Child Study Center Grand Rounds 11.30.2021

December 10, 2021

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School Mental Health, Suicide Prevention, and Wellbeing: Lessons Learned from the Last Ten Years (And Wisdom for the next 10)

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00:00Great so good afternoon everyone.
00:04Welcome to grand rounds
00:06and we have a next week.
00:11We have a grand rounds talking
00:13about the interface between
00:15our outpatient work and the law
00:17and we have an attorney whose
00:19name is escaping me right now.
00:21Kathy Mills from our outpatient
00:23program was kind enough to
00:25make this connection, so, huh?
00:30Mayor Catherine Meyer, who is an attorney
00:34who's going to be telling us about
00:36all sorts of legal interactions
00:37that can be clinically helpful.
00:39So that's next week and then in two weeks,
00:41Dr Cardona is going to be picking the
00:45lead in our last grand rounds of the year,
00:47which is going to be a compassionate
00:48care rounds that at some point I
00:50would love for Shawshank to see.
00:52And this case is going to involve our
00:55outpatient and icaps intensive in home,
00:58child and listen.
00:59Like after cases,
00:59and they're always very emotionally
01:02laden. Clinical work that we do
01:04four times a year.
01:06So today I'm just so delighted to
01:11welcome from the sister Republic
01:12of California from San Francisco,
01:15Palo Alto, my dear friend and
01:18brother from another mother.
01:20Dr Shashank Joshi.
01:22Shashank is the training director
01:24for child psychiatry at Stanford,
01:26and he has been for a long time.
01:28And he's a professor of not only child
01:31psychiatry and psychiatry at Stanford,
01:33but also a professor of in
01:35their School of Education.
01:37And as you were going to be hearing,
01:38Shanks work has been on the one hand,
01:41training and childless in psychiatry
01:44and another the interface with
01:46schools and not just schools,
01:48but educational services
01:49in systems broadly writ.
01:52And also he has had.
01:55Painfully and necessarily a interest
01:58in suicide and suicide prevention.
02:00You may have heard about some
02:02clusters of suicides that have
02:04occurred in the Palo Alto region
02:05over the last couple of years,
02:07and Shank has been really critically
02:09involved in those efforts.
02:11He also designed one of the tools
02:14and curriculum for schools in the
02:17state of California in the Republic
02:19of California to deal with suicide
02:22and suicide prevention in the school.
02:24And most importantly,
02:25he is.
02:26A great guy and a dear friend and
02:28someone who I love dearly and I'm so
02:30delighted to welcome you back to yell.
02:31So I'm that later,
02:32man.
02:34CS.
02:46Fantastic thank you, Kyle.
02:47Thank you, Andres. Uhm?
02:50And thank you audience members.
02:54It's just absolutely a thrill to be here in
02:58New Haven and at the Child Study Center.
03:02It has been a few years and I love what
03:07you've done with the place, really.
03:10This place and the one next door.
03:12So as Andre said, I.
03:15Have been doing this work for some
03:18time in the program director World.
03:21In the last. 15 years or so I've
03:24spent a lot of time thinking about,
03:27schools, school, mental health,
03:29suicide prevention, the interface of culture.
03:32The interface of well being
03:35in diverse environments with
03:37communities from all over the world.
03:41And we have had some opportunity
03:43to learn some lessons,
03:45so I'm going to try to highlight in the
03:47next 40 minutes or so some things we've
03:50learned in the last ten years. And.
03:52When it says wisdom for the next 10,
03:56I'm already self disclosing mistakes.
04:00Were made and so we are hoping as Doctor
04:06Stube has taught me over many years.
04:09Never waste a good mistake or a bad mistake.
04:15Always an opportunity for learning so.
04:20This is our campus in the
04:23Republic of California.
04:25That is, Stanford University,
04:27also known as a stand for Gunnison,
04:30to which was the name that Andres
04:34gave us when he came to do.
04:37Series of mentoring sessions.
04:40Almost eight years ago now came
04:43to the medical school and.
04:46And those workshops still have impact today.
04:49I will say my brother,
04:50so I'm really,
04:51really delighted to be with you all.
04:54And I will try not to come.
04:57I'll try to look at the zoom while
04:59I also engage the audience I am.
05:01I am really delighted to be here
05:04with a live audience.
05:06As I shared over lunch with the trainees,
05:08this is the first in person talk
05:11in quite some time and just really
05:15full of gratitude that it is
05:17here in the CHILD Study Center.
05:19So my hope is that after our time together.
05:22You will be able to list some
05:25risk and protective factors.
05:27We're going to focus on
05:28protective factors because I know.
05:30People in the audience are
05:32very familiar with the risks.
05:34We'll talk a bit about risk,
05:35but more about protective factors.
05:38Specifically in youth suicide.
05:40But also,
05:41I hope you'll be able to describe
05:44some effective strategies that
05:46involve universities as well
05:48as communities and cities.
05:50I hope you'll be able to describe
05:52some lessons learned from the youth
05:55rail suicide clusters in California.
05:57And that you will be able to
06:00identify some opportunities that
06:01have a cultural basis,
06:03both opportunities and barriers
06:04for implementing best practice when
06:07it comes to school based suicide
06:09prevention and finally to describe
06:11strategies to cultivate your own well
06:14being as well as those of colleagues.
06:17Which is dumb as we think about
06:20folks like Doctor Lechman who's
06:21been doing this for so long.
06:24And who's taught us so much?
06:26Just buy.
06:28You know when Doctor Lechman
06:30comes into a room and
06:32talks about. A patient or a family,
06:35he models what we aspire to do,
06:38which is to just be to just be.
06:41You don't have to do anything, be yourself.
06:46Hear their story.
06:47And then do your work.
06:50And this is part of what's
06:52been so important for me.
06:54In the work that I've been doing in school,
06:56mental health and suicide prevention,
06:58so putting this into perspective.
07:01This slide comes from my colleague Monica
07:05Nepomuceno who was at the Department of Ed,
07:08California Department of Ed has
07:10a school mental health policy
07:12workgroup and it's 40 folks from
07:14around the state who gather used
07:16to be in person will get back to
07:18you in person starting next month,
07:20but it really is to talk about policy
07:24policy initiatives and to propose some
07:27kinds of things that can help students.
07:31And help teachers and really highlight
07:34the idea that mental health is part
07:37of overall health and that students
07:39have to be healthy enough to learn.
07:41When the brain is not healthy,
07:43when the mind is not healthy
07:45because of a mental health issue,
07:47we do need to be thinking about this
07:49in the school settings and this
07:51is because schools as part of our
07:54community are profoundly affected.
07:56If someone dies by suicide and the
07:59data had been pretty consistent
08:02over from 2000 to 2017 eighteen.
08:051 to 2% of students in EU.
08:08S Make a serious suicide attempt
08:10that lends me emergency room.
08:12Those numbers have been going
08:14up steadily since 2010.
08:15Now it's between 2 and 3%.
08:17So in a school of 2000 and many
08:20of our high schools in Northern
08:22California are between 1500 and 2500,
08:24that's about 40 to 60 students a year.
