Child Study Center Grand Rounds 04.08.2021

June 08, 2021

COVID-19 One Year Later: How are our kids?

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00:00Let's go ahead and get started.
00:02I'm very grateful for everyone
00:04for joining us for today's
00:06webinar COVID-19 one year later.
00:08And how are our children doing?
00:11I'm doctor Linda Mays. I'm perfect.
00:12I'm a professor in the Child Study Center
00:15and the director of the Child Study Center.
00:18And this afternoon you'll have the
00:20opportunity to hear four of our
00:22colleagues who will share their
00:24first hand experiences actually and
00:26caring for children that are in this
00:29just remarkably unprecedented time.
00:30The time historians will be
00:32writing about for for many,
00:34many decades to come.
00:35We want to talk with you about
00:37our first-hand experiences and
00:39also to give some practical advice
00:41about what we've been seeing in
00:44our anticipating looking forward.
00:46One of the things that drives us
00:48in the CHILD Study Center is that
00:51one in five children need mental
00:53health care at any one point in time
00:55and that children through age 18.
00:58Anne, but 80% of those children.
01:01Do not have access to care.
01:04And those numbers have gone up
01:06with this pandemic,
01:07but even before the crisis we
01:10were seeing actually a dramatic
01:11spike and depression and anxiety.
01:14And now with the pandemic still
01:16that we're still alapana us,
01:18we expect the numbers to continue to
01:21climb as we as we anticipate this surge.
01:24So for example,
01:25in our services for youth in the
01:28Child Study Center 6 to 66 to 18,
01:31we've seen a 65% increase in referrals.
01:35So navigating as we all know,
01:37as we've all experienced navigating
01:39life during this pandemic with
01:41all its uncertainties,
01:42has been a tremendous challenge.
01:45But we also,
01:46and we've seen unprecedented
01:47changes in our daily lives in
01:50children's lives from school.
01:51Our ability to gather together
01:53and communities and family
01:54and families being together.
01:58I'm especially grateful all of us are
02:01very fortunate actually to be at the
02:03CHILD Study Center where we can be
02:05together as a community to explore these
02:07issues of the impact of the pandemic.
02:09But we can also help children and families.
02:13We've been providing behavioral
02:14health services since 1911,
02:16when the top child Study Center was founded.
02:20And we're especially proud of our
02:22embedding in the community of our trying,
02:25translating research into clinical care,
02:27and for our being there on when
02:30children and families need us.
02:32And at this point,
02:34with this pandemic and its
02:36dramatic impact on all of us,
02:38we are once again ready to help
02:40to bring our research to bring
02:42new therapies and treatments,
02:44and also to bring educational efforts
02:47as we help teachers as well as families
02:50begin to adapt to what will be our
02:53changed world in our new way of being.
02:58So today we'll have a chance over
03:00this webinar to hear from four
03:02of our colleagues for experts.
03:03Who will talk about their work with
03:06children and families in various
03:07settings through the Child Study Center?
03:09And then we'll have an opportunity
03:12for you to ask questions.
03:14We've already gotten actually a number
03:16of great questions that many of you have
03:19submitted before the session I'm in
03:21will include those in our discussion,
03:23but will also take questions later.
03:26But for now,
03:27if you hold off submitting your
03:29questions until I announced the
03:31opening of our live Q&A session,
03:33an will ask each of our panelists to
03:36present some prepared remarks that
03:39even may answer some of your questions.
03:42So let me move to our panelists and
03:44just again thank all of you for
03:47taking time out of your day to join
03:49us and to join us in our four faculty
03:51members from the CHILD Study Center.
03:53Let me just tell you quickly
03:55and briefly who they are,
03:57so you'll first be hearing from Nancy Close,
03:59who is an assistant professor.
04:01An is the clinical director of the
04:03Moms Partnership and the old parent
04:05and Family Development Program
04:07at the Child Study Center.
04:08Then you'll hear from Dorothy's to
04:10be who is the associate professor
04:13and medical director for the Yale
04:15Hub Access Mental Health Service.
04:18Next will be Pam Hoffman,
04:20an assistant professor of clinical
04:22child psychiatry,
04:23and a lecture in Biostatistics and
04:25deeply immersed in RED services
04:27or emergency room services.
04:30And then finally Jan Ponson,
04:31who is the medical director for
04:34our Children's Day Hospital in home
04:36intensive child mental essence,
04:38psychiatric services and New York
04:40Street family clinic.
04:41Each of these panelists there are for
04:44my 4 colleagues have a presentation to share,
04:47and so may I turn Nancy to get us started.
04:53Thank you, Linda and welcome everybody.
04:55It's really nice to be here with you
04:58and I'm going to share my screen.
05:05Ann begin, so I'm going to be working
05:08to talking today about how the impact
05:11COVID is having on young children.
05:14As Linda said, I'm the Co director
05:17of our parent clinic and parent
05:19and family development program.
05:22I've been working a very long time clinically
05:25with young children and their parents.
05:28I also supervise our trainees in psychology,
05:31psychiatry and social work.
05:32I do mental health consultation to
05:35early childhood education programs.
05:37I lead parent support group San Juan.
05:40Really important group has formed
05:43during COVID to really support parents
05:45during the challenges that COVID has
05:48presented to them as as parents.
05:50And then I also teach you undergraduate
05:54students and you know they too are dealing
05:58with this with this virus an are in
06:02their second year of virtual learning.
06:05So I want to talk some about the reactions
06:08that we're seeing in young children,
06:11and I guess kind of the one of the
06:13biggest reactions is that a regression
06:16an it's much more regression than
06:18what is developmentally appropriate.
06:21Parents are talking about,
06:22you know my child was talking fine,
06:25but now she's using baby talk,
06:28needing much more help with routines,
06:30having difficulty with eating and
06:32sleeping and toileting, even when.
06:34Pre COVID,
06:35they had really mastered all of
06:38those aspects of adaptive behavior
06:40and then also having a lot of
06:43difficulty managing their behavior.
06:45Children are failing,
06:47having trouble coping with really
06:49strong feelings that come up,
06:51and that is very challenging to them.
06:54We see increases in temper tantrums
06:56and not only in the younger
06:59children where you expect them,
07:01but in older children to an.
