Child Mental Health: Fostering Wellness in Children

May 13, 2024

Information

May 8

Brain, Genes, and Neurodevelopment

ID11664

To CiteDCA Citation Guide

00:05I'd like to really start
00:07off by introducing Dr.
00:08Doctor Rohrbog who is serves as
00:10Deputy Dean for Professionalism and
00:12Leadership and he also overseas
00:14the Wellness programming for
00:15the medical school community.
00:16So welcome Doctor Rohrbog.
00:20Thanks so much, Peggy.
00:21One of OAP DS mission is to elevate
00:25well-being for faculty and staff at
00:27the School of Medicine and in surveys,
00:29our faculty and staff have
00:31suggested that the well-being of
00:33children is among their their
00:34most significant concerns.
00:36We're really fortunate to have world renowned
00:38faculty at the Yale Child Study Center
00:40who can help us
00:42to address that
00:43issue and meet meet that goal.
00:46And I'm going to turn it now over to Doctor
00:48Christine Olson, the Chief Wellness
00:49Officer of Fiona Haven Hospital
00:51who will tell us a bit about
00:54the PROS for peers program and
00:55to and to introduce
00:55Doctor Linda Mays who
00:56will be our host for this program.
01:00Thank you. Pros for Peers
01:02brings our own experts
01:03to improve the well-being of
01:05our colleagues and communities.
01:06And as indicated, colleagues said
01:09that the their well-being would be
01:11improved by better knowing how to
01:13support the young people in their life,
01:15especially in these times
01:16that we're living in.
01:17So thank you Doctor Mays,
01:19the Yale Child Study Center and
01:20the experts we have here today and
01:22we look forward to being together.
01:25Thank you so much, Doctor Mays.
01:29Yes. So thank you Doctor Olson.
01:31And I'm hi everybody.
01:33I'm Doctor Linda Mays.
01:35I'm the chair of the Child Studies Center.
01:37And it's really just my pleasure
01:39both to have you here today to be
01:41joining with our colleagues from OAPD
01:43and to be talking about something
01:45that if the Child Studies Center
01:47is our abiding concern every day
01:49about the well-being of children.
01:52I'm going to introduce my colleagues
01:53and then turn it to them.
01:54But just I want to just briefly tell
01:57you for those of you who don't know
01:58that the Yale Child Studies Center,
02:00we're a department in the School
02:02of Medicine work very closely,
02:04very aligned with the health system.
02:06And our whole focus is on thinking
02:08about how children grow in their
02:09understanding of their world,
02:11of the world and their skills
02:13they have to navigate that world,
02:15that increasingly complex world.
02:16We're a department that does
02:18developmental research.
02:19We deliver extensive clinical
02:21services to children,
02:23adolescents and their families.
02:25And we have a large educational
02:27program where we train the future
02:29clinicians and leaders in this field.
02:32And really most important to us
02:34is also the ability to talk with,
02:36with you like in this webinar to
02:38really find the opportunities
02:40to talk about what children not
02:42only in our country need,
02:43but across the world.
02:46So across this month,
02:47we're going to have sessions every week.
02:50Where we are talking in this in this
02:52May is Mental Health Month where
02:54we actually talk about children,
02:55we talk about children's development,
02:58we talk about the clinical work we're doing.
02:59We talk about how science informs how
03:02we can most help children and very
03:05much interested then and also what's
03:07on your mind and how we can be helpful.
03:10Today we're going to be focusing
03:12a great deal on a number of the
03:14areas that we talk about and work
03:16on in the Child Studies Center
03:18and I'll be and start to introduce
03:20you now to to my colleagues.
03:23But most importantly,
03:24what we're going to try to do today
03:26is to bring you into thinking
03:28about how we help children manage,
03:30for example, difficult emotions.
03:31How we follow families across time
03:34and stay involved in their lives.
03:36How we bring the most contemporary
03:39techniques from neuroscience and
03:41neurogenetics to understanding
03:43children's development and even how
03:45we take insights from clinical trials
03:47also to understand children's development.
03:50Our first speaker will be
03:52Doctor Jim Jamie Mcpartland,
03:54who is the Harris Professor of
03:56Child Psychiatry and Psychology.
03:57He directs A Developmental Disabilities
03:59clinic in the Child Studies Center and
04:01is one of the Co leads for the new
04:04Yale Center for Brain and Mind Health.
04:06And Jamie will talk about how
04:08brain science and improves the
04:10care of children with autism.
04:11Our next speaker will be Doctor Emily
04:14Olson who is talking about how to
04:17leverage genetics and understanding
04:18childhood developmental needs.
04:20I mean Emily will talk about not only
04:23that particular work but how she came to it.
04:27Doctor Julie Wolf is an associate
04:29professor in the center,
04:31working very closely with Doctor
04:34Mcpartland and developmental disabilities.
04:36And we'll be talking about how we go from
04:38clinical practice to research and vice versa,
04:40how we go back and forth.
04:42Doctor Dennis Sogadowski will
04:44be our fourth speaker,
04:45a professor in the Child Studies Center,
04:48and is focusing on how we help children
04:50manage really difficult emotions,
04:52emotions that are even as adults.
04:54We're all very familiar
04:55with like irritability,
04:57how we manage them,
04:58how we give children the skills to
05:00do that so that they can flourish
05:03and reach their fullest potential.
05:05And then our final closing speaker
05:07will be Doctor Ellie Leibowitz,
05:09who is an associate professor in the
05:11center and focuses a great deal on anxiety.
05:15Anxiety is something that is certainly
05:17for both adults and children in the
05:19air often and Ellie will talk about how
05:22he thinks about families and family
05:24based kind of work in helping children.
05:29We really encourage you to have questions.
05:31Please send your questions in the chat.
05:33Speak up while we want to
05:34engage with you in a discussion.
05:36Each person will speak about 5 minutes,
05:39but our goal is to truly have a discussion
05:41and to hear what's on your mind.
05:43So may I First turn to Jamie.
05:47Thank you so much, Doctor Mays.
05:48It's such a pleasure to have
05:50the chance to participate today.
05:52As Doctor Mays said, I, I, I, I,
05:54I exist in two primary roles here at Yale.
05:58One of my jobs is that I'm
06:00a a child psychologist.
06:03Another job is that I'm a brain
06:05scientist or a neuroscientist,
06:06trying to understand the way the
06:08brain is different in children who
06:11experience developmental difficulties
06:12or mental health challenges.