08:28And when you go to a school
08:29board and you give these numbers.
08:32People pay attention.
08:33They sit up.
08:34They understand that any one of those 40 to
08:3660 students might have taken their own life,
08:39but they found a connection.
08:43There was a fellow,
08:44for example,
08:45who was in the emergency room,
08:47or a resident who really helped them.
08:50In their moment of crisis,
08:51help that family feel,
08:53heard and understood hopefully
08:54facilitated some treatment.
08:56Maybe to an inpatient unit or an
08:58intensive outpatient program,
08:59but putting it into perspective
09:01is important to start with because
09:04we have lost a number of young
09:07people in California,
09:08in particular since 2010.
09:09Now I said lessons from the last ten years.
09:13It's more like 1112 years now
09:15where this work has become very
09:17active and my group has become very
09:19engaged and in particular.
09:20Our training program has had
09:23child psychiatry fellows really
09:25take part in what we do,
09:28not only in suicide prevention but also
09:31crisis intervention and health promotion.
09:37I am going to hope that my clicker is
09:40working, but I think Kyle the clicker
09:42may be stuck. It may also be that.
09:47The interface OK so.
09:51I said lessons from the last ten years.
09:53This is actually a slide
09:54that's about 15 years old,
09:55but it's an oldie but a goodie from JAMA.
09:58John Mann published this,
09:59and I think it still is a very important
10:02paradigm for us to think about.
10:04On the left.
10:05You see, you know what we would call
10:08suicidal behavior and no surprise to
10:10those of you who have joined us today.
10:12It's not just about the mood
10:14or other psychiatric disorder.
10:16There was some interpersonal stress
10:18or stressful life event or series
10:20of events that might lead to.
10:22Suicidal ideations and then all
10:24of these other factors involved,
10:26especially as we think about young people,
10:29impulsive ITI, hopelessness, pessimism.
10:32Most importantly for our community
10:36and others.
10:37For teenagers who are very
10:40susceptible to imitation.
10:42Uhm, the access to lethal means
10:45what we think about is downstream.
10:48Suicide prevention is an
10:50important part of this slide.
10:52Imitation as I just mentioned, prevention.
10:55This is what we're doing right here in
10:57this room at the CHILD Study Center,
11:00November 30th, 2021,
11:01and those of you were joining by Zoom,
11:04Education and awareness.
11:05What we're doing right now,
11:08not only for primary care and mental health.
11:11Uhm specialists or specialists
11:14and training the general public.
11:16And gatekeepers so in my world the
11:19teachers and the school staff are really
11:22important gatekeepers that we focus on.
11:25We have treatment and for the purposes
11:27of this talk, I won't go into detail,
11:29but you all know the paradigms,
11:31pharmacotherapy, psychotherapy,
11:34family engagement, follow-up,
11:37care for suicide attempts,
11:39and as I said before,
11:41restriction of access to lethal means,
11:42and in particular you see letter G here,
11:46imitation here on the left,
11:47media reporting guidelines for suicide.
11:50We have media reporting guidelines
11:53and they were written not by.
11:55Doctors Lechman Stubie or Martin.
11:58There were actually written
12:00by the media for the media.
12:03By the media.
12:04For the media.
12:04Now there were mental health consultants,
12:06but these are folks like
12:08the Annenberg School.
12:09These are folks like The Associated Press.
12:12These guidelines have been in place for many,
12:14many years.
12:15They have been highlighted by the American
12:17Foundation for Suicide Prevention and
12:19yet the vast majority of the time.
12:21They're not followed,
12:22and that sets up a very difficult
12:25set of circumstances for our
12:27young people in particular,
12:29teenagers who are very
12:31vulnerable to contagion.
12:33More than 200 teens die in
12:35clusters every year in the US,
12:36up to 5% of all deaths by suicide
12:39among teens are part of a cluster.
12:42The media can be an enormously
12:44important partner for us.
12:46They can provide education,
12:49they can provide connection.
12:51Resources.
12:52Hoping better days to come.
12:56Or they can be a vehicle for contagion.
12:59And this is part of what Europe experienced
13:02in the 80s with the Vienna train suicides.
13:05The media got together on their
13:08own accord and decided to come up
13:10with some guidelines and they just
13:12stopped reporting what was happening
13:16during the period in the mid 80s and
13:19the suicides dropped between 80 and
13:2190% within the course of a few weeks.
13:23I mean, they were losing people really
13:26every one to two weeks. And it was.
13:29All the things you see here to
13:31not do is what they were doing.
13:33Front page stories, screaming headlines,
13:36using particulars of the method used.
13:38Simplistic explanations of
13:39why someone took their life.
13:41Use of their photo.
13:44I've highlighted the the resource
13:46is this particular resource.
13:48You'll get a copy of these slides.
13:51And in our community of Palo Alto,
13:53which is where my wife and I
13:56are raising our three boys.
13:58It's an exceptional place,
13:59but we do have in Palo Alto
14:02and in Northern California.
14:04Suicide in our family history and
14:07people who come into our community
14:09who are not from the community who
14:11are part of city leadership or
14:14school board leadership have to
14:16learn about our history before they
14:19can really feel truly effective.
14:21We had two suicide clusters that
14:23happened at the train tracks.
14:25We have five train crossings within.
14:28Four and a half mile span.
14:32And we saw that that's not only
14:34of high school students,
14:36but also of young adults.
14:38We have a particular interest now
14:40in the Asian American community.
14:42Some of you may know that the number
14:45one cause of death in young people
14:48of Asian American origin is suicide.
14:50Between 15 to 24.
14:54So this was part of our demographic,
14:57especially in the second cluster,
14:59and it's become an area of interest
15:01of ours in terms of.
15:03Some hope for well-being promotion
15:05as well as suicide prevention,
15:07so this was our coalition in 2009.
15:10Project Safety NET,
15:12which is very actively engaged in
15:15work to this day that is our website
15:18psen Youth org and these this is a
15:22sampling of the partner groups at the time.
15:25And you'll see there's there's a number
15:28of familiar sounding to you organizations.
15:31Counseling services,
15:32the hospital, the universities,
15:34the parks and Rec Commission,
15:36faith based organizations, grief support.
15:39Everybody wanted to help.
15:43Everyone must come into the table,
15:44but we looked a little bit like this.
15:46We were in unstructured network
15:49of well meaning adults,
15:51mostly adults.
15:52Not very many young people at the table
15:55initially and over time we developed
15:58this more intentional community network,
16:01fostering youth well being with
16:03connection to families with mobilized
16:06young people in the middle.
16:08An example of that is when we
16:09would meet as a coalition.
16:11It was always during.
16:13The work day.
16:15You know we were all about the youth,
16:17but where were the youth were
16:18meeting during the school day?
16:20We're not going to have any
16:21students at the table,
16:23so simple things like changing
16:25the meetings to times when young
16:27people could attend and not only
16:31engage us as adults,
16:33but also activating sectors that
16:35you saw in the previous slide
16:37with invigorated programs.
16:39Hopefully those that show evidence
16:41to work influencing civic decisions.
