Why are We So Confused by Angry, Traumatized Youth? Challenges to Diagnostic and Treatment Specificity in Youth with Complex Trauma

Transcript

• 00:02Good afternoon.
• 00:05Everybody everybody is so excited
• 00:07about today's grand rounds
• 00:09as you should be.
• 00:10So before the excitement of
• 00:12grand rounds, just a couple
• 00:13of bureaucratic thingies.
• 00:16CEUs
• 00:17are available,
• 00:18and you need to
• 00:21log on the QR code
• 00:22back there, and it'll walk
• 00:24through. That's for social work
• 00:26EEUs.
• 00:27And CMEs,
• 00:30were hard at work,
• 00:31trying to address that. So,
• 00:32hopefully, before the end of
• 00:33the presentation, we'll we'll let
• 00:35you know.
• 00:36And that's it for bureaucracy.
• 00:41So today, I'm I'm just
• 00:42thrilled with the,
• 00:44the presenter we have today.
• 00:47A dear friend
• 00:48from long long time ago,
• 00:51from Boston initially,
• 00:53but she has traveled, south
• 00:54to New York where she
• 00:55has built this extraordinary career
• 00:57that we're gonna hear a
• 00:58little bit about.
• 01:00So,
• 01:01Jenny Havens has,
• 01:03way too many titles and
• 01:05honorifics
• 01:06that I could turn into
• 01:08sophorifics, so I won't do
• 01:09that. But I'll tell you
• 01:10that she is the Arnold
• 01:11Simon professor
• 01:13and the chair at the
• 01:14NYU Child Study Center
• 01:16where she has, done a
• 01:18remarkable job
• 01:20in,
• 01:20growing the place in, put
• 01:23putting it at the at
• 01:24the cutting edge.
• 01:25And she has done so
• 01:26in in a number of
• 01:27ways, but
• 01:29the two that I'll mention
• 01:31are that,
• 01:32her long standing interest has
• 01:34been trauma.
• 01:35And,
• 01:36she and her team have
• 01:38put together
• 01:39incredible interventions,
• 01:41evidence based,
• 01:42interventions for traumatized children
• 01:45ranging from inpatient
• 01:46units
• 01:48to the outpatient world and
• 01:49everything in between.
• 01:51Some years ago, Jenny was
• 01:53the lead person in putting
• 01:55together
• 01:57the CIU, CPIU,
• 01:59CUU
• 02:00something. There's a c and
• 02:01there's a u in there.
• 02:02But it's the largest,
• 02:04child psychiatry emergency room intervention
• 02:07in, in in New York,
• 02:09again, with a lot of
• 02:10evidence based trauma informed care.
• 02:13And,
• 02:14once you know her, you're
• 02:16gonna see just how shy
• 02:17she is. She's very, very
• 02:18shy.
• 02:20And it takes a lot
• 02:21of shyness to go hand
• 02:23to hand in arm wrestling
• 02:25with the big boys and
• 02:26girls in New York City
• 02:27and New York State.
• 02:29And Jenny has done that
• 02:30through her career, and she
• 02:32has done
• 02:33changes not only at the
• 02:34NYU level, but at the
• 02:36city level and very impressively
• 02:38at the state level. She
• 02:39is, you know, right up
• 02:40there,
• 02:41with our friend the mayor
• 02:42and with all sorts of
• 02:43people in New York, you
• 02:44know, pulling doll dollars out
• 02:46of their back pockets. I
• 02:47don't know how she does
• 02:48it, but she has really
• 02:50brought child psychiatry into a
• 02:51whole new level of,
• 02:53disability.
• 02:54So I is that enough,
• 02:56or should I say more?
• 02:56That's enough. Fuck it. That's
• 02:57enough.
• 02:58She says that's enough. Okay.
• 02:59So I give you my
• 03:00dear friend, Jenny Havens.
• 03:03It's nice.
• 03:07Thank you, Andres. I'm gonna
• 03:09stand up here.
• 03:11Thank you for that kind
• 03:12introduction,
• 03:13and I
• 03:14am absolutely thrilled to be
• 03:16here at the other department
• 03:17of child and adolescent psychiatry
• 03:19in the country.
• 03:22I just met your chair
• 03:23and we have elaborate plans
• 03:26about how we're gonna change
• 03:27the world. I was at
• 03:28Columbia for my entire career
• 03:30and I went to NYU
• 03:33in two thousand and eight
• 03:34expressly
• 03:35to divide
• 03:36the child psychiatry service at
• 03:38Bellevue
• 03:40off from adult.
• 03:41And that's literally what they
• 03:42did. They divided it off
• 03:44and gave us nothing. So
• 03:45we were clawing our way
• 03:47things out of the walls
• 03:48there. But, you know, Bellevue
• 03:50is the we call it
• 03:51the cradle of American child
• 03:52psychiatry
• 03:54because,
• 03:55first one of the first
• 03:56two child inpatient units in
• 03:57twenty three, the other at
• 03:59Hopkins, and then the first
• 04:00adolescent unit in thirty seven
• 04:02in the country.
• 04:03Lots of research,
• 04:05in the, over the twentieth,
• 04:08twentieth century.
• 04:10And it's a public hospital.
• 04:13So, in New York City,
• 04:14I was explaining to my
• 04:15colleagues here in New York
• 04:16City, most of the behavioral
• 04:18health work has been delegated
• 04:20to the public hospital system.
• 04:21There are eleven hospitals,
• 04:24serving the city. And because
• 04:26behavioral health doesn't make money,
• 04:28it's been pushed out of
• 04:29the privates into the public
• 04:30system.
• 04:31So Bellevue was an extraordinary
• 04:33place to go as in
• 04:35terms of its history.
• 04:37And also, I convinced them
• 04:39that child psychiatry was important,
• 04:42to the point where the
• 04:43CMO would say things like,
• 04:44you know, we're a good
• 04:45hospital. Bellevue is a good
• 04:46hospital because of its relationship
• 04:47with NYU.
• 04:49But the only thing we
• 04:50do that nobody else does
• 04:51is child psychiatry.
• 04:53So we now have the
• 04:55entire,
• 04:56an entire floor.
• 04:57Every floor in Bellevue is
• 04:59an acre.
• 05:00And,
• 05:02we have an acre of
• 05:03article twenty hate space for
• 05:05acute child psychiatry. So I
• 05:07was blessed to be there.
• 05:08I knew about trauma before
• 05:10because my previous work early
• 05:13in my career had been
• 05:13with families affected by HIV,
• 05:15which was substance abuse.
• 05:18But it was very clear
• 05:19to me working in this
• 05:21setting that it was a
• 05:22huge,
• 05:23huge
• 05:24contributor
• 05:25to what we see in
• 05:26child and adolescent mental health.
• 05:29So,
• 05:30this talk, what I'm going
• 05:31to try to do in
• 05:32this talk is talk about,
• 05:36challenges to diagnostic and treatment
• 05:38specificity in youth with complex
• 05:40trauma, as you can see.
• 05:42And I'm going to specifically
• 05:44go through
• 05:45some of the directions our
• 05:46field of child psychiatry
• 05:49has, in my opinion, apparently
• 05:51gone in around this issue.
• 05:54And then I'm going to
• 05:54spend some time talking about
• 05:56what we did in at
• 05:57Bellevue to make our inpatient
• 05:59service,
• 06:01trauma informed.
• 06:02We run forty five beds,
• 06:05fifteen of them for the
• 06:05little ones. I just saw
• 06:06your little unit and two
• 06:08adolescent units. And, and,
• 06:11we did right away, we
• 06:12did some work on that.
• 06:13So let's get started. I'm
• 06:15just gonna move another slide.
• 06:19So I I I I've
• 06:21been speaking to a very
• 06:22informed audience. I know this,
• 06:24but we know that early
• 06:26stress and trauma,
• 06:28is incredibly destructive
• 06:30to human beings.
• 06:34And everyone's familiar with the
• 06:36adverse childhood experience study. Correct?
• 06:38Everyone heard of that? I
• 06:39don't have to go into
• 06:40too much
• 06:41depth with that, but this
• 06:43the the two or three
• 06:45really striking things about this
• 06:46study was that it was
• 06:47done
• 06:48in a
• 06:49non
• 06:50risk selected population. So they
• 06:52were middle class, Caucasian,
• 06:54insured people who were they
• 06:57were asked, what is your
• 06:58exposure to adverse childhood experiences?
• 07:01And eighty seven percent of
• 07:03the people said at least
• 07:05one, and among those or
• 07:07two thirds said one among
• 07:08those, eighty seven percent had
• 07:09more than one. So the
• 07:10message here is that exposure
• 07:12to adverse experience in childhood
• 07:14is common.
• 07:15It's it's probably
• 07:17normative.
• 07:18We're working on something at
• 07:19NYU where we're training the
• 07:21nursing staff around universal precautions,
• 07:24about how you approach people
• 07:25who are angry and belligerent
• 07:27with the expectation that probably
• 07:29they're traumatized and there are
• 07:30ways you can work with
• 07:31them more effectively.
• 07:32So that number one, it
• 07:34was common.
