient treatment. How do we offer inpatient treatment? Inpatient treatment, as many of you know, has become eviscerated of therapeutic efficacy. How do we get to residential treatment? We mostly don't, except for the very richest people. How do we manage the treatments in general? Well, we have a divorce of psychosocial treatment from medical treatment, which predisposes an over-reliance on psychopharmacology and polypharmacy as a means of cutting costs, which is pretty despicable. How do we monitor treatments to say they're going well or not? We don't. Most people don't use measurement-based care to even know if their patients are better or not. What do we do for the very most complicated of cases? Almost nothing, and just invest in an acute model that keeps failing. How do we make sure that schools are talking to doctors or talking to therapists and making sure there's interdisciplinary corresponding intervention? We don't. What do we do for these parents? I just told you that the leading variable for the problem in the youth mental health crisis corresponds to adult psychopathology. There's no, there's limited access to family-based treatments. Well, but at least we have psychiatrists, right? We have adolescent psychiatrists to help. We have about 8,400 in the country and probably about 13 million patients. This is a dystopian reality I'm presenting to you, and it's going to get worse. This is all canary in the coal mine, I'm sorry to say. Smart investments, systemic changes, more expertise, more training, and much more engagement. This kind of listless doom scrolling and the loneliness and the focus on hedonic pleasure and the kind of waning meaning and significance from our lives is going to intensify. So on that very grim note, I will end my contribution for this moment. I'd like to introduce Dr. Mayank Gupta. Dr. Gupta is a fantastic psychiatrist. He's the medical director at Southwood Psychiatric Hospital, and he's going to be talking to you today about some of the hopeful elements of my talk, where we might find engagement. He's also going to clarify some of the theoretical ideas that I've laid out, and he's going to speak for about 15 minutes, and then we're going to hear from Dr. Carlson, who is implementing some amazing changes and clinical programs where he's at. So thank you very much for your time and attention, and I'd like to introduce Dr. Gupta. Hi everybody. How is everybody doing today? So I'm Dr. Gupta, and Aaron told me to talk about engaging teens in 15 minutes. Boy, that's a task. But I thought what I'm going to do is I want to do something to engage you guys for 15 minutes. Let's see whether I can get your attention in. All right? It is tough, but we'll get it. And I want to leave you with some tips, some tips you can use today and take home and deal with teenagers. Anybody charge psychiatrists here? Anybody? All right? So we have some... Oh, wow. We have some adult psychiatrists. But, you know, other adult psychiatrists, they work with teens, too, correct? And the last thing, we've all been teens, too, before, you know, we've become adults, so we all know that. So I'm going to just give you some tips, and this is the topic. The topic is navigating in choppy waters. It is choppy. We know that. And how you can intervene, and what are the windows. And this is just about me. I have no conflict of interest. So I just try to tailor my objectives very clearly. I want to stay in the lane, all right? I want to talk about development. What is... Why development is so critical. What's going on here? Right? And the teenagers, what's going on in the brain? Because what you see is a phenotype. Secondly, I want to know, like, what are the opportunities, you know? Because we have a turbulent brain changes going on, phenotypic expression, but how you can intervene there. Because I'm a clinician. I'm not a researcher. I'm like you guys. And I want you to understand there are opportunities which I use, and I want to give you some tips today. And some tips today is one way to do things, right? And I also just want to go about the theoretical underpinnings about research, just to be sure that we can get some context. Context is important for both teenagers, families, for engagement, right? I use this slide first. So think about this wave as a teenage-adolescent development. Turbulent, right? I would say a little savage. And you are here. This is you. Right? Navigating. I think what is more important is the timing. How you intervene in the timing. What is... Second thing is part of nature. Whether you want to do it too aggressively, you do it subtly, right? The intensity. This is all... If there's one thing you can take home, this is what is it. But I'm going to go a little bit more in detail about that. Aaron talked about that 40% of kids were depressed. I mean, look at the number. These are staggering numbers. These are concerning. This should concern everybody. I'm not going to go into that. What I'm going to go into is, you know, why it is important that for child psychiatry or adult psychiatry, there has to be coordinated efforts. A lot of things come into play. This is complex work, right? It's not just child psychiatry. Developmental psychology, right? Anthropology. Genetics. Law. They all have to get together in order to get at outcomes, right? So I want you to be the alchemist who can just mix all these together and engage these teenagers, right? So that's what... I think there are risk factors, there are individual risk factors, environmental, population-based. Look at access to lethal means and SFO we are in, right? The Golden Bridge Bridge. The barriers made a lot of difference. Just one barrier, it was a list of efforts. We saw there were definitely a reduction in the number of suicides. Clinical case. Very quickly. This is what we see every day, right? 