CSC Associates Week 2021

November 09, 2021

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00:00So welcome everyone.
00:03Mom, thank you for coming.
00:04We'll get started.
00:05For those of you who are new to our
00:08annual associates event I'm Linda Mays
00:11and director of the Child Study Center.
00:13And for those of you who have joined
00:15us yearly with this coming together,
00:17welcome back.
00:18We're really looking forward to the time
00:20when we can greet you again in person,
00:22but but it's just very nice to have
00:25this way of getting back together.
00:27I'll begin with just a
00:29few introductory remarks,
00:30and then we'll go right into the program.
00:33Here we are.
00:35We are 603 days since the beginning
00:38of our pandemic journey and are
00:41rapidly adapting to this forever.
00:44It seems like really,
00:46truly forever changing and changed world.
00:50We're all very grateful for all of
00:52your continued support of the center.
00:53You're staying with us.
00:55You're continuing to give us your ideas,
00:57your encouragement,
00:58and your financial support.
01:01We are actually are coming
01:02back and coming back.
01:03By that I mean in person we now have
01:07over 250 families who are receiving
01:10services daily in person and we're
01:12continuing though to also see almost
01:15half of the families via Tele health.
01:18Our research programs are back.
01:19Our fellows are in person and then,
01:22like every other service in the country,
01:25we are experiencing a dramatic
01:27behavioral health surge.
01:29With doubling in many ways
01:30and doubling in many places,
01:32the number of our referrals.
01:34Children with behavioral health needs
01:36are struggling and they're needing
01:38longer and more intense services.
01:40It is truly a moment not only in
01:43the Child Study Center's history,
01:44but in the history for our country.
01:46For child behavioral health.
01:48And that will be a theme that you will
01:51continue to hear throughout this afternoon.
01:54For the afternoon we put together a
01:56series of short presentations tastings.
01:59We might call them to give you a
02:01range and breadth of our research,
02:03our clinical services,
02:04and the different developmental
02:06pathways of our faculty and fellows
02:09that reflect our commitment to education
02:11and mentoring across the lifespan.
02:14You are going to hear examples
02:16of our research that begins with
02:17work based in our patients stories
02:19and goes to clinical trials,
02:21addresses the impact of new treatments.
02:24Studies using zebrafish to model
02:26key genetic mutations related
02:28to developmental disorders.
02:31Developing pluripotent stem cells
02:32to create brain organoids and model
02:35disruptions in brain development in
02:37childhood. Psychiatric disorders.
02:39The range of research is just
02:41remarkable here in the center
02:43and in these short presentations.
02:45We really hope you get a sense of
02:48not only that breath but also the
02:50excitement for all of us as we work together.
02:53We're also going to highlight in
02:55greater depth than in we've had
02:57done in the past.
02:58Our clinical programs and the
03:00dedication of our clinicians
03:02seeing more and more children.
03:04As I mentioned,
03:05who need more and more services?
03:07And now that our cutting edge treatments
03:11actually reached now over 3000 families
03:13annually and that number is growing.
03:16And then you'll hear stories
03:18from our faculty and fellows
03:20about how they develop their
03:21careers at the CHILD Study Center.
03:23And our commitment to mentorship
03:26and to helping every individual
03:28find the path where they can excel.
03:32So before turning over to our team and it's
03:34really the team that I want you to hear from.
03:37I want to encourage you to listen
03:38for four themes that are going to
03:41cut across each of these sessions.
03:42Each of these three blocks of presentations.
03:46First, patients are at the
03:48center of our work.
03:50Each of our researchers,
03:52the clinicians,
03:52the developmental stories that we they
03:55have for improving care for children,
03:57is that really at the core.
03:59It's what brings meaning and
04:01purpose to all of our work.
04:04Whether it's in the lab and the clinic,
04:06the community we are guided
04:08by what families need.
04:10And those needs have never been
04:13greater with this pandemic.
04:14Second is we're committed
04:16to education and training.
04:17We listen for how often I ask
04:19you to listen for how often
04:21we involve medical students.
04:23Undergraduates in our work.
04:24How often are fellows and faculties
04:27found their path into this work in their
04:30undergraduate or medical school years?
04:33And actually, how often
04:34we think about clinical work as
04:37passing along skills and knowledge
04:39to families to help them continue
04:42their journey with their children.
04:45The Third Point is we actually
04:46strive for a virtuous cycle,
04:48and what I mean by a virtuous cycle
04:50is bringing our discoveries in the lab
04:52and in the research into the clinic,
04:55and vice versa.
04:56Having the clinic in for my research.
05:00It it's it's often really
05:02challenging to translate across
05:03research in clinical practice.
05:05It requires a lot of work about different
05:08domains of discourse and talking,
05:10but we are extraordinarily committed
05:12to this constant translation,
05:14and we're trying regularly
05:16to make that happen.
05:19And 4th the 4th theme to listen for.
05:23Is it that if patients are
05:25at the center of our work,
05:27everyone that you will hear
05:30also regularly evidences?
05:32Their humanity and how they
05:34treat their teams,
05:36how they ask their questions and how
05:39they live and practice by their values.
05:42This pandemic has been a time of
05:44remarkable change for so many,
05:46but it is also been a time that has
05:49brought brought both brought forth.
05:52The values that we all want to live by
05:54and tested those values as resources
05:57have become restricted in many ways.
05:59People have become very stressed.
06:02But I actually couldn't be
06:04prouder of all of our community,
06:06not just the people you were here from today.
06:09But if everyone in our community,
06:11the courage that everyone
06:13has shown in this pandemic.
06:15Their willing willingness
06:16to go the extra mile.
06:19To help each other and to help
06:21so many families and the pride
06:23they take in discovery and care.
06:25Which is why we actually we
06:27actually have as our tagline.
06:29For the Child Study Center
06:31where Discovery inspires care.
06:33I'm really honored to present
06:35them to you today,
06:37and I'm honored to be a
06:39part of this community,
06:40and especially after many
06:42years in this community,
06:43but especially in these last 603 days.
06:47And I hope that as you listen that you'll
06:50be as inspired as I am on every day.
06:54One other point,
06:55before I turn it over to my colleagues
06:57to encourage you to explore,
06:59we've put some additional short talks
07:01and posters online for you to view.
07:03As you know,
07:04if you've come to these events before,
07:06we always have much more to say than we
07:09can ever possibly say in the time we have,
07:12and so we are putting more
07:14online for you to look at.
07:16And as you have time,
07:17we hope that you might continue
07:20to the continue the intellectual
07:22feast and the caring feast.
07:24That we're presenting to you in these
07:27next in these next hours together.
07:29Let us know what you think when
07:31you look online and will also
07:33hope that you'll send us questions
07:36and then just one very pragmatic
07:38issue is that as we as we present,
07:40we're going to encourage questions
07:43after in the research section
07:45after each presentation.
07:46And in the clinical and education sections,
07:48at the end of all the presentations.
07:51And you can put these questions
07:52in the chat or you can raise
07:54your virtual hand or something.
07:56We've all gotten very used to on zoom
07:58and we will be sure to either read your
08:01question from the chat or call on you.
08:04So let's start. Let's start the.
08:07Formal program so we don't waste another
08:09minute and let me turn to my colleague Dr.
08:12Undress Martin to get us started undress.
08:16Thank you Linda.
08:26So, uh, good afternoon everyone,
08:30I'm delighted to be here and to kick us off.
08:33I'm doctor Andreas Martin and I'm honored
08:36to be the revival revoked professor at
08:39the Child Study Center and you will be
08:43hearing today a lot of quality research,
08:47a lot of quality research,
08:49but probably I'm going to be the only
08:52person talking about qualitative research.
08:54For those of you who don't know what
08:57qualitative research is, let me explain.
09:00This is a very serious scientist
09:02looking at brain pictures or
09:05organoids or something very serious.
09:07Probably something having to do
09:09with patients, maybe brain images.
09:11The problem with this approach is that over
09:14the years we've thrown to the cutting floor.
09:17Some of the best footage we've been so
09:20interested in getting this one that we've
09:22thrown away some of the best footage,
09:24and by the best footage,
09:26I'm referring to the histories,
09:28the stories, the personal,
09:30the individual granularity behind
09:33each person in qualitative methods
09:36is all about leveraging that.
09:39Einstein said not everything that
09:41can be counted counts and not
09:43everything that counts can be counted,
09:45and that is very true for
09:48qualitative studies.
09:49I'm going to give you 2 examples
09:51of the qualitative research that
09:53I've been involved in,
09:54and both of these projects are,
09:56I would say, not just important,
09:58but they are existential E important.
10:01They deal with existential issues and
10:04I don't say this in a theoretical way.
10:06The first one is of course,
10:08the pandemic.
10:10This is the first of two papers
10:12pivoting in the pandemic in which
10:13we talked to some 40 child and
10:16adolescent psychiatrists across EU.
10:18S. Learning what they had to say.
10:21I underlined the name of Mattie
10:23Digiovanni because she is a medical
10:25student who took the lead and was the
10:27first author on this paper that was
10:29recently published and to give you a
10:31flavor of what I refer to buy personal
10:34histories and leveraging the personal,
10:36I'm going to share the voice
10:37of one of our participants.
10:40Now,
10:40to protect confidentiality,
10:42it won't be the participant herself,
10:44but rather a voice actor with a very
10:47beautiful and mellifluous voice talking
10:50about what we've all experienced.
10:52This movie like Quality Bear in
10:54mind that this study was done
10:56in month one of the pandemic.
10:58That's when we collected these data.
11:02I was having an intake with patient and
11:05then the mother and then the father came.
11:08Then the grandparents sat here like this.
11:10I think they were watching a movie.
11:12This is not a movie The grandparents were
11:15mostly there and saying yes that's true.
11:17That's true. She does that a lot but
11:20it was like they were watching a movie.
11:23Indeed, we have all been
11:26watching a movie of sorts.
11:28This second pandemic related
11:30paper viral time capsule.
11:32What we did is exactly that.
11:34Trying to do a capsule of what these strange,
11:37strange times are all about.
11:39Once I get we did it very early in the
11:41pandemic and the methodology was very simple.
11:44I should note again that the two
11:46underlying names are Yale medical students.
11:49Paper is very simple.
11:50Do you have an iPhone or some other device?
11:53Yes, everybody does in the planet.
11:56Gives it have a camera. Yes it does.
11:58Does it have a voice recorder?
12:01Does it have a voice recorder?
12:02And yes, it does well.
12:04Take pictures and tell us your thoughts.
12:06And what we did is that we collected.
12:09Data, photographs and commentaries
12:12from 134 submissions.
12:13Individual submissions,
12:14some of them with 20 and 30
12:17photographs hailing from 54 countries.
12:20And I'm going to give you just two
12:22examples out of the menu that we received.
12:25This one about disruption to daily routines.
12:29We don't need to add much what has
12:31happened to our kids and what will
12:34be the impact of being out of school
12:36behind this black wall for so long.
12:39Or this other image coming from another
12:40part of the world in northeastern India
12:42as they dealt not just with a pandemic,
12:44but also with record flooding.
12:46And here they are doing the best of
12:48child mental health, delivering food,
12:51delivering mosquito Nets,
12:53and being where the action is
12:56in a selfless way.
12:58The second study is of a
13:01different existential nature.
13:03Ecological awareness and how can we
13:06move children from anxiety into action?
13:09Isaiah Thomas,
13:10another medical student,
13:12is a key author here.
13:14And what we did is analyzed newspapers.
13:17The six top U S newspapers and use a
13:21method of qualitative research called
13:23discourse analysis and what we saw
13:25is that over the past decade or so,
13:27citations in the newspapers about
13:30ecological issues involving children
13:32have quickly gone up and the two
13:35big peaks that you see there are
13:37what I call the TT.
13:39The first one is Greta Thunberg,
13:42the child advocate for.
13:45Environmental awareness and the second one.
13:48Is the election of President Biden
13:50after what was a very contentious?
13:53Election having where there was a
13:55lot of talk about the environment.
13:58What we came up with is this
14:00categorization of children viewed
14:02in one of four ways as fierce young
14:04activists as innocent victims as adult.
14:07If I children bearing the responsibility,
14:10perhaps a responsibility of being
14:12our ultimate saviors.
14:14Where next going to take this work
14:16that we did in the newspapers to
14:18do interviews of actual children?
14:20We have started doing that in
14:22the US and will be starting soon
14:23in Brazil and in France,
14:25and we're doing this in collaboration
14:26with my good colleague Lillian.
14:28Want a child psychiatrist but
14:30with background in sociology.
14:31Who's spending a year with us on a Fulbright.
14:35And helping us learn how to
14:37turn eco anxiety into
14:39Eco aware action in this partnership
14:42between Lilia and France and US,
14:44is the newly developed Qual app.
14:47The qualitative and mixed Methods lab,
14:49which is our partnership with the
14:52National Institute of Health in Paris.
14:54And with that I will end messy beaucoup,
14:56and I want to thank all of the
14:58associates of the CHILD Study Center
15:00for their support of the years,
15:02and very particularly to the
15:04Allenby Slifka Foundation.
15:05And its leader,
15:07the incomparable Reva Ariella Ritvo.
15:11And again,
15:11I am honored and delighted to be the
15:14holder of the Reva Ariella Ritvo chair.
15:16Thank you for your attention.
15:19Thank you very much hundreds.
15:20We have a moment for any questions
15:23either in the chat or as we said,
15:26raise your virtual hand.
15:34These are existentially scary moments.
15:36Maybe that's what's happening.
15:40We will also have time as we go through
15:42there as people start reflecting as well.
15:45So may I call on Ellen Dr Ellen Hoffman.
15:51Yes.
15:57Hello everyone I'm Ellen Hoffman.
15:59I'm an assistant professor
16:00at the Child Study Center.
16:01It's great to have the opportunity
16:03to talk to you about the research
16:06that my lab is doing an autism
16:09risk gene function in particular.
16:11We aimed to harness the power of
16:14model systems to understand more about
16:17the function of autism risk genes.
16:19This is work that we've been
16:22developing at the CHILD Study
16:24Center so as some of you may know,
16:26the largest.
16:27Genetic sequencing study in autism
16:30led to the identification.
16:33Of over 100 genes that are strongly
16:36associated with autism.
16:38This is a study that involves sequencing
16:40over 12,000 individuals with autism
16:43and led to the identification of
16:45102 genes that we consider high
16:48confidence autism risk genes,
16:49each of which is represented here
16:51as an individual point and how
16:53high up they are on this particular
16:56graph represents the strength of
16:58their association with autism.
17:00Now, despite this progress,
17:01one of the challenges that we face.
17:03Is how do we advance from the
17:05identification of this growing
17:07number of autism risk genes towards
17:09gaining an actionable understanding
17:11of the biology of autism?
17:13And this challenge is represented
17:15by this figure where you can see
17:16that even if we identify one gene
17:18that's associated with autism,
17:20this can lead to the disruption
17:22of multiple different proteins.
17:24Multiple different cells,
17:25circuits and behaviors.
17:27And the challenge is how can we begin
17:30to identify points of convergence
17:32or points of vulnerability?
17:33Across these different cells
17:35and circuits and behaviors that
17:37might represent entry points for
17:39identifying new pharmacological
17:41candidates and new interventions.
17:44And so in my lab we use this model system.
17:46The zebrafish to answer these
17:48questions and our goal is not
17:51to recapitulate in zebrafish.
17:53The clinical features of autism,
17:55but rather we can leverage key advantages
17:58of this system to begin to identify.
18:02Uhm, points of convergence
18:04across autism risk genes.
18:06So,
18:06for example,
18:07first zebrafish are easy
18:08to manipulate genetically,
18:10so it's possible using these new
18:13molecular scissors called CRISPR
18:15that we can inject into zebrafish
18:16embryos at the one cell stage
18:19to actually generate zebrafish
18:21mutants in different autism
18:23risk genes relatively rapidly.
18:25Second zebrafish have rapid
18:28external development,
18:29So what you're looking at here
18:31is the 1st 24 hours.
18:32Of zebrafish development occurring
18:34in a Petri dish.
18:36And because zebrafish have
18:37fully transparent embryos,
18:39we can visualize basic processes
18:41of neural development in real time
18:43and ask how these change when a
18:45gene that's associated with autism
18:48is not functioning properly.
18:50And finally,
18:50zebrafish are highly tractable in the lab,
18:53and they have very simple behaviors,
18:56so it's possible to pipette individual
18:58larvae into the wells of a 96 well
19:00plate and track different aspects
19:02of their locomotor activity.
19:04For example,
19:05what you're looking at here is
19:06a zebrafish larva undergoing a
19:09visual startle response,
19:10and we can quantify this response
19:12and ask how it changes in response to
19:15exposure to different psychoactive compounds.
19:18And we can use these
19:19behaviors. As a readout of how genes that
19:22are associated with autism might affect
19:24basic sensory processing and arousal,
19:27circuits which have translational relevance,
19:30and so, in my lab, we developed and
19:32are currently implementing a pipeline
19:34where we generate zebrafish mutants
19:36in multiple different autism risk
19:38genes and then ask how the loss
19:40of function of these genes effects
19:42basic processes of brain development,
19:45and then we perform large
19:47scale pharmacological behavior.
19:49Based screens to identify potential
19:51drug candidates that we can translate,
19:55possibly to the mailing systems.
20:00And thus far we have completed a screen
20:02of over 500 different FDA approved
20:04compounds and observed a readout of how
20:07these compounds affect basic sensory
20:10processing behaviors in zebrafish.
20:12And we're now leveraging this database
20:14to identify potential drug candidates,
20:17and I'll just highlight two of
20:19our recently published works.
20:21This was written by.
20:22This is work that was spearheaded
20:24by a Yale undergraduate,
20:26has worked in my work in my lab,
20:27Kristen Enriques, where we begin.
20:29To talk about potential convergent
20:31pathways downstream of autism risk genes,
20:33so we know that autism risk genes
20:36converge on gene expression regulation,
20:38synaptic function,
20:39and excited to inhibitory imbalance.
20:41Interestingly,
20:42in one of our studies in zebrafish,
20:44we found that drugs with estrogenic
20:46activity can actually rescue or reverse
20:49an abnormal behavior associated
20:50with one particular autism risk
20:52gene contact necessary protein.
20:54Two and in this paper we highlight how
20:56some of the pathways downstream of estrogens.
20:59Actually overlap with pathways that
21:02are also implicated downstream of
21:04autism risk genes representing
21:06a potential point of convergence
21:09for further investigation.
21:10Second,
21:11in a recent paper on which was written by
21:14a graduate student in a course in my lab,
21:16we collaborated with a lab at
21:18the Department of Neurosurgery,
21:19studying genes associated with
21:22congenital hydrocephalus,
21:23and interestingly,
21:23we found that there's an overlap
21:25in genes that are associated with
21:27autism and congenital hydrocephalus,
21:29suggesting that these might also
21:31represent a convergent biological
21:33pathways and represent our potential
21:37pharmacological pathways for
21:39clinical translation.