• 07:35Number two,
• 07:36it had a direct impact
• 07:38on both health and mental
• 07:40health, and an impact was
• 07:42in an allostatic
• 07:43way. So the more you
• 07:44had as a child,
• 07:46the more likely you were
• 07:47to have
• 07:48depression, suicide, drug addiction,
• 07:51obesity,
• 07:52diabetes, hypertension. It was an
• 07:54important study for us because
• 07:56it linked,
• 07:58childhood experience to health concerns.
• 08:01And we're slowly working our
• 08:02way around to that with
• 08:04the social determinants of health.
• 08:05We have long way to
• 08:06go, but we're getting.
• 08:09So and here's some of
• 08:10the data. Then you
• 08:12you you look at the
• 08:13four or more women, fifty,
• 08:15sixty percent
• 08:17will have a risk of
• 08:18major depression. So direct link
• 08:21in my mind. Direct link.
• 08:25This is the reverse.
• 08:27This is my, my our
• 08:28last chair was a psychiatric
• 08:31epidemiologist
• 08:32in the preschool period, and
• 08:33she had a structured instrument
• 08:34called the PABA. We actually
• 08:36can diagnose children zero to
• 08:38five. You all know that
• 08:38I just took the zero
• 08:39to five training myself when
• 08:41I was on vacation.
• 08:44And I did. It was
• 08:45interesting.
• 08:49But if you look at
• 08:50this at on the right
• 08:51here, if a young little
• 08:52person, this is obviously reports
• 08:54from the parents, has five
• 08:55or more,
• 08:57adverse childhood experiences in their
• 08:59little life, they almost have
• 09:01a hundred percent chance of
• 09:02having a psychiatric disorder.
• 09:04You know, so it's I
• 09:06call this the anti resilience
• 09:07slide because people with PTSD
• 09:10hate resilience
• 09:11because they feel like they're
• 09:12supposed to be well when
• 09:13they're sick.
• 09:15But the message here is
• 09:16if you do enough
• 09:17bad things to a very
• 09:19young person, they will be
• 09:20sick.
• 09:21They will be sick. No.
• 09:22That's not the end of
• 09:23the world that they're sick,
• 09:25but they will be sick.
• 09:26And we can actually
• 09:28figure this out much, much
• 09:29earlier
• 09:30than we are doing right
• 09:31now. That's what I was
• 09:32talking to your chair about,
• 09:33is how we can move
• 09:33that knee. So
• 09:37so, you know,
• 09:39the the impact, has been
• 09:41well documented. I mean,
• 09:43been looking at some of
• 09:44the history and sort of
• 09:46developmental psychopathology
• 09:47started a long time ago
• 09:49with Winnicott and Bowlby,
• 09:52and
• 09:54it's moved along
• 09:56at all through
• 09:57the last forty or fifty
• 09:59years with a really solid,
• 10:02science,
• 10:03foundation that continues to grow.
• 10:06Psychiatry kind of like ignored
• 10:08it.
• 10:09You're talking about psychiatry psychiatry.
• 10:11But we know kids, young
• 10:13kids, we can pick up
• 10:14extremely early that young kids
• 10:16have been exposed, how the,
• 10:17the effect of these exposures
• 10:19on kids. When I ran
• 10:19my HIV clinic in the
• 10:21nineties,
• 10:21I'd walk into the waiting
• 10:23room to meet a family
• 10:24who I'd never met before.
• 10:26And the two year old
• 10:26would run over and hug
• 10:27me.
• 10:29Now that's disorganized attachment. You're
• 10:31not supposed to hug people
• 10:32you don't know.
• 10:34But we're working in my
• 10:35shop. We have, Mariah Thomason,
• 10:37who's one of the neuroscientists
• 10:39who figured out how to
• 10:40do fMRI on fetuses,
• 10:43we're really looking at
• 10:45prenatal stress and,
• 10:48and exposures
• 10:49on the actual wiring of
• 10:50the brain. So we've progressed
• 10:52a lot. But the babies
• 10:54have the same things you
• 10:55see in the older kids,
• 10:57in terms of dysregulation
• 10:59and disorganization
• 11:00and difficulty calming down when
• 11:02they are living basically in
• 11:04an environment that is frightening
• 11:06to them. You all know
• 11:07how babies become children, become
• 11:09people, they become people in
• 11:11the context of the relationships
• 11:13they have with their parents.
• 11:14What did Winnicott say there
• 11:16is no such thing as
• 11:17just a baby. It's always
• 11:19a baby and a parent.
• 11:21And the appropriate
• 11:23parenting
• 11:24is soothing and your job
• 11:26is to soothe your child.
• 11:28And then when they get
• 11:29a little older, also set
• 11:30limits,
• 11:31but babies growing up terrified,
• 11:35really changes everything about their
• 11:38wired, how they're wired and
• 11:39they wire for that.
• 11:41And the,
• 11:43you know, what are the
• 11:43three trauma reactions?
• 11:47Fight, flight,
• 11:49freeze. Babies can't fight.
• 11:51They can't flee.
• 11:53Finally, I'm trying to say
• 11:54that properly.
• 11:56All they can do is
• 11:56freeze.
• 11:57So dissociation
• 11:59is a big part of
• 12:00the picture of young children
• 12:01who are traumatized. And I
• 12:02would always interview the little
• 12:04ones,
• 12:05in front of my teams
• 12:06on the on our unit,
• 12:07which is called twenty one
• 12:08South.
• 12:09And you would watch them
• 12:11go away,
• 12:12You know? And and because
• 12:13I wanted first of all,
• 12:14I wanted to teach my
• 12:16trainees
• 12:17and some of my staff
• 12:18that you can actually talk
• 12:20to kids about trauma
• 12:21without destroying them.
• 12:24But also you can there's
• 12:25language you can use to
• 12:26to work with the kids
• 12:27so they understand what's actually
• 12:28happening with them. But Frank
• 12:30Putnam's thing about dissociation
• 12:32across early childhood
• 12:34really speaks to how that
• 12:35affects the integration of the
• 12:37personality and the character.
• 12:39Little kids,
• 12:41you know,
• 12:42certainly our experience I'm interested
• 12:44in your experience, but our
• 12:45experience with our unit, with
• 12:47the three to eleven year
• 12:49olds who are almost all
• 12:50complex trauma kids,
• 12:52ADHD is actually
• 12:55very, very common.
• 12:57You know, bad ADHD. So
• 12:59I actually think
• 13:00these kind and I'm interested
• 13:01in your perspective on this
• 13:02with your work. These kinds
• 13:04of exposures actually create ADHD,
• 13:06and they also create
• 13:08depression
• 13:09and anxiety.
• 13:11Like, sixty percent of our
• 13:13little boys under the age
• 13:15of ten screen positive on
• 13:16the Columbia Depression Inventory.
• 13:18I actually think aggression
• 13:21is an obviously irritability. I'll
• 13:23get to this later is
• 13:24the simp is a symptom
• 13:26of depression, particularly in boys
• 13:28and men. We don't conceptualize
• 13:29it that way.
• 13:31But this obviously affects everything
• 13:33about a kid's development.
• 13:35And in childhood, we really
• 13:36start seeing,
• 13:38depression, anxiety. Remember we used
• 13:39to think that prepubertal children
• 13:41couldn't get depressed. Right.
• 13:44And my experience has been
• 13:46with really stressed
• 13:47pre puerperal children. They get
• 13:49depression too. And now we
• 13:50know babies can get depression
• 13:51too. So
• 13:53not that that's a good
• 13:54thing to have babies getting
• 13:55depression. I don't mean to,
• 13:56but it's a good thing
• 13:57to know about it early
• 13:59and help those.
• 14:02Adolescence, we all know the
• 14:03brain science of adolescence. The
• 14:05risk reward comes fully online
• 14:07at puberty and all the
• 14:08other stuff that is judgment
• 14:09and
• 14:10consideration of risk and thoughtfulness
• 14:13doesn't come on till later.
• 14:14We all remember the stupid
• 14:15things we did when we
• 14:16were fourteen, at least I
• 14:17do. So that's normal brain
• 14:19development. That that science was
• 14:21the basis of raise the
• 14:23age, actually,
• 14:24that said kids under eighteen
• 14:26shouldn't be put in adult
• 14:27jails because they're not fully
• 14:28culpable for what they do.
• 14:30With traumatized kids, that's really
• 14:32exaggerated.
• 14:33So more impulsivity, more risk
• 14:35taking. I I I happen
• 14:37to think substance
• 14:38abuse and use
• 14:40is almost always some of
• 14:41it's for fun,
• 14:43but a lot of it
• 14:43is really driven by trauma
• 14:45exposure and and pain.
• 14:47Promiscuity,
• 14:48we have a lot of
• 14:50the girls. The developmental picture
• 14:51on our two units, we're
• 14:52gonna we're working on publishing
• 14:54some of this. It's very
• 14:55different with the little kids,
• 14:56with the more boys,
• 14:58more ADHD,
• 14:59more aggression.
• 15:00You get to around puberty,
• 15:02and that's where the girls
• 15:03start showing up with a
• 15:04lot of sexual acting out,
• 15:05prostitution,
• 15:07trafficking,
• 15:08and suicidality.
• 15:10Trauma is a huge driver
• 15:11of suicidality for we'll talk
• 15:13about why why in in
• 15:15a moment.