16:43And so this framework comes from the
16:47search institute,
16:49the developmental Assets framework.
16:52And it's also linked to bronfenbrenner's
16:55social ecological model,
16:57which some of you have studied.
16:59Where it's not just the individual
17:01and the family and peers,
17:02but there's a nesting within
17:04communities and within society.
17:06So if you think about our
17:09project safety net coalition,
17:10we had the larger the commissions,
17:13the county, the Caltrain,
17:14which is the train that runs in a 77 mile
17:18corridor from San Francisco to San Jose.
17:20And Palo Alto is kind of right in
17:22the middle with our five stops
17:24we needed Caltrain at the table.
17:26We needed to do.
17:27We need to do a technical,
17:29so we needed to make sure that all
17:32of these interested in impacted
17:34parties were working together to try
17:37and create an organized system for
17:40not only mental health promotion
17:42and suicide prevention upstream,
17:44but also downstream in terms of means
17:47restriction and responsible media coverage.
17:52And overtime,
17:53the research has been consistent
17:55and new research is showing us the
17:58importance of family connectedness.
18:00Now this is something that doctor
18:02Lechman's been teaching us for many,
18:03many years.
18:05It's cool when some of the
18:09recent developments looking at,
18:11for example,
18:13not only positive parent child
18:14relationships and parental involvement,
18:16the right amount of parental involvement
18:18speaking to you as a helicopter
18:20recovering helicopter parent.
18:21Uhm, how do you race?
18:25You're adults,
18:26you know the teenager in your house,
18:28in particular,
18:28if they have a mental health challenge,
18:31it's a delicate balance trying
18:34to find that just right.
18:37Amount of supervision and intervention
18:40and involvement is challenging.
18:43Cultural value congruence the idea that.
18:46In our community in particular,
18:48we have a number.
18:50Really,
18:50the majority of our students
18:52have parents who did not go
18:54to high school in the USA.
18:57Very large Asian American
18:59and Latinx diaspora.
19:00So really looking at opportunities
19:03to bridge cultural values among
19:06parents and their teenagers.
19:08We know that religious knus,
19:11and that's a very broad term,
19:13but it's been called various terms
19:15over the years can be protective.
19:18Whether that is feeling that taking
19:22one's life is morally wrong,
19:25or whether it may be seen as
19:28something very negative in the
19:30eyes of the persons higher power,
19:32or whether they belong to a cultural
19:34group or religious group that has
19:36strong beliefs against suicide.
19:38We know these are protective factors
19:40and now we know emerging from the pandemic.
19:44At school,
19:44climate and peer connections that
19:46are in person are the kinds of
19:49everyday micro doses of well being
19:51that we took for granted during.
19:53The pandemic,
19:54during the zoom years in the
19:57last 20 months or so,
19:59the perceived availability of trusted
20:01adults and a sense of belonging.
20:05Those of you who are familiar with
20:07the interpersonal theory of suicide
20:09that Tom Joyner and colleagues
20:10have developed over many years now,
20:12this has been adapted for teenagers.
20:15A thwarted sense of belonging
20:17becomes a risk factor,
20:18as is a perceived sense of burdensomeness.
20:23So if we can cultivate a sense
20:25of belonging and
20:26help the young person feel that it's
20:29quite the opposite, they're not a burden.
20:31If they were to open up to their friends,
20:33if they were to say.
20:35In the words of one of our school
20:37mental health student leaders,
20:38the three magic words.
20:41I'm not OK and this was penned by someone who
20:45was always the source for all their friends.
20:48All of his friends to go to for him
20:50to say those three words and open up
20:52that he was not OK wasn't important.
20:56Piece for him to write about in
20:57the school paper and importantly
20:59how he got that support.
21:01His friends really showed up for him,
21:02as did his teachers and it really helped
21:05his parents understand his story better.
21:08And then finally,
21:09social support and connectedness through
21:11the everyday kinds of in person activities.
21:13Now whether it's a sports team,
21:16a youth group of club,
21:17other activities that are
21:18happening in person,
21:19these are all shown to be protective factors.
21:22So we do this work in schools
21:23because the vast majority of our.
21:25Children and youth are in schools
21:2965 to 68 million every day in
21:31EU S attend public school.
21:33About 20% suffer from a diagnosable
21:37mental health condition.
21:39Uhm,
21:39many of these kids are not
21:42progressing academically academically
21:43because of mental health reasons
21:45and children of immigrants.
21:47And immigrant children make up about
21:5025% of the US school population.
21:52So because these young people
21:55live in schools,
21:56these approaches may be more
21:59accessible and less stigmatising.
22:04There are of course still factors that
22:07come in the way of students being able
22:10to access mental health care in schools,
22:13and I'll get more into that.
22:14It's the talk progresses,
22:16but I just put two examples of programs
22:19of therapeutic approaches that have
22:22been adapted for school program CBT.
22:25I'm thinking specifically of the cognitive
22:28behavior intervention for trauma in schools.
22:31See bits that Lisa jaycox.
22:33And her colleagues at UCLA and Rand
22:36developed along with our sister
22:39Cheryl Kataoka and Bradley Stein.
22:41They've been.
22:42This treatment has been out
22:43now for a number of years.
22:46And it is not only accessible, infeasible,
22:48it's very good for school settings
22:50because it has a group structure,
22:52it's time limited and it focuses on skills,
22:55so less about psychotherapy,
22:57Purcell, though the interactions
22:59can be very therapeutic,
23:01it really is about skill
23:03building and empowerment.
23:04For in the case of Cbit 6 to 8th graders in
23:07the case of IPT adolescent skills training,
23:10it can be for high school,
23:11so this is a group based
23:14depression prevention format.
23:18And this is a review for you,
23:19but just to highlight the idea that
23:2220 to 25% of our young people before
23:26they walk across the stage to get that
23:28diploma from high school will have
23:30struggled with depression of some sort.
23:32Maybe not a major depressive
23:33episode out of the DSM.
23:355 TR,
23:36but some kind of severe episode
23:38where they lose interest in the
23:40things that are important to them
23:43and they have a real decrement.
23:47In their mood for at least a week.
23:505% having depression at any
23:52one time and the average age of
23:55onset is around sophomore year.
23:57We know that 65 to 80% of teens and humans,
24:01not just teenagers,
24:02have at least one diagnosable diagnosable
24:05disorder at the time of their death.
24:07Or a year preceding,
24:09but often the symptoms are not as visible.
24:12And this is one of the important
24:14lessons we've learned as a community,
24:16particularly for the males.
24:18We have lost the Asian American males wear.
24:23They may not be acculturated in the
24:25same way to be able to talk about their
24:27feelings in a way that feels safe.
24:30And yet, they may,
24:31they may struggle nonetheless,
24:33and their symptoms may not present the
24:35same way someone from another ethnic
24:38cultural background may present.
24:40And as I said,
24:41the beginning,
24:41the rates have been rising over
24:44the past ten years.
24:45So we're always thinking about culture.
24:48From the culture of my walking into
24:51this beautiful auditorium for the
24:53first time since 2006 to a patient who
24:59comes into Yale Child Study Center,
25:02you know what is the culture
25:04of the institution to them?