13-year-old coming, father passed away due to lethal overdose, living with mom, grandparent, single family, getting bullied. Mission is bullied because of, you know, coming in on binary. Academically going, struggling, having outboards at home, using marijuana because that helps. This is a narrative we're seeing from the kid. They are waiting for four months on an appointment. If one person diagnosed with DMDD, second person with ADHD, third with bipolar disorder, then depression, nothing working, getting re-hospitalized, discharged by AMA. This is what I do every day. I'm sure everybody is experiencing that. How to deal with it? So these are multiple variables, right? Interacting with each other. I can pick these like on the right-hand side. This is what I can see, right? But something is modifiable, something is not modifiable, right? We can't modify certain things, you know? Certain things we can, but who is leading the team? And I'm going to come to that very, this is very critical. You are the leaders. You are leading the team. I know we're going through imposter syndrome, but you know it all. I think I'm going to just giving, I'm refurbishing what you know, but trying to give you a little bit more narrow lane how to go in. I'm going to go first into descriptive knowledge, then I'm going to go to empirical knowledge, descriptive. I think we all know bonding, attachment. Now, individuation, what Mahler's theory, like we all become a dyad, mom and child, and then we individuate and become ourself, the unit self, right? I think there's more to it. I think I would say that, look at these folks, Mr. and Dr. Sullivan, right? These people thought about what we know now. Many years ago, they said, listen, Chomsky's is important, you know? I mean, I have a daughter who's 11. They have a friend who's the same age, and they all, you know, are friends with each other. This is very critical for adolescent development, because acceptance is critical here. I also want to talk about Peter Bloss. He said second individuation happened much more later in life, much more later. And this is where there's a disengagement of parental figures, and they want to value their friends more. Very critical, very critical, and that is not defiance. They want to be the unit self. I want to talk a little bit about Kohut. He said that that's a development of self, which is critical for their self-esteem, be intimate in relationships. And Winnicott has a great paper, which he said that the capacity to be alone is very critical for just being yourself. And I believe that's, I think when a kid said, I'm getting bored, I think it's important to get bored. It's important to be with yourself. If you are able to be with yourself, then you are able to get off the screen, and you're able to navigate yourself with essential part of interpreting yourself. So I want to go quickly to more empirical knowledge, and these are two quick videos. This is the first video I'm going to go through is two simultaneous process going on. One is pruning, and one is myelination. This is NIMH slides, and this happens, this is 20 years spanning to 30 seconds. This is another side about how myelination differs. You can see that the myelination in a normal, typically different kids completes by age nine and 10, but 80 is a kid's taking a little bit longer. It just keep on going until 13, 14, 15, 16. This is the phenotypes you are dealing with, right? These are the phenotype you're dealing with, but this is what's going on in your imaging. I think a lot of people say, listen, what is how we can empirically say that development is changing? I think this is a very beautiful research done by folks in Australia. We see smaller kids get activated on SSRIs when they're at age 10 and 12, and they get behavioral activation. They did a messenger RNA research on receptors. They found there are two kinds of receptors, which one is inhibitory and one is excitatory. Inhibitory receptors actually come online much later in life, right? So you start that SSRI, you get behavioral activation, and this is, if you see here, this is where the difference is. So this is developing, and this is empirically proven. What I think Freud said, whatever our previous seminal thinker said that has been proven, and this is just to show that these are things coming online at different times. We have this very activated limbic system. The prefrontal cortex, the CEO, is really lagging behind. So we are dealing with developmental changes. At the same time, I think this is what happening, what Aaron talked about, seven and a half hours on screen, right? Social media, you are distorted in your perception, that's FOMO, you know, we have just got into the compulsive behavior. Second thing is object, you know, hedonic, non-hedonic, right? Objects never can fulfill satisfaction, perfectionism, hyper-perfectionism, I think everybody want braces. This is research done in Australia for 20, 30 years. They found people that want to have a good smile, but