21:41And finally,
21:42we're implementing whole brain
21:44activity mapping in zebrafish mutants,
21:46in collaboration with the Department
21:47of Radiology here at Yale so that
21:49we can begin to identify how genes
21:52associated with autism might alter
21:55baseline brain activity in a very
21:57simple developing vertebrate brain.
21:59And what you're seeing here are
22:01changes in baseline brain activity
22:03differences in baseline brain
22:06activity in zebrafish mutant.
22:08Lacking the function of a gene
22:09that's associated with both.
22:11Autism and epilepsy,
22:12and we're currently doing in vivo live
22:14imaging to begin to understand how
22:17loss of functionality is different.
22:19Genes alters basic circuit function
22:22and I just want to highlight
22:24acknowledge the members of my lab.
22:25We've been involved in this work,
22:27our collaborators, and of course,
22:30thank you for your support and
22:31thank the CHILD Study Center
22:33for the support of this research
22:35and I'm happy to answer any questions.
22:37Thank you, do we have we have time
22:39for our question from the audience?
22:51OK, thank you. May I ask
22:54Chirac to come forward?
23:11Having technical difficulties, shrimp.
23:18Strawberry there.
23:27Alright, so so why don't we?
23:30Why don't we move in the scramble?
23:32Come back in a one link can you
23:35come forward? Yeah yeah thank you.
23:45Can you see my screen?
23:48Yes, we can great.
23:52Hi, my name is Wan Ling Ling.
23:54I'm an assistant professor at the
23:56Yale Child Study Center in Danville,
23:58so the Pi at the Yale Child
24:00Study Center effective Youth Lab,
24:02the Yale app and in my lab we study,
24:05irritability, brain and development
24:09and these are the members of my lab.
24:11And here I am.
24:12The P and we also have grace.
24:14Who's our lab manager and nelia,
24:17who's a visiting PhD student
24:20from Belgium and clear.
24:21Who's a masters student from the
24:24Yale UCL program and we have Vivian,
24:27Sophia, Christina, Michelle,
24:29Amanda and Eve were the undergraduate
24:32students actively helping out in
24:35various research tasks in my lab.
24:37And we also have some group lab
24:40photos lab photos pre covered
24:43and also in the COVID era.
24:49So in my lab,
24:50our research, our research
24:52can be broadly divided into 3 domains,
24:55so the first area is to use longitudinal
24:58study to study to look at their
25:01developmental trajectories of your
25:03debility and related constructs
25:05such as anger and aggression,
25:08and the second area is to better
25:11understand the neural mechanisms of
25:13pure ability and core covering symptoms
25:16such as ADHD in anxiety. Using F MRI.
25:20And the third one is to study
25:23environmental exposures including pollutants,
25:26chemicals and crime rate and their impact
25:28on brain development and childhood,
25:31emotional and behavioral problems.
25:34So the goal of this research is to
25:37leverage information from multiple levels,
25:39including the brain behaviors,
25:42social experience,
25:43and environmental factors to better inform
25:46prevention and treatment of your ability.
25:50So why do I care about your disability
25:52and related constructs such as anger
25:55and aggression and why is it important?
25:58It is important because it's common.
26:00It affects about 3 to 5% of youth and
26:03it is one of the most common reason
26:05why kids were referred to the clinic.
26:09And it is trans
26:10diagnostic, meaning that it's
26:12present in many pediatric disorders,
26:14including ADHD, anxiety,
26:17depression and autism.
26:20And it is impairing many
26:23highly irritable kids.
26:24They have high rates of school
26:28suspension hospitalization service
26:29use and are more likely to be
26:33on psychotropic medication.
26:37And research has ocean shown that
26:39early childhood irritability is
26:41a strong predictor for later poor
26:44outcomes in adolescence and adulthood,
26:47and this includes high rates
26:49of anxiety and depression,
26:51high suicidality and low income,
26:55and low educational attainment.
26:58So in my lab we use fMRI to be able to look
27:01at brain function and bring connectivity,
27:05and along with the use of
27:07clinical and behavioral measure,
27:09we aim to better understand the
27:11neural mechanism of your ability.
27:13So the motivation behind this
27:15line lab research is that there
27:18is currently lack of evidence
27:20based treatment for irritability,
27:22so we hope that one day the knowledge
27:25generated in the lab can be used.
27:28In the future to guide the
27:30development of Evidencebased targeted
27:32treatment for irritability.
27:36So this is just to give you an example
27:38of one of the one of the studies that
27:41we recently completed in 195 kids
27:44ages 8 to 18 who completed a task and
27:48that's designed to frustrate them.
27:51So then we can observe the newer
27:53responses associated with irritability.
27:56So what we found is that.
28:00Kids, uh,
28:00the more irritable the travel is
28:03is reported by parents and both
28:06the child themselves,
28:07the more activation they have
28:10in the prefrontal cortex region,
28:13such as this one, the singulate gyrus,
28:16which is very important for emotion
28:19regulation and attention control,
28:22and this effect is particularly
28:25strong in kids who have high
28:28irritability and and young.
28:30Age and so we think that this
28:33increased as increased activity
28:36associated with irritability
28:38potentially reflect a compensatory
28:40mechanism whereby irritable kids
28:43when they're frustrated they need
28:45to recruit this Pfc region more
28:48and work harder in order to better
28:51regulate their frustration and to be
28:54able to focus on the task at hand.
28:56And
28:56we're taking this research
28:58further by using the brain data
29:01during appreciation task to
29:04predict longitudinal developmental
29:06cores of your ability,
29:08and we're hoping to identify brain
29:13signature that particularly help predict
29:17high and persistent irritability.
29:20Overtime, because this is the
29:22group that's most at risk for
29:24later anxiety and depression.
29:26And suicidality.
29:29So with that I would like to thank my
29:32amazing colleagues and collaborators,
29:34trainees and students.
29:36Without them, this work would
29:39not be possible and also thank
29:40you for your
29:41support for our
29:42research at the CHILD Study Center.
29:46Thank you honey. We're open, the virtual
29:51floor is open again for questions.
29:57And once again in the question
29:59please. Thank you. Yes it's
30:02a very interesting presentation. Thank you.
30:07I wanted to know the brain
30:09signature that you're looking for.
30:11Would this then later on possibly
30:13or hopefully serve as a target
30:16for medication to to change this
30:19pattern of irritability and prevent
30:21the later consequences? Exactly
30:24that's the rationale and
30:26motivation behind this study is
30:28to identify the neuro target.
30:31Yeah, for future treatment.
30:33Excellent thank you for your question.
30:38Any other questions?
30:47OK. So sure, and I believe I understand
30:51that your computer is back alive.
31:00Hello, I'm sorry about that technical glitch.
31:04Good afternoon esteemed
31:06guests and your colleagues.
31:09My name is sheriff sharing law.
31:10I'm a fourth year resident in psychiatry
31:13here at here and I'm also a hilibrand
31:16autism research fellow in the mug
31:19pattern lab where we study brain
31:21mechanisms in social neuroscience.
31:23I'm here to talk about a project
31:26we're planning on neuromodulation
31:27for depression in autism.
31:30As we explore early behavioral and brain
31:32effects of our brain stimulation method,
31:35like transcranial magnetic stimulation.
31:38In autism spectrum,
31:40we know that there is a significant
31:42burden of Co occurring mental
31:45health conditions like depression.
31:47It is estimated that nearly one out of
31:49every two individuals with autism will
31:52have a lifetime diagnosis of depression.
31:55In a large population study out of Denmark,
31:58where they looked at six and
32:00a half million individuals,
32:01they found that individuals with autism were
32:05four times more likely to die of suicide,
32:08and if you were an autistic female,
32:11you had an 8 times higher
32:13risk of a suicidal attempt.
32:15So the question that we're all
32:17immediately inclined to think
32:19of is how do we prevent this?
32:22In this study,
32:23they also found that 90% of the cases of.
32:26Suicide had an underlying mental health
32:29condition like depression and so.
32:31How do we treat that?
32:34This blank slide kind of sums up
32:36what we know about the treatment
32:38of depression for individuals.
32:39Autism.
32:40At this point there are some studies on CBT,
32:44mindfulness or handful of medication trials,
32:47but we really don't have
32:48a specific treatment.
32:49What we do know is that there's
32:52higher utilization of services.
32:53People are on multiple medications,
32:55intensive therapies fully tolerate their
32:58medications and often don't respond,
33:01making them treatment resistant.
33:04This is where transcranial magnetic
33:07stimulation or TMS comes in.
33:09It has been an FDA approved.
33:11Treatment for treatment resistant
33:13depression since 2008,
33:15it was first designed in 1985 and if
33:18you were to look at Pub Med today,
33:20you'll find close to 19,800
33:23scientific articles on TMS.
33:25It is effective and it is safe,
33:27but how does it work?
33:29Demonstrating that on this
33:31silhouette of a head using principles
33:34described by Michael Faraday,
33:37the physicist will place a magnetic
33:40coil touching the surface of your head.
33:42And if you were to pass
33:44electric current through that,
33:45it would generate a magnetic field,
33:47and that in turn would induce
33:50an electric current that would
33:51stimulate your brain cells.
33:53In this picture on the right.
33:55Cassie and Maggie are excellent neuroscience.
33:58Fellows are standing next
33:59to our maxdome TMS device,
34:01with Cassie sitting on the chair with
34:04the TMS coil placed on her head as it
34:07would for a treatment participants.
34:10The area of the brain that we're
34:12interested in is in the front.
34:13It's the dorsal lateral prefrontal
34:15cortex and we believe that it is
34:18responsible for mood regulation.
34:20When we target this region in depression,
34:22we get remission rates of around 33%,
34:25which is significant if you consider
34:27that these are people who failed four
34:30or more antidepressant trials,
34:32and for individuals who are treatment naive,
34:34that number goes up to 75%,
34:36which is again significant if
34:38you think about groups who may
34:41not be tolerating medications.
34:43So to summarize our study, we are
34:46applying TMS to this part of the brain.
34:49And capturing changes.
34:50We look at the EG. This is a video
34:54of an EG recording from our lab.
34:56We look at eye tracking.
34:58When we study how the eyes fixate
35:01on particular parts of an image,
35:03we also look at behavioral measures.
35:05For example,
35:07participants watch videos of these two
35:11triangles that seem to be interacting
35:13with each other and their responses
35:16would indicate their social perception,
35:18and so we hope to understand what brain
35:22changes occur with treatment like TMS and so.
35:25Finally speaking about hope.
35:28In a recent pilot trial of GMs with
35:31depression and autism, they found.
35:34Is 70%.
35:36Response rate,
35:37and we believe that as we understand
35:40how to modulate changes in the brain,
35:43we can design better treatments.
35:46It takes we effort and tremendous
35:48talent of everyone listed here and in
35:51this pandemic selfie to do this work.
35:53I am so grateful to Jamie for
35:55being my mentor and friend.
35:57We are grateful to the Slifka
35:59Foundation for helping us get started
36:01and the Hilibrand Foundation.
36:02Your support really lets me do
36:03this work and I'm so thankful.
36:05I hope I've been able to convey to you.
36:07The timely need for this kind of
36:09research and I thank you all for your
36:12time and your continued partnership.
36:13Thank you.
36:16It's so much fun, so let's let's
36:19open the floor for questions.
36:22Questions, comments.
36:25I have a question, yes, so your work showed
36:31that using this type of magnet
36:33was helpful with the depression.
36:35Did it have any effect on the autism?
36:38Or like you know,
36:40in any adaptive behavior score
36:41or something like that?
36:44That that's such a great question.
36:45I think that really fuels
36:47the work that we're doing.
36:48I think the consensus right now is that we
36:51need more data and better design studies.
36:53For example, we're collaborating
36:55with the group in Australia,
36:56Identicard Group,
36:57where they're looking at specifically
36:59targeting a different part of the brain,
37:01not the front, but the temporal
37:03parietal junction to see if there are
37:06actual changes in the autism symptoms
37:08persist within the autism symptoms.
37:11Executive functioning,
37:12repetitive behavior.
37:13And social perception are areas
37:15that are being looked at as
37:17potential for being changed,
37:19and we are also engaged in a study
37:21where we're looking at if we can.
37:23When we target a different part of the brain,
37:25which is the posterior superior
37:27temporal sulcus?
37:28Can we, by targeting that region change,
37:31social perception such that this stress
37:33that some individuals face because of
37:35their difficulty in social perception?
37:37Maybe we can help treat
37:38some of that.
37:40If I can ask another question on that,
37:42how often did you have to treat the
37:44people or the individuals before
37:46you saw positive results? Is it?
37:48And is it something that you would
37:50predict needs like sustained treatment?
37:52Or is it something where you could
37:54have whatever your course was and
37:55then you didn't need to treat
37:56it very often or periodically?
37:59And again, so we are yet to do those
38:02trials in our lab at this point.
38:03But based on the work that's
38:05already been done, people have
38:07found initial the initial response.
38:09But then around the six month mark,
38:11it seems to fade away,
38:13which kind of reflects the treatment
38:14of depression in the community where
38:16you do an acute treatment and then you
38:18have some maintenance down the road,
38:20and we hope that as we better design
38:22trials will have clearer answers
38:23as to not not just how to treat,
38:26but how long to treat for.
38:29We have a question in the chat
38:31which is can you comment on how
38:33well TMS is tolerated and people
38:35with autism spectrum disorder?
38:38Absolutely, and I think that that is a
38:41very important question for us to consider.
38:43Even as we plan our study and and
38:45the trials that are going on,
38:47especially if you have, for example,
38:49a sensory integration difficulties.
38:50That makes it that much harder.
38:53I will comment those saying
38:55that people do tolerate it,
38:57just as in the general population,
39:00and some people might have difficulties,
39:02but the way it's being
39:04administered right now,
39:05the the dosing can also be.
39:07So when you administer TMS.
39:09You can also alter the dose so
39:10that you don't have to give a
39:12higher dose that is less tolerable.
39:13You can give a low dose that's more
39:15tolerable and may be as effective,
39:17and so that is the way in which some
39:19of these trials are being designed.
39:22Cute. Additional questions may
39:25I also ask
39:26what age group to date you
39:28personally have been working with?
39:31So I worked as a neuro development
39:33psychiatrist in India if I came over to EU.
39:36S. To kind of do my training again and get
39:38this wonderful opportunity at the CHILD
39:40Study Center to do this work actively.
39:42I administered TMS actively in the 18
39:45to 65 age group where I I work at the
39:47VA here where we we have a TMS clinic
39:50and I do that kind of work and the hope
39:52is then to translate this work into
39:54younger populations as we find you know,
39:57it being more effective in that group.
39:58Yes, and
39:59that's what and all of
40:00these. People you've worked with our
40:03with autism or in general with PMS.
40:06So like I mentioned earlier,
40:08a lot of times the treatment
40:10resistance that we see there might
40:13be an undiagnosed autistic spectrum.
40:15And for example I do have one
40:17individual that I'm treating right now.
40:2022 year old male and he has
40:22undiagnosed autism and he is
40:23tolerating his treatments well
40:24and starting to show improvement.
40:26So that gives me hope for
40:27the kind of work that
40:28we're doing and what is the frequency
40:31of the treatment of the sessions.
40:33Initially it would be once a day for
40:36five days a week for up to 20 sessions,
40:39and then you start tapering it off.
40:41But then there are different protocols.
40:42There are absolutely accelerated
40:44protocols now where you can finish
40:46the entire treatment in a week.
40:48And so the field is really evolving
40:50and we're trying to be part of
40:52that change at this moment.
40:54Thank you very much. And to everyone,
40:57just Jamie has put a statement in
41:00the chat about a consensus statement
41:02that speaks to the tolerability of
41:05TMS in autism spectrum disorder.
41:07So thank you Jamie for doing that.
41:12So thank you, share for for
41:15presenting appreciate it windy.
41:17May I ask you to? Come.
41:22Come virtually forward.
41:50You see, do you see my screen?
41:51Yeah, but you just need to go
41:54to slideshow icon down below.
41:56Do you see this screen icon?
41:58OK, got it. Thank you.
42:00Then go up there.
42:02Thank you, thank you,
42:03thank you very much.
42:04Thank you very very much and thank
42:06you all for the honor to present
42:09at today's associates meeting.
42:10I'm really thrilled to be here.
42:13I'd like to begin by showing the
42:15amazing team of that we have now
42:18consisting of postdoctoral Fellows,
42:20postgraduate associates,
42:20and I want to give a special
42:23shout out to Grace Hamill of a
42:25lab manager and special thanks.
42:27To Eli Lebowitz and Colin Moran,
42:29who have been with me since I
42:31first came to Yale in 2013.
42:32I also want to thank you, the associates,
42:35for you supported the CHILD Study Center.
42:37And for those of you who have
42:39supported the anxiety program,
42:40thank you so very much.
42:43This is what I'm going to be speaking about.
42:46What do we know finally about enhancing
42:48CBT outcomes for child anxiety?
42:51And what's next?
42:55Some background CBT is the
42:58strongest evidence based treatment.
43:01Depending on how you look at it, though,
43:02the glass is either half empty or half full.
43:05It's half full because in most trials
43:0750 to 60% of the children respond,
43:11but that means half empty.
43:13Almost that many also do not respond.
43:17It has been a journey for the field and
43:20for myself for 30 years to figure out
43:23what can we do to add parents to their
43:27child's treatment to get enhanced outcome.
43:30It takes.
43:31I've been doing this for 30 years 'cause
43:33it takes anywhere from at least five to
43:35seven years to conduct one randomized trial,
43:38and that doesn't include them getting it.
43:40You know,
43:41writing it up and publishing it,
43:43so it's been a long journey.
43:46And what the field has shown and these
43:50are two of my trials that I've done one.
43:53Looked at CBT and parents versus compared
43:56to individual the other one group
43:58CBT and parents compared with group.
44:01We're thrilled that everybody is improving.
44:04That's great.
44:06However,
44:06we were hoping to see if we can get
44:09enhanced outcomes and this in the red
44:12in the bottom is a recent meta analysis
44:14that showed what we've been saying for
44:17decades now that CBT in pounds does
44:20not confer advantage over individual.
44:23This is an enigma.
44:25It's a conundrum, but when one looks
44:27at these now over these 30 years,
44:30the studies you will find
44:31that most of these studies.
44:33First of all, they're all over many
44:35many different variables and mechanisms.
44:37Second of all,
44:38in many of these studies,
44:40the mechanisms are very poorly described.
44:43They're also extremely rare to
44:45ever been ever been measured,
44:47since somebody might be trying to
44:48change something with apparent,
44:49but they never measure it.
44:51But besides the research, those of us.
44:53You know who have parents and
44:55those of us who are not parents.