25:06What cultural background do
25:07they bring into the room?
25:09What does the clinician bring into the room?
25:10Every interaction is cross cultural.
25:13We touched a bit on the biological basis.
25:18We think a lot now about the
25:21psychological influences our
25:23young people generally can be.
25:25Very resilient.
25:26They have a lot of coping skills they've
25:29developed, but in the pandemic their
25:31self-esteem may have taken a hit.
25:32They may have lost their sense of
25:35belonging when they come back into school.
25:36That best friend,
25:38they might be estranged from now.
25:41The social piece here can be a
25:43very important source of strength,
25:45but can also be a stressor.
25:47So as Doctor Cohen taught us many years ago,
25:52child psychiatry is family
25:54psychiatry and we really try to
25:56engage families as much as we can.
25:59Even in the limited time we have,
26:01we're really our work is incomplete
26:03if we can't understand the family
26:05story and and then finally,
26:06when we think about cross cultural
26:08work and I would present to
26:10you that every interaction.
26:12Is a cross cultural 1 tapping
26:14into what brings that young person
26:17a sense of belonging and what?
26:20They describe as who they are,
26:22who their people are,
26:23where they come from is a very
26:26important part of the work for us
26:28in child lesaint mental health,
26:30particularly if we're thinking
26:32about depression,
26:33which can put a young person at
26:35risk for making a suicide attempt.
26:38So I I might,
26:38if I'm going to the school board
26:40pull out this brain slide.
26:41I was talking to the trainees earlier.
26:42This is just open source from the
26:45Internet from Naida and I very
26:47briefly might tell them about,
26:49you know,
26:49in the days now we're meeting in person here,
26:51but when we would,
26:52do you know in person classes or I
26:54would give a talk and there would
26:56be food or there be good coffee.
26:58It was early in the morning and say
27:00you know this blue area your frontal cortex.
27:02This is your reward,
27:03your motivation.
27:04You knew that if you arrived
27:05here you were going to get the
27:07good coffee and you would get.
27:08The good pastries, but we focus on serotonin.
27:12A lot of parents,
27:12a lot of school board members,
27:14a lot of a lot of superintendents
27:16know about serotonin.
27:17They made themselves have taken an SSRI,
27:19but we just highlight the idea that
27:22serotonin is not only important for mood,
27:24it's important for memory
27:26processing for sleep, for cognition.
27:28All of the things students
27:30need to engage the curriculum,
27:32and if our students are not
27:34healthy enough to learn,
27:35then no matter how good our curriculum is.
27:38At the school board,
27:39we would say they're not engaging
27:41if their brains and minds are
27:43not healthy enough to learn,
27:44they're not going to engage
27:45with what we want them to,
27:47so that is why we do this work in schools
27:50and that is why we always talk about culture,
27:52because what might appeal to.
27:56One community might not appeal to another
27:57when we talk about mental health in schools.
28:00So like I'm doing with you here now,
28:02I invite colleagues to consider
28:05culture in every patient.
28:07In particular Francis Luhu I
28:10reference here in the bottom,
28:12and I did a talk.
28:13This is again 10 years ago,
28:15appreciating the complexities
28:16of cultural assessment
28:18requires. Some thoughtfulness we
28:20have to know when we don't know,
28:24rather than making assumptions,
28:25we have to know about our
28:28biases and prejudices,
28:29and we have to know when to
28:31get a cultural consultation.
28:33This might involve young people.
28:34Specifically, we don't want the
28:35sun to be the interpreter when
28:37we're speaking with the parents,
28:39but we might need to if we understand
28:41a little bit about what's going on in
28:44the students world interpersonal world,
28:46we might have a better understanding
28:47of how we can help them.
28:49We might have to ask a friend to
28:52help us understand better what's
28:54going on with the patient that we're
28:57consulting on in a school setting.
29:00So the next few slides are just a
29:02reminder to us because we are right now
29:05living. This is a parallel process.
29:08We're having the hybrid version
29:10of grand Rounds.
29:11Right now there's an in person and
29:12there's a Tele health component to this.
29:15Or a Tele education component.
29:17And I,
29:17I guess that many of you who are
29:20fellows who I met over the new now
29:22we're going to continue to have a
29:24Tele health aspect to what you do.
29:25And so Barbara Stanley from Columbia,
29:28who's done a lot of work in
29:30suicide prevention and the Brown
29:32and Stanley safety planning tool,
29:34is something you've probably all seen.
29:35I'm going to show it in a minute,
29:37but at beginning of the pandemic we
29:39did a really nice summary of some
29:42of the approaches to be adapted
29:44for schools and Tele health during
29:46COVID and after,
29:47and I won't be able to get into all of it,
29:49but I'm going to focus on two aspects.
29:52In particular having to do with
29:55safety planning.
29:56And having to do with support
29:58for yourself as clinicians so.
30:03Under ordinary circumstances
30:05it is very anxiety provoking,
30:07especially if you're a trainee and
30:10you're anointed with the term expert.
30:12When you go into a school setting,
30:13they they breathe a collective
30:15sigh of relief when.
30:17Say Marie, I'm in one of your fellows
30:19were to walk onto a school campus
30:22because they feel like OK, my arms here.
30:24It's going to be OK, right? But?
30:28Maryam's heart rate might be going up
30:30because you know what is she doing?
30:31Well, she's just walked onto a campus.
30:33She has pulled the collective anxiety.
30:36But when you're doing Tele health,
30:38you don't actually see the student in person.
30:40You're doing this across the screen,
30:42so there are some unique challenges.
30:46Making sure that you have taken some of
30:49the basic preparation kinds of moves are
30:53going to help to bring your heart rate down.
30:56So for example,
30:57knowing where the student is,
30:58knowing their location,
31:00making sure you have emergency
31:02contact information, what if you're?
31:05Phone call gets interrupted.
31:06What if it gets cut off?
31:08I mean similar to what we do in interviews.
31:09You have another way to reach the
31:11person you want to make sure you
31:14can secure the students privacy and
31:15you want to make sure that you can
31:17develop a plan to stay on the phone.
31:19If the zoom the video cuts out.
31:22And then went to bring parents into
31:24the conversation. When and how?
31:26Now,
31:26for some of our communities
31:28that we work with.
31:29It may be very hard to find a private
31:32place to be able to talk for that student,
31:35so that involves sometimes
31:37connecting with them on zoom,
31:39when they may be in school,
31:41and you may also be in school,
31:42but you're in another location.
31:44Sometimes they like that setting.
31:46It also allows them at
31:48times to mute their video,
31:49but you know they're OK 'cause
31:51they're on campus somewhere.
31:52We also have fellows who for medical
31:55reasons could not come to a school setting,
31:58so the student might be in school on zoom
32:00and the fellow is at a remote location
32:03either in clinic or in their home,
32:05so this might look familiar.
32:06This is the CSRS,
32:08the Columbia Suicide Severity Rating scale.
32:10There are actually adaptations now for
32:13community settings like school settings,
32:16and they put the community
32:18card for teachers here.
32:20Just put it here to highlight its.