they eventually were not happy. I mean, I think I'm going to go straight to the solutions. What are you going to do now? We have a very good development, we have this interfacial development. I think relationship, relationship is very critical. Pick and choose your battles with a teenager, right? This is very critical. Ignore certain things, don't get into power struggles, re-info, catch them in the right moment. I mean, relationship goes a long way. I mean, I said that we did diagnosis a lot, and why it's important that when we know that the pruning, 50% of neurons are getting lost, and we are seeing this, what happens in brain pruning. What fires together, wires together, right? Motivation interviewing. It is a phenomenal developmentally targeted intervention, and Dr. Miller, I mean, I think this is one of the incredible, I think, strategic intervention, because what he's saying here is like, when you are taking a lower place, right, when you take a lower place, then you don't activate the limbic system, right? So you're not arm wrestling a teenager, right? And you're intervening, you're using the prefrontal cortex. So you want to deal with the cortex, you don't want to deal with the limbic system. And it's not just used to substance use disorder, it's used for so many other areas you can implement. This is, you want to engage these kids so that they can come to you, right? You can engage them, so use MI principles. It works. It works. Second thing, misinformation, right? I mean, child psychiatry is controversial, right? Bipolar disorder is episodic, or is it not episodic? We battled it through. We had a lab-related diagnosis, ADHD, you know, depression, or maybe DMDD. We are, cannabis is a herb, or, you know, pharmacogenetic testing. These are all going on, right? I mean, we have to counteract it. 13 reasons why. I mean, these are something which are news articles. We have to counter them with scientific information. This is critical, because I think teenagers read it, right? And they read it, and they feel this is, they feel they are more validated. Subjectivity is important, too. Context is important, too. I think your transparency is important, too. I think if you are able to take an assent of a teenager, I think you're going to have a better clinical outcome. And I think, I thought of a hard thinking on soft skills, a very good Brooking Institute article, it's all about resilience. A few more things, you know. Who is in charge of the ship? We have many providers, and they make it sound as very simple. It is not simple. It is not. It is a complex work. We are getting into very reductionist kind of things. We just want to look at symptoms, but this is complex work. I think you are in charge of the ship, and this is a collaborative model. I strongly support it. This is complex work. What are you doing? Just want to summarize very quickly. We have to understand the reason why these kids are not engaging with us. What are the reasons for disengagement? We have to understand development. We have to time the intervention. We have to counter the misinformation. We have to acknowledge subjectivity with empathy. We have to get it. All right. We understand how you feel, and develop a context. If you have a context, it could be like why activation syndrome happens with younger kids. Tell the family. If you are going to tell this family, you are going to tell the kid, there is more buy-in. Resilience, obviously. These are my references. Thank you for listening. That was Dr. Gupta, and I am now pleased to introduce Dr. Carlson. Dr. Carlson is the editor-in-chief of the journal, All Three of Us, which is part of the Association for Adolescent Psychiatry. He's been editing this really great journal. He is an assistant professor, and he is really at the vanguard of practical implementation strategies because he works primarily in an urban and very busy CPEP emergency department. I'm really looking forward to his comments. Thank you, Dr. Carlson. Good afternoon. I'm so happy that you have stayed with us and you are present today. I know that your time is valuable, and this must be a topic that is really important for all of us. The youth are our future. My topic ... Sorry. I have lost my topic slide. I apologize. The topic is, what is the response to the youth mental health crisis at a practical level? As Dr. Krasner has mentioned, the system is fragmented, and getting acute care is hard. We know that that is not the whole answer. In fact, we have to invert the pyramid, and we know from President Biden and his administration to every state and local government, more funding is being directed toward the youth mental health crisis than ever before. This is a very promising and optimistic time to really engage with adolescence, which adolescence is a time not just of risk, but of great promise. We want, of course, to engage the adult psychiatrists in the American Psychiatric Association to join, as I am. I am not a child and adolescent psychiatrist. I have, over the years, become interested in adolescent psychiatry. And I hope you, too, will at least consider the young adult or the emerging adult population and really intentionally play a hand in the future. The most impactful solutions will be focused on the social, political, and cultural factors and changes relating to the social determinants of health, equity, and social connection. This is a infographic from Vivek