07:03Those tantrums really occur over
07:05very small disappointments and are
07:08lasting much longer than usual.
07:10Behavioral challenges beyond
07:11tantrums have also increased my
07:13child's not listening to me.
07:15My child's not doing coming to
07:18the screen to do the virtue.
07:20Well school they have worries about
07:23getting sick or getting others sick
07:25and this continues to be a fragile and
07:28unpredictable time that causes much
07:30anxiety in both children and parents.
07:32Obviously,
07:33for those of you who are apparent,
07:36you understand the increased demands that
07:38that you have faced during this time.
07:41Parents are generally stressed and
07:42overwhelmed and feel pulled in many,
07:45many directions.
07:45Some parents are out of work,
07:48some parents have had to deal with
07:50COVID in their families and then
07:52the stress of juggling the work and
07:55children has always been a challenge.
07:57But now there's the additional
07:59stress of having to be responsible
08:01around the child school situation.
08:03Finding childcare,
08:04worrying that children are being
08:06socially deprived and isolated,
08:08worrying about too much screen time.
08:10It is helpful to know they're
08:12not alone alone and when parents
08:15come together in a group,
08:17they feel that you know well.
08:19She's experiencing the same thing I am.
08:22Or he's he's he's having the same
08:25struggle getting his child to
08:28engage in virtual learning.
08:30The early childhood education programs,
08:32children, and teachers have adapted well.
08:34There's been so much many of
08:36the programs have returned.
08:37There's so much joy around the return
08:39to school children are playing about
08:41the check-in requirements at school,
08:43then when they, they'll say things
08:45like when the virus is over,
08:47you can come to my house and see my trucks,
08:51or when the virus is over.
08:53I'm going to have all my friends
08:55come to my birthday party and
08:57this was really interesting.
08:58And I've heard this from
09:00multiple centers teachers have.
09:02We're ready to have children,
09:04have serious separation anxiety after
09:06being out of school for so long,
09:08and they're really reporting
09:11that children are separating and
09:13parents are separating with with
09:15ease as they return to school.
09:18I wanted to talk about a little girl
09:20and for those of you who joined us in
09:23the fall about a little girl that I've
09:27been seeing in therapy five years old,
09:29she's been in multiple foster
09:31homes since she was two.
09:33An around the beginning of Kovid.
09:35She and her sister were placed
09:38in separate foster homes.
09:40But she was able to see her sister every
09:43day until at daycare until the fall of 2020.
09:47Recently, she moved from a foster
09:49home she had been in for a year.
09:52Heartbreaking,
09:53and we're really worrisome and upsetting.
09:55And in that previous foster home,
09:58a family member had COVID and then
10:00someone in her class tested positive,
10:03so she had to quarantine
10:05twice during the school year.
10:07She's now adjusting to a new foster home,
10:10an I became her therapist.
10:12After her beloved clinician of
10:13two years left the clinic after
10:15completing her training an I've only
10:18worked with her through Tele Health.
10:20So for a long time she called me
10:22by the other clinicians name or no,
10:25or just by hey you or no name at all.
10:29She finally began to play with
10:31her baby dolls,
10:32nurturing them gently and lovingly.
10:34An invited me to play with mine
10:36in the same way.
10:38This was a game she regularly
10:40played with her previous clinician.
10:42I felt relieved that she was
10:44beginning to trust me.
10:46She avoids really even today.
10:47Exploring feelings connected to her losses,
10:49but she can express her ambivalence.
10:51Her anxiety about the fragility
10:53of relationships and be explicit
10:55about her anger.
10:56One day she had a really positive session
10:59with me where she played with the baby dolls.
11:02She called me by my name and
11:04talked about being friends forever,
11:06but when it was time to end the session,
11:09which has traditionally since
11:10the beginning of our therapy.
11:12Been a very hard thing to do the saying
11:15goodbye just brings up so much for her.
11:17She got upset and she said
11:19you are doctor oldies,
11:20mushy and sloppy.
11:21I don't like you.
11:22I don't ever want to see you again.
11:25That was pretty devastating,
11:26but luckily a few weeks later,
11:28at the end of the session,
11:30she went into her closet and she
11:33said I want to tell you something.
11:35I think you're a super girl in
11:38your beautiful Ann.
11:39Recently, she's elaborated her play
11:41about families taking care of babies,
11:43having sleepovers, and and actually
11:45get last night she engaged in a lot of
11:48caretaking of the baby and getting the baby
11:51ready for school and saying, you know,
11:53you're going to miss school if you don't.
11:56Fix your hair and get dressed and get
11:59your book bag an in a conversation
12:02with her new foster mother today.
12:04It sounds to me like that early morning
12:08routine has been very difficult for
12:10her and so some of Kay's words to me
12:14in the play or to her baby in the play
12:17really were reminiscent of what the
12:19foster mother has been saying to her.
12:22The sisters miss one another a
12:24couple of weeks ago, I.
12:26Suggested to K that she might
12:28like to write to her sister.
12:30And so here's some of her words
12:32and her sisters words in response.
12:34Dear a I miss the world with you.
12:37Did you like the world with me?
12:39Miss you and your friends?
12:40I will say happy birthday to you in August.
12:43Love K dear Ki miss the world with
12:46you and I love you very much and
12:48will not stop loving you all day.
12:50I will see you soon.
12:52I will also say happy birthday when
12:54it's your birthday again in August.
12:56Love. A deer a I love you.
12:59You are my heart.
13:00Love K.
13:01So I'm waiting for next week
13:04for the phrase response.
13:06And then finally just a tip that I like to
13:10give when thinking about young children.
13:13Anne Anne.
13:14What can be most powerful in helping
13:17them to cope is really their
13:20capacity to use imaginative play.
13:22It really does give children the
13:25chance to say what's on their minds.
13:28It gives them a chance to really
13:31assimilate something that's been difficult,
13:33like COVID or a traumatic experience.
13:36Gives children the opportunity to
13:39express feelings and conflict and
13:41it also gives us as an adult a
13:44window into their world and kind
13:46of kind of what's what's their,
13:49what they're trying to navigate.
13:51An it also most importantly at
13:54a time where nobody really feels
13:56very much in control of anything.