44:57We know it's hard to change parents behavior,
45:00especially in a short amount of time,
45:03especially in a very,
45:05very complicated dynamic between
45:07children and parents.
45:08I'm sorry,
45:09but the yellow gets to the heart of
45:12what over these years would I have
45:15distilled based on the work that in the
45:18mechanisms appear to be side control,
45:20reducing payment site control and reducing
45:23parents use of negative reinforcement.
45:26That is removing a negative event
45:29and in the case of child anxiety
45:32this is what that would look like.
45:34Site control they act like
45:36they own me at the bottom one.
45:38Look at the thing of the panel
45:39before this one where the child
45:41is crying and upset and and then,
45:43lo and behold,
45:44the Charles happy because the trial
45:46is now in the parents bed that has
45:48will move the trials negative state.
45:50These are examples.
45:53We did the first and only trial.
45:57That dismantled and specifically
46:02concretized these parents mechanisms.
46:05I want you to pay attention to the
46:08red 'cause that's where we got
46:10the the most important findings.
46:12So we had CPT alone
46:14with two different parent conditions,
46:16large and single site.
46:17A large sample size and we found in the
46:20red when we trained very concretely to
46:23reduce pain and negative reinforcement,
46:25it decreased and it was
46:27indeed associated with it.
46:29Decrease in child anxiety outcome
46:31when we targeted and we measured
46:34site control it decrease and it
46:36was in fact associated with a
46:39reduction in child anxiety outcome.
46:41Here's with findings.
46:42Happy face at this paper was just published.
46:45Like you know,
46:46very short time ago the red colored
46:48lines are showing the two payment arms.
46:50The black is the individual CBT.
46:53Overtime we find reductions
46:55based on child ratings,
46:57parent ratings,
46:58other measures that I can't put up here now
47:01and I'm based on child and parent reports.
47:04And as I said,
47:06other measures and over over follow up.
47:08So what we finally know.
47:11From this long journey is that if we
47:13want to try to enhance child anxiety,
47:16CBT try to reduce payments I control,
47:19try to reduce pain and use
47:21of negative reinforcement.
47:22These reductions associated with
47:24child anxiety outcome and they're
47:26likely key parent mechanisms.
47:30This is what I'm super now excited about
47:33because I'm seeing the fruits of this work.
47:35I believe that if we want to
47:38get sustained strong effects,
47:40we need something more available,
47:42more ubiquitous and working on
47:45a digital intervention is now
47:47what I'm very excited about.
47:49We're working on this and we're trying to.
47:52We hope to get pulmonary data
47:55to support further development.
47:56Now those of you out there might
47:59who use apps? You might say, oh,
48:00but there must be an app for this.
48:02Well, actually there was recently
48:03a review published, just you know,
48:05not in this in 2021.
48:07Basically saying yes there were apps but.
48:10None of them.
48:12Most of them are assessed based.
48:14There's never been one studied
48:16in a randomized control trial.
48:18Not one exists based on targeting
48:21payment mechanisms, and even if they did,
48:23they wouldn't be based on the
48:24science that I've just shown you,
48:26because many of these apps is
48:27just developed by people who are
48:29not working with scientists.
48:31So imagine what can happen if
48:33there is some type of ubiquitous
48:35available tool for parents.
48:37So I would like to just end by
48:40thanking you all so much for.
48:42Allowing me to have the privilege
48:45and with the team to try to fill this
48:48glass up with knowledge and to try
48:50to help children and to try to help
48:52parents of children with anxiety.
48:54So thank you very much for your attention.
48:56Question
48:58Mrs. Reagan Hotel in Dallas.
48:59When you're talking about parent control,
49:04is it the child's perception
49:06of parent control or what?
49:07What? What are you measuring
49:09when you say parent control? Yeah, so.
49:12And I want to be really,
49:14really clear on this.
49:14And you know this is not at all.
49:16But you know Pam and blame
49:18or anything like that.
49:19I I want to just make you,
49:21you know, make that really clear.
49:22But you know there there is though a
49:25lot of evidence about certain behaviors
49:28that parents do and and it is specific
49:31to payments of anxious children.
49:32I should say when people look at these
49:34same pounds with other children,
49:36you don't see that same behavior.
49:38So that's why the business dynamic
49:40between parents and their anxious child.
49:42So I mean the.
49:43Type of thing would be more like.
49:44I'm kind of like the one
49:47example was the guilt induction,
49:48which is like you know what?
49:50Why are you afraid you know
49:51your brother can do this,
49:52but you know don't be a Sissy or
49:54like you know I know you know,
49:55so that's that's the kind of type of thing.
49:58It's so it's that kind of like as I said
49:59in that slide you know that kind of guilt,
50:01induction and trying to reduce that by?
50:05Yeah yeah.
50:06So that's what we mean by that.
50:08Does that answer your question?
50:09Yes,
50:10kind
50:10of, although I would, I would have defined
50:12what you just described as negative
50:14reinforcement as opposed to parent control.
50:18Well, I mean we can, it's,
50:19you know it's is it.
50:20You know you saw that big
50:22selectable dependent variable.
50:23So they're all ways of measuring
50:25this and operationalizing it.
50:27And and I just want to say there is,
50:29I'm happy to share with you.
50:31There's a, you know,
50:32the concept of sight control has been
50:34actually in the developmental literature
50:35for like half a century in fact,
50:37so I didn't create that and so and
50:39so it is a little bit different.
50:42'cause again, the negative reinforcement is.
50:44You know, if you go back
50:46to the cartoon, I'm sorry.
50:48Negative reinforcement is
50:49rescuing or exactly thank you.
50:52It's rescuing. It's a rescue.
50:54Yeah, exactly exactly.
50:55Negative reinforcements are very,
50:57very high concept,
50:58but you know the best example is when
50:59you have a headache and you take,
51:01and that's really distressing.
51:02You take an aspirin that
51:03gets Twitter the headache.
51:05That's why we keep taking aspirin.
51:06So that's a perfect example
51:08of negative reinforcement
51:09that I always like to use.
51:11Thank you for your Question
51:13Time for one more question,
51:14Carol Schaefer had
51:16submitted a question about.
51:17Can you talk about Carol?
51:19Be sure I'm framing this question
51:21correctly about anxiety across
51:23development and how your research
51:26is addressing different ages. Carol,
51:29I can always count on Cole for a really,
51:31really hard question,
51:32but thank you Carol for that.
51:33Great question.
51:34We actually are in the anxiety
51:36program working across development.
51:38I do want to say so. We work from
51:42the ages of salt with age or six.
51:44We we are not going yet younger although I
51:48I do work with the people in development,
51:51the toddler layout we're doing some work
51:53with but we work from age 6 and you know,
51:56and Ellie and Yuri Burger are working with.
51:59All the way up to young adults with
52:00the family to launch projects.
52:02So we are working across the lifespan in the.
52:04In terms of this app I'm working,
52:06I'm going to talk at this to middle school
52:08is I'm going to target middle school.
52:11It's 'cause I believe that is
52:13the pivotal group I believe.
52:15I think the data show this.
52:16It's that transition into middle
52:18school where most things happen
52:20with kids with the peers and and
52:23and those kind of risky behaviors.
52:25And so we're going to be targeting
52:26middle schoolers with the app.
52:27But in terms of the anxiety program.
52:29Research and clinical services go across
52:32young childhood through young adulthood.
52:35Thank you so much, Wendy. Thank you, Soraya.
52:43Oh hi everyone.
52:48I hope you can see my my screen.
52:50Yes, it looks perfect. Thanks
52:53so high everyone.
52:54It's a pleasure for me to be here and
52:57speak about our new organized model of
53:00human brain development. I'm sure I ask.
53:03Barry and Associates are scientists
53:04in the Vaccarino's lab where we
53:07model neurodevelopmental disorder.
53:09Like all these men trapped for
53:11several years by using this system,
53:13please visit our website For more
53:16information about the other project.
53:19But So what are brain organoids?
53:21So we can generate them from Donald patients?
53:25Somatic cells?
53:26Like the fibroblast here,
53:27and they're redoing it down to a stem
53:30cell fate that can be done differentiate
53:33in many kind of mature cells.
53:36So in our body like kidney muscles
53:38and in our lab we are specialized in
53:42generate neurons brain organoids.
53:44Please here you can see like a brain
53:47organoids are under the microscope.
53:50These are three dimensional cultures.
53:54Cluster of stem cells. And new ones.
53:57But so why we are really focusing
54:00on studying organoids?
54:01Because most of the child neuropsychiatry
54:04disorders arise during brain development
54:06and we know that one fundamental
54:09obstacles beside the species species
54:11differences is have access to the brain.
54:14And so there is and look at their
54:17cells that are specialized cells.
54:19That's why we there is an urgent
54:21need of a human cell based models
54:24to study these disorders.
54:26And they organize have become a very
54:29powerful tools because as I told you,
54:31like today are retained,
54:33they have the same genetic background
54:36of the donor and so we can feature
54:38recap Italy there the future
54:40of a disorder in the dish.
54:42And also we can study them over
54:46time and see how they say evolve.
54:49And we can also use for drug discovery
54:53and genetically manipulate them.
54:56And then recently we are in trying also
54:59to a better adapted system to generate
55:03different human brain regions as many
55:06are affected in various disorders.
55:09So here on the left I'm showing you
55:12a nice fMRI of you want an embryo
55:15stage where you can appreciate the
55:18words well our brain come from that
55:21is basically this along neural cubist
55:25structure that it's full formation
55:28and subdivision rely on a small
55:31molecules that we called morphogens
55:33that if we imagine so this is our
55:36neural tube are secreted in different.
55:39Regions of the neural tube and their
55:42cells that occupy and form the neural tube.
55:45They sense these morphogens,
55:47so if you look here on the bottom,
55:49I imagine all of these are the
55:51training cells on the neural cube.
55:53They sense the morphogen concentration
55:56and other respond they activate
55:59the specific genes,
56:00and so acquiring a specific faith
56:03so they will become blue cells
56:06or white cells and so on.
56:08So our hypothesis that we can model
56:12the different brain regions and
56:14see if between disorders there
56:17are differences in the capacity
56:19of their cells and to do so.
56:22But thanks to our wonderful collaboration
56:24with a biomedical engineer department here,
56:27I yell with left ankle up.
56:29We designed.
56:30This is a culture system.
56:32Imagine in in vitro we have
56:34we are able to create these
56:37morphogen concentration gradient.
56:39So here we have the massively
56:41device has two sources in which
56:43we can apply the morphogen.
56:45Imagine the blue morpho Jenn and I,
56:47yellow, morphogen and our organize
56:50the stem cells are played with.
56:52In between the source and
56:54exposed to the to the gradients,
56:56so you will see there the organs
56:58close to the blue Morpho journey
57:01will receive a higher those,
57:03while the one that we are
57:05occupied this area they see five.
57:07They will receive less morphogen.
57:09And so the same for the yellow morphogen.
57:12So to monitor that we will be able to
57:16recapitulate the different brain regions.
57:18Of course we will use knowledge from
57:21literature and other model system
57:24where genes are expressed in different
57:27position of the neural tube from the
57:29left to the right or top to bottom.
57:32And so here I'm very happy and dentist
57:35to share with you our preliminary
57:38results of the organized that we
57:41differentiate in this massive lyric device.
57:44To A to a double gradient,
57:46and these are RNA sequencing,
57:49so we look at gene expression and we
57:51observed that the the organizing the
57:54device are able to acquire different faith,
57:57both anterior or posterior and also that
58:00we can recognize you late important
58:03regions like the cortex and the basal
58:06ganglia by looking at specific gene
58:09expression and not least I want to
58:11show you how the system can be used to study.
58:15Inter individual variability.
58:17So in this experiment we
58:20differentiate six line in.
58:23That are coming so from different
58:26individuals and we of course
58:29I'm exposed to the morphogen,
58:31our device.
58:32And when we look at gene expression,
58:35we noticed that overall the
58:37pattern as you can follow each
58:40of these line plot is maintained.
58:42It's pretty similar among
58:44individuals but with some exception.
58:48For example here we can see that
58:50the individuals in purple show a
58:53different response to the morphogens.
58:55So meaning that the itself sends
58:58the morphogen differently.
58:59So, uh,
59:00I hope I can.
59:01I show you how we can use this
59:04massively device to recapitulate
59:06different brain regions in vitro.
59:09We can use the system to study
59:12inter individual variability,
59:13and so sooner we want to apply
59:17this culture system to study
59:21neurodevelopmental disorders.
59:23So why this work would not be made
59:25without the help of all the vaccarino
59:27slab member and the left ankle apps.
59:30And of course the support of
59:32the Child Study Center,
59:33our agency and Funding Agency
59:36and not least Arnstine family.
59:38So I'm I'm happy to take any
59:42questions and thank you so much.
59:44Thank you so much, Ryan.
59:46Any questions from the audience?
59:53If I if I mail in the.
59:56Right, just like to
59:57thank you for highlighting
59:59some of the really amazing
60:00cutting edge neuroscience work
01:00:01that's going on in the center.
01:00:02That was really fantastic.
01:00:04And, you know, you hinted at this towards
01:00:06the end of your talk.
01:00:07I was wondering, you know if you
01:00:08could talk a little bit more about the
01:00:10specific neurodevelopmental disorders
01:00:11that you think might be prioritized for.
01:00:15You know the wind Sonic
01:00:16hedgehog signaling pathway?
01:00:17What kind of mental disorders do
01:00:19you think would you prioritize
01:00:20for the application of this work?
01:00:22Yeah, like of course so this
01:00:24work can be a bridge up with all
01:00:27the previous like presenter,
01:00:29researcher, the Child Study Center
01:00:31because as ellenoff man showed,
01:00:34like so many genes are affected as
01:00:38being identified as a potential target.
01:00:41But in the end the pathway the
01:00:44signaling pathway that are very
01:00:46converging and both the wind and
01:00:48the Sonic hedgehog has been recently
01:00:50associated with notice for sure.
01:00:53And for example,
01:00:54Sonic hedgehog is involved in the
01:00:57mentalization of the neural tube,
01:00:58UM, and the eventual isation is a
01:01:01fundamental if we want to recapitulate
01:01:04basal ganglia here on the left.
01:01:07So definitely basal ganglia
01:01:09is another regions, uh,
01:01:10that has been identified even in our level,
01:01:14like Flora, Vaccarino's,
01:01:15my mentor was the pioneer studying
01:01:19Tourette syndrome using true brain
01:01:21samples and also more recently.
01:01:24Our, UM our PhD.
01:01:26My colleague Melanie Brady also
01:01:29develop and study are accurate court.
01:01:33So we have group of control and to
01:01:35read patient and she was able to
01:01:38recapitulate some of the features
01:01:40like because into rap patient flow.
01:01:43Please intervene there is a down
01:01:47regulation of several population
01:01:49of interneurons and this was
01:01:52proven both by of course.
01:01:54Actual brain sample for smarter
01:01:56but also our system showed that
01:01:59there is a developmental defects
01:02:01in the generation of these cells.
01:02:04So definitely many many disease we opt
01:02:09to apply this system and of course all
01:02:12the neuroimaging data from the other.
01:02:15You can see it so I'm really
01:02:17like interest to would be amazing
01:02:20to have a common project.
01:02:22All the labs be court.
01:02:26Great, thank you so much, Ryan.
01:02:28Thank you, thank you.
01:02:30So we'll move now to our clinical
01:02:34section and then right after that,
01:02:36we'll have a brief break.
01:02:38But I may.
01:02:39I may I call on Terra Davila,
01:02:43Terra is our Chief Diversity Officer,
01:02:45as well as one of the senior
01:02:48clinical supervisors in our
01:02:49outpatient services, Tara.
01:02:53Good afternoon and welcome.
01:02:55My name is Tara D'avila.
01:02:56I'm so honored and pleased to be here today.
01:03:00I am an assistant clinical professor
01:03:02of social work and as I said,
01:03:04it's my honor and an absolute
01:03:06pleasure to share with you and shine
01:03:08a light on our clinical mission.
01:03:10For the last ten years,
01:03:12I've served as a clinical coordinator
01:03:14for outpatient clinical services.
01:03:1512 months ago I also became the
01:03:18inaugural Chief Diversity Officer
01:03:19for the Child Study Center,
01:03:20and while I'm passionate about both
01:03:22of those roles and could honestly talk
01:03:24to you for hours about both today,
01:03:26I'm really thrilled to speak to
01:03:27you about the part of the CSC
01:03:28that first stole my heart,
01:03:29which is our clinical services.
01:03:32We have a magnificent team of caring,
01:03:34dedicated and gifted faculty and
01:03:37staff committed to furthering
01:03:39our clinical mission.
01:03:41The
01:03:41care experience at the Child
01:03:42Study Center begins with a phone
01:03:44call when families call us,
01:03:46they're greeted in there,
01:03:48greeted in both English and
01:03:49Spanish by skillful, compassionate,
01:03:51kind and supportive staff.
01:03:54They're the first people our patients
01:03:55interact with when calling our clinic,
01:03:57and it is because of their excellent
01:03:59support that they provide that we
01:04:01have many families choose to return
01:04:02and refer others as you'll hear
01:04:04in one of our vignettes today.
01:04:07I cannot say enough about how
01:04:09important they are to our mission.
01:04:11Our complete clinical care experience
01:04:13takes a village in addition to our
01:04:15clinical faculty and support staff.
01:04:17Our village includes security guards
01:04:18and environmental service team members
01:04:20who each play a role in creating a
01:04:23safe and welcoming environment for
01:04:25our families when they come here.
01:04:27Our clerk or clinical team is
01:04:29comprised of psych cologist,
01:04:31nurses professional counselors,
01:04:33social workers,
01:04:34marriage and family therapists,
01:04:36pediatricians, interns and fellows.
01:04:39We have about 3000 unique patients
01:04:42in our care.
01:04:43At any given time in fiscal year 2021,
01:04:46we had about 45,000 derived appointments
01:04:48and we're on track to have us to
01:04:51have similar numbers this year.
01:04:53It's a lot of sessions we see children
01:04:55from ages 0 to 19 in our Youth Services,
01:04:58but across our clinical services,
01:05:00we go up to age 85.
01:05:03We have six core clinical
01:05:06areas which are outpatient.
01:05:08Services are in home services,
01:05:10assessment services,
01:05:12parent and Family Services
01:05:14or trauma services,
01:05:16and our Children Day hospital.
01:05:19So we have a variety of ways
01:05:20that we can support families
01:05:22at varying levels of acuity.
01:05:24And I wish we had the time to
01:05:26highlight every single piece of
01:05:27our clinical mission and everyone
01:05:29that contributes to it because the
01:05:31work is really just so stellar.
01:05:36In March of 2020,
01:05:38along with the rest of the world,
01:05:39we were faced with this global pandemic.
01:05:42We were not only sharing the
01:05:44very human experiences of
01:05:45feeling terrified and uncertain,
01:05:46but we were challenged to shift our
01:05:48entire practice to Tele health,
01:05:50something that we've never done before.