Murthy's call to action for the Youth Mental Health Crisis, which was published in 2021, focusing on Dr. Krasner's comments about the need to think about things from the socioecological standpoint. And again, the point here is really political will to focus on things such as housing for everyone. For example, the forbading of people being evicted from their homes during COVID had very positive beneficial effects on people's mental health, both parents and children. And the child tax credit, for example, particularly at lower socioeconomic levels, was an outstanding factor that interrupted the harm to our youth. I'm going to switch gears and talk about what I know, which is the emergency mental health crisis of our youth. And I want to share with you something optimistic, something positive in the developmental trajectory and a change. The introduction of 988 in July of 2022 is a real central piece of the hope and the future of our youth. It is unprecedented opportunity to expand behavioral health crisis systems nationwide. Youth who are suicidal, have mental health problems, or substance use crises can call, text, or chat via 988lifeline.org. It connects youth to the Suicide and Crisis Lifeline, formerly known as the National Suicide Prevention Lifeline. And it currently consists of over 200-plus crisis centers that operate 24-7, 365 days a year. From the Kaiser Family Foundation, or KFF, you can see here that the 988 implementation had extreme volume increases. I want to point you to two time periods. At the very beginning here, in July of 2022, you can see a real inflection point in the top curve of the total number and volume of calls to 988. You can see from a decrease in the chat function through the internet, you can see a steady increase in texting. That was an opportunity that youth had to text when they are in crisis. And then finally, I want to just point you toward the data ends for the 988 data in December of 22. But you do see an uptick again most recently. So this is good news that the 988 is already demonstrating a positive benefit in terms of utilization, that more people who are alone or lonely or separated or in crisis are able to connect with someone to help. I want to talk a little bit about the variability over time in the utilization of the answer rates of 988. You can see between the different types of ways that you can connect with 988, whether through chat, text, calling, that in every area that the numbers increased from December 2021 through December 2022, and they were all positive. We went from 24% of people texting to 96% in terms of the answer rates. We went from 52% of texting to 99%, 81% of calls to 87%. So this is a positive sign that the utilization and the answers at the 988 level are increasing and improving. Now I want to talk about some of the statewide variability and why there is still much gain to be had. Of course, the implementation of 988 was funded federally. However, as states were thinking about their 2024 budgets, the long-term funding of local 988 crisis call centers is an issue because only five states in the nation have chosen to enact legislation for the 988 telecommunication fees that are intended to sustain funding for the local crisis calling centers. So you can see here in this map that the dark colored blue states are those states which have 90 to 99% answer rates and are associated with this funding through the telecommunication fees that the federal government intended for states to take action on. However, in particularly the orange states are where the answer rates of 988 are the most dismal in the 51 to 69% range. So there is a variability in funding and, of course, access utilization of our most important resource at this time for youth to connect when they are in crisis. When we talk about equity and we talk about the social determinants of health, we need a 988 system that has metrics and data which are beyond what the lifeline general metrics are, such as accessibility and demand and answering calls. But in this slide, you can see what we need moving forward is we need to understand accessibility in terms of how easy it is for 988 users to reach counselors in terms of we want to know who are they referred from. Are they self-referred? Are they referred from 911, health care providers, etc.? We need to know the reasons. Now, I want to say that there are some states that have developed dashboards that allow you to extract some of this knowledge. However, outcomes. So what kind of outcome happened? Was mobile crisis called? Was police involved? Were there ED referrals? And finally, we need to know about the quality and the satisfaction and the experience of the consumers, of our families and our adolescents and of certain communities, black and brown communities and other communities in terms of the equity investment in our future. Finally, I want to say that there are some guidelines which are leading us in terms of how things should be and how things can be better for the youth behavioral health crisis. And those, for example, from SAMHSA in November of 22, they published national guidelines for child and youth behavioral health crisis care. And there was an additional technical guidance provided from SAMHSA by the National Association of State Mental Health Program Directors called a safe place to be crisis stabilization services and other supports for children and youth. I would please direct