13:59It gives them control over
14:01their imaginative world.
14:02So I'm going to stop and I
14:05look forward to engaging.
14:07With you with your questions and.
14:11I'll stop this,
14:12Nancy.
14:13Thank
14:13you very much Dorothy, might I.
14:16I would like to invite Dorothy's to
14:18be now to present to us Dorothy.
14:23Can everyone see this? Yes, OK, good.
14:27So I'm really delighted to be here and.
14:31I think we all have been
14:33through a lot in the last year.
14:35There's a little bit of light in the future,
14:38but. As with all of us,
14:42I think we're still nervous
14:44about a what's coming and B.
14:46What will be the repercussions for
14:49all of us in our children after COVID?
14:54One of the things that I do is
14:57work with access mental health,
15:00and in 2015 the state gave funding
15:03to support pediatricians in
15:04their work with mental health.
15:06In the kids that they treat.
15:09So the primary care physicians can call
15:11a line or access mental health line and
15:14talk to a child psychiatrist between
15:179:00 to 5:00 Monday through Friday.
15:20And this was started well before COVID,
15:22but I think it is really blossomed
15:25in COVID because.
15:27The pediatricians are seeing more and
15:30more kids that maybe had a few issues,
15:33but now it seems as though
15:35they are really struggling,
15:37particularly with virtual school not
15:39being able to be with their friends etc
15:43and families are struggling as well.
15:45So what do we do?
15:47Well, it's as I mentioned a telephone
15:50consultation so a pediatrician
15:52can call up and say hello.
15:55I'm treating little Jenny and she
15:58is really struggling with XY and Z.
16:01If it is a an area that the
16:04child needs extra services,
16:06one of the things our team
16:09does that's multidisciplinary.
16:10With social workers,
16:11the person who answers the phone
16:14as the administrative person and
16:16a peer specialist who has a child
16:19with mental health issues were
16:21able to connect with families and
16:24help them to connect to services.
16:27As you may know,
16:28in mental health some places
16:30take this insurance.
16:32Some places take that insurance,
16:34some places don't take.
16:36Any insurance and for a family to
16:39try to sort through all of that and
16:42find services can be really just
16:45overwhelming and we help them with that.
16:48In addition,
16:49if the pediatrician has questions
16:51about some of the medical issues
16:53about starting medication for
16:55treatment of depression, etc,
16:57they can call and get it in,
17:00you know, and in time consultation,
17:03sometimes even when the family
17:05is sitting there.
17:07If the pediatrician is really
17:08concerned about a child,
17:10maybe they've been treating them for a while,
17:13but the child seems to have more
17:15problems than what they were thinking.
17:17They can get a one time
17:19psychiatric evaluation,
17:20and I have really enjoyed doing that.
17:22I also.
17:24Do supervision with the child and
17:27Adolescent psychiatry fellows and we
17:29do this as a group and talk about
17:31the cases and how to be helpful and
17:34then give those recommendations both
17:36to the family and the pediatrician,
17:38and then our last.
17:40Service is education.
17:42We provide zooms monthly for the
17:46pediatricians in the state.
17:48Talking about depressions,
17:50anxiety etc etc as educational offerings.
17:54We can do educational offerings for just one.
17:59Office we do some tools, handouts,
18:03etc to help the pediatricians stay up to
18:07date on what's going on in mental health.
18:12So what's COVID done?
18:14Well, if you can see here,
18:17it seems like things were
18:20really fairly acute back in.
18:232018 and then they sort of
18:26evened out until Kovid.
18:28And this is where we are now.
18:30An actually probably since
18:32then we're way up here,
18:34where we've continued to go up,
18:37and in fact, we're up 60% in terms of
18:40the number of consultations we've had
18:43this year between July and December,
18:45an last year between July and December.
18:48And as I said, it's the the.
18:52Numbers just keep doubling,
18:54and the pediatricians will call.
18:56And here's a frequent thing that they may
18:58say I'm doing my annual physical exam on Joe
19:02and in doing his screening for depression,
19:05he scored high and now I'm hearing about
19:08all of these other issues that he's having.
19:12So oftentimes these are kids that have
19:14never been in a mental health system at all.
19:18But when they go and talk to their
19:21pediatrician, someone that they've
19:23known their whole lives and they trust.
19:26They're beginning to talk about
19:28what their struggles have been.
19:30Now, if you know adolescents,
19:32sometimes it's really hard to read them.
19:35The moods of an adolescent can look the same,
19:38so this is a humorous slide that says,
19:41you know, happy, depressed,
19:42excited, anxious, manic, suicidal.
19:44All of those look exactly the same,
19:47and many parents will say my child seems to
19:50be more withdrawn or they stay in their room.
19:53But I don't know what's going on with them.
19:56They you know they don't
19:59really talk too much to me.
20:01And so it may be difficult for
20:04them to know how much is my child
20:07really struggling right now?
20:09So I'd like to tell you a
20:12little bit about Melanie.
20:13This was one of the
20:15consultations we received.
20:16Pediatrician called and said that he's been
20:19taking care of Melanie since she was a baby.
20:22She's 16 years old now and she has not
20:25had previous psychiatric history or care.
20:28She's always been a high achiever.
20:30She's been active in sports and clubs etc.
20:33But her parents say that she's always
20:35had some problems with herself
20:37image and tends to put herself down
20:40or think she doesn't look.
20:42Pretty enough, etc,
20:43but she's never really needed.
20:45Mental health care and she's always
20:48been well adjusted in school,
20:50has done well but phone COVID
20:53in the fall of 2020.
20:55Following virtual classrooms
20:57and more virtual classrooms.
20:59The family notice that she was spending
21:02more time in her room when it came
21:05time to get onto the video for her classes.
21:10Sometimes she wouldn't.
21:11Put up her visual.
21:13She would, you know,
21:15sort of keep her.
21:17Camera closed and her grades were falling.
21:20She seemed to have less motivation.
21:23She wasn't eating very well and she
21:26really wasn't keeping up with her friend.
21:29She wasn't talking much to family.
21:32All of the things that she used to
21:35like it seemed like she wasn't doing,
21:38and the pediatrician when they saw her
21:42an weighed her found that she had lost
21:45£15 over the last four or five months.
21:49So.