• 15:17So I'm one speaking to
• 15:19the choir. So PTSD,
• 15:21this is the DSM
• 15:23five
• 15:23version. This diagnosis came into
• 15:26our nomenclature when?
• 15:30After the Vietnam War.
• 15:32We used to call it
• 15:33shell shock. But when all
• 15:34the guys it was all
• 15:36guys at that point came
• 15:37back from Vietnam,
• 15:38this is when we started
• 15:40talking about post traumatic stress
• 15:41disorder. And, again,
• 15:44you know, I'll I'll get
• 15:46to the next. So here's
• 15:46the symptoms. I don't have
• 15:47to go over this with
• 15:48all of you.
• 15:51Very useful
• 15:53construct, I think, to have
• 15:54it, have it defined like
• 15:56this.
• 15:59How common is PTSD,
• 16:02full diagnostic criteria PTSD?
• 16:06I call this going up
• 16:07the acuity ladder.
• 16:09So you look at kids,
• 16:10it goes up during adolescence
• 16:12because adolescence is a time
• 16:13of risk taking.
• 16:15We work in, we work,
• 16:16we run the mental health
• 16:17services in the jails,
• 16:19a lot of both familial,
• 16:21inter familial trauma and also
• 16:22community trauma.
• 16:24You go into some outpatient
• 16:26populations. We call them SED
• 16:27kids in New York, very
• 16:30high rates.
• 16:31And when you there's five
• 16:33or six studies on inpatient
• 16:34adolescents, and the rates are
• 16:36between thirty and forty percent
• 16:38of of diagnosed diagnosed PTSD.
• 16:42So
• 16:43if you're a mental health
• 16:44professional
• 16:45and and if you're working
• 16:46in an acute environment, you
• 16:47should expect that this trauma,
• 16:50number one, trauma exposure is
• 16:51the norm and PTSD
• 16:53is as common as depression
• 16:56is.
• 16:59So I was talking about
• 17:00this before, you know, when
• 17:01the little kids are developing
• 17:03in these environments that are
• 17:04scaring them,
• 17:06whether it be chronically
• 17:08or,
• 17:09intermittently.
• 17:11There's we're beginning to understand
• 17:13there's a difference in the
• 17:14brain circuitry associated with threat
• 17:16from deprivation,
• 17:18but very commonly, they occur
• 17:20in the same mix.
• 17:22The wires then
• 17:25come together in that way.
• 17:27So this is really important.
• 17:28This is what I'm trying
• 17:29to tell the nurses. If
• 17:30you have this experience, when
• 17:32you're very little, it sets
• 17:33you up for a stress
• 17:35reactivity
• 17:36that is you're gonna live
• 17:38with, you know, you can
• 17:39deal with it. You can
• 17:40really deal with it, but
• 17:41you're gonna it's gonna be
• 17:42there. It's how your brain
• 17:43is wired.
• 17:44And we know that this
• 17:46this is a PET scan
• 17:47with a normal brain on
• 17:49I don't know my right
• 17:50from my left. That's why
• 17:50I'm not a surgeon.
• 17:52The normal brain,
• 17:54perfusing in a connected way
• 17:56versus the,
• 17:59abused kid on the right.
• 18:01So
• 18:02this is I call this
• 18:03being wired for terror,
• 18:06and that's where the stress
• 18:08reactivity comes from for these
• 18:09folks.
• 18:10And then you think about,
• 18:14this everyone's read the body
• 18:16keeps the score.
• 18:17Right? So poor Bessel.
• 18:20He's been trying to get
• 18:22complex PTSD, he calls it
• 18:23developmental trauma disorder, into the
• 18:25DSM for twenty years.
• 18:28He has not succeeded. We'll
• 18:29talk about that in a
• 18:30minute. But this is the
• 18:32picture of it. So complex
• 18:34multiple trauma exposure during across
• 18:36development
• 18:38interferes with everything,
• 18:39attachment, regulation,
• 18:41stress reactivity.
• 18:44And, I don't know about
• 18:45on your unit, but we
• 18:47have little kids on our
• 18:48inpatient unit who once they
• 18:50go over the edge, they
• 18:52will howl for three hours.
• 18:54I mean, just their capacity
• 18:56to come back to homeostasis
• 18:57is so impaired.
• 19:00And these kids don't necessarily
• 19:02meet criteria
• 19:03for PTSD in the classic
• 19:05sense,
• 19:06but they definitely
• 19:09have
• 19:10enormous impairment from their exposures.
• 19:13So when I got to
• 19:14Bellevue,
• 19:16this is two thousand eight.
• 19:18So and I'll talk about
• 19:19what was going on in
• 19:20the field in a minute.
• 19:20But we had a whole
• 19:21bunch of kids,
• 19:23not all of them, but
• 19:24a lot of them who
• 19:24had complex trauma backgrounds. Younger
• 19:26kids, much more common that
• 19:28they have complex trauma backgrounds,
• 19:30mood lability, volatile aggression, self
• 19:33and or self
• 19:35destruction, impulsivity and dysregulation. And
• 19:37they were coming to us.
• 19:38Remember, this was two thousand
• 19:39and eight.
• 19:40So this this was they
• 19:42were coming to us as
• 19:43bipolar.
• 19:45The puerperal kids were being
• 19:47bipolar.
• 19:48Mood disorder NOS. If you
• 19:50see mood disorder NOS in
• 19:52a diagnosis, think trauma.
• 19:54Conduct disorder, which is a
• 19:56meaningless diet or ODD. Don't
• 19:57forget ODD. An angry kid
• 19:59is ODD.
• 20:00And they were being treated
• 20:01with antipsychotics and mood stabilizers.
• 20:09And we know we know.
• 20:11I don't know what you
• 20:11guys do here, but we
• 20:13know that the mental health
• 20:14field is very bad.
• 20:16Even the kids' mental health
• 20:17field is very bad at
• 20:19recognizing
• 20:20a trauma exposure and identifying
• 20:22it systematically
• 20:24in their populations. This is
• 20:25a study that was done
• 20:26in some of those SED
• 20:28kid
• 20:29kids in New Hampshire,
• 20:30And they had like fourteen
• 20:32percent
• 20:33of the kids were diagnosed
• 20:34with PTSD. When they did
• 20:36structured PTSD instruments, which I'll
• 20:38talk about when I talk
• 20:39about trauma informed care,
• 20:41the number dropped to twenty
• 20:42eight percent. So, they were
• 20:44not being diagnosed.
• 20:46And they but they were
• 20:47sicker.
• 20:48They had more,
• 20:50they were on more drugs,
• 20:51and they had more hospitalizations.
• 20:53And they had all these
• 20:54behaviors like running away and
• 20:55self injure injurious.
• 20:57When we did the first
• 20:59bunch of kids we screened
• 21:01at Bellevue,
• 21:02the adolescents who came in,
• 21:03and this was probably like
• 21:05two thousand twenty twelve, they
• 21:06came in and said, oh,
• 21:07I'm bipolar because someone told
• 21:08them they were bipolar.
• 21:10They were more likely
• 21:12to, if we them and
• 21:13they were positive for PTSD,
• 21:14we used the UCLA, which
• 21:16I'll talk about in a
• 21:17bit. They were more likely
• 21:18to be told to have
• 21:19someone else tell them they
• 21:20were bipolar.
• 21:21They were more likely to
• 21:22have MDD when we discharge
• 21:24them.
• 21:25They were more likely to
• 21:26be on anti psychotics
• 21:29on admission. So people in
• 21:31the community were responding to
• 21:32this symptom picture with antipsychotics,
• 21:35more likely to be at
• 21:36leave on anti depressants.
• 21:38And they were on more
• 21:39meds, more suicidal
• 21:40ideation and higher levels of
• 21:42hospitalization. In other words, they
• 21:43were sicker. So nonrecognition
• 21:45is a huge issue.
• 21:47I was I gave some
• 21:50some there was a ACAP
• 21:52talk about how to manage
• 21:53aggression
• 21:54and inpatient
• 21:55services, and they all were
• 21:57talking about all kinds of
• 21:58things. And I went to
• 22:00the inpatient
• 22:01psychiatry group afterwards, and there
• 22:03are about fifty people representing
• 22:04inpatient psychiatry units
• 22:06around the country. I said,
• 22:07how many of you screen
• 22:09for trauma exposure?
• 22:11Like, not not have you
• 22:12ever been abused or neglected,
• 22:13but screen.
• 22:15Three people
• 22:16raised their hands. So I
• 22:17hope we've moved on that
• 22:18a little bit. But at
• 22:20that point, we hadn't. So
• 22:21under recognition
• 22:23and the really, really
• 22:26I won't use the word
• 22:27I was thinking of. The
• 22:28really, really uninformed
• 22:30concept that if you ask
• 22:32a kid about trauma, you're
• 22:33traumatizing them.
• 22:35So you can ask anybody
• 22:36about their trauma exposure,
• 22:38not tell me the details.
• 22:40Did you this happened to
• 22:41you or not?
• 22:42If you're if you're cool
• 22:44with it. So the notion
• 22:45that people
• 22:46wouldn't ask because, oh, it's
• 22:48an acute
• 22:49acute,
• 22:52care environment. We can't destabilize
• 22:54them or
• 22:55or,
• 22:56oh, it's opening Pandora's box.