your attention to these guidelines and supplements to learn more. I want to say that SAMHSA strongly encourages some core principles for the youth crisis system. Keep youth at home. Use the least restrictive environment. Provide, of course, developmentally appropriate services as Dr. Gupta mentioned. Integrate family and youth peer support providers, people with lived experience so that we can scale this resource and make it available to everyone and meet the needs of all families by providing culturally and linguistically appropriate equity-driven services. The guidelines that I showed you earlier are attached to adult emergency behavioral health guidelines, which really emphasize some additional important parameters. Addressing recovery needs, trauma-informed care, significant role of peers as we've already mentioned, the zero suicide initiative, safety and security for staff and people in crisis, de-escalation techniques and skills and competencies for all mental health care providers. And crisis response partnerships and multi-sector integration, utilizing data to allow the law enforcement, dispatch and emergency medical services to work in an integrative and collaborative fashion. The youth crisis continuum really has three components for the design for its services. The first most important thing though is that the family and the consumer, the youth, define the crisis. So when they call, you know, it really is important for the person on the other line to really take it as something that's important to this family, to this youth, because we know if we want to engage families, if we want to engage youth, as Dr. Gupta mentioned, we have to listen. And that is how we will motivate families and youth to utilize these services. So from a 988 perspective and from the whole continuum of services, everybody wants someone to talk to. And that's what 988 is allowing people to do. Everybody needs, and 988 is delivering, on someone to respond. Generally, SAMHSA recommends this occur within two hours and national databases are measuring this response. And if the patient or if the consumer is in the home, we want it to be a safe place. Or if they need to be transitioned to a different level of care, we need a safe place to be. And these are the three fundamental components of the continuum of the mental health crisis continuum. The integrating these systems of care approach involves some additional factors. Family-driven, engaging the family, individualized, strength-based and evidence-informed approaches. Youth-guided approaches. If we want to engage youth, there must be youth advisory boards for both the service delivery and the service development. Culturally linguistic competent providers. We've heard that. Providing the least restrictive environment. Community-based. Communities know best what they need. And so we really need to direct our Medicaid funding and other financial investment resources to the community so that they can best utilize those funds. The resources, of course, need to be accessible. And 988 is leading the way toward that accessibility. And of course, we need a collaborative and coordinated access. And that will come as the data and measurement and monitoring improves with implementation science and new forms of private sector technology, including things like quantum computing and chatGBT, which will revolutionize over time the way these resources are scaled up and delivered. This is just simply another infographic explaining the continuum of the integrated systems of care approach. Really just starting with the family-defined crisis and that that occurring, hopefully, within a two-hour period. And that crisis period extending up to 72 hours, where in most states, a mobile crisis response of some sort, depending on the service capacity of the state, comes to the site of the crisis and intervenes and continues to intervene up to 72 hours. And they are funded and reimbursed through various Medicaid and other mechanisms to allow these services to continue. And not only for those who have insurance, but for people and youth who do not have insurance. And it can continue up to eight weeks. Finally, I'm going to leave you with a few thoughts as we are here in California. The child birth rates are flat in the United States, like they are in Europe. And where are children today? Where are our adolescents? They are primarily in the Southeast United States, where we have the worst coordination and integration of Medicaid. And this is really astounding. The immigrants, immigrant families, are our future. In California, 46% of adolescents and children are of immigrant families. Please let that sit in. In Texas, 33% of children under the age of 18 are immigrant families. What that means is if we don't get something right about the immigrant situation and change the legal statuses and such, we are not going to have a youth population who is going to grow up to help take care of us someday and to run the United States. Finally, just a short word about poverty. These are things that we know, but just to say again, comparatively, 27.7% of them are below the poverty line, whereas on Hispanic youth, 23.1% versus 9.9% of white youth. What we know about that is that poverty hurts our youth and is destructive and deleterious to their development. That's why, for example, the child tax credit was a tremendous support and buoyed and helped make our youth resilient. What