21:50What we did we called.
21:52We talked to the family.
21:54It became clear that that her
21:56issues were fairly complicated.
21:58We were starting from scratch.
22:00She didn't have any services,
22:01so we decided to do a one time evaluation and
22:04during that evaluation
22:06we diagnosed depression.
22:07It seemed like she had a serious
22:10depression and we were concerned
22:11that it seemed as though her body
22:14image was such that she may have
22:17a restrictive eating disorder.
22:18She seemed to still think
22:20that she didn't look right.
22:22Even though she had lost this weight
22:24and we were concerned that this was
22:27going to be a really big issue soon
22:30because she was losing weight quickly,
22:33we recommended psychotherapy and
22:34helped her get into psychotherapy and
22:37helped have Family Services as well.
22:39It seemed as though she was
22:41withdrawing from her family how to
22:43help them communicate how to help
22:45the family know how to help her
22:48and increase their communication.
22:50We referred to a nutritionist.
22:52The PCP was going to have
22:55weekly weights at the office,
22:58and the pediatrician started
23:01an antidepressant.
23:02They felt comfortable doing that
23:04because they had our consultation,
23:06which he knew he could do.
23:08You know,
23:08anytime if things weren't going
23:10so well and we would look for a
23:13higher level of care if needed.
23:18So what tips can we give
23:20for families during kovid?
23:22Well, the very first thing that I always
23:25think of is how are the parents doing?
23:28How are the caregivers doing
23:31caregivers who are stressed children
23:33pick that up from a mile away.
23:35They can feel the tension.
23:38They know their family stress tan
23:40as Nancy brought up you can see real
23:43regressions and distress in kids when
23:46they know something isn't right so.
23:48Really helping the caregivers
23:50remember to take care of themselves.
23:54Help them remember to stay engaged
23:56with their support system through zoom
23:58planning something special every week.
24:01It can be very helpful for them
24:03to know that we're not the only
24:06ones everybody struggling.
24:08And as Nancy said,
24:10sometimes a parent support
24:12group can be extremely helpful.
24:15Other things to do for children
24:18communication is really really key.
24:21Kids who are depressed who are anxious
24:24who are otherwise distressed may have
24:27the tendency to behave differently.
24:30They may become irritable.
24:32They may be oppositional.
24:34It may seem like they're
24:37having behavior issues,
24:38but probably these are real
24:41sort and symptoms of stress,
24:43anxiety and predictability.
24:45So having the family have times
24:48together where they can just.
24:49Relax together, talk together,
24:51take a walk,
24:52have meals together and it's
24:54important for parents to actually
24:57ask their child what's going on.
24:59How are you feeling and be able
25:01to validate those feelings,
25:03whether they're positive or negative.
25:06Routines are always helpful for all of us,
25:09but particularly for kids and
25:11especially for kids who maybe have
25:14some ADHD or some other issues.
25:16Having schedules posting it,
25:17putting time for both work and for pleasure.
25:20For kids who are on online all day,
25:24they have some time off.
25:26What can they do to sort of unwind during
25:28those times and giving positive attention?
25:31Kids who are distressed may act up,
25:34and they get a lot of negative attention,
25:37making sure that you.
25:39Catch them being good and as I mentioned,
25:42practicing self care everyone in the family.
25:47And lastly,
25:47how to help your child stay
25:50connected with their friends if
25:52they can't physically be there,
25:54there's there's actually a
25:55lot of sort of fun,
25:57zoom or other video things that
25:59kids can play together there.
26:01You know,
26:02card games or or board games that
26:04you can actually play online.
26:06Being a bit more lenient about social media,
26:09we don't want kids to spend all
26:12of their time on social media,
26:14and we especially don't want
26:16them to get into big drama and.
26:19You know bullying,
26:20etc.
26:21But making sure that they do have
26:24some time in there encouraged
26:26to keep up with their friends.
26:30Making plans for how they can get
26:32together now that it's getting to be warmer.
26:36There.
26:36Maybe sometimes when they can
26:38be outside together,
26:39particularly after vaccinations,
26:40and some kids are just really
26:43pretty happy with the way things
26:45are when they're online.
26:46Kids who have had school anxiety
26:49for a long time may have this.
26:52I don't have to go into school.
26:56Which for that period of time
26:58may feel pretty good for them.
27:00But when you think about how
27:02to get them back into school,
27:05you know the longer they're out,
27:07the more difficult it comes.
27:09And sort of planning ahead,
27:10how are we going to begin to think
27:13about getting back into school?
27:15And how can we help this
27:18child feel ready to do so?
27:21Communicate, communicate,
27:22communicate with teachers with the
27:25primary care doctor as a family and
27:28know that if a child is irritable,
27:31cranky, more annoying than usual,
27:33all of those can be signs that they
27:37are having anxiety, depression,
27:39so asking it's important,
27:41particularly for teens that are withdrawn,
27:44asking about thoughts of self harm,
27:46it never increases the risk if you ask.
27:51And frequently they will say so if
27:53they're feeling like hurting themselves,
27:56or even if they've already started
27:58doing things that are self injurious.
28:01Any other risk behaviors,
28:02what stresses are you having and
28:05just helping them feel validated?
28:07An understood and of course,
28:09seeking mental health care when either
28:12the child or the parents are not coping well.
28:17So thank you.
28:17It's been a pleasure and I look
28:19forward to our Q&A at the end.
28:24Thank you very much Dorothy.
28:25How may I turn to Doctor Hoffman?
28:36Thank you so much for having me.
28:39I'm really glad to be here and talk
28:41a little bit about some updates
28:44that we've had over the past year.
28:46Specifically for two of my favorite topics
28:49in Tele health and emergency psychiatry.
28:51So I really only have two
28:53specific graphs to talk about,
28:55but they really do say a lot.
28:58This first one goes through
28:59our past year and experience.
29:01Through Tele health and what it
29:04shows is that both in the two months
29:07prior to Cobit we had maybe 30 to 40
29:11video visits in our health system
29:13and since then we have had over
29:16600,000 visits via video for our
29:18patients here in the health system.
29:21The second graph at the bottom goes
29:24through from why I'm so jel medicine,
29:26and this is of which child Study
29:29Center is apart. We've had almost 100.