06:14One of the the biggest challenges in
06:17my role as a psychologist working
06:20with children is the very limited
06:23number of tools that we can deploy
06:26to understand and to anticipate
06:28difficulties in children's mental health.
06:31So really the way that I can learn how to
06:34help a child is by by talking with them,
06:38by playing with them.
06:40We work with adults,
06:41of course we can talk with adults.
06:43It's very important for us to talk
06:45with parents or caregivers so we
06:47learn about things that happen
06:48outside of the context of our clinic.
06:50But really when we think about all
06:52of these different strategies,
06:54we're relying upon a a human being's
06:57ability to observe differences in
07:00behavior and then we're putting
07:02a lot of weight making very,
07:04very important decisions based
07:06on these observations.
07:07This really, when you think about it,
07:09the way that we diagnose and treat autism
07:12and related conditions hasn't changed
07:14in the history of autism since the 1940s.
07:19The the challenges are that even among very,
07:22very skilled clinicians like that I'm
07:24fortunate to work with here at Yale,
07:26there's only so much you
07:28can see with your eyes.
07:29There's only so much a parent can see.
07:31And that kind of information doesn't
07:34give you much at all to go on if
07:36you really want to tell the future
07:39or if you want to intervene in
07:41a very nuanced and specific way.
07:44And so some of the work that we do,
07:47you know in the intersection of brain
07:50science and clinical work is to try
07:52to see if whether some of the tools
07:54that we and others have developed to
07:57understand differences in the brain can be,
07:59can be useful in these clinical settings,
08:01can kind of serve as a supplement,
08:04A bolster if you will,
08:06to the clinical insight that
08:08we rely on currently.
08:09If we could do this,
08:11if we could use a biological
08:13tool to inform clinical practice,
08:15we would call that tool a biomarker.
08:18So we apply this in a few different ways.
08:20Now we're actually in the middle
08:22of a very large study.
08:24We've seen 400 children with
08:26autism and without autism between
08:28the ages of 6:00 and 11:00.
08:30We're actually seeing a second group that
08:33will bring our total to 800 children,
08:35which is very large for neuroscience study.
08:37And we're measuring specific things
08:39in the brain that we think are
08:42very relevant to how they perform
08:44socially and to how they'll fare
08:46mental health wise in the world
08:48with these these 6 to 11 year olds.
08:52Unfortunately for 6 to 11 year olds
08:54with autism, about 42% of them will
08:57have clinical levels of anxiety
09:00by the time they're adolescents,
09:0214% will have clinical depression,
09:04which will be more like 30 or
09:0740% by the time they're adults.
09:09And so one of the the,
09:10the ways that we hope to apply
09:13these biomarkers is to understand
09:15and to anticipate these kinds
09:17of difficulties down the line.
09:19I mean we'll hear from my colleagues
09:21some of the really effective clinical
09:23tools they've created to intervene
09:26when these symptoms are manifest.
09:29How wonderful would it be if we could
09:31intervene even before these symptoms are
09:34causing difficulties in a person's life?
09:36I'll talk about one more
09:39application of biomarkers,
09:40and that's actually perhaps using biomarkers
09:42as a treatment target unto themselves.
09:45So when we develop a biomarker,
09:47we therefore have an understanding
09:49of the neural systems that
09:52are involved in a condition.
09:54So for example,
09:55when we develop biomarkers
09:56for depression and autism,
09:58we have a sense of what brain regions
10:00are functioning atypically there.
10:02And we actually now have technologies
10:04where we can change directly the
10:06way those brain systems work.
10:08We can use magnetic forms of
10:12stimulation that illicit,
10:14you know,
10:15that encourage the brain to be
10:16malleable to change that stimulate
10:18under active brain regions.
10:20And this,
10:21this may sound like science fiction,
10:23but it's not.
10:24This technique is actually an FDA
10:26approved treatment for depression.
10:28It's long been established in
10:30adults and actually last week was
10:33approved for use in adolescence.
10:35So we,
10:35we really feel like we're on the
10:38threshold of being able to make
10:40significant advances in both
10:42anticipating and then intervening in
10:44mental health issues for children
10:46and adolescents with autism.
10:48I'll stop there.
10:49Great.
10:51Thank you, Jamie. Thank you so much.
10:52What we'll do is we'll hear from
10:55each person and then please
10:57keep your questions and I'll
10:59be following the chat and then
11:01we'll have questions at the end.
11:02So Emily, please.
11:05So thank you for this opportunity and
11:08it's lovely to get to follow Jamie.
11:11So I am a child psychiatrist
11:14and a genetics researcher.
11:16And my interest in genetics really
11:18stems from my experiences seeing
11:21patients and wanting to understand
11:22why they have a condition and the hope
11:25that if we can better understand the
11:27biology and what's going on that we
11:29can then improve treatments for that.
11:31And so I'm going to start with kind of
11:33a historical perspective and kind of
11:35bring us up to what we're doing right now.
11:37So, you know,
11:38we've known for a long time as clinicians,
11:41as researchers that genetic factors are
11:43important for the development of childhood
11:47onset neuropsychiatric conditions.
11:48And we know this, you know,
11:50from family studies that look at
11:51how these traits run in families.
11:53We know this from twin studies that
11:56compare identical twins who share
11:59100% of their DNA with fraternal
12:02with fraternal twins that share
12:04on average 50% of their DNA.
12:06And these studies have provided us with
12:08what are called heritability estimates.
12:10So this is how much of A trait is
12:13due to inherited genetic factors.
12:16And what we know is that childhood onset
12:18psychiatric conditions are really heritable.
12:21So things like autism that we
12:23just heard about ADHD,
12:24these have heritability estimates of 7080%.
12:27And to me as a genetics researcher,
12:30those are really impressive numbers.
12:32But I think it's also important
12:34to try and contextualize those in
12:35terms of other medical conditions.
12:37So things like coronary artery
12:39disease has a heritability about 50%,
12:41breast cancer is about 30% and
12:45these are conditions where we know
12:46that genetics are already impacting
12:48prognosis and treatment.
12:50And so this makes me hopeful that
12:51if we better understand what are
12:53those specific genetic risk factors
12:55involved in childhood psychiatric
12:57conditions that that could really
12:59inform our clinical care.
13:02But it's really only been recently
13:05with advances in genomic technologies
13:07that we're starting to get a handle on
13:09what are those specific genetic risk
13:12factors and especially kind of genomic
13:14technologies like DNA sequencing and
13:17genome wide arrays that really look
13:19across all the genes in our bodies to
13:21try and understand what are the genes
13:24associated with these conditions.