01:05:52Our support staff,
01:05:53who I mentioned to you earlier,
01:05:54were so important in helping
01:05:56us set our families up to be
01:05:58able to access Tele health.
01:06:00They were so incredible in taking
01:06:01calls and walking the families
01:06:03through the steps 'cause no one
01:06:05had done this before for behavioral
01:06:06health in our clinic and really
01:06:08in the state of Connecticut,
01:06:10everything got turned over with the pandemic.
01:06:13We rally together and we continue
01:06:15to provide services with the goal of
01:06:18keeping children out of the hospitals
01:06:20for psychiatric emergencies so that
01:06:22all of the hospital resources could
01:06:24go to caring for COVID patients.
01:06:26Our team was challenged to find
01:06:28ways to translate our treatment and
01:06:29our supervisory practices to this
01:06:31new way of delivering services.
01:06:33It invited creativity and innovation
01:06:35as a supervisor.
01:06:36Here I have been in complete all of
01:06:38the ways that our clinicians have
01:06:40been able to engage children on the screen.
01:06:43They are at never at a loss for
01:06:46creative ways and methods using
01:06:48whatever they could find at home
01:06:50to make their work translate and
01:06:52engaging on screen.
01:06:55But we had this unique
01:06:56experience of needing to support people
01:06:58through the stressors that we
01:07:00ourselves were also being impacted by.
01:07:02We were managing our own fear and isolation.
01:07:05Morning losses of our own and uncertainty,
01:07:08which were some of the same things
01:07:11their families were seeking support on.
01:07:13Seemingly overnight.
01:07:14Our clinicians learn how to do their jobs
01:07:16virtually and still maintain great outcomes.
01:07:19Our clinicians have been tried in many
01:07:20ways and it remains steadfast through
01:07:22a global pandemic transitioning to
01:07:24telehealth and now to a hybrid service
01:07:26delivery where we're doing a little bit of
01:07:28Tele health and a little bit in person,
01:07:31all while trying to meet the current
01:07:33demands for behavioral health services,
01:07:36there's a mental health crisis that
01:07:38we're in right now that's been
01:07:40imposed by the pandemic.
01:07:41More children than ever are
01:07:42in need of our services,
01:07:44and they're more acute than ever before.
01:07:47The demand is so great.
01:07:49That for the first time in ten years,
01:07:51or at least in the ten years that
01:07:53I've been here, we have a wait list,
01:07:55which is antithetical to how we practice.
01:07:58We've always prided ourselves on
01:07:59being available to families when
01:08:01they took the brave step to call,
01:08:03but we simply don't have the capacity
01:08:04to meet the demand right now.
01:08:06In addition,
01:08:07behavioral health services are
01:08:08not supported on part with other
01:08:11health related services.
01:08:12This really impacts access
01:08:13and service delivery.
01:08:15We have never been more needed,
01:08:16and our system has never been more stressed.
01:08:19Making support from our associates critical.
01:08:22Many families in the greater New Haven
01:08:24area have not had access to important
01:08:26assessment services in the past thanks
01:08:29to a fund created by generous donors,
01:08:31we've been able to remove those
01:08:32barriers and make these services
01:08:33available to more families.
01:08:37So today you'll hear from a small
01:08:39sampling of our clinical faculty
01:08:41about snippets of their work.
01:08:43I'm confident that even
01:08:44through these tiny samplings,
01:08:45you'll understand why I'm often
01:08:47heard saying that I love what I do.
01:08:50I love who I do it with,
01:08:51and I love who I do it for.
01:08:53Thank you so much for being with us
01:08:55and for your support of our mission.
01:08:59So our first presenter today
01:09:01is Doctor Jenny Dwyer.
01:09:06Hi everyone, nice to see you.
01:09:08I'll be at virtually.
01:09:10I have a couple of slides so I'm
01:09:13gonna go ahead and share those.
01:09:15Are you all able to see the spines
01:09:18of thumbs up would be good.
01:09:20OK, excellent.
01:09:22Well, I know I've spoken with
01:09:24you all over the past couple of
01:09:25years about my research program,
01:09:27but I am thrilled to be able to talk
01:09:29to you about our clinical work as well,
01:09:31particularly during this
01:09:33mental health crisis.
01:09:36So I've started with a slide like
01:09:38this before that adolescence is a
01:09:40significant time for depression,
01:09:41and it's a significant health problem.
01:09:44So pre pandemic,
01:09:45we know that nearly one in five
01:09:47adolescents will experience
01:09:48major depressive disorder by the
01:09:50end of their teenage years.
01:09:52And that depression increases the risk
01:09:55for suicide by thirtyfold suicides.
01:09:57Now, the second leading cause of
01:10:00death in young people in America.
01:10:02So it was this serious situation
01:10:04even before COVID-19.
01:10:06And then we layer on a pandemic,
01:10:09UM,
01:10:09so we know from recent data taking a
01:10:11global perspective that internationally.
01:10:14The prevalence of pediatric
01:10:16depression and anxiety has doubled
01:10:19compared to pre pandemic levels.
01:10:21And then if we look specifically
01:10:22in the United States,
01:10:24we know that during these
01:10:25intense phases of the pandemic,
01:10:27the proportion of mental health emergency
01:10:30visits increased substantially,
01:10:32both in younger kids and in teenagers.
01:10:35And when you look at these
01:10:37broken into boys versus girls,
01:10:38we see that the the pandemic increase
01:10:42hits girls particularly hard.
01:10:44If we focus in not just on
01:10:47mental health emergencies,
01:10:48but visits specifically for
01:10:50suspected suicide attempts in girls,
01:10:52we can see the huge increase
01:10:54just by looking at this graph.
01:10:56So this other line is showing 2021 and
01:10:59the weeks are on the bottom on the X axis,
01:11:02so showing through about May of
01:11:04this year and you can see an over
01:11:0650% increase in emergency room
01:11:09visits and girls specifically
01:11:10for a suspected suicide attempt.
01:11:14And then if you look on the Y axis.
01:11:15But the numbers this is thousands of
01:11:19emergency suicidal presentations per week.
01:11:22So while I used to have this title where
01:11:23I say it's a significant health problem,
01:11:26I don't think that quite
01:11:27does it justice anymore.
01:11:28And I agree with the American
01:11:30Academy of Pediatrics and the AKAP
01:11:32that we're really in a state of
01:11:34a national emergency for child
01:11:36and adolescent mental health.
01:11:38So how do we treat depression
01:11:39if someone comes in with a new
01:11:42Depression diagnosis?
01:11:42Are Firstline treatments are really
01:11:45selective serotonin reuptake inhibitors.
01:11:47So medications like Block City nor
01:11:50Prozac and evidence based psychotherapies.
01:11:53So things like cognitive behavioral therapy.
01:11:56But we know that 40% of adolescents,
01:11:59even if they're getting this
01:12:00standard of care,
01:12:01won't get better with
01:12:03these initial treatments.
01:12:05The second line treatment the
01:12:07next evidencebased step,
01:12:08is to switch to a different SSRI and
01:12:11then add CBT if you haven't already.
01:12:13But even then,
01:12:15nearly half of these patients
01:12:17will remain depressed.
01:12:19And so if you put these numbers together,
01:12:20that's about one in five pediatric patients
01:12:23with depression that will have what we
01:12:26call treatment resistant depression.
01:12:27So depression that persists despite
01:12:30getting evidence based treatments.
01:12:32And so our question is how
01:12:34do we treat these patients,
01:12:35particularly in Pediatrics,
01:12:36where the evidence base is very
01:12:39thin compared to adult psychiatry?
01:12:42And that is the purpose of this service.
01:12:45So the pediatric treatment resistant
01:12:47Depression service is really a relatively
01:12:50young program we opened in November of 2019.
01:12:54It's Co directed by myself and
01:12:56Michael Block my colleague,
01:12:57and it's really an outpatient
01:13:00subspecialty consultation service.
01:13:02So what do we actually do on this service?
01:13:04UM, so we're providing comprehensive
01:13:07assessment of complex patients,
01:13:09and I will say the folks that come through
01:13:11our door for this type of referral
01:13:14are genuinely generally quite complex.
01:13:16So the average number of prior medicines
01:13:19before coming to see us is 9 medicines.
01:13:22So I gave this level of
01:13:23having tried at least two,
01:13:25and most of our most of our
01:13:28patients have tried many.
01:13:29There's also a high number
01:13:31of comorbid diagnosis.
01:13:33Often several hospitalizations and
01:13:35intense acuity with histories of suicide
01:13:40attempts or non suicidal self injury.
01:13:43So we review all of the prior
01:13:46available mental health records.
01:13:48We speak with their outpatient providers
01:13:49and try to piece together really the
01:13:52trajectory of the illness and and
01:13:54the factors that seem to be at play
01:13:57during periods of relative Wellness.
01:13:59This is 1/2 day in person or virtual.
01:14:03We also adapted to Tele Health during
01:14:06the pandemic evaluation where we
01:14:08do diagnostic interviews and also
01:14:10structured rating scales and at the end
01:14:13we provide a diagnostic formulation.
01:14:15There are often questions about
01:14:18primary diagnosis and that a set
01:14:20of treatment recommendations that
01:14:22span across the biological,
01:14:24the psychological and the social.
01:14:27There are times where we think the
01:14:30helpful approach might be something in
01:14:32the space of interventional psychiatry,
01:14:34so it's kind of a new term,
01:14:36but is talking about things like
01:14:39ECT or KETAMIN or RTMS,
01:14:42and in the cases that that seems
01:14:44like an appropriate step,
01:14:45we facilitate referrals to our colleagues
01:14:48and interventional psychiatry.
01:14:49Or if there's a research study that's
01:14:51appropriate, we can refer them there.
01:14:54So really,
01:14:55my vision for this program is growth.
01:14:57UM,
01:14:58and and that growth would look like
01:15:00an increased capacity not only to
01:15:03deliver specialty level recommendations,
01:15:05but also to start providing some
01:15:07of the specialty level of care,
01:15:10particularly when we're recommending
01:15:12medication changes that can feel
01:15:15daunting or complex compared to sort
01:15:17of the standard medication regimens
01:15:19that are typically being used.
01:15:21So we hope that with the recruitment
01:15:23of additional providers.
01:15:24And resources will start to be able
01:15:27to increase our capacity and really
01:15:30meet the the surging demand for
01:15:32treatment for these complex patients.
01:15:35So thank you so much for giving
01:15:36me some time to speak with you and
01:15:38enjoy the rest of the afternoon.
01:15:41Thank you so much Jenny.
01:15:44Come take just a moment,
01:15:46I know we said we would do
01:15:47questions at the very end,
01:15:48but any any questions at this point
01:15:50or we'll move on to our next part.
01:15:53I have a question again.
01:15:54Reagan for child Dallas.
01:15:55Hi, Jennie, thank you for help.
01:15:59Still haven't found anybody
01:16:00by the way Michael no.
01:16:03The half day and the half day
01:16:06assessment that obviously is
01:16:07significant and in terms
01:16:09of growing or scaling.
01:16:11Is there any thought how that
01:16:14might be compressed or so that
01:16:17you could see more patients?
01:16:18Yeah, so I mean, we've tried to gather
01:16:21as much information at the beginning
01:16:23as possible so we have them fill out a
01:16:26pretty lengthy symptom questionnaire to
01:16:28really try to target the focus of the
01:16:31discussion and also the rating scales.
01:16:33And I think I think a division of
01:16:35Labor would probably help us right now.
01:16:37Michael and I are the ones that
01:16:39are actually doing the interview,
01:16:40but also doing the ratings.
01:16:42Scales and so I think being able to grow
01:16:44our staff in a way that someone else is
01:16:46able to do some other reading skills
01:16:48while we're talking with the parents,
01:16:50I think we could probably compress our time
01:16:53if we had a little bit of a bigger team.
01:16:56Thank you.
01:16:58Carol, may I turn to you too?
01:17:01Bring our next two speakers.
01:17:05Mute. You know how
01:17:08long we have to be in using zoom for us
01:17:10to remember to check if we're on mute
01:17:13before we start talking many months now,
01:17:16but the next clinical story that
01:17:19I'm going to share is one from
01:17:20one of our social work fellows,
01:17:22Hector shy this hotel so it is a video,
01:17:24but he is also here to answer some questions.
01:17:27Should you have any.
01:17:28So bear with me 'cause the technology
01:17:29for me is often a challenge.
01:17:36Oh my, let's see. As I said,
01:17:38it is blocking the challenge.
01:17:40I can't seem to make it larger. Here we go.
01:17:44My name is Hector Chandler Rachel.
01:17:46I am a licensed Masters level social worker
01:17:48and I am in my second year of the Social
01:17:51work fellowship at the outpatient clinic.
01:17:53My fellowship position here consists of
01:17:55doing therapy with youth and their family,
01:17:57as well as getting access and
01:17:59to different forms of training.
01:18:01I think I may have had a very
01:18:03different experience than many
01:18:04clinicians here since I started my
01:18:06time here in the middle of a pandemic,
01:18:08which is to say it lightly
01:18:10has had several challenges.
01:18:12I do want to start though,
01:18:13by sharing a little bit about my.
01:18:15Work with one of my families and
01:18:17how this services have really made
01:18:19a difference at the human level.
01:18:21Yes, I'm sure you are all aware this
01:18:24pandemic has created a major crisis
01:18:26in the mental health field and as it
01:18:30has exacerbated and problems that many
01:18:32families already were struggling with.
01:18:34This was specially the case for
01:18:36one of the families who I started
01:18:38seeing earlier this year.
01:18:40My client is an 11 year old girl who
01:18:42sense with a lot of anxiety and she
01:18:44has also previously been diagnosed
01:18:46with learning disorders in reading,
01:18:48writing and math, among others.
01:18:51This is why it was no surprise and
01:18:53that you know she really struggled
01:18:56to adapt to the virtual learning
01:18:58offered during the pandemic.
01:19:00One of the biggest stressors that
01:19:02family first came in with was
01:19:04that they had requested a meeting
01:19:06with school so that they could
01:19:08receive special education services,
01:19:10yet they've had fallen through the cracks.
01:19:12As is often the case for many
01:19:14families of color.
01:19:15Mum though,
01:19:16is a fierce advocate for her daughter,
01:19:19but even then she.
01:19:20Reported to me that she often
01:19:22felt like her voice was not heard
01:19:24in those different systems to
01:19:26do language barriers and because
01:19:27they were a Hispanic family.
01:19:29Unfortunately, you know,
01:19:31coming back to in person school has only
01:19:34increased her daughters symptoms as she
01:19:36presents with a lot of school anxiety,
01:19:39primarily due to her reported
01:19:42team of feeling behind the rest
01:19:45of her peers academically.
01:19:47Despite the difficulties the families
01:19:50experience, I cannot say enough.
01:19:51Good things about the family.
01:19:53Mum always comes back to me with
01:19:55this phrase and she says like that
01:19:58I can see in which angle by landed.
01:20:00But we have to keep fighting moving forward.
01:20:04So when I asked the family,
01:20:06you know if I could share this story I I
01:20:09felt it was important to elevate their voice,
01:20:12specially moms voice and in our space.
01:20:15And so I asked them what they thought
01:20:18and what she thought would be important
01:20:20that I share with all of you today.
01:20:22She asked me to share how important
01:20:24therapy has been for her and her family.
01:20:26She told me to mention that she
01:20:28has been treated like family not
01:20:30only by me just by me, but by you.
01:20:33Know front desk staff.
01:20:35When when she first gets here
01:20:37and even though up
01:20:38to the prescriber who she sees her for
01:20:41her other two boys and she mentioned
01:20:43that these are services that are
01:20:45so badly needed among our Hispanic
01:20:47community and every time she is able
01:20:50to achieve her first families to us.
01:20:52Which I think speaks very highly of her
01:20:55experience here at the CHILD Study Center.
01:20:57I think it's important to acknowledge how
01:20:59your contribution is making an important
01:21:01difference for families at this human level,
01:21:03especially right now when mental health
01:21:05services are so urgently needed.
01:21:07I want to thank you for making
01:21:09fellowships such as mine possible,
01:21:12as well as a Mexican immigrant.
01:21:13Myself.
01:21:14I feel strongly about not only
01:21:16using my Spanish speaking ability
01:21:18to serve community by community,
01:21:20but also placing myself in environments.
01:21:23Ranking grow to be the clinician.
01:21:24My families deserve.
01:21:25This is why I'm here and I think this
01:21:28fellowship is so important to my growth here.
01:21:32I have been able to have access to
01:21:34a Spanish lead supervisor who has
01:21:36helped me fill gaps in my learning
01:21:38related to my work with Spanish
01:21:40speaking immigrant families.
01:21:42I also have access to opportunities
01:21:44such as forming part of the trauma
01:21:46clinic and being able to learn
01:21:48it's exciting interventions such
01:21:50as CFTS I which I plan and to use.
01:21:53In my future work with Spanish
01:21:55speaking immigrant families.
01:21:57I am thankful for the opportunities
01:21:59which all of you make possible
01:22:00and hope they only continue to
01:22:02grow for future social work films.
01:22:05Thank you.
01:22:11Thank you very much and just
01:22:13on that connection to the
01:22:14trauma service and to see FTSI let
01:22:17me turn it over to Carrie Epstein.
01:22:21Thank you Linda.
01:22:30OK.
01:22:38So hello everyone, I'm Carrie Upstein
01:22:40and I'm the Co director of the Yale Center
01:22:43for Traumatic Stress and Recovery along
01:22:45with my Co director doctor Steven Marans.
01:22:48I'm honored to be with you today.
01:22:51I'd like to continue to shine a light
01:22:53on the incredible clinical work is
01:22:55being done at the CHILD Study Center,
01:22:57particularly with respect to the clinical
01:22:59work and research being done with
01:23:02children and families impacted by trauma.
01:23:04You'll you've heard from and will
01:23:06continue to hear from other colleagues
01:23:08about their important clinical work
01:23:09with children impacted by trauma
01:23:11you just heard from Hector and
01:23:13what I'd like to highlight today.
01:23:16Beginning with.
01:23:18Sorry mommy.
01:23:21What I'd like to highlight
01:23:22today is an early intervention
01:23:24called the child and family.
01:23:26Traumatic stress, intervention or CF
01:23:28TSI with which Hector just mentioned,
01:23:31which is a brief 5 to 8 session
01:23:34trauma focused evidence based mental
01:23:35health treatment developed by myself
01:23:38and doctor Steven Marans CFTS.
01:23:40I grew out of more than three decades
01:23:43of closely observing on learning about
01:23:45the phenomena of trauma from children
01:23:48and families impacted by abuse,
01:23:50violence and other traumatic events.
01:23:53Currently see if TSI is the only evidence
01:23:55based treatment that was specifically
01:23:57developed for implementation in the
01:23:58early phase of trauma response.