29:321000 visits for patients to be
29:34seen from by their providers.
29:36This is huge and what we see is that
29:39it was essential as as COVID started
29:42and everyone went into lockdown,
29:45we really had no other choice.
29:48Time we had a bit of a dip that allowed
29:51for people to start making better
29:54clinical decisions about whether
29:56Tele Health was the right venue and
29:58was the right tool to use to see,
30:01evaluate, and maintain our children.
30:03And going forward,
30:04we can see that as we're in the middle
30:07of another little uptick in wave,
30:09we are studying and growing
30:11in ambulatory video visits,
30:12so this is really good news.
30:15This tells us that Tele health has been
30:17adopted in a really seamless way in our.
30:20In our health system and in
30:23the CHILD Study Center,
30:24we have group therapy.
30:25We have individual therapy.
30:27We have medication management.
30:28People are being seen where
30:30they need to be seen.
30:32We also have in person visits
30:34because there are some children
30:36for whom Tele health is not.
30:38The does not make the most
30:40appropriate clinical sense,
30:41so we do allow for different
30:43kinds of treatment when necessary.
30:45So this was a good news.
30:48Let's let's talk a little
30:50bit about the bad news.
30:52So I'm currently clinically working
30:55in the emergency department today
30:57and I've been on call for the
30:59last week or so so I can tell you
31:01both from a personal emotional
31:03feeling as well as the numbers here
31:06that these are not really lying.
31:08Now let me kind of describe
31:10this graph to you.
31:11This is the percent of behavioral
31:13health children who've scored
31:15from the moderate to high range
31:17on the Columbia suicide screen.
31:18Now we can see this is 2019.
31:21Things were a little all over the place,
31:23but it averaged around.
31:2530% so when you think about it like that,
31:2830% were moderate or high and the
31:31other 70% were closer to the mild
31:33to mild to no suicide screen.
31:35So what that meant is that people might
31:38be coming in for different reasons,
31:40but suicide was not really the issue.
31:43We haven't had an uptick that's
31:46really remarkable,
31:47since since late September
31:49in October of this past year,
31:52and we've seen an 11% increase in
31:56the severity of the Columbia screen,
31:58so from 30% to 41% are scoring higher
32:02than in the moderate to higher range.
32:06So we're noticing this acuity.
32:08We're seeing these children in our
32:11emergency rooms that are requiring.
32:14A different level of care and let me
32:16describe it in some examples of some
32:19of the patients that I've seen over
32:21the last several weeks in months past
32:23and prior to the epidemic and the
32:25pandemic that we're dealing with,
32:27kids might have come to the emergency
32:29room almost as a front door to service.
32:32Let's say their pediatricians didn't
32:33know about access mental health.
32:35Let's say they didn't have any
32:36kind of prior psychiatric history,
32:38and they're coming in because
32:40they don't know where to go,
32:42and they're trying to reach out.
32:44To start, health,
32:45mental health care for a child.
32:48We don't see those really anymore.
32:53You'd also get in the in the old days BC
32:56before COVID that children would come in,
32:59brought in by school because they
33:01mentioned to their teacher or the
33:04guidance counselor or a friendly
33:06pier and they then went to a grown
33:08up and was asking for some help.
33:10They were thinking about suicide.
33:12They were reaching out in some
33:14way in school in school,
33:16brought them to our attention
33:18to get them help in services.
33:21We're seeing that now a little more
33:24now that schools are opening up,
33:26but we weren't seeing that when when
33:29schools weren't really in session,
33:30what we are seeing now is that
33:33instead of kids coming in with suicide
33:35ideations thoughts about wishing
33:37that they were no longer alive,
33:39or feelings of hopelessness and helplessness,
33:42we're now seeing children after
33:44they have attempted suicide.
33:45So we see kids now following
33:47an overdose and ingestion of
33:50medications that were made as a.
33:52As a true suicide attempt in the past week,
33:55we've seen suicide attempts via
33:57hanging overdose, attempted cutting,
33:59and everything in between.
34:00So these kids, who might several months ago,
34:04have been able to get help in a
34:07slightly lower level of care are now
34:09coming to a point where there is
34:12nothing else that can be done except
34:15put them in a secure location while
34:18we stabilize them so that they can,
34:21you know, attempt to have.
34:23A better future. So this is the bad.
34:25We're seeing this.
34:27We're feeling this families are stressed
34:29and they don't know where to go.
34:32And so on that.
34:34Lovely note,
34:35I'm hoping that that Doctor will
34:39have more positive things to say.
34:47Thank you so much, Pam Ann.
34:49May I turn down to young doctor Ponsan.
34:51Alright, thank you and
34:52a pleasure to be here as well.
34:55So one of my hats is medical director
34:57of the Children's Day Hospital.
34:59So that's a service that
35:01provides care to children.
35:03Stop 626 to 12.
35:04Currently 8 to 12 in COVID that
35:06have significant need and if not
35:08for being in a Children's Day
35:10hospital would require inpatient
35:12care emergency room care so many of
35:15the kids were serving in the day
35:17hospital or kids with with high needs
35:19and this kind of services available
35:21to adolescents and adults as well.
35:24But our program is for is for young kids.
35:28It's a group based program that's
35:31supplemented by work with families
35:34and individual work with families.
35:37Uhm? And So what is the what is the?
35:41What is the beauty of group work?
35:43And what's the difference about group work?
35:45I think is where we start.
35:47And so this.
35:48So we're located on the
35:49Saint Rayfield campus.
35:50We haven't identified spot at 3:50 George,
35:52but we're still in the Saint Rayfield campus.
35:54A lot of this was delayed by COVID.
35:58I think you can imagine a sunny room.
36:00But with very old looking
36:02furniture and carpets,
36:03carpets that don't seem like they've
36:05been changed since the 1970s,
36:07even though maybe they they have been,
36:09but it's a beautiful place to
36:11be when the kids are are really
36:14communicating with each other.
36:16And so I think of just happened this week.
36:19We have Sam fictitious names.
36:21Find Maya a female, and identifies as male.
36:27He was talking about their
36:29depression and their suicidality.
36:31And putting a lot of blame for that,
36:34or reasons for that on external
36:37forces their parents school.