13:26And specifically in child psychiatry,
13:29one approach that's been really fruitful
13:31for helping us find risk genes is
13:34comparing children to their parents DNA.
13:37So what we call looking at these parent
13:42child trios and this allows us not only
13:44to look at inherited genetic changes
13:46that are associated with conditions,
13:48but also new or de Novo mutations
13:51in the child That and all of us
13:54have some de Novo mutations,
13:56but when they occur within genes,
13:59they can really disrupt the
14:01function of the gene.
14:03And this approach was really
14:05pioneered in the field of autism.
14:07We've already heard a little bit about that,
14:09and they started by just looking at a
14:11few hundred of these parent child trios.
14:14But now they've looked at thousands
14:17of families and they've
14:18found hundreds of different genetic
14:21risk factors, So specific genes that
14:24are strongly associated with autism.
14:26And so now in a group of kids who have
14:29autism, you can find one of these genetic
14:31risk factors in 10 to 20% of kids.
14:34And this is really already informing
14:37clinical care because for families just
14:39understanding why they are child has a
14:42condition can be helpful understanding
14:44recurrence risk in other family members,
14:47certain of these genetic mutations are
14:49associated with medical comorbidities,
14:51things like seizures and cardiac conditions.
14:54And so recently with our work
14:55in the CHILD Study Center,
14:57we've been applying this genetic approach
14:59to try and better understand what are
15:02the genetic factors associated with other
15:05childhood onset psychiatric conditions.
15:07So looking at ADHD,
15:09looking at obsessive compulsive disorder,
15:12looking at anxiety,
15:13we'll hear a little bit from Ellie
15:15later and that's a we've been doing a
15:18collaboration with his group as well.
15:20And our work is showing that these
15:22conditions also have an increased rate
15:25of these new de Novo mutations and
15:27that we can then use that approach
15:30to try and find new risk genes
15:32associated with these disorders.
15:33So I'm going to wrap up now,
15:35but I guess,
15:36you know,
15:36my hope is that as we learn more
15:39about the genetics of these conditions
15:41that this will help us not only
15:44understand the biology but also
15:46inform our treatments and really
15:48help us care for these children
15:49who are continuing to struggle,
15:51right,
15:51that we're seeing in the clinic
15:52despite kind of our available
15:54interventions right now.
15:55So thank you so much for your time.
15:59Thank you so much. Emily.
16:01Julie, might I turn to you.
16:03Yeah, hi everyone.
16:04Thank you for the opportunity to speak today.
16:07So we've been hearing from my colleagues
16:09about some of the exciting and ground
16:11breaking science that's being done at
16:13our center in the field of neurodevelopment.
16:15I'm going to shift gears a little bit
16:17and talk a little bit more about the
16:19clinical side of our research and in
16:21particular how participation and our
16:23research can really benefit the families
16:25that that choose to volunteer their time.
16:28And I'll illustrate this through a case
16:30presentation of a boy who I'll call Aiden.
16:32So I first met Aiden in our
16:35developmental disabilities clinic
16:36when he was five years old,
16:38and he came in with an existing
16:39autism diagnosis, but he'd never had
16:41a comprehensive evaluation before.
16:43And so we saw him as part of a
16:45multidisciplinary team to take
16:47a look at how he was doing.
16:49And Aiden was a adorable,
16:52very chatty little guy,
16:54talked our ears off.
16:55But he really struggled with social
16:57reciprocity in the way that we expect
16:59to see in a child on the spectrum.
17:02And in particular,
17:02he tended to get really stuck
17:04on preferred topics,
17:05had difficulty sort of shifting
17:08topics and he also really struggled
17:11to follow another person's agenda.
17:13So he's very self-directed,
17:13kind of wanted to do his own thing
17:16and didn't really have that social
17:17reciprocity understanding of how
17:19you have to kind of give and take a
17:20little bit in social interactions.
17:23And what happened is that this
17:25this tendency really impacted
17:27his test performance.
17:28So I did a cognitive measure with him,
17:31an IQ test and his score came out in the
17:33range of intellectual disability at a 64,
17:36which is you know,
17:38much lower than we expect to
17:39see for a child of his age.
17:41But our entire team really felt
17:43like this was an underestimate
17:45because he was so self-directed.
17:47So for as an as an example,
17:49when I asked him to build with blocks,
17:51you know,
17:52I would have a target please
17:53try to make this design.
17:54He would say no thanks,
17:56I'm going to build a house, right.
17:57So he was really following his own
17:59agenda and really struggled and as a
18:02result that really affected his performance.
18:03And so our team gave the family the
18:06feedback that you know we're really
18:08not sure that this is accurate and it
18:10would be really great if you could kind
18:12of monitor his development over time.
18:14Well,
18:14of course clinical evaluations can be
18:16cost prohibitive for a lot of families.
18:18Even with insurance coverage,
18:20there's a often a pretty significant
18:22out of pocket expense.
18:23And this is where the benefits of
18:25research really came in for this
18:27family is because our research studies,
18:29at least in the autism program
18:31all include a no cost clinical
18:33evaluation with a psychologist.
18:34And so participating in our studies
18:38gave this family an opportunity
18:40to really obtain updates on
18:42their son's progress over time.
18:44So I saw him again about seven
18:45months later when
18:46he came in for a study
18:48in Doctor Ventola's lab.
18:50He continued to be pretty self-directed,
18:52but I started to see a little bit of emerging
18:55flexibility I think as a result of some
18:57of the interventions that had been put in
18:59place following our initial evaluation.
19:01So for example, when I said,
19:03you know it's my turn to show
19:04you what to do with the blocks,
19:05instead of resisting, he kind of self
19:07talked through it and said it's OK,
19:09I can't wait for it to be my turn again.
19:11So there's a little bit more flexibility
19:15there and this increased flexibility
19:16was really evident in his test scores.
19:18So his IQ where it was a 64 before just
19:21seven months later came out at an 88,
19:24which is in the low average range and that's
19:26a huge jump to see in just seven months.
19:28Now clearly we don't think that he actually
19:31gained 24 IQ points in seven months,
19:33but that this was really a reflection of his
19:36improved social communication and ability
19:38to follow or engage in adult LED activities.
19:41And then I saw him one last time at the
19:43age of seven when he participated in one
19:45of the studies that Doctor Mcpartland
19:47was just talking about in his lab.