32:22Pretty simple,
32:23it's six questions and
32:25teachers can be trained,
32:27not teachers.
32:27As much I'd say counselors tend
32:29to use this more,
32:30but teachers can be trained as they can.
32:33Also with the ASK which is the ask
32:36suicide screening questions the ASK.
32:38I want to highlight something that one
32:40of your very own psychology fellows,
32:43Andrea Tab Wanka at the time she
32:45was not noticed that one 'cause
32:48she was Llewellyn but she is
32:51now with us at Stanford and she
32:53did a beautiful adaptation of
32:55the suicide risk assessment.
32:57Worked here actually on one
32:59of your inpatient units and
33:00developed these ideas with
33:02Marie Gibson who came out and was
33:04with us for a short time from Boston
33:07Children's and the two of them.
33:08Together worked on an adapted safety plan,
33:12so on inpatient units,
33:13as is true in emergency rooms,
33:15as is true in real life.
33:17You have this slide, which you may have seen,
33:21or you may know the concept which is.
33:25There is a danger that goes up very acutely.
33:27The risk overtime happens.
33:30It peaks the danger of acting on
33:32suicidal feelings is at this peak,
33:34and if we can get them through that period.
33:38Think about it as an extinction burst.
33:42Overtime their risk will come down, but.
33:44These curves may happen at
33:46different points during,
33:47for example, the school year.
33:49Like now, for example,
33:50as we are facing some some
33:53stressors for students,
33:55many of which you'll be able to name.
33:57They're not just academic ones,
33:59we're headed into the holidays,
34:00we just got out of a holiday.
34:02Sometimes that's really good,
34:03but for others it may be
34:05all the more stressful.
34:06And when you have the interaction
34:08with a mental health condition and
34:10they may not see their therapist
34:12during the holiday period,
34:14especially if they have school
34:16mental health clinicians.
34:17The suicide risk may again go up.
34:20So this is the safety planning intervention.
34:22There are a number of apps here.
34:24This is the most established verse
34:26published in the 20 teens I have.
34:29The reference here from Stanley and Brown.
34:33It's basically seven steps and
34:35it's all familiar to all of you,
34:37so I won't go into the detail.
34:38It's available on apps.
34:40There's an app called safety plan,
34:42and this one appears there.
34:44There's one called my 3M Y and the number 3.
34:48These are very useful because
34:50you can have them in your phone.
34:52You can create the plan with the young
34:54person in the room and then there are
34:56the usual things that you're aware of.
34:58The warning signs the internal coping
35:00strategies of a young person by themselves,
35:02whether their distraction techniques,
35:04whether their social supports for
35:07distraction and for help in a crisis,
35:09the number of their therapists there Dr.
35:12What are some ways that they can
35:14make the environment safe and
35:16last and perhaps most importantly,
35:18what are the things?
35:19To live for and look forward to.
35:21So when you do the safety plan,
35:22the thing you're ending with is.
35:25What is the single thing or what are
35:28a couple of things that are most
35:30important to you to go on living for?
35:33So it starts from within self strategies,
35:36and it builds outward.
35:37It's a little bit like the broth
35:38and Brenner model I showed you,
35:40and so you really want to make sure
35:42that you develop the safety plan.
35:44Whether you're in person or virtually,
35:47and that we're creating this plan
35:48so that they can stay out of
35:51the emergency room if possible,
35:52reminding them that hospitals are great.
35:56If we absolutely absolutely need to go there.
35:58But let's see what we can do to keep
36:01you safe in your home environment.
36:04So here's the adaptation
36:05that Andy came up with,
36:06so this might look familiar to you, right?
36:09It's a feelings thermometer.
36:11Subjective units of distress on a
36:13scale of 1 to 10 you have a Green
36:16Zone yellow zone and red zone and
36:18one of the things she did was.
36:21Talked about this idea of the
36:24temperature as related to a stoplight,
36:26so they actually call it
36:28the stoplight safety plan.
36:29So this is the adaptation.
36:31Again, if you think about the thermometer,
36:32you have a Green Zone yellow zone red zone,
36:35and they adapted using some basic
36:38cognitive behavioral terms,
36:40thoughts, feelings and actions,
36:42and green, yellow red zone.
36:44So in the Green Zone,
36:45what does that look like to your parents?
36:47What does that look like to
36:48others where you're chilling?
36:49Things are going well.
36:51What might you be thinking?
36:53What might be feeling?
36:54What would it look like to others,
36:56and what can you do to stay in
36:58that zone in the yellow zone?
37:01Again, what might should be thinking?
37:03What might you be feeling?
37:04What would it look like,
37:05and how can you communicate to others
37:07that you are starting to get to stressed?
37:10And what can they say and do to
37:11help you not get any higher and
37:13hopefully come down to the Green Zone?
37:15And what should they avoid doing
37:17in order not to trigger you?
37:18Similarly for the red zone.
37:22This is actually the the book
37:24that Andres and I have edited,
37:27which is coming out in January.
37:29It's in a chapter that they've
37:31written called when time is tight
37:33and stakes are high pharmacotherapy
37:35alliances in the inpatient unit.
37:38So here are some examples of Green
37:41Zone thoughts that they might put.
37:43Life is going better.
37:45I'm doing better.
37:46My feelings are hopeful and motivated
37:48and I'll be doing more activities
37:50talking more with everyone.
37:51Instead of isolating,
37:53including my parents.
37:54And then there are some specifics
37:56here around the coping plan.
37:59In the yellow zone, similarly,
38:02you see specifics as you see in the red zone.
38:05So it's the idea that you place some
38:08behavioral anchors for the young
38:10person that they create with you
38:12on the inpatient unit as therapist,
38:14and then the young person presents this
38:17safety plan to their parents and a family
38:19meeting so that everyone can be on the
38:22same page more or less about green,
38:24yellow and red zone.
38:26One of the things we notice when
38:28things are going well when should we
38:31start getting worried and when do we
38:33employ the strategies in the red zone?
38:36The coping plan.
38:37The supervision plan that triggers it
38:39can be avoided and the coping skills
38:42a young person can use to hopefully
38:44stay safe and out of the hospital.
38:47Again, step seven.
38:49Last but not least.
38:51The most important things for me to
38:53go on living for are.
38:55And I think it's so important to
38:58when you are safety planning to
38:59end with this in that session,
39:01because you are conveying this sense
39:03of hope from their point of view,
39:06their perspective, and on an
39:07inpatient state three to seven days.
39:09I don't know what it's like here for you
39:11all three to seven days, a little higher.
39:15By the time they get here,
39:16it needs to be longer,
39:19but in you know in our locale,
39:21for the vast majority,
39:24things happen very, very fast,
39:26which is why they named this chapter.
39:28When time is tight and stakes are high.
39:30So every time you leave the room
39:33after you've done safety, planning,
39:34tweaking and you revisit step seven,
39:37it could be a very powerful message of hope.
39:40So those of you who speak Mandarin
39:42will recognize this character.
39:44It's got two parts.
39:47It's a symbol for crisis.
39:49There is danger and there is opportunity.
39:53So.