36:39Friends, which is not,
36:41which is something of kids can have.
36:44But in this case the kids took it.
36:47Took it as not having a sense of
36:50responsibility for getting better.
36:52For making the changes in their thinking
36:54and feeling and the changes in their
36:56life that could that could help them.
36:58And so the kids were challenging,
37:00and this is the beauty is that the
37:02adults weren't suggesting why don't
37:03you think of it of another way?
37:05Or try another method? Yes, we have.
37:07We have ideas and yes we have a
37:09program but the beauty is when the
37:11kids really support each other
37:13and and confront each other.
37:14And Sam wouldn't really have much of
37:16it and says well I think I'll just.
37:18I'll just kill myself.
37:19Doesn't really matter.
37:20I'll just do it.
37:22And it's both, I think,
37:24real painful feelings,
37:24but also slightly flipping.
37:27And so there was a pause and
37:29in someone asked, well,
37:30how does.
37:31How does Alejandro feel about
37:33all this given that your aunt
37:36her aunt died of COVID this week?
37:38And you know, Alejandro responded,
37:41I'm this is really hard to hear
37:45that you would take things so
37:46lightly and say it so lightly.
37:48When my aunt didn't didn't have a choice.
37:51To live or to die.
37:53So it's really, really hurtful to hear that.
37:57And I dropped pause little further
37:59and started to develop tears in
38:01her eyes and to be honest with you,
38:02I've done this program before and
38:04I would not be alive today if it
38:06weren't for from his Terran to help
38:08me and my family through this. Uhm?
38:10And I think Sam was quiet and took it in.
38:14I don't think they were ready to
38:16really look at their vulnerabilities
38:18and their fears and why it's
38:20easier to stay in the stance of.
38:22Of of of Angst and dread and blame.
38:25Rather than looking at themselves,
38:26that might be overwhelming,
38:27but that's that.
38:28Will be part of the an ongoing work.
38:32So many of the kids that come to us
38:35have really some deep seated feelings.
38:37Distortions,
38:38negative emotions are struggling.
38:39I think everyone that spoken today.
38:41These are the I think the kids were
38:44suffering the final common pathway of
38:46all the difficulties of life living in
38:49their head in the social media world
38:51without the chance to try their their
38:53hats on in the in the real quote.
38:56Real World School Avoidance difficulty,
38:58managing distance,
38:59learning stress.
38:59So these are all things that are coming
39:02together and really heightening.
39:04Heightening the distress.
39:07Think we see more more sign females
39:10in the program then we had before.
39:12I think a lot of that has to do with
39:14social relatedness and social media stuff.
39:17I'm not blaming social media but I
39:20think kids being in their head all the
39:23time is a real or a real challenge.
39:26And so, that's that's where we are,
39:28and I think I'll, in the interest of time,
39:30I think I'll leave my my comments there
39:32and we can gladly answer questions.
39:34Thank you.
39:36Thank you Ron. Could I ask all the
39:38panelists to come back on screen?
39:43So Pam, there's a question from the from
39:46the audience that I'd like to start with.
39:49I'm actually from a very good colleague
39:51of the Child Study Center asking
39:53saying that the data you present or
39:55alarming and do you have the numbers
39:58or percentages on the increase in
40:00post suicide attempts of presenting
40:03to the YD? So
40:05I'm I'm sorry I don't have the
40:07exact numbers or the percentages.
40:09Right now, though I could probably
40:12get some clear numbers to you.
40:14I can tell you from from a gestalts
40:18standpoint, the CL service,
40:19the consultation liaison service
40:21that that treats patients with
40:23behavioral health needs who are
40:25admitted for medical reasons.
40:26This would be where a child who
40:29has completed an overdose to a
40:32point where they are requiring.
40:35Antidotes and monitoring of liver
40:37function and other metabolic tests
40:39to ensure that their bodies can
40:41be saved from what had happened.
40:44Those kids actually don't even get
40:46seen by me in the emergency room.
40:49They go directly to the inpatient medical
40:52unit to be treated from Pediatrics
40:54and they get seen by consultation.
40:57Liaison psychiatry.
40:58I can tell you that before COVID
41:00the average number of kiddos on
41:03the consultation liaison service.
41:05Could vary by by month and we
41:07always had an ebb and flow.
41:10For those of you who've worked
41:12in in children's mental health,
41:14but typically you'd see around
41:16anywhere from 4 to 8. That would be.
41:19That would be an average.
41:218 would be a lot and five would
41:23be more typical.
41:25Now I haven't seen the CL service be
41:27lower than eight in several months time,
41:30so with that is saying is that there are
41:33serious medical issues and complications.
41:36For behavioral health patients,
41:37this could be eating disorder kiddos
41:39who have gotten so bad where they need
41:42re feeding and nutrition services.
41:43An monitoring during that to ensure that
41:46they don't get ill from from the refeeding.
41:49This could be kiddos following
41:50an overdose or an attempt where
41:52they're getting treated for that
41:54before they can be medically cleared
41:56and go to an inpatient unit.
41:58And so I think the numbers are high.
42:01If I had to guess a percentage,
42:03it would probably be anywhere from
42:0540 to 60% higher than previous.
42:07Years and times,
42:08but I I can get those numbers and
42:11what's interesting is those are
42:13not kids that we see in the ER.
42:15So the increase in acuity that we're
42:17seeing are not counted by those kids
42:20who have had those serious attempts.
42:22They would jump and actually
42:24go directly to Pediatrics.
42:25I hope that answers it in some way and
42:28I I do agree this is quite alarming,
42:31and we're hoping that we can try
42:33to lessen this risk mitigated.
42:35Try to reach out sooner rather than later.
42:37That's really going to be our hope for
42:40the future to ensure that we're not
42:42having to constantly play catch up to
42:45a year where kids have been struggling.
42:51Another another question from our audience.
42:55As COVID, let me just read it as
42:57COVID related easing of rules.
42:59MGH is expanding virtual visits
43:00to many many States and now things
43:02are a bit better but regular.
43:04But because of the regulations they will
43:06only have to be able to have virtual
43:09visits in New England States and Florida.
43:11Are there any regulations or
43:12proposed regulations that may
43:14impact our Tele medicine and Pam?