19:50And he again,
19:51having now also completed Doctor Ventola's
19:55Social Communication Intervention Study,
19:57I saw even more improvements in his
20:00flexibility and social reciprocity,
20:02and that's reflected again in his
20:04test scores.
20:05He now came out with an IQ of 108,
20:07so solidly in the average range.
20:09And this was really much more on
20:11par with our team's initial clinical
20:14impressions that this was a boy
20:16who probably was average cognitive
20:17ability in the in from the get go,
20:20but just didn't have those social
20:22communication skills to be able
20:24to demonstrate his abilities.
20:25So it was really exciting to see
20:28this progress over time to get
20:30to follow this youngster.
20:32And I think that this case really
20:35highlights the benefits of our
20:37research program for families.
20:38We were able to follow his
20:40trajectory at no cost to the family,
20:41which might not have been possible for
20:43them given their resources if they were
20:46pursuing purely clinical evaluation.
20:47And as a result of this updated
20:50knowledge about his trajectory,
20:52we were able to kind of make
20:55developmentally appropriate
20:56recommendations for continued supports
20:57and interventions for their child.
20:59So I will stop there.
21:01Thank you.
21:03Thanks so much, Julie,
21:04and thank you for making it come
21:06to life with this story too.
21:08Thank you, Dennis.
21:10And I turn to you. Thank
21:13you. It's a pleasure to
21:14be part of this panel.
21:16I'm a clinical psychologist by training
21:19and professor in the El Child Study Center.
21:22My lab conducts research on challenging
21:25emotions in children and adolescents,
21:28and this includes experiences such
21:30as being easily frustrated and
21:33behaviours such as anger outbursts,
21:35meltdowns and temper tantrums.
21:37On one hand, this experiences and behaviours
21:41are part of life and typical development.
21:44On the other hand,
21:46if outbursts become too frequent,
21:48too intense, or pose risk of
21:50injury to the child or to others,
21:53this could represent a symptom
21:55of a mental health disorder.
21:57Some psychiatric disorders are diagnosed
21:59based on the presence and severity of
22:02anger outbursts as the primary concern,
22:04and this include oppositional
22:06defined disorder and disruptive
22:08mood dysregulation disorder.
22:10Other childhood disorders,
22:11such as ADHD, anxiety,
22:13and depression and autism often
22:16include frequent and impair and anger
22:19outbursts as an associated feature.
22:22During the past 10 years,
22:24this tendency to become easily frustrated
22:27and express anger and developmental
22:29inappropriate ways has been referred
22:33to as pediatric irritability.
22:35So my lab investigates different
22:38forms of psychotherapy that can be
22:41helpful for reducing irritability.
22:44For younger children,
22:46family therapy or parenting interventions
22:48can be particularly effective.
22:51During this type of therapy,
22:52parents learn how to best anticipate
22:55and understand their child's
22:57experiences or being upset,
22:59frustrated,
23:00and how to provide guidance when
23:04navigating potentially frustration
23:06situations in a common way.
23:08This includes strategies
23:09such as validating emotions,
23:11identifying alternative,
23:12more appropriate course of actions.
23:15This is something that we refer
23:17to as positive opposites and
23:20providing consistent praise and
23:22appreciation when the child
23:24demonstrates appropriate behavior
23:27in potentially frustrating situations.
23:30Starting from 8 years of age,
23:32children are also likely to
23:34benefit from cognitive behavioral
23:36therapy for irritability,
23:37and this is a form of psychotherapy
23:40that teaches emotion regulation
23:41and problem solving skills that are
23:44practiced in therapy and then between
23:47sessions to address potentially
23:50anger producing situations.
23:52Specific skills may include appropriate
23:54verbal responses to peer provocation
23:57and collaborative problem solving
23:59of disagreements with parents about
24:02rules and expectations at home.
24:04Social perspective taken is also another
24:06skill that is stored during cognitive
24:09behavioral therapy for irritability,
24:11and it refers to recognizing emotions
24:13and motivations of other people who
24:16are involved in a conflict situation.
24:20In addition to developing
24:22behavioral intervention in,
24:23my lab is also testing if clinical
24:26improvements can be parallel by
24:28changes in the brain mechanisms
24:31or biomarkers of irritability.
24:34And to this end,
24:35we discovered a number of structural
24:38and functional differences in
24:40prefrontal cortex of children
24:42seeking treatment for irritability.
24:45This includes reduced thickness of
24:48ventral lateral prefrontal cortex and
24:51reduced connectivity of prefrontal
24:53cortex with the rest of the brain.
24:57We're also testing if the effects of
25:01multiple occurring disorders influence
25:03the brain systems implicated in
25:06irritability and aggressive behaviour.
25:08So, for example,
25:09we found that the presence of social
25:12impairment such as difficulty
25:14understanding social situations is
25:17mediating the association of anygdala
25:20connectivity with ventralateral
25:22prefrontal cortex and known by a
25:25marker of emotion dysregulation.
25:27So this knowledge about brain structure,
25:29function and development is guiding our
25:32search for biomarkers and newer predictors,
25:35or psychotherapy for emotion dysregulation.
25:39Even best evidence,
25:42evidence based interventions are only
25:44helpful for about 60 to 65% of participants.
25:47So we're all hope that finding by
25:50markers of effective psychotherapy
25:52will help us identify who is
25:56likely to benefit and develop new
25:59treatments for children who are not
26:02benefiting from existing treatments.
26:03So currently we're developing and
26:06testing new psychosocial interventions
26:08for patient populations where effective
26:11treatments are not yet available.
26:13We are conducting A clinical
26:15trial of comprehensive therapy
26:17for irritability in adolescence
26:19with Otis and spectrum disorders.
26:21So this is a fairly narrowly
26:24defined population in terms of
26:27age and symptoms severity,
26:29but a group that really doesn't have
26:34much by ways of research or clinical
26:37services for anger outbursts and
26:39irritability that can be really
26:42impaired for these children.
26:44And the long term goal of our clinical
26:47research is to identify evidence
26:50based treatments that engage brain
26:52mechanisms of psychopathology,
26:54reduce symptoms,
26:55severity and most importantly,
26:58optimize quality of life of
27:01children and their parents.
27:04Thank you,
27:05Dennis. Thank you very much.
27:06And there is a real relationship
27:09between irritability and anxiety and.
27:11And anxiety. Yes. Yeah.
27:14Let me turn to Ellie.
27:17Well, thank you very much.