• 22:58I think that's actually nonsense,
• 22:59and we'll talk about that
• 23:00when we talk about what
• 23:01we did at Bellevue.
• 23:05So how do we get
• 23:07to the mess we found
• 23:08ourselves in? I think we're
• 23:10still in that mess from
• 23:11my perspective. We're still in
• 23:12that mess of over medicating
• 23:13kids,
• 23:15very commonly black and brown
• 23:16kids who are in the
• 23:17child welfare system with the
• 23:19wrong medications.
• 23:20So this is, this we
• 23:22can blame
• 23:23Joe Bitterman at Mass General.
• 23:26No. It's important to he
• 23:27was running a ADHD service
• 23:30at Mass General, big one.
• 23:32And about a third, a
• 23:33quarter or a third of
• 23:34the kids on his service
• 23:36were were,
• 23:38irritable
• 23:38and
• 23:39had volatile moods,
• 23:42and he thought,
• 23:44I'm a genius. This must
• 23:46be the pre pubertal presentation
• 23:48of bipolar disorder.
• 23:51So, literally,
• 23:53the diagnostic
• 23:54criteria was changed
• 23:56to eliminate
• 23:57the most important symptom
• 23:59of mania,
• 24:00which is euphoria.
• 24:02Now there are irritable manics,
• 24:04but euphoria
• 24:05up is part of bipolar
• 24:06disorder. And the durational criteria
• 24:10were played with, like, you're
• 24:11not manic if you're manic
• 24:12for an hour or two.
• 24:13You know, you have to
• 24:14have days of it. So
• 24:16he
• 24:17decided he was the only
• 24:18person in the world who
• 24:19could diagnose these people properly.
• 24:21This aligned with when they
• 24:23had just released
• 24:25Seroquel.
• 24:27So the farmer was interested
• 24:28in this because it was
• 24:29a big a big population
• 24:31that they could they could
• 24:34use that drug on. So
• 24:35and this is the data
• 24:36from New York City sparks
• 24:38discharge data,
• 24:40and red is the diagnosis
• 24:41of bipolar disorder, and the
• 24:43blue is PTSD from inpatient
• 24:45admission zero to nineteen. So
• 24:47just right up.
• 24:49Now
• 24:50I absolutely
• 24:52do not believe this.
• 24:54The the bipolar NOS is
• 24:56actually bipolar disorder. I've seen
• 24:58six prepubertal
• 25:00manic kids in my entire
• 25:01career, three of them since
• 25:03I came to Bellevue. They're
• 25:04just like adult.
• 25:06Manics, they're like, I'm Spider
• 25:08Man, I can fly. They're
• 25:10up.
• 25:11But they're extremely,
• 25:13extremely rare, just like real
• 25:14psychosis is extremely rare in
• 25:16children.
• 25:18So this was really bad
• 25:20news,
• 25:21because people really bought this.
• 25:23The next bad thing that
• 25:25happened, and I blame Peter
• 25:26Jensen for this,
• 25:28is that people wrote guidelines
• 25:31for the use of antipsychotics
• 25:32and aggression.
• 25:33Now that's probably sounds like
• 25:34a good idea. We knew
• 25:35we were using Respiral for
• 25:37really aggressive kids.
• 25:39But when you write guidelines,
• 25:41what happens, and they all
• 25:42say the same thing, do
• 25:43the psychosocial interventions first, start
• 25:46slow, go low, take it
• 25:47off when the kids better.
• 25:49When you write guidelines,
• 25:51people start just doing it
• 25:53as first line practice.
• 25:55And that has that has
• 25:56is what has happened.
• 25:58So angry children
• 26:00who are aggressive,
• 26:02who almost always, in my
• 26:03experience, are traumatized,
• 26:06were it sort of sanctioned
• 26:08giving them antipsychotics.
• 26:10And and so we had
• 26:12bipolar, so we have mood
• 26:14stabilizers
• 26:15and some of the anti
• 26:16psych the second generation antipsychotics.
• 26:19And then we had
• 26:20antipsychotics for aggression. Now antipsychotics
• 26:23do not treat anger.
• 26:25Right?
• 26:27They do not. They treat
• 26:28their their chemical restraint,
• 26:30but they they treat psychosis
• 26:32nicely.
• 26:33They're hard to live on,
• 26:34but they do not treat
• 26:36anger. They're dulling.
• 26:38So so
• 26:39this also, I think, added
• 26:41to
• 26:42you know, we're like Yale,
• 26:44NYU.
• 26:45We think about what we
• 26:46do. When you go out
• 26:47into the field
• 26:49and you've got a neurologist
• 26:51or a poorly trained
• 26:52child psychiatrist
• 26:53or a pediatrician
• 26:55and the kid's acting out
• 26:56and they think it's okay
• 26:57to give me a nice
• 26:58psychotics,
• 26:59that's what they
• 27:00do. So this is the
• 27:01second.
• 27:06So then
• 27:08the next thing,
• 27:10I'm the opposite of your
• 27:11chair. I focus on the
• 27:12negative.
• 27:13The next thing that happened,
• 27:15I'm from New York, right?
• 27:18Was,
• 27:20Bessel was trying really hard
• 27:21to get developmental trauma disorder
• 27:23into DSM five.
• 27:25There were these people down
• 27:26at NIMH,
• 27:28who were working on severe
• 27:30irritability,
• 27:31and they decided they weren't
• 27:34gonna do anything related to
• 27:36trauma. They were gonna focus
• 27:37on this thing they invented
• 27:39called disruptive mood dysregulation
• 27:41disorder.
• 27:42And you can read the
• 27:43criteria. I'm sure you know
• 27:44the criteria because we use
• 27:46it all the time, but
• 27:46it's basically kids who are
• 27:48impossible in fighting and angry
• 27:50and don't do what they're
• 27:51supposed to do. And and,
• 27:52you know, of course, these
• 27:53kids are angry. They should
• 27:54be angry. That's what I
• 27:55always say to them. No
• 27:56wonder you're so it's amazing
• 27:58you're alive, I say to
• 27:59them.
• 28:00So
• 28:00I don't think there's any
• 28:02real
• 28:03validity to this diagnosis, but
• 28:05it got it to DSM
• 28:06five. And when you read,
• 28:08like, the clinical trials
• 28:09of what they're doing at
• 28:10NIMH, they're, like, adding,
• 28:12you know, citalopram
• 28:15to Adderall.
• 28:16So that's that's good. That's
• 28:18you know, you should treat
• 28:19the impulsive disruptive part with
• 28:21stimulants. We'll talk about this
• 28:22a bit. And if there's
• 28:23anxiety and mood stuff, that's
• 28:25the other but that's not
• 28:26what happens in the world.
• 28:28That is not what's happened.
• 28:30I think this is
• 28:32nonsense. And now I do
• 28:33a lot of consulting with,
• 28:34like, teams that are working
• 28:35in the community with high
• 28:36utilizing kids, and they have
• 28:38their
• 28:39bipolar,
• 28:40DMDD.
• 28:41You know,
• 28:43the mood's usually in there,
• 28:44which is good, but it's
• 28:45just a mishmash.
• 28:46And, actually,
• 28:47I think I didn't know.
• 28:49I don't think it was
• 28:50you, Andres, I wrote this
• 28:51editorial for.
• 28:54But, I think it was
• 28:55Doug. So Bob Findling did
• 28:57a big study with a
• 28:58big, commercial claims database,
• 29:01really interesting study,
• 29:02looking at,
• 29:05the diagnosis of bipolar disorder
• 29:07and the transition to DMDD.
• 29:09So DMDD came in, like,
• 29:11I think, at two hundred
• 29:11and two thousand sixteen.
• 29:13So we watched the numbers
• 29:15of bipolar diagnoses in this
• 29:17large dataset over time go
• 29:18down and the number of
• 29:20DMDD
• 29:21diagnoses go up, but the
• 29:23drugs were even worse.
• 29:25So the community was responding
• 29:27to this in the same
• 29:29way they were to
• 29:30angry by maybe bipolar kids
• 29:33with antipsychotics
• 29:34and mood stabilizers.
• 29:37So we we it didn't
• 29:39and I said to Ellen,
• 29:40poor Ellen, we left.
• 29:42Danny Pine,
• 29:43facilitated a conversation for, I
• 29:45said, how did you find
• 29:46the two hundred children in
• 29:47America
• 29:48that have this phenomenological
• 29:51preparation,
• 29:52presentation
• 29:53that don't have any trauma?
• 29:55And she said she said,
• 29:56oh, you know, when I
• 29:57go out into the community
• 29:58and talk about kids who
• 30:00present like this, everybody talks
• 30:01about trauma.
• 30:02So, again, I think we
• 30:04lost our way a little
• 30:05bit there,
• 30:07to put it mildly.
• 30:09So this is and this
• 30:10is not this is not
• 30:12benign.
• 30:13I mean, these drugs are
• 30:14terrible.
• 30:15You know, you should not
• 30:16take these drugs unless you
• 30:17need these drugs.
• 30:19So
• 30:20this is not benign.