are we missing? Finally, one last thing. With the conflict and the misinformation that came about during COVID, some of our presidential people used division to divide us as a nation. And they divided us by, for example, rural white youth who are a missed population among initiatives by APA, the AMA, the American Psychiatric Association. They, too, have a part to play in the future and need our help and our support and our services. Finally, the big picture solution for youth mental health for the ecosystem redesign is promoting resilience at the system level, not only at the individual level, but in the Medicaid system. And to use and utilizing the socioecological framework, which Dr. Krasner spoke about, to buoy up and promote well-being in the multiple ways that it is discussed in the research literature and as we are learning more about. Contextual factors, Medicaid funding, it will be the main driver of the future of our youth mental health crisis. Political will, and one short shout out to us all, care and development of our mental health workforce. We all learned during COVID how essential and integral it was that we need to be cared for and taken care of as well. That's the only way we can take care of others. With that, I thank you, and I want to give it back over to Dr. Krasner. Thanks, guys. I'd like to now invite Dr. Dan Becker up. Dan, come on. Dan is a very unassuming person, but I'm going to sing his praises for a minute, not too long because it will irritate him. I've known Dan for about 15 years, and he is a quiet, unassuming, tremendous leader in psychiatry. He has a very important position at UCSF. He's worked administratively. He's worked clinically, and he's worked among many different organizations, including the Group for the Advancement of Psychiatry, which is where I met him originally. Dan was the recipient of the Schoenfeld Award that our Society of Adolescent Psychiatry offers for Distinguished Life Fellows, and trust me when I say he deserves it. So I'd like a round of applause, if you don't mind, for Dan. Thank you very much, Aaron. It's really a pleasure to be here. I want to thank Drs. Krasner, Gupta, and Carlson for the overview of the situation we're in with adolescent and young adult mental health. I also want, and I want to thank ASAP, American Society for Adolescent Psychiatry. I've been with this organization for I think over, I don't know, over 30 years, it seems, and it's really, really been a great place for me to meet people like this and to think out loud with others about what we do and why we do it. I also want to give a shout out to the gentleman taking pictures in the back, Dr. Barkley, who is, who heads up the American Board of Adolescent Psychiatry and who has devoted and continues to devote his career to the education of those who choose this type of work. I'm just going to hit a very few high points. Well, they were all high points, but I'm going to pick up on a few themes, just say a couple words about them, and then we'll see if there's time for a question or two. First of all, the importance of paying attention to adolescents. Different studies come up with different estimates, but somewhere around 50% of all psychiatric disorders have their onset by age 14, which means that it's a little bit before, a little bit after. In any event, the disorders, again, this was alluded to by some of our speakers, really coalesce or pathology coalesces, if you will, during that, let's say, approximately 15 to 25 age year period. So that's a really key time to understand what's going on with young people to intervene if we can at all possibly do that. And certainly another reason why we should take care of those in those age ranges who have not yet developed severe psychopathology. Rapid development, as was mentioned during this age range, including brain and endocrine system development, is key to why so many things happen at this time. Another thing that happens at this time related to brain development is the development of socialization and of social problem-solving skills. Social problem-solving skills are key to how we as humans cope. So what you've got is young people who are learning how to employ their mental processes to solve interpersonal or larger social problems, and that's what allows them to get by and to deal with stress. We have so many stresses to think about. We talked about some, especially in relationship to the pandemic. Those of us who have reached, have gotten well into adulthood have developed ways to cope with some of these stresses. Teens are facing the same levels of stress over time as society becomes more and more complex due to things like social media and so forth, worsened or enhanced even more by the pandemic. But unlike us, teens haven't developed these coping skills, if you will, these social problem-solving skills to the extent that some of us have, and that puts them especially at risk compared to the general population. There's also chemical stresses, and I don't want to let this go by without mentioning the importance of the, again, this was alluded to, the high potency of things like cannabis that are available now, and perhaps more importantly, the increasing social acceptance of certain types of psychoactive substances, in particular cannabis. That is, that makes it tougher to have frank conversations with young people about how that may affect them. Lastly, on the topic