27:19I'm Ellie Leibowitz.
27:20And I have to say just this past
27:24half hour really captures why I
27:29love my job and working at a place
27:33like the child study center and
27:36why I feel so fortunate to be you
27:39know this this is my my day-to-day
27:41of people listening to this call.
27:43Maybe they're you know have like
27:45a here's a chance to listen this
27:47is my day-to-day of you know
27:49just be working with these folks.
27:50And so it it's such an honor and
27:53and a real joy and my focus is on
28:00anxiety which even as I like to say
28:04even in the best of times is the
28:07most common mental health problem in
28:10children really throughout the lifespan.
28:13And the reality is that we haven't
28:17been living through the very best of
28:19times and there are so many stressors
28:22kids you know are coping with over the,
28:25you know, recent years and we've
28:27seen so much escalation,
28:28so much real surges in the
28:33prevalence of anxiety disorders
28:35and elevated anxiety overall.
28:37And so it's a really important
28:39field to be to be thinking about.
28:41I know that so many parents are concerned
28:44about anxiety in their in their kids.
28:47And one thing that has been really
28:50exciting for me is to be part of a
28:53rethinking of the way that we understand
28:56and think about anxiety in children.
28:59Because historically,
29:01anxiety in children was understood
29:05essentially as the same thing as
29:07anxiety in adults in a smaller package,
29:11but basically the same problem And
29:14treatment was also geared toward that,
29:17toward that understanding.
29:20But one thing that has really
29:22become more and more a focus for
29:25our field in this area of anxiety
29:27is the acknowledgement of the fact
29:29that actually anxiety doesn't work
29:31quite the same way in children.
29:33And one reason for that is that
29:36children are born not really very good
29:39at defending themselves from threats.
29:41And so we're kind of evolutionarily
29:44programmed when we're anxious
29:46and young and immature,
29:47and this is true across mammalian life,
29:49we're really programmed to look
29:51to our parents, our caregivers,
29:52to look to them for help when
29:54we're feeling anxious.
29:56And that means that when a young
29:58person struggles with chronic anxiety,
30:00their parents tend to struggle as well,
30:03and to get really sucked in to
30:06responding to that child's anxiety.
30:08And parents of anxious kids face endless
30:11dilemmas about how should I best respond?
30:13You know,
30:14when is it right to push?
30:15When is it right not to?
30:16How much should I reassure?
30:18And they find themselves doing a lot
30:20of accommodations of their child's anxiety,
30:23meaning changing their own behavior in
30:24order to help their child not feel anxious.
30:27And that's really well-intentioned,
30:29but a lot of research actually
30:31shows that it doesn't necessarily
30:32reduce anxiety over time.
30:34And so one implication of this,
30:36one really important translation
30:38of this has been into an entirely
30:40parent based treatment that
30:42we developed right here at
30:43the Child Study Center and that is
30:46now really widely disseminated around
30:47country or around the the world.
30:50And it focuses on helping parents
30:52to change how they are responding
30:55to their child's anxiety in order
30:58to help that child to cope better.
31:01And another really important benefit
31:03of that is that if you have an
31:05anxious child who is not themselves
31:07an ideal candidate for treatment,
31:09well parents are actually able to
31:11do that treatment even then and
31:13still help the child to get better.
31:15And going back to what I really
31:16started with about, you know,
31:17really the the joys of working here,
31:19some of that is the collaborations that
31:21we've been able to form in this context.
31:24Emily mentioned the work that we've
31:26done together in in in genetics.
31:29I also work with collaborators who are
31:31collaborators who are really brilliant
31:33neuroscientists like Dilly G in psychology.
31:36And we did some really interesting research.
31:38And what we showed is that when
31:40parents are able to follow this
31:42treatment and change how they're
31:44responding to their anxious child,
31:46cut back on some of those accommodations,
31:48build the child's own confidence in coping,
31:51you actually see really significant changes
31:54in that child's brain response to fear.
31:58So that before the treatment children
32:01tend to really struggle with engaging
32:04anxious children at least really struggle
32:07to engage their regulatory circuitry.
32:09You know those parts of their
32:10brains that are going to be crucial
32:12in turning off the anxiety ones,
32:13it is triggered and following the treatment.
32:17We see a really big increase in
32:18that so that children are just
32:20engaging those regulatory regions
32:22in a much more powerful way.
32:24I think that's an incredible take
32:25home message for any parent.
32:27It's like you can change how
32:29you're responding to your anxious
32:30child and not only do you see them
32:32getting less and less anxious,
32:34you're actually changing how
32:36their brain processes fear.
32:38That's I think a really hopeful message.
32:42And I'm sure lots of you listening have
32:45a lot of questions from everything that
32:48you've from everything that you've heard,
32:50starting with Jamie and and and Julie
32:52and Emily and Dennis and myself.
32:55And so we're happy to do our best to,
32:58you know,
32:59answer whatever questions there might be.
33:00Thank you so much,
33:05Linda. I think you're muted.
33:08Thank you. Thank you.
33:09After so many years on Zoom,
33:10I remember that never goes away and
33:13I never heard that there's a number
33:15of there's a couple of questions
33:17on in the question and answer that
33:19that may just start with and Emily,
33:21I think maybe both of these
33:23might be good for you.
33:25First one is how early the
33:27earliest age can you compare
33:29children to their parents DNA.
33:30That's one.
33:31And then the second is how accurate
33:34is QB testing in the diagnosis
33:37of ADHD in teens And there's some
33:39question about the Vanderbilt tool.
33:41So I know that ADHD is one of your
33:44your areas of interest as well.
33:46So may I turn both of those to you?
33:50I will. I will do my best, but I have,
33:52I think there's other expertise here
33:54as well in the group on on this.
33:56So in terms of specific DNA testing,
34:01so clinical testing usually right
34:05now is restricted to as I as I
34:08discussed in my talk really autism.
34:10We we know the most about the
34:13genetics and most of the governing
34:15bodies kind of suggest that if a
34:18child has a diagnosis of autism
34:21that they should have a chromosomal
34:24microarray which looks at these larger
34:27copy number variants and that they
34:29should have Fragile X texting and if
34:35and and as well as kind of a few
34:38other specific tests but the but the
34:41and then if nothing is found on those
34:44tests then they often kind of maybe
34:46we'll consider DNA sequencing really
34:48looking at all the bases in the body.
34:51And I will say you know those
34:54recommendations have been here for a
34:56while and I think the field is actually
34:58moving faster like we're discovering
35:01more and more genetic changes.