01:24:00Soon after a recent traumatic event
01:24:02or soon after the recent disclosure
01:24:05of abuse. So based
01:24:07on a family strengthening approach,
01:24:09CTSI increases communication between
01:24:11the child and caregiver about the
01:24:14child trauma symptoms and as a
01:24:17result increases family support.
01:24:19For children impacted by traumatic events.
01:24:24CSI has demonstrated effectiveness
01:24:27in significantly reducing traumatic
01:24:29stress symptoms and reducing and
01:24:31interrupting PTSD and related disorders
01:24:33in children as well as their caregivers.
01:24:36In fact, our studies indicate that
01:24:38children who receive CFTS I are 65%
01:24:41less likely to meet criteria for post
01:24:43traumatic stress disorder and are 73%
01:24:47less likely to be diagnosed with related
01:24:50anxiety and depressive disorders.
01:24:52In addition, in a recent study we
01:24:55also learned that CFTS significantly
01:24:57reduces trauma symptoms and caregivers
01:24:59who participate in treatment as well.
01:25:04Hearing about the horrors that too
01:25:05many children are confronted with
01:25:07when they're exposed to violence and
01:25:09trauma can be especially unbearable if
01:25:11we feel helpless in providing relief,
01:25:13or if we believe that there is no
01:25:15escape from their immediate suffering
01:25:17or were convinced that their futures
01:25:18are forever damaged or impaired.
01:25:21CFTS, I not only reduces immediate suffering.
01:25:28Of traumatized children and families,
01:25:29and reduces long term damage
01:25:31to their development.
01:25:34But it also identifies and ensures
01:25:36that they receive additional
01:25:37psychotherapeutic help when needed.
01:25:41Let me illustrate this
01:25:43with the story of Alexa.
01:25:45Alexa was a 10 year old girl who was
01:25:48referred to us by Child Protective
01:25:50Services following her disclosure
01:25:51of sexual abuse and a long history
01:25:54of exposure to domestic violence.
01:25:56At the time of her referral,
01:25:57Alexa was frightened.
01:25:58She was withdrawn and had multiple
01:26:00symptoms of traumatic dysregulation
01:26:02that disrupted her daily life,
01:26:04including her inability to attend school.
01:26:08As for all children impacted by
01:26:11trauma Alexis presenting symptoms of
01:26:12traumatic dysregulation perpetuated
01:26:14the original loss of control that
01:26:16she experienced as a victim of abuse.
01:26:19And as a witness to the violence in her home.
01:26:22CFTS, I offered Alexa an alternative
01:26:25to these painful,
01:26:27disturbing reactions by helping
01:26:28her to better observe and find
01:26:31words for her symptoms.
01:26:32Find recognition and understanding of her
01:26:34distress by her foster parents as well
01:26:37as learning strategies to gain support,
01:26:39mastery and control over the
01:26:42symptoms of her traumatic distress.
01:26:45So over the course of seven sessions of TSI,
01:26:48Alexa was re able to return to
01:26:51school and was no longer having the
01:26:53nightmares and angry outbursts that
01:26:56had been happening on a daily basis.
01:26:59And because she was feeling in greater
01:27:01control of herself and her symptoms,
01:27:03she was now able to re engage into a
01:27:07safer world which she had withdrawn from.
01:27:10And then three months after
01:27:12finishing CTSI treatment,
01:27:14when we checked in with Alexa
01:27:16and her foster parents,
01:27:17Alexa was continuing to grow and re
01:27:20engage in a healthy, happier life.
01:27:23Alexa is not alone in this experience.
01:27:27Since the development of CFTS I cases
01:27:30involving thousands of children in
01:27:31New Haven around the country and
01:27:34across the world have demonstrated
01:27:35the clinical efficacy of CSI.
01:27:39To date,
01:27:40we've trained close to 1200 clinicians
01:27:42around the country in the CF TSI model.
01:27:45Additionally, in response to a
01:27:48considerable interest abroad,
01:27:49we've trained colleagues in 12
01:27:51European countries,
01:27:53Australia and Lebanon.
01:27:56CF TSI has been and continues to be
01:27:58an essential intervention for so
01:28:00many children who have suffered in a
01:28:02world that is now additionally altered
01:28:04by the restrictions of the COVID-19 pandemic.
01:28:07While so many children may be
01:28:10impacted by violence and trauma,
01:28:12it's so important for us to all
01:28:14remember that these children can
01:28:16also have the opportunity to heal
01:28:18and although there is darkness,
01:28:20there's also light and hope.
01:28:23I'd like to finish with the
01:28:25following thought.
01:28:25As we've come to learn more about trauma
01:28:27through our research and our clinical work,
01:28:30we've also come to recognize
01:28:32that however much we've learned,
01:28:33just like the children and
01:28:35families we work with,
01:28:36if we are to have any chance of
01:28:38being successful on their behalf.
01:28:40We cannot do this work alone.
01:28:42I for one could not do the work that I do
01:28:45without my colleagues who bring their ideas,
01:28:48their resources,
01:28:49their shared experience and their true
01:28:52dedication to the challenges that we
01:28:54tried to meet together every day.
01:28:57Our work is never done.
01:28:59We are enormously grateful for
01:29:01the support of our work
01:29:02that we've received from the Harris
01:29:04Family Foundation from the Israel
01:29:06Family Foundation and the support
01:29:07from the associates over the years.
01:29:09I really want to thank you all for the
01:29:11opportunity to speak with you all today.
01:29:15Thank you so much Carrie.
01:29:18So we have two more just clinical
01:29:21clinical vignettes and teremia
01:29:23turned back to you. Sure,
01:29:26sorry about that interruption before.
01:29:28I didn't realize it wasn't on mute and.
01:29:31Carrie Epstein just spoke with us
01:29:35about some of the trauma interventions,
01:29:37and about 60% of the kids that come
01:29:41through our clinic have had exposure
01:29:43to at least one traumatic event,
01:29:44and we're going to hear now from
01:29:47one of our clinical faculty,
01:29:49Stephanie Gary, who is going to share
01:29:53a case that is related to trauma.
01:29:56And you, I will ask for your Grace again,
01:29:58because I will be sharing a video.
01:30:00I'll
01:30:00see what happens.
01:30:10Hello everyone my name is Stephanie,
01:30:12Gary and I am an outpatient clinician
01:30:15at the Yale Child Study Center.
01:30:18Professional journey began at the
01:30:20center a little over six years ago and
01:30:23during my time here I have served as
01:30:26a clinician and clinical supervisor.
01:30:29Reflecting on my career,
01:30:30I recall entering this field
01:30:33because I saw the value in mental
01:30:35health and particularly early
01:30:37interventions for children.
01:30:39I was motivated by the idea of making
01:30:42a positive impact on the lives of
01:30:44children and it is my hope that by
01:30:47introducing argued to therapy early on,
01:30:49our society will come to
01:30:52destigmatize mental health concerns.
01:30:54Now before capturing a snapshot of my
01:30:57clients treatment experience today.
01:30:59I will lead with mentioning that it is
01:31:01an honor and a privilege to share with
01:31:04you all a glimpse of the clinical work
01:31:06we provide to families in our care.
01:31:08Thank you for this opportunity for
01:31:11supporting this mission and for
01:31:14your contributions to this practice.
01:31:16To protect the privacy of my client,
01:31:19I will refer to them using fictitious
01:31:22names to begin Sierra and adolescent
01:31:24female was referred to the clinic by her
01:31:28mother Mrs Night for anxiety treatment.
01:31:31Sierra,
01:31:31an exceptional student,
01:31:32was so overcome with anxiety that
01:31:35she struggled to attend school
01:31:37on a regular basis.
01:31:38When she did attend school,
01:31:40she would have panic attacks,
01:31:42often calling her mother frantically
01:31:44and requesting to get picked up
01:31:47for early dismissal from school.
01:31:48Other times,
01:31:49her anxiety emerged during long
01:31:52road trips and she had no idea
01:31:55what was triggering her panic
01:31:57attacks and working with Sierra,
01:31:59it was initially very
01:32:00challenging to engage with her.
01:32:02Sierra was highly guarded
01:32:04and understandably so,
01:32:06as she worried greatly that therapy would
01:32:08force her out of her comfort zone to Sierra.
01:32:11Therapy was a place where she would
01:32:13have to confront her fears so that
01:32:16she could finally overcome anxiety.
01:32:18With that mindset,
01:32:19naturally she had her walls up.
01:32:22However,
01:32:23in building a therapeutic relationship
01:32:25and creating a safe space to explore
01:32:28Sierra's feelings,
01:32:29she gradually opened up.
01:32:31Meanwhile, in working with Mrs.
01:32:33Night,
01:32:33she supported CRS therapy in a way that
01:32:36was anchoring for her daughter, Mrs.
01:32:39Night learned ways to model courage.
01:32:41She was also invested in supporting her
01:32:44daughter to challenge negative thoughts
01:32:47as she was instrumental in applying
01:32:50problem solving skills to help her
01:32:53daughter advocate stressful situations.
01:32:55As Sierra symptoms stabilize,
01:32:57she eventually revealed that
01:32:59a traumatic experience was the
01:33:01driving force behind her anxiety.
01:33:04As a result of her commitment to therapy,
01:33:06she ultimately arrived at a place
01:33:08where she was ready to process
01:33:10these underlying stressors,
01:33:12and her anxiety was deeply rooted in trauma.
01:33:16As treatment progressed,
01:33:17Sierra had a revelation where she
01:33:20discovered that when stuck in traffic
01:33:22during long rides away from home,
01:33:24it reminded her.
01:33:26Feeling trapped like during
01:33:28her traumatic experience.
01:33:30Reading these insights to
01:33:32Sierras consciousness,
01:33:33she had finally found herself
01:33:35in the driver's seat,
01:33:36so to speak,
01:33:37where she was in control
01:33:39of her symptoms and her
01:33:41symptoms no longer had the power over her.
01:33:44This was truly an empowering and
01:33:46triumphant moment for Sierra,
01:33:48who continues to thrive today.
01:33:51I'm happy to say that since
01:33:53working through her traumas,
01:33:54she attends school on a daily basis.
01:33:57And she has taken several road
01:33:59trips to visit college campuses
01:34:01in the absence of panic.
01:34:03Sierra is currently a senior in
01:34:05high school looking to pursue a
01:34:07college education at the nation's
01:34:09top universities where she hopes
01:34:11to major in forensic psychology
01:34:14and to ask for Mrs Night.
01:34:16She is feeling more confident
01:34:17that her child is now equipped
01:34:19with the tools necessary for
01:34:21Sierra to travel away from home
01:34:24for her collegiate experience.
01:34:25Thank you for your time everyone.
01:34:33Thank you so much and so we have
01:34:35our last last clinical tasting.
01:34:38Our clinical vignettes from that
01:34:39doctor Nancy Close, Nancy. Thank
01:34:43you Linda, and it's just an honor and
01:34:46a pleasure to be here with all of you.
01:34:49I'm going to share with you
01:34:51the story of a little girl,
01:34:53seven years old whose name is Tiana.
01:34:55She is a child who has witnessed
01:34:58intimate partner and community violence.
01:35:00She's experienced neglect,
01:35:02loss of her caregivers,
01:35:04physical and sexual abuse,
01:35:06and she is about two in one week.
01:35:09Moved to her 10th foster home
01:35:11since she was removed from.
01:35:13Her mother at age 2 at age 4,
01:35:16she was placed in her grandmother's home
01:35:19and began child parent psychotherapy,
01:35:21which we refer to as CPP
01:35:24with her grandmother.
01:35:25CPP is an evidence based treatment
01:35:28that supports family strengths and
01:35:31relationships and helps families
01:35:33feeling grow after stressful
01:35:35and traumatic experiences.
01:35:37Unfortunately,
01:35:37Tiana was removed at age 5 after she
01:35:41was hit and bruised by her grandmother,
01:35:44but CPP and supervised visits
01:35:47continued with grandmother.
01:35:48Grandmother still longs to be reunited
01:35:51with Tiana and is working hard on her
01:35:55case plan and her attendance is exceptional.
01:35:58My work began with Tiana,
01:36:00Tiana when she was five,
01:36:02when her beloved clinician finished
01:36:04her training and left the center.
01:36:07This clinician had worked with Tiana and
01:36:09grandmother to repair their relationship,
01:36:12to support grandmother to understand
01:36:15Tiana's trauma system symptoms,
01:36:17things like difficulties regulating
01:36:19her behaviors that were really
01:36:21driven by deep sadness,
01:36:23fear and anger,
01:36:24and difficulties trusting that
01:36:26adults would care for her.
01:36:28Keepers save and really see her as
01:36:31somebody who was worthy of love.
01:36:33I was able to provide continuity
01:36:36in this treatment because I
01:36:39was her clinician supervisor.
01:36:41Then COVID happened and in
01:36:43person treatment and DCF.
01:36:45Regular supervised visits were
01:36:48suspended from March 2020 to May 2021.
01:36:51The court date to determine permanency
01:36:54was scheduled for June 2020.
01:36:57It's been postponed multiple times.
01:36:59Due to COVID and will not occur
01:37:02until March 2, 2022.
01:37:05I think that the CHILD Study Center
01:37:07has been a stable and secure place
01:37:10for Tiana during during COVID and
01:37:12I want to talk a little bit about
01:37:14what I've done and we've what we've
01:37:16done as a team to ensure safety in
01:37:19place and relationships for Tiana.
01:37:22I've developed a very good working
01:37:24relationship with the DCF caseworkers,
01:37:27her various foster parents and
01:37:29her grandmother.
01:37:31We have regular conversations and
01:37:33meetings and we discuss and acknowledge
01:37:35the impact that trauma has had on
01:37:38Tiana's development, her relationships,
01:37:40her emotions and behavior.
01:37:43I think I've really helped the team
01:37:45to understand her difficult behavior
01:37:47and I'm hopeful I really do believe
01:37:50that their trauma lenses have grown.
01:37:52I think they big now appreciate
01:37:54the importance of being with her
01:37:56when she's upset when she's engaged
01:37:58in long and mournful crying.
01:38:00It's not a good idea to let her
01:38:02cry it out alone that she needs
01:38:04somebody trusted to be with her.
01:38:06They understand that attempting to
01:38:09make connections between her feelings
01:38:11and her experiences and her behaviors
01:38:13can be organizing for her and at the
01:38:16same time I've really honored the
01:38:18commitment that they have made tetiana.
01:38:21It's really been quite remarkable.
01:38:24One of the things that's foundational
01:38:26in CPP is really developing an
01:38:29empathic therapeutic relationship
01:38:30with both the child and the parent,
01:38:34and this has been really hard work.
01:38:36Not so hard with the grandma,
01:38:37because we've, I think Rick
01:38:40developed a very nice relationship,
01:38:42but with Tiana it was very hard.
01:38:45I saw her virtually that was that I met her
01:38:48virtually and saw her twice a week once
01:38:51with grandmother and once individually.
01:38:54It was three months before
01:38:55she called me by my name.
01:38:57She would call me by the other clinicians
01:38:59name or she would stop and say what's your
01:39:02name again at the end of the session.
01:39:04One day she said,
01:39:05and I think some of you have
01:39:07heard this before.
01:39:08You are Dr Oldys mushy and sloppy.
01:39:10I don't like you.
01:39:11I don't ever want to see you again.
01:39:14I said to her I knew how much she
01:39:16missed Doctor Katie and she was sad
01:39:18and mad that doctor Katie left her.
01:39:20She responded to that by saying
01:39:22she really didn't feel that way,
01:39:24which she often does.
01:39:25Protesting a little bit too much when it
01:39:28really does hit a chord a few sessions later,
01:39:31she went into her closet where
01:39:33she regularly went.
01:39:34When playing or talking about
01:39:36something difficult.
01:39:37Can I tell you something?
01:39:38I think you are a super
01:39:41girl and you're beautiful.
01:39:42I said I think you're getting to know me
01:39:45better and share all kinds of feelings.
01:39:47So I think her comments really illustrate
01:39:50her struggle with relationships
01:39:53and managing ambivalent feelings.
01:39:55I think her consistent weekly
01:39:57connection to grandmother and our
01:39:59capacity to be reflective about her
01:40:02feelings and consistent in the limits
01:40:04we set when she becomes dysregulated.
01:40:06And she believed me.
01:40:08He becomes dysregulated were very
01:40:11organizing during the difficult times
01:40:14of COVID with great joy in person.
01:40:17Sessions began in May of 2021,
01:40:19and what I've seen is a growing capacity
01:40:23in Tiana to grow to play imaginatively.
01:40:27Play is very much an important
01:40:29component of child parent psychotherapy
01:40:30because it's through imaginative
01:40:32play that children learn how they
01:40:35feel and make meaning of experiences.
01:40:37And I'm just going to show you.
01:40:39Some props,
01:40:40these are her favorite babies and
01:40:43dollies that she spends a lot of time.
01:40:46Plain family kit.
01:40:48Being a loving and caring mother
01:40:50which makes me think there have
01:40:52been times when she has received
01:40:55that kind of care grandmother who
01:40:56initially with the other clinician
01:40:58didn't sit on the floor,
01:41:00sat on a chair and watched Tiana
01:41:03play is down on the floor engaged
01:41:05in the play and following her lead.
01:41:08The babies need feeding and bathing.
01:41:11They go to the park.
01:41:12They get ready for school.
01:41:13They do a lot of eating and going to bed.
01:41:16Her role shifts from being the
01:41:18baby to being a little girl,
01:41:20teenager an aunt and a mother.
01:41:23The play has developed to
01:41:26be more explicit about her fears and
01:41:28traumatic things that have happened to her.
01:41:30She worries about getting shot or
01:41:32somebody coming to take her away.
01:41:34If she hears a loud noise during session,
01:41:37she played about a baby who was.
01:41:39Left on the sidewalk by
01:41:40the mother and a family,
01:41:42finding her and taking her in.
01:41:45Recently she played a mother of these
01:41:48babies who was going away to get
01:41:51married and Auntie was babysitting and
01:41:53Auntie said I hope he does not hit you.
01:41:56The baby gets in trouble.
01:41:57This one gets in trouble for not
01:42:00following the rules and has and
01:42:02has to go to bed for being bad.
01:42:04Babies are hiding in the basement because
01:42:06a man is coming to get them grandmother
01:42:09and I stay with her in this play,
01:42:11helping her to expand and feel safe
01:42:13enough to examine her underlying feelings.
01:42:16And finally,
01:42:17I think that we've also helped her
01:42:20find ways of coping or discover
01:42:22things that help her cope.
01:42:24One of the things that she's been doing
01:42:27doing recently is taking responsibility
01:42:29for knowing how much time is left in
01:42:32her session and plans for it so that
01:42:35she can leave in a more regulated way.