of systems of care, psychiatry in general is just way behind the rest of medicine, not by our choosing necessarily. But primary care was, let's say, invented many decades ago, somewhere in the 70s, I guess 60s. It was thought about in the 70s. It started to get going, really got going in the 80s. That was a point at which increasing focus on education, risk reduction, early intervention, mitigation of illness, and much more attention to public health measures that might reduce risk for things like cardiac disease, pulmonary disease, and so forth. That made a big difference, I think, in the health status of our population, but psychiatry sort of missed the boat on that one. So we still are at a point now where instead of, generally speaking, looking, early intervention, educating people who may have risk factors before they become ill, we are still sort of getting to them once they've developed fairly severe symptoms. Whether we approach this through collaborative care, through things like integrated behavioral health care or other models, whether we use tools like telehealth or some of the other tools that were mentioned at the end here by Dr. Carlson, we're not going to be able to make enough psychiatrists or mental health providers. We're going to have to get smarter about how we get to people before they get sick. That's the challenge before us for all of our population, but especially for the teens who are, as I said, at rather high risk. Thank you so much for your patience with us this afternoon, for hanging in, and for all of your dedication to adolescents and young adults, and I'll turn it over. We would love some questions. As you're mulling a question, I'll tell you... Or comments. Or comments, yeah. As I was sourcing some of my commentary, I went looking for a citation to indicate the stability of adolescent psychopathology into adulthood, and I came across a, I think it was a 1995 study authored by none other than Dr. Becker with Dr. McGlashan. I hold a position at Yale, and Dan was at Yale for a long time, and one of the original citations on the enduring nature of adolescent psychopathology, it was only a two-year study, but the implication was clearly beyond two years, was yours, Dr. Becker. So good to know that he's been at this for some time. Please, if there are any questions, we would like that. Otherwise, we're going to have to... Please come to the mic. Yeah. For the sake of the recording, the virtual simulcast, would you mind just approaching a microphone? Thank you, sir. Hi. I appreciate all of your thoughtful considerations to kind of really look at what's been happening. I'm curious, I keep hearing a lot about the systems changes that need to occur and some of the funding issues, but obviously it's like an actively bleeding wound right now, and I'm just wondering your thoughts about what we can do, kind of triage or like tourniquet solutions in the immediate future while we try to go about some of these more like lofty systematic changes. I can take this, if you have a thought too. I'm primarily a clinician, so I'm in the business of coming up with solutions for problems that are insoluble. I think offering care is what we can do. We can offer care. We can offer some education for peers who are working with teens. We can offer education at the level of giving a talk in the community. Does anyone here ever give talks in the community? I would urge you, if you have any interest, even if you've just heard... If you just take my slides, right, you can go locally and start talking about parental psychopathology as a leading vulnerability for families, and I would urge you as a psychiatrist, we take for granted how much we know. We know a lot, and we can parlay more than we know, and if I could do anything, I would deputize you to get out there and try to say, you know, this is what's going on. This is what we know is going on, and at a minimum, you should know what's going on, because clearly offering treatment at multiple levels, really what we're saying here is that things are messed up at multiple levels, right, from soup to nuts. The system, individuals within a family, blah, blah, blah. So, you know, Anna Freud once was interviewed about what she would do in terms of psychoanalysis if she were brought to the favelas in Brazil, and she said, I wouldn't do psychoanalysis, I would build a latrine. So that's what I would say to you. Let's build some latrines. I just want to say one simple thing, which is I think a lot of the messaging today was caused some hopelessness and some disillusionment, and what I tried to say at the end is there are some bright lights, and there are some bright spots of improvement in our health care system, and our adolescents are eternally promising and resilient, and there are a number of political, social, and things at play that are really at a real vanguard moment in addressing this youth mental health crisis. Dr. Vivek Murthy's wake-up call and then the huge expansion of Medicaid is really going to drive the innovation and the change in a very short period of time. Just at One Brooklyn Health, where I work, we received a $500,000 per year, three-year grant to expand our emergency behavioral health services and to implement peer-based services, which we've talked about, which is one of the most important ways that we're going to engage our youth and our family is by having people work within the system who