39:54To be captain obvious for a moment,
39:56this pandemic we've been through
39:59the largest disruption of education
40:01in history affecting children
40:03and youth all over the world.
40:05But out of crisis comes opportunity so.
40:09Without Kyle and the technology
40:11here without Rosemary to set
40:14this ground rounds up in person.
40:16Without the audience, there would be no me.
40:19There would be no talk today
40:21we need two hands to clap.
40:23We need both a speaker and a
40:25group of participants.
40:26So similarly where there's a lot.
40:29Of upheaval crisis pain loss.
40:32Out of the pandemic,
40:33I think all of you could think of
40:35at least one or two Silver Linings.
40:37So in school settings we we need
40:38to think about that as well.
40:40Not all distance learning is bad.
40:43Some research suggests that more
40:45material might be learned online might
40:48be retained compared to the classroom.
40:50E learning can take less time.
40:53Some students have felt empowered by
40:55this when we went in 2020 and into
40:58hybrid and into asynchronous zoom.
41:00Students will get their assignments
41:02on Mondays.
41:03They'd be in class,
41:04maybe Tuesday for a few hours,
41:06Thursdays for a few hours on zoom,
41:08but then they would have the rest of the
41:10time to devise their own strategies for
41:12getting through the work during the week.
41:14So I think there there is going to be
41:16online learning and some hybrid version
41:18of what we've learned going forward,
41:21and that can be really useful.
41:23We've also learned to cultivate some
41:25strategies to enhance our own well being,
41:28so this comes from California's first
41:30surgeon General, Nadine Burke Harris.
41:32Some of you may have seen.
41:34Her Ted talk on Aces and Trauma
41:37informed work. She's a pediatrician.
41:39She was a Stanford resident and she is now
41:41our first surgeon general in California.
41:43She has a wonderful playbook for
41:46managing stress during COVID-19.
41:48I think it's even more relevant now
41:51that we emerge and hopefully not
41:53have to deal with new variants.
41:56But these things might be obvious to you.
41:58I I like how she focuses on safe,
42:02stable and nurturing relationships.
42:03It might just be one relationship.
42:06For some of our young people,
42:08it's a parent or a young or
42:09a person in the home,
42:10or it might be a teacher.
42:11It might be someone in the community.
42:15So this is very nice because it's very
42:18simple to do and she has a nice website
42:21which really helps you devise your own plan.
42:24Second,
42:25the six daily questions for quarantine.
42:27Even though we're not in quarantine and
42:29hopefully we don't enter a new quarantine
42:31with a Micron or with micro hello Oma
42:34Cron or whatever comes next after that.
42:38These are written by Brooke Anderson.
42:41She is a writer,
42:42Bay Area writer and this was posted on
42:45the greater Good Science Center website.
42:47Even though I'm from Stanford up,
42:49I'm not too proud to highlight what
42:51Berkeley is doing and and greater
42:53good Science Center is really
42:56a trove of wonderful resources.
42:59What am I grateful for today?
43:01Yes, this was important during the pandemic,
43:03but it's important for you to cultivate.
43:05Now all of you is mental health practitioners
43:08ought to think about a gratitude practice.
43:10More on that in a moment.
43:11Who am I checking in on or
43:14connecting with today?
43:15I happen to have four relatives and
43:18close friends over the age of 90
43:20and my parents are in their 80s.
43:23So if I'm calling them regularly if I
43:25call my parents every day now I call my.
43:28Nonagenarian friends once a month,
43:31but that means they call each of
43:33you know one of them once a week,
43:34and it's great for me and I.
43:37I just love hearing their story.
43:39It might be 5 minutes.
43:41What expectations of normal am
43:43I letting go of today?
43:45All the more important as we raised
43:47three boys and have had to let go of
43:49some things we really want to do around
43:51media restrictions while also still
43:53maintaining some sense of semblance
43:55of control around time limits and sleep,
43:58for example.
43:59How am I getting outside?
44:01How am I moving my body?
44:03We're on the West Coast.
44:05We're still mostly unzoom,
44:06and so this is still very important.
44:10Really getting to to go outside
44:12feel the grass, see the skies,
44:14and I love this one.
44:16What beauty am I either creating,
44:17cultivating or inviting in today?
44:19So I think these questions are
44:21important even as we emerge out of
44:24the last 18 months that comes from
44:28this particular link guides well being
44:31during coronavirus and this comes from.
44:34Another Yale graduate Grace Jean Gu,
44:37who published this book on
44:39professional well being last year.
44:42And it's a great.
44:43It's a very simple slide,
44:44but you know what you're doing right now.
44:47With connection in person you
44:49had the choice to be on zoom.
44:52You made the trip here to be in person.
44:56This is a social activity.
44:58This is something that has helped to engage
45:00you and cultivate your work in this field.
45:03There is mentorship,
45:04there's intellectual stimulation.
45:05There's psychosocial support,
45:07and this is in order to buffer the
45:10system that you live in with all
45:12the negative inputs, the stress.
45:14The the the very,
45:17very challenged family.
45:18You're going to work with this afternoon.
45:20The time and energy demands.
45:22So trying to avoid this part of the
45:24battery or your low Batt or you're
45:27burned out or you're having compassion,
45:29fatigue and building your capacity
45:31with these positive inputs to
45:33really try and recharge your
45:34batteries for your own self care.
45:39And then a couple of things we teach in
45:41our undergraduate course on well being.
45:44I mentioned gratitude.
45:45You might know the three good
45:48things or three blessings practice.
45:51And this was one study that was
45:53published in the British Medical Journal.
45:55They looked at more than 200 health care
45:57workers who did this practice for two weeks.
46:00And it's essentially for 10 minutes
46:03every night they were asked to write.
46:05Or type if it with our students.
46:07We asked them to write and keep a journal.
46:10Three things that happened
46:12that went well that day.
46:14My team would take 5 minutes,
46:15but they can be very simple things,
46:17but the most important piece is
46:19not only what went well, but why.
46:21What went well and why?
46:23So I'll give you an example.
46:24This morning,
46:26my 83 year old mother I'm staying
46:28with my parents in New Hampshire.
46:30My 83 year old mother who doesn't
46:32sleep really well and she also
46:34takes care of my 85 year old Father.
46:36So she's up during the night
46:39making sure he's OK,
46:39but she woke up early and you know,
46:42of course I'm back in my house so she
46:44made my favorite breakfast and it
46:46was not only amazing 'cause you know
46:48mom cooked it, but I was so aware.
46:52That I have this time with my mom.
46:55And she got her health and she's
46:57able to make this for me.
46:59And we had like 20 minutes
47:00together before I drove down.
47:01But it was gold,
47:02so for me that's one good thing.
47:05And why it went well, I feel very fortunate.
47:08I have that relationship with
47:09my mom and she's still living.
47:10So that's an example of one good thing that.
47:13I may not normally be aware of,
47:15UM, but you know,
47:17I'm thankful for kaylin and
47:19Rosemary for connecting us today
47:21and creating this on short notice.
47:23Why did it go well?
47:25Well,
47:25'cause you all know how to have
47:29respect and keep great colleagues who?