35:02And so I my sense is in the future it
35:05will shift to kind of DNA sequencing
35:07coming earlier on in the algorithm as we
35:10know more of the genes involved and the
35:13clinical implications are more clear.
35:15And I I think also the other
35:17thing about this is you know the
35:18cost is dramatically declining.
35:19I didn't talk about this,
35:21but you know often in these genetics
35:23talks when they're slides you see that
35:25classic kind of curve of how the cost of
35:29DNA sequencing has dramatically dropped
35:33and and so now you know it's only a few
35:37$100 to sequence your DNA which compared
35:40to like a brain MRI is really cheap.
35:43So, so it's it's I I think it
35:45is something that will become
35:47part of more in clinical care.
35:50But I I wanted to say that I don't
35:52think there's a limit on the age
35:55definitely for research studies,
35:56not necessarily We tend to in our research
35:59studies see kids above a certain age
36:01when we do it just because they have to
36:03have kind of had the diagnosis already.
36:05And usually kids, you know,
36:07there's can be a delay in terms of
36:09when they received these diagnosis,
36:11but I don't think there's a limit.
36:12And the thing about looking
36:14at your DNA is your DNA,
36:17it doesn't really change that much, right.
36:19Like you have that test done and it's kind
36:21of those are your genetic changes throughout.
36:24Yeah.
36:24I mean, you acquire some mutations, right,
36:26like cancers and acquired mutations,
36:28but you know, your DNA is your DNA.
36:31So it's kind of one of those
36:33tests you only do once and you
36:36can reanalyze it as we know more.
36:39So anyways,
36:40so those are some thoughts,
36:41but others please feel free to add on
36:45to that as well 'cause we have a lot
36:47of the autism experts on the call,
36:49if they may have different thoughts.
36:51The other question about ADHD testing,
36:55so I'm not I wouldn't say I'm in,
36:58I do do research on ADHD,
36:59but I think probably some of the
37:01groups that other the psychologists
37:03on the group may be able to answer in
37:06terms of the validity of these tests.
37:08I will say classically when we diagnose ADHD,
37:12we do kind of look at multiple assessments,
37:15right.
37:16So if you're doing it based on
37:19kind of self report,
37:21which is what the Vanderbilt is or
37:23the SNAP or something like that,
37:24you know, we give screeners,
37:27we have the parents complete them,
37:29we compare them to the teachers
37:30because we want to see that they're
37:33having kind of clinically significant
37:35symptoms in multiple settings.
37:37They do kind of work differently
37:39a bit in teens.
37:40Like if you look at the questions,
37:41some of the screeners are a
37:43little better for some age groups
37:46compared to other age groups,
37:48but but there also are.
37:50So that's kind of the self report testing
37:52that often like pediatricians will give out,
37:54they'll give out Vanderbilts
37:56like at an appointment,
37:57but then there also are kind of
38:00more formal kind of clinician
38:02administered assessments,
38:03so things like the Connors and
38:05stuff like that which can be a
38:08little more specific as well.
38:12Does anyone want to add any thoughts to
38:13these? I know we have a lot of people who
38:15do these types of assessments as well.
38:18Any other thoughts? I'm
38:21happy to add. Specifically I wasn't
38:23familiar with the the QB test.
38:25I just looked at it online and
38:27it actually it's you know it's a
38:30proprietary version of of a test
38:32that psychologists or and and others
38:34use really to evaluate symptoms of
38:36ADD to the test that requires you to
38:39continuously maintain attention and and
38:40sees how good you are at you are at.
38:42So that in principle it's it's
38:45a valid approach.
38:46I think the problem with anything like
38:48that is that your attention can be
38:51disrupted because you're anxious that day.
38:53You're depressed because you
38:55have autism many.
38:57And so that that style of approach is valid.
39:01But you would want to pursue it
39:03in the context of a relationship
39:05with a clinician who can think in
39:08a careful way about not just your
39:10performance on the test today,
39:12but your history and then all the
39:14other different kinds of diagnosis
39:16that could be ruled in or ruled out.
39:22I think another question comes up
39:24that actually may apply to to everyone
39:26and to is to ask how can people
39:29in the community, our community,
39:32our health system community more more
39:34broadly and help make advances in the
39:37areas that you've been talking about?
39:39Do you have any of you have
39:40thoughts about that?
39:41Well, Jamie in particular,
39:44Oh my gosh, do I have thoughts about that?
39:46Yes, we have the we have a really
39:49strange job in that we our whole
39:52purpose is to learn about these
39:54conditions that affect children.
39:56But we can't make any progress at all
39:59without the collaboration and partnership
40:01with those children and their families.
40:05Every person that you heard speak
40:07today can't do their work unless a
40:10family decides it is worth their
40:12while to get in the car to come to the
40:15Child Study Center to meet with us.
40:18Whether it's for a clinical appointment
40:19or whether to come to one of our
40:21research facilities and participate
40:22in the study so that, you know,
40:24I'm so glad that Doctor Wolf talked
40:26about the way that research can benefit
40:29participants from a clinical perspective.
40:32You're also benefiting everyone else
40:34in your shoes forever down the line.
40:38And so really it is,
40:40it is an important,
40:41it can be beneficial to you on that day,
40:45it can be beneficial to you and
40:46your child down the road and
40:48it can be beneficial to earth.
40:50And so it is a families are hugely important
40:53and can help us forward in that way.
40:58So here's here's some other
40:59questions that have come forward
41:01in the question and answer.
41:02Then I think I'll pose this next
41:04one broadly again to the group Can
41:07spirituality help with interventions
41:08and growth for children's for children,
41:12Anyone want to start with that?
41:19And I can say it's not my area of expertise,
41:21but we definitely think about spirituality
41:24as a protective factor for kids.
41:27You know if they if that's an
41:29important part of their life.
41:31In fact even you know if we
41:32conduct a risk assessment,
41:33if we have concerns about,
41:34you know, child harming themselves,
41:35one of the questions we ask about is
41:38spirituality and whether that is something,
41:40you know, that's important to them.
41:41And and if so,
41:42we see that as a positive,
41:43as something that would be sort
41:45of protective against them wanting
41:47to bring harm to themselves.
41:48So it's definitely a relevant
41:50factor that we think about.
41:53Maybe I could, I would just add IA 100%
41:56agree spirituality is a protective factor
41:59and it it can be a really important one.