are consumers, who have faced struggles like all of us have, who can remind us that there is hope and that there is a future for our youth. Hi, my name is Seth. I'm a medical student interested in psychiatry. I'm wondering about, there's a slide about FOMO and perfectionism and how those dynamics in adolescence are exacerbated by social media. I'm just wondering, and then anecdotally for me, having two younger sisters who use TikTok and social media and seeing it affect their mental health, is there anything being done on like a policy or regulatory perspective when it comes to social media use? And then any other comments generally around social media use in adolescence? Yeah, I can comment a little bit. I feel like I'm the Grim Reaper for this discussion. Listen, the bad news on that topic is that since its inception, it was designed as a means of co-opting and commodifying human behavior. And there have been plenty of memos that have been circulated where concerned quasi-whistleblowers within like an Instagram have said, dude, I think this may be a problem for adolescent mental health. And they're like, yeah, yeah, yeah, but the money. So I'm afraid from a regulatory and from a policy standpoint to date, including there was a recent Supreme Court judgment in favor of big tech, the upside in terms of finance and influencers and selling everything has dwarfed the kind of sinister underbelly that I keep like ringing the bell regarding, which is again, I want to just give you, I'm going to give you a visual, right? It's this doom scrolling, looking and watching a video. And then I say to my son, dude, it's like time to do this thing. And he's like, who are you again? And the, you know, setting up, I could sit here and say, well, what would be really great would be if we as parents authoritatively said, well, don't do that. We'll do something else. But there's no other else thing to do. If you don't have, if you don't have kids, it's hard to imagine that if you, if you take away their screens, then you have to like do something with them because they they're so crippled by the screen that their sense of ingenuity and independence is like just zero. So when I take away the screen from my kids, they're like, oh, so now what? So it's, it's, it is a scenario that has transcended bad, right? It is like an addictions scenario. It is a profiteering scenario. It is sort of a late stage capitalism scenario. It's like pretty bad. And I'm a musician and I went and saw a good buddy of mine play over the weekend and he plays improvisational music and he, he plays jazz. He's watching the other person he's playing with like very carefully. I had this thought, that is the, that is the opposite of the doom scroll, right? He's exquisitely attentive to the, the musical choices and improvisations of a musical partner versus this passive recipient status of like content that I don't even want to watch, but I'm like, why am I watching a rabbit? What am I doing? So, and kids don't have that, you know, frantic inner voice because they've just been inculcated into that culture. So I'm afraid your question has bad news. I want to say something directly opposite of Dr. Krasner, but, but modify it. The overwhelming evidence is that digital resources were health promoting and promoting for mental health overall. Vastly so. I will direct you, for example, to one scoping review from Haddock in 2022, the positive effects of digital technology use by adolescents, because as we know, our youth and our adults, we felt alone or lonely. That's the subjective experience of the objective phenomena of separation that we experienced. And of course, there are deleterious effects when it is overused, when it's kept in the bed and all the other, and when they're, when there's cyber bullying, there's all kinds of negative pockets of the data. But overall, the digital technology was a buoy and a positive element in, in, in, in promoting and protecting youth and allowing youth to receive education through Zoom technology and to connect at night and through all kinds of social connection opportunities. It does need parental observation and supervision and structure. And our parents need to, of course, take it away like Dr. Krasner says, but I don't want to dismiss or make you think all doom and gloom, that technology is a bad thing and it's going to destroy our youth's lives because that's not what the data shows. It's true. And there's also the devil being in the details, right? What, what content people review and how they do also totally matters. So how about one more question? Can anyone rally? Thank you. Thank you guys for being here. We got one more. It's just a comment. There's an organization called the Institute for Humane Technology with Tristan Harris. Just a resource where there's like sort of hope. I didn't hear, we didn't hear what you said. It's an online resource called the Institute for Humane Technology with Tristan Harris. Look it up. There's a big movement about helping with social media and making it more humane. Thank you. That's a great tone to end on. Thank you all for spending your afternoon with us.

youth mental health

psychopathology rates

COVID-19 impact

adolescent vulnerabilities

systemic inadequacies

relational interventions

motivational interviewing

988 crisis hotline

family dynamics

parental psychopathology

social media impacts

community engagement

systemic reforms