43:15I know you've been in the middle of this,
43:18so could I turn to you absolutely and I could
43:21talk about this all day.
43:22So thank you so much for the question.
43:25This is really interesting and.
43:26And has been an advocacy efforts by many
43:30different people in the health system.
43:33What MGH was able to do was provide
43:37alternatives during the pandemic,
43:39different states offered each
43:41individual lessening's of regulations,
43:43especially as it relates to physician
43:46licensure during the treatment and
43:49and that seeing kiddos over video.
43:51Now, because there's still a
43:54public health emergency and some
43:56states have continued that.
43:58We have different rules in different states,
44:01So what MGH has probably done is they've
44:04probably set up their providers to be
44:07able to have the Tele health license that
44:10is required for the state of Florida.
44:13They have the pleasure of
44:15our Connecticut government,
44:16allowing anybody with any state
44:18license to be able to treat patients
44:20in the state of Connecticut.
44:22Because of this public health emergency,
44:25which has the same rule that
44:27has been offered by New York.
44:29I will say MGH does not have that
44:32courtesy it for the state of Rhode Island.
44:35So it would be very interesting
44:37to see how they're handling their
44:39patients that have crossed over.
44:40Rhode Island has gone back and forth
44:43with their public health emergency
44:44rules and regulations related
44:46to Tele health and licensure,
44:48and so that one gets a little tricky.
44:50We thankfully, as part of our health system,
44:53because we do treat patients
44:55across several different states.
44:56Rhode Island, New York, and Connecticut.
44:58We've already been trying to think about
45:00this from a long term perspective,
45:02so.
45:03We are working with federal legislators
45:05and advocates to try to change these rules,
45:08not just during public health emergencies,
45:10and we've also had several different
45:13people from around the Tele health.
45:16From all over Tele health within
45:18the health system and through I am
45:21giving both written and oral testimony
45:23for our state General Assembly.
45:25To ensure that we can continue to
45:27treat children and families via video
45:30when appropriate as going forward,
45:32regardless of the public health emergency.
45:34So far,
45:35the governor has signed an executive
45:37order extending the permissions for
45:39us to do so through April 20th,
45:42and I expect that either there will
45:44be a permanent solution.
45:46Via a bill that gets passed,
45:48hopefully,
45:48or a continued executive order
45:50that will allow this through
45:51the public health emergency,
45:53I hope that does answer the question.
45:55I'm happy to talk about it more.
46:00Think of the other payments
46:01to advocate with your state
46:03legislator, right? Please, do
46:04they need to hear from the
46:06constituents that this is something
46:08that you want that it's not
46:10just an improved min of access,
46:12but it's that patient.
46:13An person choice should be
46:15available to allow people to decide
46:17how they want to receive care.
46:21So I want to turn to another
46:23question then that was submitted
46:25ahead of time and we have a couple
46:27of questions in the chat as well.
46:29So I would actually ask Dorothy
46:31and Nancy both to address this
46:33question about how worried should
46:34we be about our children who have
46:37moved to a new town in summer
46:38and school in the summer of 2020,
46:41and yet still have yet to make
46:43a single friend because of the
46:44pandemic and being at home.
46:49So I can. I can speak to that and then
46:52I'll turn it over to Dorothy, I think.
46:56I'd like to say that you know, children.
47:00The children have just moved or
47:03obviously with their parents and they
47:06have relationships with their parents,
47:08and while they don't,
47:10if they are connecting virtually to school,
47:14they might not really have a physical friend,
47:18but perhaps a virtual friend and
47:20perhaps appearance could ask
47:23the teacher to help support some
47:25interactions on line between the.
47:28The the new child and the children have
47:31been at school for awhile with the hope
47:34that when things go back in person they can.
47:37They can connect an an also.
47:40I would also be in touch with the
47:42school as the new school year comes
47:45up and children are probably returning
47:48to school to ask if there are children
47:51in the neighborhood that that might
47:53be in their child's class.
47:55Could they get together finding
47:57places in the community where?
47:59Their child could spend time outside,
48:02you know,
48:03on playgrounds and things like that.
48:05If if the playgrounds are open,
48:08but really looking into all opportunities to
48:10help the child engage with other children,
48:14and I'm assuming that the child also
48:17might have friends from the place they moved,
48:20so maintaining those connections,
48:22even just by like zoom play dates,
48:25might be helpful to the to the child
48:28to and to the parents too.
48:31To feel like yes,
48:32this is this is going to be OK.
48:35I mean for all children I think
48:38parents have felt there.
48:39The hardest thing for them as parents
48:42is seeing how socially isolated
48:44their children are.
48:45So for even children who've been friends,
48:48they really haven't had play dates
48:50and opportunities to be together.
48:52If they're still learning virtually
48:54so Dorothy.
48:56You said it beautifully.
48:57One thing I would say is when
49:00families move during kovid,
49:02in particular, the parents don't
49:04have supports either and you know,
49:06did they have a church community before?
49:09Did they have you know where there's
49:12some other communities reaching
49:14out to schools, social services,
49:16etc to see what's around?
49:18And how can they connect
49:21with other families so that?
49:23They and their children can feel
49:25more connected to the new community.
49:30So another another question
49:31submitted earlier was how can we
49:34help children under three adjust
49:36to their parents going back to
49:38work into the workplace and.
49:39Given the length of this pandemic,
49:41it may be that some children
49:43have only known having a full
49:46time mom and dad Nancy.
49:47Would you like
49:48to start? Or that's often I mean,
49:50back in the old days that was often
49:53the adjustment that young children
49:55had to make when they turn 3 and they
49:58were going off to nursery school.
50:00Maybe for half day.
50:01You know three half days a week or two,
50:04half days a week.
50:05Making that adjustment is a really big
50:08step for someone that little and so.
50:10Being able to do things to familiarize
50:14the child with the school they're
50:17going to be going to to go and see it
50:21physically to try to see if the school.
50:25Many, many good preschools do home
50:28visits before the year starts.
50:30So asking the teacher if they could
50:33have a home visit sometimes can be
50:37a useful thing to do sometimes.