• 30:22So this is the way
• 30:22we think about it. I
• 30:23can't take credit for this.
• 30:24My genius
• 30:26protege Molly Mar did this.
• 30:28You know, there's an overlap
• 30:30between
• 30:31depression, PTSD and ADHD,
• 30:33And they all come. We
• 30:34call this the three triangle
• 30:36slide. Now,
• 30:37this is important when you're
• 30:39dealing with acute populations
• 30:41because you are going to
• 30:42have to medicate kids.
• 30:44If they're that sick to
• 30:45be in the hospital, you
• 30:47are gonna have to medicate
• 30:48them. So what's our job
• 30:50as psychiatrists?
• 30:52The right diagnosis, the right
• 30:53medication.
• 30:55So we spend a lot
• 30:57of our time with our
• 30:58little ones and some of
• 30:59our time with our older
• 31:00ones, taking them off
• 31:02Depakote
• 31:04and Resperdal
• 31:05and Abilify
• 31:06and putting them on stimulants,
• 31:08God forbid stimulants
• 31:10and, and alpha agonists
• 31:13and antidepressants,
• 31:14because what they have is
• 31:16depression, anxiety,
• 31:18ADHD,
• 31:19and PTSD. Now what drug
• 31:21treats PTSD?
• 31:28It's a trick question.
• 31:32It's not. OFT. Prazosin is
• 31:33good for the nightmares.
• 31:35If you have comorbid depression,
• 31:39antidepressants can be helpful. They
• 31:40can be tricky, but they
• 31:41can be helpful. The only
• 31:42drug that treats PTSD
• 31:52Yeah. The prep panel was
• 31:53like an alpha agonist that
• 31:54they damped down the autonomic
• 31:56nervous system. Yeah. Yeah. But
• 31:58what really treats PTSD?
• 32:00Heroin.
• 32:03Seriously.
• 32:04I mean, heroin is a
• 32:05painkiller.
• 32:07It works like a charm,
• 32:09you know? And
• 32:10that's why so many people
• 32:12take opiates
• 32:13because they're in pain and
• 32:14they're not necessarily in physical
• 32:16pain. They're in psychic pain.
• 32:17And that is what is
• 32:18driving the opioid epidemic in
• 32:20this country, in my opinion.
• 32:21Marijuana
• 32:22helps some of the kids
• 32:24in jail.
• 32:24They don't feel normal unless
• 32:26they smoke a lot of
• 32:27marijuana. And, Cuomo put it
• 32:29on the medical marijuana list
• 32:30for New York.
• 32:32But we do not have
• 32:33a pharmacologic
• 32:35treatment for PTSD.
• 32:36What is the treatment for
• 32:38PTSD?
• 32:44Psychotherapy.
• 32:46Evidence based. Many, many, many
• 32:48studies
• 32:49for kids, for moms and
• 32:51babies, child parent psychotherapy. Linda
• 32:53and I were talking about
• 32:54that.
• 32:55Many, many studies.
• 32:56That's what works for PTSD.
• 32:58Okay? So what's the problem
• 33:00if you think you can
• 33:01treat if you have a
• 33:03kid with ADHD, depression, anxiety,
• 33:06and trauma related symptoms
• 33:08and you give them antipsychotics
• 33:10which block block dopamine,
• 33:13wrong, wrong for ADHD. You
• 33:15increase dopamine for ADHD and
• 33:18and
• 33:19mood stabilizers
• 33:20are really, really depressing,
• 33:23you know? So you're not
• 33:24only is it
• 33:26unhealthy
• 33:27and wrong,
• 33:28but it doesn't work.
• 33:31K. So this this I
• 33:32consider an embarrassment
• 33:34in our field that this
• 33:36is this is how people
• 33:37think, and this is something
• 33:38that we all have to
• 33:39try to change.
• 33:41So
• 33:44I'm gonna skip
• 33:45because
• 33:50they're all the same. Making
• 33:51this important. So what happens
• 33:52if you don't
• 33:54diagnose
• 33:56this stuff?
• 33:58You, as I've hope I've
• 34:00made painfully clear, you use
• 34:02the wrong medications,
• 34:04you don't prescribe the right
• 34:06treatments,
• 34:07kids suffer,
• 34:09kids start to fail in
• 34:10school.
• 34:11The average reading level in
• 34:13our jails is fifth grade.
• 34:14Not because the kids
• 34:16are stupid. Some of them
• 34:18are, some of them aren't,
• 34:19some of them are very
• 34:19smart actually, but because fourth
• 34:21or fifth grade is about
• 34:23when you really disengage from
• 34:24school, when you're being told
• 34:25all the time that you're
• 34:27bad.
• 34:28A lot of ADHD also
• 34:30in the in the juvenile
• 34:31justice population.
• 34:34So we
• 34:35we fail to when we
• 34:37fail to identify this
• 34:39properly and intervene
• 34:41properly,
• 34:42we we do not
• 34:44use the amazing opportunities we
• 34:47have to take kids and
• 34:48families off the trajectories
• 34:50that they're on. We now
• 34:51have amazing things that we
• 34:53can do,
• 34:54but we don't use them
• 34:55if we think like this.
• 35:00And the psychological
• 35:01sequelae
• 35:02of early childhood
• 35:04adversity
• 35:05is
• 35:07shame,
• 35:09guilt,
• 35:11self loathing. The way I
• 35:13think about this is if,
• 35:14when you're a very small
• 35:16child and a baby,
• 35:17you need, you absolutely need
• 35:19your objects to be good.
• 35:21So if your objects are
• 35:22bad,
• 35:24you take the bad and
• 35:25they keep the good. And
• 35:27I learned this working with
• 35:28kids who parents were just
• 35:29done amazingly awful things to
• 35:31them because of their own
• 35:32illnesses, obviously not because they
• 35:34were bad people.
• 35:35And the kids always needed
• 35:37to hold on. We're hardwired
• 35:39to hold on to our
• 35:41internalized good objects.
• 35:43So, you know, people who've
• 35:45had even people who've had
• 35:46adult trauma feel guilty and
• 35:47ashamed, but the little kids
• 35:48really feel terrible about themselves.
• 35:51So if you don't actually
• 35:55understand that that's part of
• 35:56what's happening to them, and
• 35:57if you don't have the
• 35:58language to talk to them
• 36:00about this is because of
• 36:01what happened to you,
• 36:02not because of who you
• 36:04are, you're colluding with that.
• 36:07You're colluding with that silence
• 36:08and self blame. As I
• 36:10said before, you don't know
• 36:11what you're doing diagnostically.
• 36:12You're not prescribing the right
• 36:14treatments.
• 36:15You're using really bad medications
• 36:18and you're not recommending. And
• 36:19this is our job, recommend
• 36:22what the patient needs. You
• 36:23are not recommending the evidence
• 36:25based treatments for what the
• 36:26kid has.
• 36:30Does anyone have any comments
• 36:31before I move to the
• 36:32next part?
• 36:35Questions?
• 36:36Anyone wanna argue with me?
• 36:37I love it when people
• 36:38argue with me.
• 36:40I'm from New York. I
• 36:43beat the Boston out of
• 36:45me. Okay. So so here
• 36:47that's
• 36:48Yeah. Does what? We can
• 36:50bring up OBD. Oh, what's
• 36:51he saying? Oh, OBD.
• 36:54Oh, I'm I'm sorry. I
• 36:56just ignore ODD, just like
• 36:59I ignore CD.
• 37:05It's like the same argument
• 37:06for the interview.
• 37:07Yeah. No. I mean,
• 37:09the kids are very oppositional.
• 37:11There's no question about it.
• 37:12And not only will they
• 37:13not do what you want
• 37:14them to do, but they
• 37:15really freak out when you
• 37:16don't give them what they
• 37:17want. I mean, they're
• 37:18all their reward circuitry is
• 37:20all screwed up, right?
• 37:21So, I think ODD is
• 37:22a terrible diagnosis. And there
• 37:24was actually a JAMA article
• 37:25from Peds about how this,
• 37:26why diagnoses are not supposed
• 37:28to do harm. That and
• 37:30conduct disorder.
• 37:31The only, in my fight
• 37:32with my docs in Juvy,
• 37:33the only reason they use
• 37:34conduct disorder is because it
• 37:35can get you MST,
• 37:37which works. It's good treatment.
• 37:39So,
• 37:40those are all, those are
• 37:41all,
• 37:43diagnoses about how you're behaving,
• 37:45right? Those two diagnoses, they're
• 37:47not about what's going on
• 37:48inside of you. So, and
• 37:49the most common thing these
• 37:51kids come in with is
• 37:51ODD.
• 37:52Yeah.
• 37:53And ADHD.
• 37:55You got Nat to argue
• 37:56as well.
• 37:59Oh, she doesn't wanna argue.
• 38:00Smart woman. Not from New
• 38:02York.
• 38:05Yeah. I was in New
• 38:06York for seven years. But,
• 38:06no, not an argument. I'm
• 38:07just, I mean, I'm excited
• 38:09to see what what, you
• 38:10know, what the rest of
• 38:11this presentation. I'm so grateful
• 38:12for this presentation.
• 38:14I work part time at
• 38:15a state hospital, and a
• 38:16patient came in, and she
• 38:18is, fifteen fourteen or fifteen.