42:02But it is also important to remember that
42:06spirituality is not the forceful imposition
42:10of a particular attitude on a child.
42:14It is the, you know it Sometimes it's it's
42:18hard to distinguish between your spirituality
42:21as a parent and how your child feels.
42:26And I think the things that provide
42:28the that protective element,
42:30that build that resilient, you know,
42:33they're the shared factors.
42:34They're things like the
42:35the sense of community,
42:37the sense of purpose in life,
42:39the sense of love and belonging.
42:42These are the elements that end up providing
42:46that really important protective factor.
42:49So just I guess what I'm saying is
42:52important to remember the distinction
42:54between spirituality and the and the
42:56sense that it provides and any specific
42:59or particular attitude or approach or,
43:01you know, thought system.
43:04Thank you, Allie. Anyone else?
43:10Molly, another question has come
43:12across in the question and answers
43:14about our holding parent workshops
43:16for parenting an anxious child.
43:18I thought that might be for you. Yes.
43:21Well stay tuned is the is the best answer I
43:26can give right now because actually yeah,
43:29we are planning to have current workshop.
43:33We have done events with many parents.
43:36We have had an annual anxiety forum that
43:39was typically live in person and then
43:42also was done over zoom because of COVID.
43:45But we're we're planning to have a
43:48parent specific sort of mini workshop and
43:50we're ironing out some of the details.
43:52So I guess I would say stay tuned for
43:54that and more information to follow.
43:57But in the meantime, without the workshop,
43:59if people want to kind of learn a
44:01little bit more about the parenting
44:03approaches that I was referring to
44:05and if that's why they're asking,
44:08I would point to some other resources.
44:09Like there's a website that focuses
44:12on the treatment that I mentioned and
44:15the website isspacetreatment.net and
44:17there's a book that really lays it out
44:19in a very parent friendly kind of way,
44:21which is called If you'll forgive
44:22the self plug,
44:23because I am the author of the of the
44:26book and make $0.05 every time you buy it.
44:28So I I'll acknowledge that,
44:30but the book is called Breaking
44:33Free of Child Anxiety and OCD.
44:36And so until you tool work is worth
44:40coming for the parent workshop,
44:41those are other ways to gain
44:43more information about it.
44:46Thank you. Another question,
44:47which I actually would just
44:49put to the whole group.
44:52When will a child's brain
44:55fully finish to develop?
44:56And is there any point in that
44:59development where things like
45:00anxiety or depression or any of
45:03the things that we're talking about
45:05will change as the brain develops,
45:10certain systems develop?
45:11May I bring that to the group?
45:17So I I can probably start by
45:22expressing my hope that the
45:24brain doesn't stop the device
45:26that doesn't start to develop,
45:28that it continues to
45:29develop through a lifetime.
45:31And there are certainly developmental
45:33periods that provide windows of
45:36opportunity to give children the tools of
45:41emotion regulation or social emergencies.
45:44That can change the transition of
45:49symptom development from chronic
45:51anxiety to time limited anxiety where
45:54a child can outgrow a particular
45:57emotional disorder such as anxiety,
46:00depression or temper tantrum.
46:02So that in my area we actually see that
46:06the majority of children outgrow anger
46:09management difficulties so that we're
46:11trying to see how to help those who
46:14tend to stay on a chronic trajectory
46:20miss others other responses.
46:24I I would agree with what Jenna said.
46:26I think, I'm not sure what
46:27is behind the question,
46:28but I I guess I would just say for
46:30anxiety and for depression, yeah,
46:32these things can change as the brain matures,
46:36but everything we know about these
46:39problems suggests you should not be
46:42waiting for a child to outgrow them.
46:45And I I don't know that that is like
46:47part of the thinking in the question.
46:48But if it is, it would not be my advice
46:51to wait for a child's brain to kind of
46:53mature out of anxiety and depression.
46:55These problems untreated actually
46:57tend to be quite chronic,
46:59lasting well into adulthood,
47:01even if they start in childhood.
47:05And I think a much better suggestion
47:08would be to treat it and treat it soon
47:11because they are treatable problems,
47:13but they don't actually tend to
47:15all that frequently just kind
47:17of go away on on their own,
47:18even as the brain does develop
47:20and some changes might occur.
47:24And I think the one thing that
47:25I would also add is one of the
47:28very exciting things about our
47:29field is we used to have this,
47:31this notion that brain development,
47:33by the time you got to a certain
47:35age and adolescence was done,
47:37what we realized is the brain is an
47:40extraordinary dynamic organ and is changing,
47:42developing throughout the lifespan,
47:44even in old age, which is one of
47:47the reasons now we know that with
47:49strokes that the quicker we intervene,
47:52the more likely for recovery because
47:54the brain is repairing itself.
47:56So we think a lot about periods of what
47:59we call plasticity or openness to change,
48:02but we know that the brain is really
48:05changing tremendously throughout and very
48:08open to input from environment experience.
48:13Let's see,
48:14there's some other questions here.
48:17Are there clinical, are there clinical
48:20differences in treatment when it is
48:21a child has a mental health diagnosis
48:24due to a traumatic brain injury?
48:27Anyone want to start with that?
48:35I mean, yes, I think that it's going to it.
48:38Traumatic brain injury can mean many
48:40different things, but I mean it means
48:43that the in a generic way it means the
48:46brain isn't going to be working as
48:48you would expect it to and how that
48:50can look and can be in different ways.
48:52So individually, you might treat anxiety or
48:55irritability using the same kinds of tools,
48:58for example, that Ellie and Dennis described.
49:01But you'd also really want to be aware of
49:03many of the different kinds of learning,
49:06sensory, perceptual differences that
49:07might be at play in a person who's
49:10experienced traumatic brain injury.
49:12Because, you know, most of the most of
49:14the therapies that we heard are about are
49:16about teaching in one form or another.
49:18And so those children are going
49:20to learn very differently.
49:21But it's a, it's a complicated question.
49:23But yeah, there's in fact, in fact,
49:25even if you don't have TBI,
49:27any person with a different kind
49:29of learning profile is going to
49:30experience some nuance in the way
49:31they're going to respond to him,
49:32you know, and best be taught these
49:34different kinds of therapies.
49:35So that's an extreme example.
49:37But yes,
49:39more thoughtful and nuanced
49:40approaches would need to be applied.
49:42And what in that circumstance,
49:43what you probably want to do is have
49:45what's called the neuropsychological
49:47assessment so that you have a really
49:49deep understanding of what kinds
49:51of cognitive systems are intact and
49:53which have been affected in a in
49:55a detrimental way by the injury.