50:40Preschools will have open houses
50:42for all the children returning and
50:45the parents the parents come to and
50:47then also finding a program that
50:49really understands the importance of
50:52supporting children through making
50:53that adjustment to a new school
50:56while it's while it means having
50:58to say goodbye to Mommy and Daddy
51:01or Mommy and Mommy or Daddy and
51:04Daddy for part of the day for the
51:07very first time and get to know.
51:10New people it holds so many growth
51:13producing experiences for the child.
51:15So while it's difficult,
51:17it really does promote growth and
51:20development and so having teachers
51:22who are sensitive to the fact that
51:25separation anxiety is real and we we
51:28want to see that because it speaks to
51:31the importance of the relationship
51:33that the child has with the parents.
51:37At the same time the parents
51:39also have their own.
51:41Feelings of separation anxiety.
51:43It's hard enough without the COVID overlay,
51:45but with that it makes it even more
51:48even more difficult and also not
51:51knowing the school they're going to
51:53and not really knowing the teachers.
51:56There are these teachers gonna
51:58love my child as much as I do,
52:01and so really kind of attending
52:03to our own anxiety about that,
52:06but also supporting the child's movement
52:09forward and acknowledging you know
52:11the sadness and the anger and the and
52:13the anxiety that come with making.
52:16Such such a big developmental stone.
52:19Great thank you Nancy Jan.
52:21Could I turn to you for two
52:23questions that might be related?
52:25We've known that the pandemic
52:27has really shown a lot of shone
52:30a light on a lot of differences,
52:32and in equities.
52:33Could you speak?
52:34This was a question submitted
52:36earlier about the difference in
52:38impact between Inner city school
52:40children who have been less likely
52:42to have been able to stay in person
52:45with school versus children from
52:46less populated or rural areas,
52:48and then similarly the demographics
52:50of the children that are presenting.
52:53To both Bradley Hospital in the Ed.
52:57Right, I think I'll try to keep
52:59it brief 'cause this could be.
53:02This could be a big topic.
53:04I think there are the issues of
53:06the pre-existing pre-existing
53:08strains and the pre-existing
53:09numbers then magnified by COVID.
53:11So for example,
53:13town like Bridgeport has maybe one
53:15guidance counselor in you know 303
53:18hundred students or as a town found
53:20like like Westport will have half of that.
53:23So you bring the COVID pandemic and a big
53:26part of the COVID pandemic is outreach.
53:29Kids are not getting online.
53:31Or resource issues with getting online.
53:33There are family demands about getting
53:35online in terms of parents ability to be
53:37at home and work depends on the community.
53:40So so the strains on already reduced staff
53:42are much greater in those communities,
53:44so that makes it very difficult.
53:46I don't think we have all the numbers
53:48yet on how many kids just simply
53:50dropped out and didn't attend.
53:52Even get online.
53:53I think there's some preliminary
53:55numbers there.
53:55I know in New Haven at least,
53:57you know maybe 15% of kids get at least
54:00one F and this semester I think it's doubled.
54:03This last semester,
54:04so clearly kids are declining in
54:06their in their in their work function.
54:08And then of course all the things
54:10that you can imagine as well that
54:13the higher socioeconomic areas have
54:15more folks that can work from home.
54:18It's a challenge in terms of
54:19supervising your kids,
54:20but at least you have an option as
54:23opposed to folks that have to go in and
54:25work in person have limited resources.
54:28I think the other piece that we've
54:30seen is that the sum of the urban
54:33areas have more higher death rates.
54:35People love brown and persons of color,
54:37so that kids are also exposed to those
54:39environments in those complications and
54:41people getting sick more frequently.
54:44As far as the numbers,
54:45just quickly.
54:46On the demographics,
54:47I think the demographics the Ed serves both
54:50the Yale New Haven and the surrounding areas,
54:53like the last figures that we had,
54:55were perhaps,
54:56you know,
54:5750% thirty percent 4050% people up
54:5930% people of color and 70% white,
55:01but that could be that could
55:03be off at this point.
55:08And the and the Children's Day hospital.
55:10One other pieces.
55:11We serve the same population,
55:13but we also have the added demand of
55:15transportation which is not available,
55:16which we'd like to make available to
55:18families because some families have
55:20better capacity to transport than others.
55:22So another piece for socioeconomics
55:23can play a role in treatment.
55:28So big thanks to all our panelists and
55:30we have one more minute and Dorothy.
55:33Did you want to mention that the about
55:35access mental health that you just
55:37put in the chat so one of the.
55:41Participants here asked about a 15
55:43year old that they have who's had
55:46sort of chronic anxiety but has really
55:48gotten worse during COVID and the
55:51usual thing my insurance gave me.
55:53You know names and names and
55:55others gave me names and names,
55:57and I've been calling and no one
56:00has any spots and it is true
56:03that it's difficult to get spots
56:05if you're in Connecticut,
56:06may I suggest that you ask your
56:09pediatrician to call access mental health?
56:12The resources that we have in
56:14terms of who are all the providers,
56:17what insurances do they take?
56:19Who has spots open?
56:20Can really help make this so much
56:22easier because you are correct.
56:24It can be just really overwhelming
56:27trying to find someone.
56:30I'd
56:30only add that from the emergency perspective,
56:32one of the beautiful things about
56:35Connecticut and I can say this as a
56:37transplant into this state is 211.
56:40The ability to access someone
56:41at a more urgent level.
56:43If you're not sure who you're supposed
56:45to go to where they can then help
56:48guide you through this process that
56:51even as someone who's in the process,
56:53sometimes I have trouble navigating
56:55it myself.
56:56So like we've been talking about a lot of
56:59this can be murky and difficult to navigate.
57:02So sometimes reaching out to two on one,
57:05it is not just a COVID number,
57:07it can be used for for mental health crises,
57:11not just emergency crises,
57:12but crises of attempting to
57:14find treatment an access.
57:17So thanks to all our panelists and thanks.
57:20Thanks to everyone for joining.
57:21While I know what we've presented
57:23is sobering, there also is light
57:25beginning to come and we are very
57:27much together as a community to
57:29help children and families help them
57:31return back to school on to return
57:34back to whatever life will look like.
57:36Post COVID, but we're most grateful
57:38for all of you for joining with us.
57:41Send us your additional questions.
57:42We'd be glad to answer by email and just
57:45very much appreciate your interest and.
57:47And support thank you.