• 38:20And she has
• 38:21a lot of trauma, like,
• 38:22a lot of trauma, and
• 38:23she's very hostile and aggressive.
• 38:25Yeah.
• 38:26Fighting for her life. The
• 38:27positive thing is that we
• 38:29did screen, and we do
• 38:30have it in the list
• 38:32of her, you know, diagnoses
• 38:33of trauma.
• 38:35The, I guess, not so
• 38:36forward thing is that we
• 38:38are,
• 38:39when she came in, she
• 38:40was on a very high
• 38:41dose of Seroquel.
• 38:43And I I don't know
• 38:43about children, but for adults,
• 38:45you know, once you go
• 38:45above two hundred milligrams of
• 38:46Seroquel, you're increasing chances of
• 38:48metabolic syndrome. And this is
• 38:49someone who's gained ninety five
• 38:50pounds in the last year.
• 38:51Yep. And, I saw her
• 38:53her last labs and as
• 38:54suspected with her new labs,
• 38:56her triglycerides,
• 38:57her cholesterol, she is she
• 38:59is now obese. Right? And
• 39:01it's not helping her
• 39:03at all because it's not
• 39:04helping she's she's still
• 39:05Take her off. Frustrated and
• 39:07and hostile and what have
• 39:08you. So to your point
• 39:09of that, it it doesn't
• 39:10treat
• 39:11anger.
• 39:12Thank you for saying that.
• 39:13Yep. And then she was
• 39:14on, Prozac ten, which is
• 39:16like, you know, taking gummy
• 39:18bears for someone who's really,
• 39:20depressed and and, and traumatized.
• 39:22And so we know we're
• 39:23we're definitely gonna go up
• 39:23on that. But, I just
• 39:25really appreciate this perspective.
• 39:27I can't I can't tell
• 39:28you how many consultations I've
• 39:29done in New York State
• 39:31Hospital system
• 39:32where they said,
• 39:34we don't know what's going
• 39:35on with this kid. I
• 39:36did one, but the worst
• 39:37one was a six year
• 39:38old boy up in Western
• 39:40New York who they were
• 39:41about to put on clozapine,
• 39:43little white kid.
• 39:44And,
• 39:46I said, you have to
• 39:46let me talk to the
• 39:47kid before you do this.
• 39:48And they did. And so
• 39:50I,
• 39:51they said he won't talk
• 39:52about his trauma.
• 39:54That's what they said. So
• 39:55I was talking to him
• 39:57video, you know, I said
• 39:58to him, so tell me
• 39:59about your step, your, your
• 40:01mom's boyfriend.
• 40:02And she said, he said,
• 40:04he has tattoos all over
• 40:05him.
• 40:07He's really scary.
• 40:09He, I said the only
• 40:10place said the only place
• 40:11he doesn't have tattoos is
• 40:13on his private parts.
• 40:16Right? So then we opened
• 40:17up the whole thing.
• 40:19Right? So the state hospitals
• 40:21contribute to this
• 40:23because and I've often
• 40:25often I've probably did about
• 40:26twenty of these consoles. I'm
• 40:28often the first person
• 40:30taking the trauma history
• 40:32from the child
• 40:33who's been in the hospital
• 40:34for six months.
• 40:36So I think they really
• 40:37missed the boat and
• 40:39that they didn't put that
• 40:40boy on clozapine. So that's
• 40:42so let me talk to
• 40:42you about what we did
• 40:43inpatient wise
• 40:45to deal with this. And
• 40:46I'm not there anymore, so
• 40:48I can't speak to what
• 40:49they're doing now. I know
• 40:49they're very trauma informed, but
• 40:51COVID changed some things.
• 40:52So these are the SAMHSA
• 40:54platitudes
• 40:55about trauma informed care. Okay.
• 40:57They're good platitudes.
• 40:59No, they are, but they're
• 41:00platitudes.
• 41:02And and
• 41:04this is really important. It's
• 41:06part of the,
• 41:07movement to try to prevent
• 41:09restraint and seclusion.
• 41:11I mean, you think about
• 41:12four point restraints
• 41:14for people that have been
• 41:14abused. You know, you're tied
• 41:16to a bed with your
• 41:17legs spread very bad.
• 41:19Sometimes you have to do
• 41:20it, but shouldn't be run
• 41:21of the mill.
• 41:23So,
• 41:25these are kind of the
• 41:26tenants that and we we
• 41:27did this in the outpatient
• 41:28in the inpatient service,
• 41:30and then we took it
• 41:31actually into the jails, this
• 41:33model.
• 41:34So the first thing is
• 41:35you have I think you
• 41:36have to screen
• 41:37systematically.
• 41:39You can't make a diagnosis
• 41:40of PTSD
• 41:41without going through a set
• 41:43of exposures
• 41:44and then linking the worst
• 41:46exposure to the symptoms of
• 41:47PTSD. That's why you can't
• 41:49it's very hard to do
• 41:50it well on on
• 41:52automated instruments.
• 41:53And so we use the
• 41:54UCLA,
• 41:55which starts with,
• 41:57of course, earthquakes because it's
• 41:59from LA,
• 42:00but then goes all the
• 42:01way down to,
• 42:04more more interpersonal stuff. And,
• 42:08so that's number one. And
• 42:10that's that in and of
• 42:11self it in and I
• 42:13have till till one, don't
• 42:14I, Anders? Yeah. That in
• 42:16and of itself is an
• 42:17intervention
• 42:18to ask the kid, did
• 42:20this happen to you? Did
• 42:20this happen to you? Did
• 42:21this happen to you? Did
• 42:21this happen to you? Did
• 42:22this happen to you? That
• 42:23that's
• 42:23normalizing
• 42:24it. And then when you
• 42:25make your staff do that
• 42:26and we had undergrads from
• 42:28NYU doing this screening. We
• 42:29never had a problem.
• 42:31Okay.
• 42:32Okay. There's a lot of
• 42:33questions. Alright. So screening.
• 42:36Then we had to figure
• 42:37out, oh, what should we
• 42:38do now that we know
• 42:40that all these kids have
• 42:41trauma?
• 42:42We tried to find anything
• 42:44that existed for acute settings
• 42:46that was had any evidence
• 42:48at all. There wasn't anything.
• 42:50So we took
• 42:51the
• 42:52the strength based
• 42:54part and intro part of
• 42:56STAIR,
• 42:57which is a complex trauma
• 42:58intervention Marylin Cloichord developed, and
• 43:01we made them into groups
• 43:02for the kids. And I'll
• 43:04talk about this in a
• 43:05minute. And you have to
• 43:06just educate the staff.
• 43:09My nurses, when I got
• 43:10there, did not know the
• 43:11difference between a flashback
• 43:13and an oppositional child
• 43:15and that for them to
• 43:16have empathy
• 43:18for the way these kids
• 43:19are nasty,
• 43:20you know, when they're angry
• 43:22and they hurt people,
• 43:24you know,
• 43:25and
• 43:26the staff need to understand
• 43:28where this is coming from.
• 43:29And it's because of what
• 43:30was done to that kid.
• 43:32And if you can't generate
• 43:33genuine empathy for these kids,
• 43:35you cannot be therapeutic.
• 43:36So that's an ongoing, and
• 43:38it's very hard to be
• 43:39empathic to someone who's hurting
• 43:40you.
• 43:41So that's an ongoing
• 43:43piece of work. And I'm
• 43:44very proud of my nursing
• 43:45staff where they've gotten with
• 43:47that. Psychiatric nursing is the
• 43:48fourth most dangerous profession
• 43:51after police, fire, and EMS.
• 43:54So and violence
• 43:56is very destabilizing.
• 43:57So you have to have
• 43:59a context to deal with
• 44:00it, and people have to
• 44:01understand where it's coming from.
• 44:06So as I said, identification
• 44:09is an intervention.
• 44:10Education is there are now
• 44:12people doing psychoeducational
• 44:14interventions that have no
• 44:16exposure
• 44:17as treatments.
• 44:18Some people can't do exposure.
• 44:20Exposure is the part where
• 44:21you go over your traumas.
• 44:22Some people can't do that.
• 44:23It's too much, but psychoeducation
• 44:26can be done
• 44:27with anybody. And it's actually,
• 44:29I think the first step
• 44:30is teaching people, oh, this
• 44:32happened to you And this
• 44:33happens to everybody and this
• 44:35is how it affects your
• 44:36body and your feelings
• 44:38and your brain. And we're
• 44:39going to help you understand
• 44:41that.
• 44:43And
• 44:46screening tools, we are using
• 44:47the we're using UCLA. There's
• 44:50the CDI
• 44:52for the older kids. We
• 44:53couldn't do the UCLA on
• 44:55kids under seven,
• 44:57even though they were usually
• 44:58the most traumatized kids because
• 44:59it doesn't go below there
• 45:00in the CDI. CDN is
• 45:01a good instrument, I think,
• 45:02for inpatient use, better than
• 45:04the PHQ by a long
• 45:05shot. So this is our
• 45:06data.
• 45:08So
• 45:09you can see the difference
• 45:10by age.
• 45:12Thirty three percent of the
• 45:14kids were above the cutoff.