47:33Bring lectures in and sharing the
47:35learning process.
47:36That's a simple thing,
47:37but it's important that these are
47:39examples and it forces us every night.
47:41And in this study,
47:42the idea is you focus on the things
47:44that went well in order to not dwell
47:47on the things that didn't go well.
47:49So it's very simple,
47:50but after two weeks there was
47:53not only improved happiness,
47:54work, life balance,
47:55and reduce burnout.
47:56When you look at them six weeks
47:59and six months and one year later,
48:01their indices are are much higher.
48:03In these domains compared to those who did
48:06not do gratitude practice just two weeks.
48:09Self valuation this is work that
48:11Mickey Trockel and some other
48:13folks in our department are doing.
48:15And they published this work
48:17in Mayo Clinic proceedings,
48:19focusing again on personal well being
48:22and growth mindset that called out my
48:25sister Dorothy's to be before out.
48:26Like if you make a mistake as a
48:28program director, just just own it,
48:30learn from it,
48:31move on and embrace the growth mindset.
48:34Never waste the mistake to really learn
48:37something about it and that will help you.
48:40To improve and increase your self valuation
48:43so you're prioritizing your personal well
48:46being as opposed to lower self valuation when
48:48you really dwell on the mistakes and that's
48:50associated with a higher risk for burnout.
48:52So it's something that we tend to forget.
48:55This is a picture of brief
48:57picture of our toolkit.
48:58The K12 toolkit for mental health
49:00promotion and suicide prevention.
49:01Maybe that was a silver lining out of
49:04some of our losses in 2009 and 2014.
49:06We've compiled this toolkit
49:08that is a collaboration.
49:10Among mental health primary care.
49:13And school professionals.
49:14If you're looking for it,
49:16it's open source.
49:17Just reference heard K12 toolkit and it
49:21will be the first link that you see.
49:24I've highlighted some work that happens at
49:26the National Center on School Mental Health.
49:28Sharon Hoover.
49:29Some of you may know her at
49:30the University of Maryland.
49:32Nancy Levy really just an amazing
49:35trove of resources there,
49:37including those resources that focus
49:40on cultural responsiveness and equity.
49:43A bunch of other toolkits that we
49:46have come into contact with and that
49:48we have convened in our toolkit,
49:50but also highlighting some important
49:52websites like transition year.org,
49:54the Stanford Center for Youth
49:56Mental Health and well being.
49:58Here's a group that arose from
50:00the students who lived through
50:02those tragic years in Palo Alto.
50:04They they put together a group called
50:07Youth United for responsible media
50:09representation where they highlight best
50:11practice where they share their narratives.
50:14About the things that have really helped
50:16them in terms of responsible media
50:18reporting and what things were not helpful.
50:21Sources of strength.
50:22One of the only evidence based peer
50:25LED programs for suicide prevention
50:27and well being promotion on high
50:29school campuses now being adapted from
50:31middle school and elementary school.
50:34Uhm, and that is the end.
50:36We have almost 10 minutes for some
50:38discussion. Thank you so much.
50:54Zoom crowds getting warmed up
50:55and we have a question already.
51:10Thank you so much for the
51:11shout out for Grayson Andy.
51:13There are psychology fellows.
51:14I trained the mother here
51:15so thank you so much.
51:17I have a question about how you create.
51:21Paraprofessional champions within the
51:24schools, in other words, so often,
51:26the burden of dissemination falls
51:28on mental health professionals,
51:29IE social workers,
51:31school psychologists, psychiatrists.
51:32But how do you create,
51:34let's say, teacher champions,
51:35who will use the tool kits?
51:38Use the materials so in terms of this
51:40idea of dissemination science moving
51:42it beyond us because there's too few
51:45of us in any given public school.
51:47And so the natural folks to disseminate.
51:52These guidelines would be the educational
51:55staff or staff or other paraprofessionals.
51:59So what strategies do you use to make
52:02sure that kind of train the trainer
52:05philosophy gets embedded in schools,
52:07but a great question,
52:09so I I would say there are a couple
52:11of ways we've learned to do that.
52:14Before you get into any school
52:16district and certainly doctor Comedy
52:18wrote about this years and years ago,
52:20it is about the relationship you have and
52:23the trust you have with the community.
52:25It takes at least a year and in
52:28that year your understanding.
52:31Who are the interested parties?
52:33Who are the impacted parties we used
52:34to call these people stakeholders?
52:37I'm kind of moved away from that
52:39term because of its colonial roots,
52:41but the idea that there are a number
52:43of really important people to have
52:44at the table so that you as a school
52:47mental health consultant or advisor
52:48if you will use that term loosely.
52:51'cause I I feel like as much the learner
52:53as I am an advisor or consultant.
52:55You understand from them what
52:56they're seeing on the ground.
52:58So for example, in California we have.
53:01Past help to pass A,
53:04B,
53:042246 and 1767 which is the people
53:08suicide prevention policies and
53:10this requires that every one of the
53:13school districts in the 58 counties
53:15has a suicide prevention policy with
53:17administered regulations and that
53:19now a recent bill requires that
53:21if they have a health curriculum,
53:22they have to have mental health
53:23as part of that well,
53:24who's going to deliver that?
53:25The teachers, right?
53:28How do you get the teachers feeling
53:30comfortable to use the language?
53:33Well,
53:34there are new programs now like cognito.
53:37For example cognito with a K.
53:38They're out of New York.
53:40I have their reference in my slides and
53:42you'll all get a copy of the slides,
53:43but they have developed virtual
53:46world play software where teachers
53:49can play themselves and there are
53:51three vignettes and it's about
53:531 1/2 to two hours long.
53:55But you learn the language of how to
53:59have a conversation with a student you
54:01might be concerned about how to have a.
54:04Conversation in your class about
54:06something related to sexual and gender,
54:09minority youth, and what their risk might be.
54:11There are also platforms designed
54:13for students to be allies and to
54:15speak up on behalf of their peers.
54:17So this is an example of, well,
54:19that's a really good strategy.
54:20But will the teachers use them?
54:23Or will it be just seen as one
54:25more thing they have to do so some
54:27districts have gotten creative?
54:28They've used some of the Biden money
54:30and some of the new some money that
54:33in California and the and the prop
54:3563 the mental Health Services Act
54:37money to actually pay their teachers
54:39to do this professional development,
54:41and so you can do this on your own time.
54:42You've got to have so many hours
54:44of PD like we have to have so many
54:46hours of CES or CME's and that's
54:48the way they've used their money.
54:50So rather than requiring it
54:51for their teachers, say, well,
54:53you can get paid to do this.
54:54So thinking about ways to like well,
54:57what's going to motivate either the
54:59paraprofessionals or the teachers,
55:00or the people who are asked
55:03to lead this work,
55:04and then the other part for us is
55:07checking in on the teachers and seeing
55:09how they're doing with this stuff.
55:10So last year I was privileged to
55:15run a pilot of a curriculum that was
55:18developed by our colleague Jeff Bostic,
55:20who was formerly at mass general
55:22now at Georgetown,
55:23and they have a whole teacher well being.