49:59Thank you. Anyone else on that question,
50:04I
50:07want to pick up another question that I
50:09can certainly start with a response to,
50:12but then I'll turn to my colleagues as well.
50:15One of the questions is,
50:17are barriers being addressed
50:18for families to be able to
50:20participate in accessing treatment.
50:22And the person asking the question
50:25raises something that keeps us up at
50:27night all the time and that is that
50:29families face difficulty in getting
50:31access to mental health treatments.
50:33And that is absolutely true.
50:36And and I'm not being light when
50:38saying that it actually is one of the
50:41things that worries us a great deal
50:43and that we're trying to work on.
50:45Indeed it is.
50:46It is true across the country that
50:50among the many children who need care,
50:53mental health care,
50:5580% of those children won't have access.
50:58So access is not just a local issue,
51:00it is a national issue,
51:02indeed an international 1.
51:03So I can say First off,
51:06we would be if you have a if you have,
51:08you say that the questioner says they
51:10found it really difficult to provide.
51:12Find a provider. I'd be glad.
51:14I'd be glad to talk to you.
51:17We'd be glad to try to help to connect you.
51:20The other piece I would say is that
51:21some of the things that we're doing
51:23and then I'll turn to my colleagues is
51:25that for example we're Co locating or
51:28embedding mental health clinicians,
51:30psychologists and pediatricians practices
51:33in our Pediatrics subspecialty services.
51:37We have a new grant from the state to help
51:39us do that in community pediatric practice.
51:42We're really working on telehealth and
51:44how to continue to make telehealth or
51:47virtual virtual treatments available.
51:49We're still about a third.
51:52Our treatments are delivered
51:54virtually and we're constantly trying
51:56to breakthrough this access issue
51:58'cause it it is, it is probably,
52:00I think,
52:01the most single concerning thing
52:03about mental health care for children
52:05and adolescents in our country.
52:07But let me let me turn to my colleagues
52:09and see what else they would add.
52:18I mean, I would read it,
52:19reiterate what you said.
52:22You know, it is a huge challenge that
52:24we're facing and trying to grapple with
52:27and it's something we think actively a lot.
52:28We don't always have perfect solutions.
52:30But for example, I sit on our
52:32department's assessment triage team
52:34where we review intakes from families
52:36interested in psychological assessment
52:38and sort of decide which of our
52:40programs would be best for them.
52:42And and access and sort of getting
52:43families in as quickly as possible
52:45is one of the things we're always
52:47talking about in that meeting.
52:48You know, which clinic can see them soonest.
52:50A lot of times we send them to
52:52research studies just to again,
52:53highly benefit of research as many
52:56times their needs can be met through
52:57a research study that doesn't
52:59have a weight at all.
53:00So, you know,
53:01there's no perfect solutions to this problem,
53:02but it is something that we're
53:04always thinking a lot about.
53:05Thank
53:06you, Julie. So I think we have time for
53:10maybe one more question and and Dennis
53:12this to be a question for you on the
53:15question is in any of the interventions,
53:18the interventions that you're doing
53:20like something like positive opposites
53:22be helpful for parents who are managing
53:25episodes of irritability in their
53:27adolescence and their teenagers?
53:32Absolutely. And I I think that in
53:36clinical practice we always use
53:38kind of a combination of parenting
53:41strategies and interventions that
53:43are conducted with the child.
53:45So there is always a mix of working with
53:48a family and working with a teenager
53:51and there is like a long list of of
53:57strategists that clinicians can pick
53:59depending on the family circumstances
54:02and particular personality profiles of
54:05the teenager and and their parents.
54:08So overall I would say that the
54:12strategists exist and of course then
54:15kind of irritability and anger outburst
54:19could be just the top portion of like
54:24a long list of other difficulties
54:27that a teenager might experience.
54:29So this is really important to have
54:32a comprehensive evaluation to make
54:35sure that this emotional outbursts
54:38are understood in terms of like deep
54:42clinical evaluation of the child.
54:46Thank you, Dennis. So I did say we
54:48had time for one more and that was it.
54:50But there's one more of that maybe Julie,
54:53Jamie, you can take the accuracy of
54:56assessment tools for non-native English
54:58speaking children comments on that.
55:03I mean they're most of the
55:04tools that we use are available
55:06in many different languages.
55:07I think the the more relevant
55:09limitation is the the,
55:11the diversity of languages
55:12spoken by the clinicians,
55:13that's a real challenge.
55:14And so the way that we address
55:16that we'll never have a clinician
55:17who could speak every language and
55:19all that all the patients that
55:20we would love to see can speak.
55:22And so the way we we handle that
55:23as we leverage the resources of
55:25the hospital system which have
55:27interpreters who do speak just
55:29about every language that anyone
55:31whoever want to see with us.
55:31And so we administer those those
55:33assessments in tandem and partnership
55:35with an interpreter so that we
55:36make sure we're understanding
55:37families and children in a in
55:39the language that they're most
55:41comfortable communicating in.
55:43The only thing I'll add to that is
55:45that we also have to be mindful about
55:47the content of the tests because if
55:49we're giving a a test that was norm
55:51for an English speaking or American
55:53population with somebody you know
55:55from a different country or culture,
55:57then there might be content in there
55:59that's not, you know, relevant.
56:00And so we just have to be thoughtful
56:01when we're interpreting those
56:02results of those factors as well.
56:05Thank you. Well,
56:07we really appreciate all of you joining.
56:10I thank you for taking the time.
56:13If you want to hear more about our work,
56:16First off we're doing three more
56:18sessions with others of our colleagues.
56:20Next week, next Wednesday we'll be talking
56:22about work in the community because
56:24the trial studies center you heard a
56:26lot about our clinical research today.
56:29We are very embedded in the community.
56:30We do a lot of work in the community.
56:32So next week we hear about that.
56:35You're also very welcome to come to our
56:38grand rounds on Tuesday afternoon at 1:00.
56:40They we do always have a virtual link
56:42which we can certainly send out.
56:44And next week we're talking about
56:46the use of art and mental and work
56:49with mid children and adults around
56:52mental health and have a one of
56:54our faculty who is also an artist
56:56on giving giving a talk.
56:58So again thank you so much for joining us.
57:01And to OAPD and Dr.
57:03Rohrbao and Dr.
57:04Olson thank you for bringing us all
57:06together and honor Mental Health Month.
57:08Thank you.