01:42:38Attending church has been very
01:42:40organizing and I would say her
01:42:42grandmother is very religious and
01:42:44her other foster families have
01:42:46participated in their church communities.
01:42:49Singing and dancing are very special talents
01:42:52that I'm II try to nurture in session.
01:42:55And I hope will be nurtured
01:42:56outside of this session.
01:42:58She'll sing original songs during
01:43:00sessions that have things on her mind.
01:43:03I've learned that singing calms her,
01:43:05and when I see her kind of revving
01:43:07up at the end of the session to
01:43:09maybe have a difficult time,
01:43:10I suggest that she sings a song and she
01:43:13will often sing a song to grandmother.
01:43:15And here's an example of one
01:43:17we don't have a family.
01:43:20My family is in my heart.
01:43:21I miss you every morning when you
01:43:23take care of me and my sister.
01:43:25In your heart is a big family.
01:43:28I love you.
01:43:28I am very happy to be with you
01:43:30'cause you are so special special
01:43:32and you were like a dream to me.
01:43:34A very special dream and you are special
01:43:37and a grandma that is special to me.
01:43:40Certainly there is more work to
01:43:41be done but I remain hopeful.
01:43:44I want to thank you all and thank
01:43:46you especially for all of the
01:43:48continued support that you give
01:43:50to us and and or center.
01:43:53Thank you so much, Nancy.
01:43:55So I just want to look at the clock
01:43:58'cause I want to give everyone a chance
01:44:00for some questions and discussion.
01:44:02We have a a built-in break.
01:44:05I think we can take a few minutes
01:44:07for questions and then we'll come
01:44:08back and take a little bit of time
01:44:11from our concluding question session.
01:44:13So are there any questions for
01:44:15our our clinical presenters?
01:44:18As a group, and I hope you've
01:44:20given you a sense of the.
01:44:22I'm just a bit of a sense of the range
01:44:25of clinical work going on in the center.
01:44:27Will open up for questions.
01:44:38I think a car yeah.
01:44:42Go ahead.
01:44:44Can you hear me? Yes
01:44:46Carol we can. OK
01:44:48so I wanted to ask how old do
01:44:51when you presented these cases?
01:44:53How old were the children on
01:44:55the spectrum? You know on
01:44:56the age group with developmental.
01:44:59Are there age limits or this specific?
01:45:04Ways you work with different ages.
01:45:07And do the children know that
01:45:10is a time limit? Because
01:45:12these children are the first people
01:45:14that they could ever trust,
01:45:17and do they know how?
01:45:18If it's going to be 6-6?
01:45:21Or how do you frame that for
01:45:22them so they understand that?
01:45:26So who would like
01:45:27to take that? I mean, Tara,
01:45:29do you want to address the
01:45:30age range that we serve and?
01:45:33Store in our outpatient in our youth
01:45:37clinical services we serve children from
01:45:40birth through their 19th birthday, so that
01:45:44that's the range within those services.
01:45:47And so we have a team that Nancy is on
01:45:49that works with some of the younger
01:45:50group and then from four and a half up.
01:45:52We have our other team that the time
01:45:55really depends on what what's going on and
01:45:59and what the particular intervention is.
01:46:03You know Carrie was talking about CSI,
01:46:06which has a certain number of sessions,
01:46:08so that's different than some of
01:46:10the other work that we might do.
01:46:11CPP might be the opposite and
01:46:13take longer through the play.
01:46:15It's really about what is
01:46:17clinically indicated in that time,
01:46:19and as we go along in treatment, we are.
01:46:22We talked with the children and their
01:46:24caregivers about where we're at every about,
01:46:27every three months when it's the longer
01:46:29term treatment about where we're at and
01:46:32where we think we need to go in about.
01:46:34How long we think it might be,
01:46:35and so we're constantly having
01:46:36that conversation with them and
01:46:38revisiting what progress is.
01:46:39Well,
01:46:39if you have a very
01:46:40young child, they don't
01:46:42understand that I don't.
01:46:43I don't know how you would frame it
01:46:45so they would because when I worked
01:46:48in the clinic they children drew a
01:46:53picture of their is sitting in a car
01:46:56going off the click, the cars going
01:46:58off the Cliff and it was the end of
01:47:00the treatment and I just wonder,
01:47:02you know, with the short term.
01:47:05Treatment how that?
01:47:07Can be explained to them or how you would.
01:47:12Handles that.
01:47:14Well, Nancy, since
01:47:15you are one of our younger child
01:47:17experts, I wondered if you could
01:47:19share your thoughts on this one.
01:47:22I'm sure happy to come.
01:47:26I think that certainly the the UM,
01:47:29it's important to be explicit
01:47:32upfront with the family about the
01:47:35nature of the treatment and what
01:47:38we're going to be working on.
01:47:41And in child parent psychotherapy we
01:47:43do a lot of gathering information from
01:47:47the parents over several several weeks,
01:47:51so that together.
01:47:52But the parent we can form a
01:47:55treatment triangle that talks about
01:47:57what has happened to the child.
01:47:59You know, if you think about Tiana
01:48:02you you were taken from your mommy,
01:48:04you've lived in a lot of foster homes.
01:48:07How the child has responded to that.
01:48:10You have a lot of temper tantrums.
01:48:13You really lose control.
01:48:16You have a hard time being a good
01:48:18boss for yourself and this is
01:48:20a place where we can help you.
01:48:23Understand what has happened to you
01:48:25and you can feel safe and whoever
01:48:28is the parent in the in the CPP
01:48:31with them you and Mommy or Ewing
01:48:34and Grandma are going to work are
01:48:36going to work on this together and
01:48:38this is a place where you can feel
01:48:40safe and you can learn about some
01:48:42of the feelings you have connected
01:48:44to being taken from your mommy.
01:48:47And then that's a little kind of
01:48:49simple and concrete, but we also use.
01:48:53Animals or people to to show what you know,
01:48:57show what the child's experience has been.
01:49:00We try because of the young age.
01:49:01We keep it simple and maybe don't you know,
01:49:04certainly with Tiana,
01:49:05we wouldn't address all of
01:49:07her experiences at once.
01:49:09You know we didn't.
01:49:11We didn't talk about them initially
01:49:14when she was for all of them.
01:49:16I mean,
01:49:17the big the big issue for her
01:49:19was the removal from her mother.
01:49:24So we have a. We have a couple
01:49:27of questions in the chat,
01:49:28so Jennifer is asking how to CPP
01:49:32compared to using TF CBT with young
01:49:35children who experienced trauma Carrie,
01:49:37would you like to or Nancy
01:49:38either won't take that. CPP
01:49:41is and carry out.
01:49:42I'll let you you go after,
01:49:44but CPP is an intervention that's
01:49:48meant for children zero to 6.
01:49:52And TFCBT, I'll let you take over. Carrie.
01:50:02So in TF CBT is a model that can be
01:50:05implemented with preschoolers and older,
01:50:08although a lot of folks really focus
01:50:10on sort of maybe 6 year olds and up.
01:50:12But it can be done with preschoolers
01:50:14and older and this is a model that
01:50:18it's a very phase based approach and
01:50:20components based approach and really
01:50:22focuses on and this kind of goes to
01:50:24your question Carol about how do you
01:50:28actually work with the younger kids?
01:50:30This is really about.
01:50:32The opportunity to predict if the
01:50:34essence of the traumatic experience
01:50:35is all about loss of control.
01:50:37I couldn't control what's happening
01:50:39to me or to a loved one.
01:50:41In the case of domestic violence
01:50:42that we want our treatment to be
01:50:44all about reversing loss of control,
01:50:46of putting words to symptoms,
01:50:48identifying coping strategies to
01:50:49bring those symptoms down and also
01:50:51being able to predict treatment.
01:50:53So here's what we're going to do today.
01:50:55So you're right,
01:50:57it depending developmentally.
01:50:58Whether or predicting what we're
01:50:59going to do today,
01:51:00whether it be predicting the
01:51:02overall trajectory of the model.
01:51:04But the the treatments really folks?
01:51:06TF CBT in particular focuses
01:51:07on as well as safety aside,
01:51:09bringing symptoms down and regaining
01:51:11sense of control of symptoms first
01:51:13and later getting to a trauma
01:51:14narrative in the context of TFCBT,
01:51:16I don't know if that answers your question,
01:51:18Jennifer.
01:51:19Thanks Carrie. So Tom,
01:51:20I see you have a couple of questions
01:51:23when I'm going to suggest that we gave
01:51:25everybody a chance to take a brief break,
01:51:28a 5 minute break stretch,
01:51:30grab a glass of water, coffee, whatever,
01:51:31and then we'll come back and start
01:51:34our education part and Tom I will.
01:51:36I will respond to your questions in our
01:51:39and our question and answer at the end.
01:51:42But thank thanks for people for
01:51:43putting the questions in the chat
01:51:45so it is 452 if we could be back.
01:51:49Just it. This sounds so concrete,
01:51:52but if we can be back at three
01:51:54minutes or four and we will,
01:51:56we will get started again.
01:51:57So we're just taking a brief pause.
01:52:23And for the answers, the questions
01:52:25in the chat that were about DBT,
01:52:28both Tara and Carrie had provided
01:52:31some information in the chats.
01:52:33So we now come into our education section.
01:52:36Or are we probably should call
01:52:38this more career development and
01:52:40I'm really excited for you to have
01:52:43a chance to hear these individual
01:52:45stories from former colleagues.
01:52:47Let me first turn through Doctor
01:52:49Emily Olson, Emily.
01:52:54Hello everyone. Uhm, good afternoon.
01:52:58My name is Emily Olson and I'm currently
01:53:01in my 6th and final year of training and
01:53:04the combined child and Adult Psychiatry
01:53:06residency and I'm delighted to have
01:53:08the opportunity today to talk with
01:53:10you a little bit about my experience
01:53:13here at the Yale Child Study Center.
01:53:16So just a bit about my background
01:53:18and what drew me to Yale.
01:53:19I was raised in Brooklyn,
01:53:20NY and then I went to a small
01:53:22liberal arts school in Ohio before
01:53:24attending the MD PhD program at
01:53:27Washington University in Saint Louis.
01:53:28During my PhD I developed an interest
01:53:31in using translational genomic
01:53:33approaches to better understand
01:53:35and treat psychiatric conditions,
01:53:37but it really wasn't until my medical
01:53:39school clerkships when I was working with
01:53:42children and families that my clinical
01:53:44passion for child psychiatry solidified.
01:53:46So when I applied to residency,
01:53:48I knew that I ideally wanted to
01:53:50attend a program where I could start
01:53:52working in child psychiatry early
01:53:54and also continue my genetics work.
01:53:56So I was especially delighted when
01:53:59I found this woman integrated
01:54:01residency program and this truly
01:54:02is a one inch of a kind program.
01:54:05And here I'm just showing you a
01:54:07general schematic of how I've spent
01:54:09my time over the last six years.
01:54:10But essentially this program
01:54:12combines three things.
01:54:14Residency training in general.
01:54:16Adult Psychiatry subspecialty fellowship
01:54:18training and child psychiatry as well as
01:54:21rigorous research training throughout.
01:54:24The entire six years.
01:54:25So for someone like me,
01:54:27who was the spy ring to be a physician,
01:54:29scientist and child psychiatry,
01:54:31this was really an ideal program.
01:54:33The leadership of this program is also
01:54:36incredibly supportive and I'm just
01:54:38showing a few of the many key people here.
01:54:42So my first two
01:54:43years, the majority of my time was
01:54:45spent seeing patients in Pediatrics,
01:54:46neurology, and psychiatry,
01:54:48and during this time I honed my clinical
01:54:51skills and these early experiences
01:54:53also gave me a sense of some of the
01:54:55important unanswered questions in
01:54:57their field and during this time I
01:54:59became especially interested in two
01:55:01significantly under study conditions,
01:55:03TRICHOTILLOMANIA and excoriation disorder.
01:55:05Individuals afflicted with these
01:55:07conditions often spend hours a day
01:55:09pulling or picking at their hair skin,
01:55:11which causes significant distress
01:55:13and impairment.
01:55:14But there are no first line pharmacologic
01:55:17treatments for either condition,
01:55:18which really highlights that we
01:55:20need to have a better understanding
01:55:21of the underlying biology.
01:55:23But I was surprised to find that there
01:55:25were no state of the art large scale
01:55:28genomic studies for either condition.
01:55:30So I went to my mentors,
01:55:31Tom Fernandez and Michael Block with
01:55:33this idea of conducting the first DNA
01:55:36sequencing study in these conditions,
01:55:37and with these conditions,
01:55:39and with their guidance,
01:55:40we developed the TAB study.
01:55:42And here is a picture of
01:55:43our recruitment table,
01:55:44and this was at a meeting back in.
01:55:45April 2018,
01:55:46for individuals who had these
01:55:48conditions in San Francisco,
01:55:51and you can see that we have all the
01:55:53supplies to collect saliva for DNA and
01:55:56to collect our clinical assessments.
01:55:58But when I took this picture,
01:55:59I was a little nervous.
01:56:00I honestly didn't know what to expect,
01:56:02but shortly after this photo,
01:56:04we enrolled our first research participant
01:56:06and over the three days of the meeting,
01:56:08we were able to enroll over 50 families
01:56:11and individuals who had these conditions.
01:56:14I was really moved by the support
01:56:16for this research and hearing
01:56:17their stories compelled me to
01:56:19continue this line of work.
01:56:23Over the next four years,
01:56:24I expanded the TAB study and
01:56:26also led other genomics projects.
01:56:28I have now analyzed DNA sequencing data
01:56:31from hundreds of individuals and families
01:56:33to help to understand the genes and
01:56:35pathways that lead to these conditions.
01:56:38My hope is that this work will
01:56:40identify new treatment targets.
01:56:42But it's important to note that I have
01:56:44only been able to do this because of the.
01:56:46Because of my protective research time,
01:56:48which was made possible by grants and
01:56:50donations to the Yale Child Study Center.
01:56:52I've also continued to develop my
01:56:54clinical skills because I also want
01:56:56to be a practicing child psychiatrist
01:56:59and this model of simultaneously
01:57:01working with patients while conducting
01:57:03research is incredibly powerful
01:57:05because there's a constant feedback.
01:57:07I find that my clinical work informs the
01:57:10research questions I ask and my research
01:57:12findings also improve our clinical work.
01:57:16On a more personal
01:57:16note, I want to add that during my training
01:57:19I also became apparent to two kids.
01:57:21This experience has been wonderful
01:57:23in many ways, and it's also further
01:57:25solidified my commitment to the
01:57:27work that we do here at the center.
01:57:28And just as the center has helped so
01:57:30many children and families that we've
01:57:32heard about just in the last session,
01:57:33they've also been incredibly
01:57:35supportive of my own family.
01:57:39I'm now in my last year of training and
01:57:41I'm in that process of transitioning.
01:57:43Unfortunate that I recently received
01:57:45a strong score on an NIH grant,
01:57:47a career development award which
01:57:49really builds upon the work that I
01:57:51mentioned to you today at the TAB study,
01:57:53and my hope is to be able to continue
01:57:55this work as a faculty member
01:57:57at the Yale Child Study Center,
01:57:59which, over the last six years has
01:58:01become my academic home.
01:58:03With
01:58:03that I just want to thank UM, all
01:58:06my funding and everyone who's supported me.
01:58:11Thank you so much.
01:58:12I'm really how I would just say
01:58:14that we share your hope so.
01:58:16So let me turn to Karthik.
01:58:19Gotta be Roman kartik.
01:58:25Right, uh, I'm Karthik I'm
01:58:26the other six year along with
01:58:28Emily and usually I give a talk about
01:58:31my interest in the neuro developmental
01:58:33trajectory of schizophrenia.
01:58:34But being at the end of my training,
01:58:36I thought it would be a great opportunity
01:58:37to talk about my own developmental
01:58:39trajectory and the essential role.
01:58:40The Child Study Center has had
01:58:42in helping me develop my voice.
01:58:43And really being someone that,
01:58:45in this trite saying of
01:58:46bench to bedside lesson,
01:58:47that I really strive to try to do.
01:58:49And it's only recently have
01:58:50been able to do that at
01:58:51the CHILD Study Center.
01:58:53Alright, and so prior
01:58:55to coming to Yale,
01:58:56I did my MD PhD on the West Coast
01:59:00and during my Graduate School time.
01:59:01I studied very early brain development.
01:59:03I was really interested in the
01:59:05intricacies of gene regulation.
01:59:06How do you turn on a gene at the
01:59:08right place in the right time?
01:59:09This is just a figure from one of my
01:59:11papers from grad school and actually just
01:59:13came out and then it's an overwhelming
01:59:15slide 'cause it's a lot of data.
01:59:17It's a lot of information
01:59:18and I absolutely loved it.
01:59:19I'm a little transcription factor nerd,
01:59:22I think, however.
01:59:24I was struggling at the end of grad
01:59:25school of how I could translate this work
01:59:27into something clinically meaningful.
01:59:28How could I actually help patients with this?
01:59:30So I put that concerned aside and went
01:59:33back to Medicine Medical School and
01:59:34finished my last two clinical years.
01:59:36Wow, those during those last two
01:59:38years that I realized I love child
01:59:39psychiatry working with children
01:59:40that have always enjoyed and I was
01:59:42really struck by children and their
01:59:44resilience as well as how much they
01:59:46struggled and at the same time I
01:59:48realized the patients that really
01:59:50struck me and really drew me in
01:59:52where patients with schizophrenia,
01:59:54which is traditionally the purview
01:59:56of adult psychiatry.
01:59:57So when I went onto the interview trail,
01:59:58I got advice from people that
02:00:00really respected that I shouldn't
02:00:02do child psychiatrist.
02:00:03Stick to adult psychiatry as that would be
02:00:05better for my clinical interests as well as.
02:00:07More supportive of my basic science
02:00:09research and so my last interview was
02:00:11at Yale at the at the SONET program,
02:00:13and I was really excited to
02:00:14learn about the program.
02:00:15As Emily mentioned,
02:00:16it's one of these unique programs
02:00:19that integrates adult child
02:00:21psychiatry along with research,
02:00:23and it was really great to talk to
02:00:25people that were current trainees that
02:00:26as well as mentors that integrated both
02:00:29that did basic signs that did research
02:00:31as well as seeing patients that did
02:00:33someone something that didn't have
02:00:35very much experience with previously.
02:00:36And so I was really excited to get into the.
02:00:39Program and so.
02:00:40Over the first couple years I was
02:00:43able to work with adults with
02:00:45schizophrenia both in the acute setting,
02:00:47the emergency room and including page.
02:00:49They were actively psychotic,
02:00:50as well as the inpatient setting
02:00:52and the outpatient setting,
02:00:53but addition had the unique opportunity
02:00:55to work in a young child inpatient unit.
02:00:58And during that time I met a couple
02:01:00of children that were just starting
02:01:01to hear voices that were on this
02:01:03very scary pathway to schizophrenia.