• 45:15Remember, there's the over seven
• 45:16year olds and twenty five
• 45:18percent of the adolescents.
• 45:20A lot of abuse,
• 45:22was being reported by these
• 45:23kids. The most problematic kids
• 45:26and I would have my
• 45:27little screening results and I
• 45:28would go to my rounds
• 45:29every week and I would
• 45:31know what the kids said.
• 45:32The most problematic kids were
• 45:33the kids who, you know,
• 45:34had significant trauma histories, who
• 45:35denied everything.
• 45:37Right. Because they're the numbed
• 45:38out ones. And
• 45:40that's probably the most
• 45:43profound
• 45:44impact is the dissociation numbing
• 45:47depression.
• 45:48So forty four percent. And
• 45:50when you looked at just
• 45:51boys, it was more like
• 45:52sixty percent of prepubertal boys
• 45:55with depression, and that was
• 45:56the irritability. Irritability is depression
• 45:58in kids.
• 45:59And I think Gay has
• 46:00finally figured this out that
• 46:02they followed these bipolar NOS
• 46:04kids, and when they grow
• 46:05up, they were depressed.
• 46:09So I told you about
• 46:10this. We, we took these
• 46:11three,
• 46:13strength building
• 46:14groups,
• 46:16affect recognition, trauma psycho ed,
• 46:19emotional regulation and coping skills,
• 46:21communication
• 46:21skills,
• 46:22Traumatized people tend to be
• 46:24very difficult to communicate effectively
• 46:26with. So teaching them some
• 46:28skills
• 46:29and they create an individualized
• 46:31safety plan for themselves that
• 46:33they leave with when we
• 46:34laminate it and they leave
• 46:35it. So this
• 46:36and we're not doing any
• 46:37exposure. Kids aren't talking about
• 46:39their trauma. And this we're
• 46:41still doing in the inpatient
• 46:42unit and we're doing a
• 46:43different version of this in
• 46:44the juvenile detention settings.
• 46:47We couldn't find anything for
• 46:48the little ones. We called
• 46:49up Judy Cohen who developed
• 46:51trauma focused CBT.
• 46:52We said, Judy, can you
• 46:53help us? She said, oh,
• 46:54you can't put all those
• 46:55kids in the room together.
• 46:57She was probably right, but
• 46:58we didn't listen. So we
• 47:00took,
• 47:01we took part of trauma
• 47:03focused CBT and part of
• 47:04CBITS, which is a trauma
• 47:05intervention for older kids in
• 47:07schools. And we made a
• 47:08little cares intervention. They read
• 47:10a terrible thing happened, which
• 47:12is a terrible thing, which
• 47:13is a book about a
• 47:14red panda named Sherman. It's
• 47:16a great book, but this
• 47:17is the first time they've
• 47:18ever, these little ones have
• 47:19ever talked about, oh, this
• 47:20is what happens. And they
• 47:21do all the relay, all
• 47:22the physical, you know, the
• 47:24relaxation,
• 47:24the breathing,
• 47:25little bit of cognitive behavioral.
• 47:27And then, and they, they
• 47:28graduate. The point of both
• 47:30of these interventions are not
• 47:32to cure them,
• 47:33not to treat their PTSD,
• 47:35but to have them understand
• 47:36what's going on inside themselves
• 47:38and have some basic skills
• 47:41about how to manage their
• 47:42reactions to things.
• 47:47I would not gonna talk
• 47:47about that. So I'm gonna
• 47:49stop because I want I
• 47:49know there are lots of
• 47:50questions. So
• 47:52to anyone doing any kind
• 47:53of acute mental health work,
• 47:55ed, obviously,
• 47:57I think of I actually
• 47:58think as trauma exposure as
• 48:01causational
• 48:02in terms of the presentation
• 48:03of mental illness in kids
• 48:05and adolescents.
• 48:06It's it's correlational
• 48:08largely because of the way
• 48:09we collect data. We're working
• 48:10on this in my place,
• 48:11going retrospectively
• 48:13with families and young pregnant
• 48:15and
• 48:16young families.
• 48:18Staff education
• 48:20is vital,
• 48:22because you can either make
• 48:23these kids better
• 48:24or you can make them
• 48:25worse.
• 48:26And when you make them
• 48:27worse, it's much more dangerous
• 48:28for everyone. You can't fix
• 48:30everyone. And and, you know,
• 48:32some kids are just really,
• 48:34really damaged and really hard
• 48:35to deal with, but you
• 48:37can bring down the temperature
• 48:39by doing all this stuff.
• 48:42You
• 48:43there's no such thing as
• 48:44bipolar disorder without mania in
• 48:46little kids. I know sometimes
• 48:48the presentation of bipolar disorder
• 48:50in adolescence is depression first.
• 48:52But
• 48:53if my clinical experience of
• 48:55thousands and thousands of kids
• 48:57is is is correct,
• 48:59when you have real bipolar
• 49:00disorder and prepubertal kids, they're
• 49:02manic.
• 49:03Antipsychotics
• 49:04do not treat anger,
• 49:06and
• 49:07identifying this for kids and
• 49:09educating them are foundational
• 49:12to ongoing treatment. We've had
• 49:13kids leave the jails and
• 49:15go out to their outpatient
• 49:16psychotherapy and say, I have
• 49:18PTSD,
• 49:19You know, and they had
• 49:20to tell their therapist. Because
• 49:22remember, most people go out
• 49:23and get community services that
• 49:25are not very sophisticated.
• 49:27So having the kid understand
• 49:29what's happening within, their family
• 49:31understand
• 49:32what's happening within them is
• 49:34foundational.
• 49:36The kids don't know why
• 49:36they're bugging out the way
• 49:37they're bugging out. And if
• 49:38we don't help them understand
• 49:40that, and we're the people
• 49:41that can distinguish between someone
• 49:43who's actually
• 49:44psychotic
• 49:46and someone who is traumatized.
• 49:48So there's lots of confusion.
• 49:50Kids here have,
• 49:51perceptual
• 49:52things related to traumatic experience.
• 49:54They're have hearing voices. There's
• 49:56a lot. Generally speaking, that's
• 49:58not the case, particularly with
• 49:59the younger kids.
• 50:01So I think this is
• 50:02what we should all be
• 50:03doing
• 50:03in our inpatient environments,
• 50:06and I look forward to
• 50:07your comments and questions.
• 50:16The first question comes from,
• 50:19Zoom world. Christine
• 50:21Emens, can you hear me
• 50:22over there?
• 50:25Hello, Christine?
• 50:29Hold on a sec.
• 50:31Yes. I can hear you.
• 50:32Let's try it again. Can
• 50:33you hear me, Christine?
• 50:35Yes. I can hear you.
• 50:36Oh, good. Well, go for
• 50:37it. Your question.
• 50:40Oh, okay. My question has
• 50:41to do with the difference
• 50:43between PTSD
• 50:45and
• 50:45continuous
• 50:47traumatic stress disorder.
• 50:49If someone
• 50:51if kids are living in
• 50:52a situation
• 50:53of continuous
• 50:54traumatic, you know, continuous
• 50:57traumatic situation over a period
• 50:58of time,
• 51:00can you still call it
• 51:01PTSD,
• 51:02or or is it something
• 51:04else?
• 51:06Are the symptoms different? Do
• 51:08you have something that might
• 51:09be
• 51:10termed continuous traumatic stress disorder?
• 51:13And how would that present
• 51:14differently from PTSD where, you
• 51:17know, they've had traumatic events,
• 51:18but they're over? Well, that's
• 51:20that's Christine, that's exactly what
• 51:21the issue with with the
• 51:23diagnosis of PTSD
• 51:24is. It was designed for
• 51:26adults
• 51:27who went into a situation
• 51:28that was continuously
• 51:30traumatizing like war, and then
• 51:32came back with a syndrome
• 51:34of PTSD. What we're dealing
• 51:36with is kids who experience
• 51:38exposure
• 51:39chronically
• 51:40over childhood.
• 51:42And as I said, the
• 51:43complex trauma kids
• 51:45don't
• 51:46necessarily meet criteria for PTSD.
• 51:51So,
• 51:53and I think part of
• 51:53this is because DSM
• 51:55really DSM three really moved
• 51:58away from etiology.
• 52:00You know, it's really a
• 52:02system that was focused on
• 52:03describing
• 52:04relatively coherent set of syndromes
• 52:07and symptom pictures
• 52:09so people could be doing
• 52:10the same thing when they
• 52:11were doing research and doing
• 52:12treatment.
• 52:13I want us to go
• 52:14back to etiology
• 52:15in in this arena.
• 52:18So the obviously, the first
• 52:19rule of trauma intervention is
• 52:22stop traumatizing the kid.
• 52:24And that's the first safety
• 52:26first. That's the first thing
• 52:27you do. All of us
• 52:28in our work, if you
• 52:29do the kind of work
• 52:30I do, deal with kids
• 52:31we cannot protect,
• 52:33and we cannot necessarily stop
• 52:34the trauma.
• 52:36So, you know, often that's
• 52:38very frustrating and hard because
• 52:40you know the kid is
• 52:41being really hurt by it.