55:25In school environments or wise WIC,
55:29if you look that up.
55:31Well,
55:31being in school environments is a
55:33curriculum that they developed that
55:35he developed with teachers that uses
55:38principles of CBT and it uses principles of.
55:43Of connection,
55:44but also builds in.
55:46You know it's sort of taps into
55:48where are they on the burnout scale?
55:50And so for me the important piece
55:53was checking in with this group
55:54of staff that were piloting this
55:56to see how they were doing.
55:58Not just in implementation,
56:00but how were they doing themselves?
56:02How were they able to do this work?
56:04Are they getting enough release time?
56:06Sometimes you need what we call a Tosa,
56:09which is a teacher on special assignment.
56:11If you're going to bring a
56:12program like sources of strength.
56:13Into a school community.
56:14Who is that teacher leader who's actually
56:16going to get some release time and
56:18extra prep time to meet with their students?
56:21And it might only be one hour a month,
56:23but that can be gold for anyone who's
56:25fought for FTE for any of your faculty.
56:28If you can protect some part of the week,
56:30even an hour a week,
56:31that can be enormous.
56:32So if you can get some time for
56:35that teacher to make sure that they
56:37have the time and the space to be
56:39able to be with their students
56:41to to propagate these messages.
56:43Of hope,
56:44help and strength.
56:45You're most likely to do it so for
56:47us as the as the clinician,
56:49the consultant it's important
56:51to really help those folks who
56:53are doing the work on the ground
56:55feel supported and hurt.
56:57Shashank,
56:58there's lots
56:59of comments on zoom
57:01when I get to please them, but
57:03we're going to get to two
57:04comments here in the live crowd.
57:06And then we're going to close and gotcha.
57:08So the first one comes
57:10from someone you tapped on.
57:11So that's Dr.
57:12Lechman and then the second
57:14one and the closing one
57:15appropriately will be by a teacher
57:18who does the work. OK, so good.
57:24Well, I know what I'm going to
57:26say in terms of what positive
57:28thing happened to me today.
57:29Thank you so much for being here
57:31and thank you from being from
57:33New Hampshire and it's such an
57:35inspiration to see you in action,
57:37and I guess I really wanted
57:38to stand up and clap,
57:39but you're leading the way and we
57:41are so grateful for your efforts and
57:44time and it's making a real difference and
57:46we need to do more in Connecticut
57:48and around the world.
57:49And I am looking forward
57:50to spending some time
57:52with my grandchildren.
57:54Thank you doctor Lechman.
57:56Well, thank you.
57:57So the final word and I have to thank
58:00you for saying all those wonderful,
58:02important things about teachers.
58:03We are very blessed with teachers
58:06and I'm blessed to work with
58:08the teacher every single day.
58:09She's not just a teacher,
58:10she's a principal. Yes, so
58:12on behalf of the Republic
58:14of Teachers. Mary gunsalus.
58:17Thank you so much,
58:18no pressure there from Doctor Martin,
58:20so thank you so much.
58:22That was a wonderful presentation.
58:24II learned so much. I am a teacher.
58:28I have worked on the inpatient unit for
58:31many many years and I wish our teacher,
58:34Tammy good master, were able to be here.
58:36She's just wonderful.
58:38I've and also Connecticut is back in person,
58:42full time learning and so all of our schools,
58:45that is the expectation that
58:47children will now be in full day
58:49five days a week and.
58:51We know the importance on the inpatient
58:54unit of having good transition plans
58:56when children leave the hospital,
58:59it is really overwhelming for middle school.
59:02Middle school children is the
59:03primary age that we work with.
59:05And those gatekeepers are
59:08so essential in the schools.
59:10And there are too few of them.
59:14To you know, to be managing
59:17things as as you know,
59:19to manage things with all of
59:21the children with so many needs.
59:23But I think if we can connect a child
59:27with one adult within that school
59:31doesn't have to be social worker.
59:33Psychologist could be a teacher.
59:36Could be the assistant principal.
59:38I think that is just so important
59:40in the life of the child as they
59:42transition back from an inpatient unit
59:44and just to have that go to person
59:48and someone who can welcome them and.
59:51Have the ability to just go in and process,
59:55particularly on those first few
59:57days from the hospital transition.
59:59In fact,
59:59they're pretty critical times
01:00:02for for children.
01:00:04That is such a crucial piece
01:00:05Mary that you mentioned.
01:00:06First of all,
01:00:07thank you for the work you do and
01:00:09for being that connection when
01:00:11they're on the inpatient unit,
01:00:13but a big part of the toolkit
01:00:16initially was around creating some
01:00:18forms that one can use to sign off on.
01:00:21That's one of the greatest barriers
01:00:23is what's my liability?
01:00:24What's my risk as a teacher if
01:00:26I'm having these conversations,
01:00:28but part of the training we do
01:00:30in the toolkit?
01:00:31Is is how to utilize this
01:00:34kind of documentation?
01:00:35So that OK, we've taken care of that part.
01:00:37Now let's just have a human conversation
01:00:39because I know I'm covered on that side,
01:00:41so I can really,
01:00:42you know,
01:00:42be the human and this work has been
01:00:45out there for many many years.
01:00:47Gary Ladd and his colleagues were
01:00:49publishing about this in the early
01:00:512000s about the the single adults,
01:00:53the trusted adult,
01:00:54maybe from their community at home.
01:00:56But it may be in school.
01:00:57It may be someone else,
01:00:58but really, if you have that one,
01:01:01it can make such a difference.
01:01:03So that feels less daunting.
01:01:05And have to create having
01:01:06to create a whole village.
01:01:08But if we can have that one in
01:01:10particular around the transition,
01:01:11so we ask our fellows to
01:01:13actually in the emergency room,
01:01:14ask parents to sign off on the
01:01:17form that allows us to communicate
01:01:19with at least one person in school
01:01:20so that they are aware we have a
01:01:23student who's in the hospital who's
01:01:24going to be transitioning out.
01:01:26They're going to be calling
01:01:28you and really trying to.
01:01:29Advocate for the relationship
01:01:32across the different.
01:01:34Partners and in some ways and
01:01:39I have been that parent in the
01:01:42emergency room with my own teenager
01:01:44are my wife and I's teenager.
01:01:46When he was vulnerable and needed
01:01:48a hospital and so in that moment.
01:01:50Yes,
01:01:50I'm probably going to sign anything
01:01:52that fellow puts in front of me said,
01:01:54will you sign this so we can?
01:01:55Let's say yeah I'll sign this but
01:01:57I really I want you to talk to this
01:01:59person in this person 'cause they know
01:02:01what's up and other parents say no way.
01:02:03I don't want you to talk to the school.
01:02:04I don't want anyone to build.
01:02:05That's an opportunity.
01:02:06Maybe they don't sign it now,
01:02:08but maybe they do sign it when they come
01:02:09to the inpatient unit 'cause they've
01:02:11had some time to think about it and
01:02:13they've met Someone Like You who can
01:02:14be the bridge back to the community.
01:02:17Miller so thank you for your
01:02:20wonderful and thoughtful work.
01:02:23Thank you.