02:01:05And that was something that
02:01:07really resonated with me.
02:01:08And this is the population I really want to.
02:01:09Work with
02:01:10at the same time. I was also
02:01:12working in the laboratory of Doctor Nets,
02:01:14Aston in that lab I was really
02:01:16interested in understanding
02:01:17how the front of the brain,
02:01:18the prefrontal cortex, develops,
02:01:20as well as how it evolves.
02:01:21The prefrontal cortex is greatly
02:01:23expanded in humans as well as
02:01:25special properties that are thought
02:01:26to underlie our unique capabilities
02:01:28in complex social behaviors. But
02:01:30these same unique changes in the human brain
02:01:33may underlie our risk for
02:01:35Neuro psychiatric disorder.
02:01:36So while I was doing my second stint on
02:01:39Winnie one as a fellow sister my 4th year,
02:01:42I stumbled upon this really exciting finding,
02:01:44which is displayed here.
02:01:45Just summarizing it.
02:01:46Basically what we found was disruption
02:01:49of development of the prefrontal cortex.
02:01:51So think the second trimester of
02:01:53pregnancy could produce the exact same
02:01:55circuit deficits described in patients.
02:01:57Adults with schizophrenia, for example.
02:02:00This is an image of a five day old
02:02:02mouse brain and what you see on the
02:02:03right is the connection between the
02:02:05front of the brain or the medial
02:02:07prefrontal cortex and the thalamus.
02:02:08You see this thick bundle of connection.
02:02:10It's a very important circuit
02:02:12for memory cognition,
02:02:13but in the mutant mouse
02:02:14where we disrupted genes,
02:02:16a certain set of genes,
02:02:17we saw a huge reduction of connectivity
02:02:19and this is something that's been
02:02:20described in adults with schizophrenia
02:02:22as well as inpatients or prodromal
02:02:25adolescence that are starting to
02:02:27have mid like the initial symptoms of
02:02:30schizophrenia prior to conversion to
02:02:32psychosis and these findings as well
02:02:35as my clicker experience had really
02:02:36coalesced into my future plants,
02:02:37right?
02:02:38I really see a way of integrating
02:02:39my basic science.
02:02:40Interesting to something clinical,
02:02:42but I'm hoping to study is how
02:02:44can disruption of second trimester
02:02:46pregnancy and this so well established
02:02:48point for example during famines
02:02:50or pandemics or any type of stress
02:02:53during pregnancy.
02:02:53There is a massive increase of the
02:02:56risk of schizophrenia 20 years later,
02:02:58so I'm interested in understanding
02:02:59what's going on in those twenty
02:03:01years from that initial genetic
02:03:02or environmental stressor to that
02:03:04later diagnosis.
02:03:05Schizophrenia,
02:03:05I think if we can understand
02:03:07what's going on those 20 years,
02:03:08we can possibly prevent
02:03:10schizophrenia completely.
02:03:10Which is my big long term goal.
02:03:13I couldn't have done this research and
02:03:15had this experience anywhere else,
02:03:16so I'm so grateful to be at
02:03:18the Yale Child Study Center.
02:03:19I'm excited to continue this, hopefully here.
02:03:21Just like Emily said as well.
02:03:23And of course,
02:03:24I'm thankful for everyone that was involved.
02:03:26This test in lab,
02:03:27all our collaborators, all the funding.
02:03:29Some of my work that I'm going
02:03:31into really trying to create better
02:03:33models of psychiatry was funded
02:03:35by the Alan Sipka Foundation.
02:03:37Starfinder pronounced that as
02:03:38well as everyone that was involved
02:03:39in the solar program.
02:03:41The child space,
02:03:41and they've been so supportive
02:03:42the whole way through.
02:03:44And as I said,
02:03:45I'm really grateful for the opportunity,
02:03:46thanks.
02:03:51Thank you so much Karthik.
02:03:54May I turn to doctor Kareem Abraham?
02:04:21You're on karine.
02:04:23I thank you for this wonderful
02:04:25opportunity to share with you. My story.
02:04:27My name is Kareem and I'm an earth
02:04:29scientist and child psychologists.
02:04:30Here Child study center.
02:04:32The overall goal of my research
02:04:35is to understand brain networks
02:04:36related to emotion regulation,
02:04:38impairments and child mental health
02:04:40that can inform clinical interventions.
02:04:43And with the ultimate goal of improving
02:04:45the life of children and their families.
02:04:48So my story really begins with a handshake.
02:04:50Well at least.
02:04:52Pre COVID several years ago
02:04:54and shaking hands was a norm.
02:04:57I remember that day quite well because
02:04:59I was at the Seaver Autism Center Mount
02:05:01Sinai drives in my graduate research,
02:05:03and at the time I was a doctoral
02:05:05student in clinical psychology.
02:05:06In my research focused on understanding brain
02:05:09regions important for social functioning.
02:05:12Here I'm showing you some of the
02:05:14main findings where children who
02:05:16receive social skills training showed
02:05:18increased activation in a region
02:05:21called the medial prefrontal cortex.
02:05:23When interpreting ironic scenarios and
02:05:25viewing faces with different gaze directions,
02:05:27so even at this very early stage
02:05:30of my career,
02:05:30this really sparked my interest to
02:05:33understand how brain activation
02:05:34changes following treatment and how
02:05:36this can be leveraged to develop
02:05:38better and even more focused clinical
02:05:40treatments for child mental health.
02:05:47So it was again.
02:05:48It was a raining day and I remember
02:05:50thinking it's actually perfect day for
02:05:52catching up on reading and paper writing.
02:05:54Then my graduate mentor found me and
02:05:56invited me to join her at grand Rounds talk.
02:05:59She emphasized that his right at
02:06:01my alley and that the speaker was
02:06:02from the L Child Study Center,
02:06:04but she didn't really provide
02:06:05much more detail,
02:06:06leaving it quite mysterious,
02:06:08and I will also admit I actually
02:06:10did not ask for more detail.
02:06:12I guess a part of me actually like this.
02:06:14Spence so we braved the rain.
02:06:16I went to this Grand Rapids talk.
02:06:18It was about two to three slides into this
02:06:20talk when I knew that this was the research
02:06:22I imagine myself doing in the future.
02:06:24It had everything it was patient,
02:06:25oriented with a focus on neuroscience
02:06:28and neural response to treatment.
02:06:30I was also really fortunate to have
02:06:32the opportunity to join my advice
02:06:34or needing with the speaker.
02:06:35After the talk,
02:06:36the speaker was actually Doctor
02:06:38Dennis Super Dulski, shown here,
02:06:39who is a faculty at the center.
02:06:41Here we shook hands.
02:06:43We had a great conversation about our shared.
02:06:46Interest.
02:06:48Uhm?
02:06:49So I would later go on to complete
02:06:52my graduate training in cognitive
02:06:53behavioral interventions and NSS
02:06:55lab and then a T32 postdoctoral
02:06:58research scholarship directed
02:06:59by Doctor Michael Crowley.
02:07:01Were Dennis served as my primary mentor.
02:07:04But during my postdoc,
02:07:05Dennis played a vital role in
02:07:07really fostering my collaborations
02:07:09with neuroimaging experts who
02:07:11are now my Co mentors,
02:07:13which has been crucial for
02:07:14my training and leading to a
02:07:16research award from the Yale
02:07:18Center for Clinical Investigation.
02:07:22So now as a junior faculty,
02:07:24my research focuses on brain networks,
02:07:26underlying emotion regulation,
02:07:27impairments across child
02:07:29psychiatric disorders,
02:07:30and one aspect of my work focuses on
02:07:33understanding brain connectivity and
02:07:35developmental disorders such as autism.
02:07:38Another aspect of my research focuses
02:07:40on understanding impairments and brain
02:07:42structure as well as sex differences
02:07:44in structural and functional networks.
02:07:47So my research is really multi
02:07:48modal because it merged his
02:07:50information from both structural.
02:07:51And functional imaging to understand what
02:07:54goes awry and these neural connections
02:07:56related to mental health conditions.
02:07:59More recently,
02:08:00another aspect of my research leverages
02:08:02was called Network Neuroscience,
02:08:04which allows us to understand long
02:08:07range neural connections across the
02:08:09entire brain called the connectome.
02:08:11We've also applied this connector modeling
02:08:14method to understand childhood aggression.
02:08:18And with the support of a child study
02:08:20center Pilot Research award and grant,
02:08:22this has allowed me to add
02:08:24new aspects to my work.
02:08:25And understanding the temporal
02:08:27dynamics of these neural connections
02:08:30which we can use to identify
02:08:32distinct brain States and test how
02:08:34disruptions here are linked to emotion
02:08:37regulation impairments in children.
02:08:38So I'm very thankful to have met
02:08:40Dennis and to be at a place where I
02:08:42can focus on the three things that
02:08:44I loved most in my research career.
02:08:46Neuroscience,
02:08:46mentoring and teaching students.
02:08:49And maintaining my skills as a violinist.
02:08:53Actually, I'm also founding member
02:08:54of the Send string quartet here.
02:08:56The Child Study Center,
02:08:58which is named after Dr.
02:08:59Milton Son who was a child
02:09:01psychiatrist and the second
02:09:03director of the Child Study Center.
02:09:05I'm also extremely thankful to doctor
02:09:07Linda Mays for her immense supporting
02:09:09guidance on this path and to illustrate
02:09:11the dedication and support from
02:09:13Dennis and the Child Study Center.
02:09:15I would like to share with you a review
02:09:17or comment from my recent NIH career
02:09:20work grant that I think captures this.
02:09:23So the reviewer writes that quote
02:09:25the candidate referring to me and the
02:09:28project received exuberant support
02:09:29from all mentors and leadership
02:09:31at the Yale Child Study Center.
02:09:33By the way,
02:09:34this is actually the first time I've
02:09:36ever found myself quoting a grant viewer.
02:09:41So to think that my path was influenced
02:09:44by attending a 45 minute grand
02:09:46rounds lecture New York that led
02:09:48me here to the child study centers.
02:09:50Really quite amazing and
02:09:52perhaps even serendipitous.
02:09:54So I'll leave you with one of our
02:09:56favorite lab pictures of Doctor
02:09:58Dennis Ucode Ostian myself,
02:09:59reviewing emerging data together.
02:10:01Thank you.
02:10:04Thank you so much, kareen,
02:10:06we should we should have the sense string
02:10:10quartet actually virtually play as well.
02:10:13May I turned to Doctor Carol Thompson Felix?
02:10:23OK, are you able to see my slides?
02:10:26Yes, they look great. Awesome so
02:10:29good afternoon everyone.
02:10:30My name is Tara Thompson Felix
02:10:32and today I'm excited to
02:10:34share with you my experiences
02:10:35as a trainee
02:10:36here at the CHILD Study Center.
02:10:39So sometimes a simple email
02:10:41can change the course
02:10:42of your life
02:10:43and this was the case for me
02:10:45when I was a junior in college. I
02:10:47reached out to a world renowned scientist
02:10:49here at the Child
02:10:50Study Center and expressed my
02:10:52interest in learning a little
02:10:53more about research. Shortly
02:10:56after joining the lab, I became a
02:10:58postgraduate research associate at
02:11:00the Child Study Center and received
02:11:02funding to develop my skills
02:11:04as a scientist. This experience solidified
02:11:07my interest in epigenetic research.
02:11:09I then continued my training at
02:11:11medical school and also at residency
02:11:15and after completing
02:11:16my adult psychiatry
02:11:18training at Temple University,
02:11:19the Child Study Center was my number
02:11:21one choice for the
02:11:22next phase of my training. My fellowship.
02:11:25This was because I could see how
02:11:28the educators at the CHILD Study
02:11:30Center prioritized the professional
02:11:32as well as the personal growth
02:11:33of their trainees. So obtaining
02:11:36a PhD while completing
02:11:38my clinical training
02:11:39with something I had
02:11:40hoped that I could achieve,
02:11:41but I wasn't sure if it would be
02:11:44possible and when I discussed
02:11:45this idea with my mentors here
02:11:46at the CHILD Study Center,
02:11:47they made the seemingly
02:11:49impossible possible.
02:11:50So I'm now enrolled
02:11:53in the investigative
02:11:54medicine PhD program
02:11:56and receiving a financial
02:11:57support through a competitive Federal
02:11:59funding award here at the Child
02:12:01Study Center. I feel supported
02:12:03not only as a scientist,
02:12:05but. Also, as a clinician and as
02:12:07a mother with two young children
02:12:10and so coordinating all of this
02:12:12would not be possible without
02:12:13tremendous support for my program.
02:12:16So during my clinical supervision I got
02:12:18advice and guidance about my clinical cases,
02:12:21but also a lot of support and advice on
02:12:24affordable childcare options and financial
02:12:27support available to me as a Yale fellow.
02:12:29This support is so critical to
02:12:32scientists like myself who are just
02:12:35embarking on their research. Here's
02:12:37another amazing part
02:12:38of being at Yale
02:12:40is the opportunity to
02:12:41work with world renowned
02:12:42leaders in the field. So an example
02:12:45of this is I will be working
02:12:46with Nobel laureate James Rothman for one
02:12:49of my PhD courses this fall and Doctor
02:12:53Rothman's work provided new insight
02:12:55into the mechanisms
02:12:56responsible for cell signaling
02:12:58for my PhD. My advisor, Kieran
02:13:01O'Donnell, is a renowned leader
02:13:03in pregnancy, mental health
02:13:05and how this shapes child brain.
02:13:07Development these opportunities have
02:13:09allowed me to pursue
02:13:10my scientific passion of
02:13:12trying to understand how the prenatal
02:13:14environment shapes child development
02:13:17and to do so in one of the best
02:13:19environments in the world.
02:13:21So how then how is the
02:13:23environment communicating
02:13:24with the baby forming
02:13:25in the womb? This
02:13:26is something that fascinates me.
02:13:29How does this stress response of
02:13:31the mom get through to the baby?
02:13:33And how can we get real time information
02:13:35on how the baby is affected?
02:13:37This is fundamentally a question
02:13:39about communication and through my PhD
02:13:42program I'll be able to investigate
02:13:44a novel signaling pathway that
02:13:47involves these tiny little cellular
02:13:49packages called exosomes. These exosomes
02:13:52are released from most cells
02:13:53in the body and were previously
02:13:56thought to be waste products
02:13:57of the cell. Now we're learning
02:13:58that they play a very critical role
02:14:01in maternal fetal communication
02:14:03and general communication
02:14:04between cells. Through
02:14:06this work we hope to better
02:14:08understand why and how prenatal
02:14:10stress effects child development.
02:14:12By doing this, we hope to find ways to
02:14:14identify and help those children who
02:14:16are likely to be affected. Please
02:14:19come to my poster to learn more. I
02:14:21want to say a special thank you to my Co
02:14:24fellows members of the O'Donnell lab and
02:14:27to leadership from my fellowship program.
02:14:29The T32 training and
02:14:31Investigative Medicine program
02:14:33and also a special thank you to
02:14:35the associates for supporting
02:14:36the Faculty Development Fund. Thank you.
02:14:42Thank you so much Terra.
02:14:44May I now turn to Doctor Chen Reyes?
02:14:55Can everyone see my?
02:14:57Perfect your great great so
02:14:59I'm here to share about how
02:15:01I raised the child at the
02:15:03Yale Child Study Center.
02:15:04In addition to my own children,
02:15:05I'll explain all these acronyms in
02:15:08a bit. So I my journey is rather
02:15:13unique and like different
02:15:14from my colleagues. I traveled all
02:15:16the way from Manila to New York City
02:15:20during my PhD in applied
02:15:22developmental science.
02:15:22I was always enamored by the
02:15:24idea of using science in
02:15:27the service of society,
02:15:28so it's really about using
02:15:29science to improve practice. But
02:15:31in order to improve practice,
02:15:33how do you inform policy to
02:15:35sustain it? And so luckily there's
02:15:38such a thing. As the Yellow Child
02:15:40Study Center, the Zigler Center
02:15:42in Child development social
02:15:43policy unit that Ed Zigler was
02:15:47a childhood hero
02:15:48of mine. When I
02:15:49saw it was just amazing to you know,
02:15:52you know for someone who comes from
02:15:54across the ocean to be working at
02:15:56someone's lab and working with
02:15:58tremendous people, so to speak.
02:16:00So I started working with
02:16:02Doctor Pia Brideau who's
02:16:06now at UNICEF
02:16:07working on Global E
02:16:08Early childhood development policy.
02:16:11When she left
02:16:12I I worked alongside Dr.
02:16:15Walter Gilliam and his work
02:16:17on preschool expulsions,
02:16:18and both these vendors have really
02:16:21encouraged me to dream big and have
02:16:24supported me throughout the years.
02:16:28You know to develop
02:16:28my own career
02:16:30path and I've always been dissatisfied
02:16:34with the way we're measuring the quality
02:16:37of how teachers foster social emotional
02:16:40skills in early childhood classrooms. Like if
02:16:43we were to believe what other measurement
02:16:46tools are telling us, which is
02:16:49we're actually doing really good in
02:16:52the early education field in terms of
02:16:54how we're supporting young children,
02:16:56social and emotional development? I know that
02:17:00that might be quite the stretch,
02:17:01and so we developed
02:17:03the climate of healthy interactions
02:17:05for learning and development
02:17:06or the child tool. It's
02:17:11preliminarily a measurement tool,
02:17:13and it serves as a lens or organizing
02:17:16framework for assessing
02:17:17the quality of interactions that
02:17:20foster children. Social,
02:17:21emotional and holistic development.
02:17:24It's comprised of nine dimensions
02:17:27that make up this healthy environment.
02:17:29Correct price price.
02:17:30Antiquorum developmentally
02:17:32appropriate practice the
02:17:33equitable treatment of children.
02:17:35We focus on things not just on verbal
02:17:37behaviors but a non
02:17:38verbal and para verbal behaviors.
02:17:40We focus in addition to adult child
02:17:43interactions. We look at adult
02:17:44to adult interactions.
02:17:47And all these and the scores
02:17:49are placed along a quality
02:17:50spectrum of mental healthiness,
02:17:53and we actually have data showing that
02:17:55scores and the child are associated
02:17:58with teachers adverse childhood
02:18:00experiences. So those
02:18:02teachers who experienced
02:18:04adversity in childhood having
02:18:06an incarcerated parent and
02:18:07experiencing emotional abuse,
02:18:09we found that their scores as
02:18:11teachers of young children were
02:18:13actually lower on the child tool.
02:18:15We also have emerging evidence
02:18:17showing that. For
02:18:18some, the child predict end
02:18:20of year, teacher turnover and
02:18:23something that's a little more
02:18:25exciting. But it's also emerging
02:18:26is that we're showing correlations
02:18:28between scores and the child
02:18:30and English language Learners
02:18:32language proficiency test scores.
02:18:34So it's really, really exciting.
02:18:36But the real power behind the
02:18:38child tool is its utility,
02:18:41and specifically in early
02:18:42childhood mental health consultation. So
02:18:44mental health consultation instead of pulling
02:18:46out a child with severe
02:18:48challenging behaviors. Out of the
02:18:50preschool and bringing that child
02:18:52into the clinic, what we're doing
02:18:54is we're pulling
02:18:54out the mental health professional
02:18:57out of the clinic and into the
02:18:58child's program, and so they use
02:19:00the child tool as as an organizing
02:19:02framework for their consultation. We found
02:19:05in a recent
02:19:08study that was published
02:19:10that child informed
02:19:12early child mental health consultation does
02:19:15work, and what's powerful
02:19:17about this study is that.
02:19:19Not only did we find effects
02:19:21on the children who prompted
02:19:22the need for services
02:19:24in the first place, but
02:19:25we found a horizontal diffusion
02:19:28of effects such
02:19:28that it affected all the other
02:19:30children in that classroom,
02:19:31not just the children, not just the child,
02:19:33with presenting problems, and arguably
02:19:36because we're changing teaching practices.
02:19:38We might find vertical diffusion
02:19:40of effects such that future
02:19:42generations of children who will be
02:19:44under the that particular teacher
02:19:47will also benefit as a result.
02:19:50Uhm, so where we are now?
02:19:52You know, again, solely by word of mouth.
02:19:55You know we have zero marketing.
02:19:57We are in 21 child friendly states
02:20:00with a couple more pending plus Canada
02:20:04and we're being used in a variety
02:20:06of ways either in statewide
02:20:08efforts or in these independent
02:20:10requests for for training.
02:20:13But I wanted to focus specifically
02:20:15in New York City because we
02:20:17are now in the midst of an
02:20:19opportunity for statewide diffusion
02:20:22of the infant toddler child,
02:20:24so that focuses on children zero to three,
02:20:27but in particular, in family,
02:20:29family, child care settings,
02:20:30serving infants and toddlers
02:20:32in neighborhoods with high poverty
02:20:34rates. So it's neighborhoods
02:20:35that. Programs that serve
02:20:38mostly children of color.
02:20:39Immigrant children.
02:20:40You know, addressing all their
02:20:42linguistic barriers and we're working
02:20:44closely with the State Office of
02:20:46Children and Families Services.
02:20:49So right now we are in the RCT phase.
02:20:53We're in the process of
02:20:55recruiting and recruitment
02:20:57and then statewide diffusion. Hopefully
02:21:00by the end of 2025,
02:21:02we're able to reach,
02:21:03you know, all the children,
02:21:04all the infants and toddlers
02:21:05that are being served
02:21:06by these different programs.
02:21:09So the Child
02:21:11Study Center is the home of the child
02:21:13and I am but one tiny individual in
02:21:16a sea of esteemed colleagues who
02:21:18all work toward you. Know a common
02:21:20goal, and we have dedicated staff
02:21:22who work just as hard, if not
02:21:24harder than we do. So it's been
02:21:26a pleasure to work here
02:21:27and to the associates.
02:21:28Thank you so much for supporting the
02:21:30work that we collectively do.
02:21:33Thank you so much, Jeff. Thank you.
02:21:36I love the picture on that last slide.
02:21:39Uhm, so may I turn to Doctor Alsip too.
02:21:42Bring us bring us home. Thank
02:21:45you Doctor Mays since I'm the last speaker.
02:21:47I'll hold you all hostage but now I'm happy
02:21:50to share a little bit about my journey in
02:21:53science and why I'm so excited to be at
02:21:55a place like a Yale and to do research
02:21:57in the Child Study Center. As a child.
02:21:59I was really curious and so I feel like I
02:22:02was always into sign from a very young age.
02:22:05I was into the ability to be creative, so
02:22:07music was another really big passion of mine.
02:22:10Eventually that led me to North
02:22:12Carolina Central University, where I
02:22:14majored in biology and minored in jazz.
02:22:16That he's a philosophy played on the tennis
02:22:18team really got a chance to explore myself,
02:22:20but importantly got some mentorship there and
02:22:22got into basic science research at that time.
02:22:25I was doing molecular cancer biology and
02:22:27went to my first scientific conference.
02:22:29Had a chance to participate in a summer
02:22:32research program and I was really hooked
02:22:34on science and academia and the idea that
02:22:36we could take basic science and use it to
02:22:39actually make a difference for people in
02:22:41the clinic and in the community so that
02:22:43eventually took me to do and MD PhD program.
02:22:46And I was really fortunate to get a PhD
02:22:48training with Katie in the Department
02:22:50of Brain and Cognitive Sciences at MIT.
02:22:53And at that time I got really interested
02:22:55in this idea of how does the brain
02:22:57represent social information?
02:22:59How is that biased to produce different
02:23:01behaviors like empathy versus aggression?
02:23:04And then how do those sorts of
02:23:05processes go wrong?
02:23:06And a lot of different psychiatric
02:23:09conditions at that time.
02:23:10When we looked at,
02:23:11you know this idea of the social brain.
02:23:13It was really confusing
02:23:14and it still is there.
02:23:15All these different brain.
02:23:16Regions all these different networks.
02:23:17Some of them are involved in social
02:23:19and non social behaviors and so
02:23:21we became really reductionist at
02:23:23without approaching Rascal and said,
02:23:25let's isolate one circuit and understand
02:23:27what does this circuit represent?
02:23:29What kind of behavior is it driving?
02:23:31Then?
02:23:31Maybe connect that to downstream
02:23:33circuit and from there start to
02:23:34build up an idea of how social
02:23:36information is being represented,
02:23:37integrated and computed
02:23:38on throughout the brain.
02:23:40And we focus on a very
02:23:42evolutionarily conserved behavior.
02:23:43Social learning.
02:23:44How does one animal learn about
02:23:45the environment from another?
02:23:46Animal we've we were able to show that
02:23:48there's a circuit from the cortex they made.
02:23:50Oh,
02:23:51that's really important for
02:23:52representing social information
02:23:54during this kind of learning.
02:23:55From there I stayed to do a postdoc,
02:23:57'cause I was really interested in
02:23:59how we could use machine learning
02:24:00approaches to better understand the
02:24:02neural data that we were looking at.
02:24:03But there was something a little
02:24:05bit dissatisfying,
02:24:06with only working with mice,
02:24:09and I knew that I wanted that human touch.
02:24:11So after my post Doc,
02:24:13I returned to Med school,
02:24:14finished the MD PhD program and really.
02:24:17Decided to pursue clinical training
02:24:18inside in psychiatry and wanted to
02:24:20be in a place where I felt like I
02:24:22could be creative where I could bring
02:24:24these different things together and
02:24:25begin to understand how to really
02:24:27apply some of the things that I was
02:24:29learning in the mouse to people.
02:24:31So I was really excited when I was
02:24:33able to come here as a resident in the
02:24:36Neuroscience Research training program
02:24:37which gave me the opportunity to not
02:24:40only keep my research trajectory,
02:24:41but to begin to learn new tools so
02:24:44I could ask some of these questions
02:24:45in humans as well.
02:24:46And so I started off looking at
02:24:48very basic behaviors and animals
02:24:50and looking at neural signals.
02:24:52Now we have the tools using things
02:24:54like functional near infrared
02:24:56spectroscopy and EEG.
02:24:57And in the Mcpartland that we're
02:24:58able to use brain stimulation to ask
02:25:01how are these social representations
02:25:02changing in humans?
02:25:03We can then apply machine learning
02:25:05tools to ask how these things similar
02:25:07and where are they different in terms
02:25:09of computational strategies that
02:25:10their brain is using to represent
02:25:12social information and all of this
02:25:14is kind of with the gear of how
02:25:15do we then take this to build?
02:25:17Clinical and community interventions.
02:25:18I'm really grateful to be at
02:25:21the young Child Space Center,
02:25:22'cause I really found it to be a place
02:25:24where the kinds of discoveries that
02:25:26were making can really inspire other
02:25:28care that we're delivering to patients.
02:25:30So thank you all for being here
02:25:32and for listening to my talking.
02:25:33All the other talks.
02:25:35Thank you so much.
02:25:37So while we are we are at 4:30,
02:25:40I think all of us are very willing
02:25:43and eager to actually stay and
02:25:45take any questions in the chat.
02:25:47Any questions from the audience?
02:25:49We just really appreciate
02:25:51your joining us virtually.
02:25:53And the let's let's see
02:25:55if people have questions.
02:25:57We will monitor the chat as
02:25:58well as just listen for you.
02:26:11Learn to thank you and the team.
02:26:12It's been a wonderful
02:26:14way to spend 2 1/2 hours.
02:26:15Well thank you K. Thank you
02:26:17so much for being with us.
02:26:21I also want to thank all the
02:26:24underachievers on this zoom.
02:26:26It's a wonderful, wonderful afternoon
02:26:30and very, very exciting to
02:26:33hear and see what everybody
02:26:36is doing, how and and and
02:26:39there are a lot of new
02:26:40people that I haven't met before and that's
02:26:43also exciting to and so to the new ones.
02:26:46Welcome and and so glad you made
02:26:50Yale your home. OK, yeah, we also
02:26:53had thank you Ari.
02:26:55We also had some questions submitted
02:26:59earlier which I can open up to the.
02:27:02To the audience or or not,
02:27:04to the audience to our speakers?
02:27:06Susanna, do you have here?
02:27:07I've got the so one was asked if
02:27:11they were very interested to learn
02:27:12about the clinical utility of
02:27:14genetic screening and individuals
02:27:16with autism spectrum disorder.
02:27:18Uhm and.
02:27:20Any any element or anybody
02:27:22want to address that one?
02:27:27Charge 1 happy to
02:27:29say something. I think I'm Tom Hernandez
02:27:32could also comment on this as well.
02:27:34I think that there's there's some sort of
02:27:38an increasing need for doing more genetic
02:27:42screens in individuals with autism.
02:27:45I think that there's more of an
02:27:47availability now of the ability to
02:27:51identify risk genes and affected
02:27:53individuals so the cost of being able
02:27:56to do what we call xom sequencing.
02:27:58This coming down and so now we
02:28:01have the ability to do this and
02:28:03implement this at the clinic.
02:28:05I think one of the challenges is
02:28:07that even if we do identify a gene
02:28:10that's associated with autism,
02:28:11there's that still doesn't necessarily
02:28:14translate into a new treatment.
02:28:16And so I think that's still very
02:28:18much at the research stage.
02:28:20And so I think we need to do more
02:28:22work to really be able to make
02:28:24those findings more meaningful.
02:28:25I think there's so meaningful
02:28:26at the research level,
02:28:28but I think we still have more work to do.
02:28:30Had to really translate that to a
02:28:33new treatment at the clinical level,
02:28:35but I think I think Tommy could
02:28:36probably comment more on implementing.
02:28:40Sure, no, I think the question
02:28:42used the words of clinical
02:28:44utility, and I think that's
02:28:46there's an important distinction there where
02:28:48you know to date
02:28:49the clinical recommendations
02:28:51for screening. If
02:28:53an autism spectrum disorder
02:28:55is suspected, really
02:28:56goes after the
02:28:57low hanging fruit.
02:28:58I guess I'll say of the
02:28:59genetic on the genetic spectrum,
02:29:01the larger deletions or duplications
02:29:04which are really clearly clearly
02:29:06and were some of the first genetic
02:29:09mutations that were. Linked with autism
02:29:11spectrum disorders and
02:29:13so that still makes sense, but we're getting
02:29:15to the point. And
02:29:16we're at the point of. Quite
02:29:17frankly, I think where
02:29:20we should be looking at a
02:29:21with a little bit higher resolution.
02:29:23So looking at genetic sequencing,
02:29:26you know Alan.
02:29:27You presented your
02:29:27work today on sequencing.
02:29:28Emily presented her work on
02:29:30sequencing. We can identify.
02:29:34Various point mutations in
02:29:36genes that we can predict
02:29:38and even gone to study in
02:29:40the lab will actually damage
02:29:42the function of the gene. And so, while
02:29:45clinically it's not at the level of a
02:29:47clinical recommendation yet, certainly
02:29:49you know I. If I see patients
02:29:52in the clinic that I suspect
02:29:54might be on the autism Spectrum
02:29:56II, try to push and
02:29:57advocate for sequencing and
02:29:59looking at the sequencing data so
02:30:01we're there, I think you know there's
02:30:03always a lag between the research
02:30:04and the clinical recommendations, but
02:30:06you know what we're getting there.
02:30:09Come and Tom is a let's say
02:30:11some questions in the chat.
02:30:12Tom is asking Doctor also a
02:30:15question about how far along are
02:30:18you in your in your work? Yeah,
02:30:20so I'm a I'm a third year in the program.
02:30:23One of the great things I think
02:30:25about UM Yale is that there is
02:30:26some degree of flexibility that
02:30:28you can build into your schedule,
02:30:30and so I've been able to not only keep
02:30:32some of the basic science things going,
02:30:34but work with J Mcpartland learning
02:30:37how to do things like TMS,
02:30:39and again asking if we see certain neural
02:30:42signatures or certain networks involved
02:30:44in rodents are those the same kinds of
02:30:46networks that if we get access to it,
02:30:48brain stimulation in humans that we could.
02:30:50Sort of affect those representations,
02:30:52so being allow me to actually start
02:30:54to make progress towards that yeah.
02:30:59Any other questions from the
02:31:01from the audience? We have one.
02:31:04We have one other question that
02:31:07submitted that we might close on,
02:31:08but I just want to be sure if there's any
02:31:11other questions before I ask this one.
02:31:17So you've heard many of you have heard
02:31:19and heard us talking in various.
02:31:21I actually each of the each of the
02:31:23sections about the changes that the
02:31:26pandemic has brought and the changes with
02:31:28the behavioral health needs increasing.
02:31:31And Tom, you ask a question of how
02:31:34we're meeting this behavioral health.
02:31:37Sir, excuse me the surge.
02:31:40In a more general question,
02:31:41but barely a very poignant
02:31:43question that's been asked is are
02:31:46our children going to be OK?
02:31:48Uhm, with all that has happened
02:31:50in all that is still happening.
02:31:53I think that I am a perpetual
02:31:54optimist and I would say yes.
02:31:56But but yes,
02:31:57with all that we're trying to do,
02:31:59but I would.
02:32:01Really turned to my colleagues
02:32:04because we cannot.
02:32:05One single group cannot do all B.
02:32:07Ensure that our children will be OK,
02:32:09but it certainly takes all of our attention
02:32:12to this and it is an opportunity.
02:32:16Like we have never had to put
02:32:19forward the support and the case
02:32:21make the case for the lifelong
02:32:22impact of behavioral health.
02:32:24But let me let me turn to my
02:32:26colleagues for any additional
02:32:28remarks or things you would end to.
02:32:41Anybody in the audience?
02:32:46I would just as a
02:32:48sort of colleague.
02:32:50Definitely.
02:32:52And. You know you've
02:32:54highlighted. Obviously the increase in
02:32:58the difficult issues that young people
02:33:01in particular have had during
02:33:04the pandemic. I think
02:33:06BI two am optimistic
02:33:08and in part the other side of that
02:33:10is because it's been so highlighted.
02:33:11There are a lot of opportunities
02:33:12and I think greater funding
02:33:15sources for people who are going
02:33:18to recognize the importance of this
02:33:21and some decrease in the stigma.
02:33:24Also attached to mental health services.
02:33:26So I think there is
02:33:28a lot of opportunity along with the
02:33:32challenges that. That we're facing,
02:33:35and I I always believe in kids
02:33:40and they're going to, you know,
02:33:43every generation of kids gets
02:33:44bad mouths in some way and not
02:33:45that these kids are being bad
02:33:47about. But people
02:33:48always worry about the younger generation
02:33:50and somehow they they generally
02:33:54prove their elders. Wrong when they.
02:33:59When they worry too much about them.
02:34:03Thank you for that
02:34:04I think. I think Linda,
02:34:06UM I too and am an optimist and I
02:34:09and I think we know that children
02:34:11do as well as their parents do,
02:34:13and I think it's important to underscore
02:34:17the necessity of caring for yourself
02:34:20and finding the ways to get that care.
02:34:25Time away from work doing
02:34:28pleasurable things on your own,
02:34:31but also with your family.
02:34:32Also appreciating that children
02:34:34will have big reactions.
02:34:36So we all have world having big
02:34:38reactions to what we've been through,
02:34:40but understanding that children
02:34:42will have them too and the the best
02:34:45thing we can do is to not rush them,
02:34:48not rush them back into making sure
02:34:51they catch up in six months time,
02:34:54but appreciating that it may take time.
02:34:56They are resilient.
02:34:57They do have this huge drive to move
02:35:01forward in their development, so I,
02:35:04but I think really appreciating that.
02:35:06There will be some rocky times ahead
02:35:09and some some will require more mental,
02:35:13more intensive mental health care,
02:35:15but others will will need the
02:35:18support of their families and their
02:35:20teachers and understanding from them.
02:35:24Thank you, Nancy. Anything else
02:35:26from from all of you who have
02:35:28have joined us this afternoon?
02:35:36Well Alex also roped
02:35:38me in the chat and that it will
02:35:40be great to be able to be busy in
02:35:43person again and we certainly would
02:35:45be really really delighted for that.
02:35:47I think what I would just be able
02:35:49to say is just this afternoon,
02:35:50just as we were all meeting Yale,
02:35:52Cherney changed the alert
02:35:54level from yellow to green,
02:35:56which means that we can start to
02:35:58have slightly bigger groups and
02:36:00we're headed in the right direction.
02:36:02But its been along 603 days.
02:36:06Right? So thank you again too.
02:36:09Uh, yes, I understand totally
02:36:12fine under Sir question.
02:36:14Please do. Under comment on that.
02:36:18Thank you Linda. Yeah,
02:36:19I asked Linda along this line of hopefulness.
02:36:22I think that it's worth adding that in
02:36:25addition to the hopefulness for all kids.
02:36:28The pandemic and zoom has opened
02:36:31possibilities that would have been
02:36:33undrivable before we have conducted
02:36:36randomized control trials across countries.
02:36:38We've established and strengthened our
02:36:40international connections in ways that
02:36:43we haven't, and that's across the world.
02:36:44But I think it also applies to
02:36:47across the street across the campus,
02:36:49the interconnectivity that
02:36:51we realized was right there,
02:36:52in front of us, but we haven't seen it.
02:36:54So again, as a perennial optimist,
02:36:56I think that that's one of
02:36:58the Silver Linings.
02:36:59This all to terrible horrible time.
02:37:03To undress, I think we're
02:37:04closing on a theme of optimism.
02:37:07So again, thanks everyone for joining us.
02:37:10Very much appreciate your
02:37:11being with us virtually,
02:37:13and until we can be together in person
02:37:15we will be will be following up as well.
02:37:18Thank you again.