• 52:43The best thing you can
• 52:44do certainly on an outpatient
• 52:45basis is stay with that
• 52:46kid over time
• 52:48and be someone who admires
• 52:49and respects the kid and
• 52:51tries to help the kid,
• 52:52but you can't necessarily save
• 52:53these kids.
• 52:55And many, many children
• 52:57have very difficult things happen
• 52:59to them in their lives.
• 53:00Many, many children do. We
• 53:01don't like to think that
• 53:02way about children, but that
• 53:03is the reality.
• 53:05Anyone else?
• 53:06You know, I,
• 53:08I'm so happy that you
• 53:09mentioned nursing.
• 53:10I'm gonna forget the part
• 53:11about the danger. I'm gonna
• 53:12remember the part about the
• 53:14wonderfulness.
• 53:14Because some of the nurses
• 53:16are here. We have here
• 53:17some of our, fabulous inpatient
• 53:19The best the the backbone
• 53:21of the hospital.
• 53:24It's great to meet you.
• 53:25It was great to meet
• 53:26you on the unit and
• 53:27share our unit with you.
• 53:28My question
• 53:29goes to the last couple
• 53:31of slides that you shared
• 53:32about the trauma informed care
• 53:33on the inpatient unit. And
• 53:35do you have any tips
• 53:36and tricks or,
• 53:38or support you can give
• 53:39us to how do we
• 53:40manage a child that has
• 53:42multiple hospitalizations
• 53:45in a short period of
• 53:46time? Like, you read a
• 53:47story and you had the
• 53:48five steps that you went
• 53:49through, but what if they
• 53:50get admitted a month later?
• 53:51What what is staff doing
• 53:53then with that child?
• 53:54I think you I mean,
• 53:56first of all, you have
• 53:57to that
• 53:58speaks to what I was
• 53:59talking about, that they're we're
• 54:01discharging kids back to the
• 54:02same craziness.
• 54:03This happens a lot with
• 54:04the little ones. It's very
• 54:06frustrating.
• 54:08And one of the reasons
• 54:09I'm gonna
• 54:10your chair and I are
• 54:11gonna try to do some
• 54:12work on
• 54:13scaling our very effective interventions
• 54:16more systematically
• 54:18to populations that we know
• 54:20need secondary prevention, like the
• 54:22child welfare population.
• 54:24I think you just keep
• 54:26doing the same thing you
• 54:27do every time,
• 54:29which is you that you
• 54:31understand that child and you
• 54:33have empathy with that child,
• 54:35and you try to help
• 54:36that child feel safe enough
• 54:38to develop some other kinds
• 54:39of skills when they're there.
• 54:41You know, the kids come
• 54:42in. The first time they
• 54:43come in. I know you
• 54:43nurses know this and they
• 54:45rip the shit out of
• 54:46the unit and they're like,
• 54:48you know, Hey, no swearing.
• 54:49You're sorry.
• 54:51And, and they, you know,
• 54:53they're tearing things up and
• 54:54they're
• 54:55bullet. They can be the
• 54:56girls in particular can be
• 54:57so rough.
• 54:59And if and you say
• 55:01it's okay. You're safe. That
• 55:02doesn't work. You're safe. Doesn't
• 55:04work.
• 55:05You can trust us. That
• 55:06also doesn't work. But they
• 55:08know
• 55:09they know who actually sees
• 55:11them
• 55:12and who can
• 55:14find who they are. Very
• 55:15often, in my experience, is
• 55:17some of the techs
• 55:18who are the best with
• 55:19the kids.
• 55:21And
• 55:21and the kids know when
• 55:23they're in a place where
• 55:24they're valued and they're protected.
• 55:27You just, you know, it's,
• 55:28it's like what, what the
• 55:30old, you know,
• 55:32detox facilities used to do.
• 55:33You just keep detoxing them.
• 55:35They come back, you detox
• 55:36them again.
• 55:37You can't change their world.
• 55:39That's the problem.
• 55:41And eventually some of those
• 55:43kids calm down and eventually
• 55:45they come to you and
• 55:46they feel safe. Now they
• 55:47may be wanting to come
• 55:48to you to be safe,
• 55:50right, which is a challenge,
• 55:51but
• 55:52sometimes the only place they
• 55:53are safe is the hospital.
• 55:54So, I mean, we we
• 55:55have to fix the world
• 55:57before we can fix this.
• 56:00Again,
• 56:01there's lots of questions.
• 56:04Thank you. Hi. I'm Lilia
• 56:06Benoit. I'm child and adolescent
• 56:07psychiatrist from France. We're doing
• 56:08my residency
• 56:09right now
• 56:11here. And so I'm currently
• 56:12working, in Winchester One, the
• 56:14inpatient unit.
• 56:16And something I like to
• 56:17tell medical students is that
• 56:19kids are sick from social
• 56:21adversity,
• 56:22which is the main etiology
• 56:24even for the trauma. And
• 56:25then the trauma leads to
• 56:27all those stickers from DSM
• 56:29that we try to patch.
• 56:32And then that's my question.
• 56:33Like if in the DSM,
• 56:35we're not talking about trauma,
• 56:36maybe,
• 56:37it's also because trauma means,
• 56:40talking about social justice,
• 56:42about,
• 56:43systemic racism. And
• 56:46should our film
• 56:47take a more political
• 56:49stance at saying, like, there
• 56:50is a real ideology
• 56:52between behind all of those
• 56:54developmental,
• 56:56issues that are those trauma
• 56:58and this is social injustice?
• 57:01That's one question. And then
• 57:02the second one really quickly.
• 57:04Take that. Yeah. Okay. So,
• 57:08I have a
• 57:10I know poverty is associated
• 57:12with
• 57:13problems for people.
• 57:14I took it I take
• 57:15a slightly different angle on
• 57:17it, as a psychiatrist and
• 57:19not a politician. And, of
• 57:20course, we have to be
• 57:21political. Yes. We do.
• 57:24I see it in my
• 57:25town where there are three
• 57:28really,
• 57:29really still very disadvantaged
• 57:31areas, and there's a lot
• 57:33of inner familial and intergenerational
• 57:35trauma.
• 57:36I think those exposed trauma,
• 57:38poverty is extremely stressful,
• 57:41and stress causes mental health
• 57:42problems.
• 57:43But I think
• 57:45my take on it is
• 57:46there's a subset of people
• 57:47who can't get out of
• 57:48poverty
• 57:49because they have these kinds
• 57:50of interpersonal challenges.
• 57:52And that that's something we
• 57:54as a field could be
• 57:55helpful with If we did
• 57:57the right thing. Are we
• 57:58going to be successful if
• 57:59we don't deal with the
• 58:00fact that America doesn't give
• 58:01a you know, what about
• 58:02children? Probably not.
• 58:05Second question very quickly.
• 58:07What do you make when
• 58:08the kids build a secure
• 58:09attachment to the inpatient unit?
• 58:12What do you, what do
• 58:13you Once you manage your
• 58:15trauma in front care within
• 58:16the unit and the kids
• 58:18come and come back and
• 58:19come back because they have
• 58:20a secure attachment to the
• 58:21unit. Most kids don't.
• 58:23They have to have secure
• 58:24attachment in the inpatient unit,
• 58:26these kids.
• 58:27And that's why it's so
• 58:28important to make the units
• 58:29work this way. I mean,
• 58:31it's not the same as
• 58:32the attachment you have to
• 58:33your mother,
• 58:34but
• 58:35kids, you know,
• 58:37having experiences
• 58:38during adolescence,
• 58:39I mean, we do this
• 58:40in the jails with kids
• 58:41where you you see things
• 58:43a different way and you
• 58:44understand yourself differently
• 58:46can do something really useful
• 58:48for a kid. It might
• 58:49not show up immediately,
• 58:51but that's all we can
• 58:52really do.
• 58:53And the state hospitals
• 58:55make a mess because they
• 58:57could do more because the
• 58:58kids are there longer if
• 58:59they did it right.
• 59:00Two things. The first one
• 59:02is that right after this,
• 59:03we're gonna meet to descend
• 59:05with, the fellows and with
• 59:08doctor Havens,
• 59:09please,
• 59:11join us.
• 59:12Everybody's everyone is welcome. And
• 59:14we have the final question
• 59:15from, our trauma world. So
• 59:17Carrie Carrie Epstein.
• 59:21Thank you so much.
• 59:23Jenny, I am a New
• 59:25Yorker, so I love it.
• 59:26And, I don't know if
• 59:28you were we've our paths
• 59:29across many times over the
• 59:30last few decades,
• 59:32and you're singing my song.
• 59:34And so I just loved
• 59:35your presentation to thank you.
• 59:36And I think that what
• 59:37you're really speaking to
• 59:39you know, we think about
• 59:40the different moments in the
• 59:41child's life where we may
• 59:42interface with the child. And
• 59:44what I think is so,
• 59:45you know, heartening about your
• 59:47presentation is that working with
• 59:49children with significant trauma histories,
• 59:51complex trauma histories,
• 59:53high level of symptomatic acuity
• 59:56can really place enormous demands
• 59:58on providers and clinicians
• 60:00whose And she nurses.
• 01:00:02With and nurses. Thank you.
• 01:00:04Mhmm. And whose
• 01:00:05all of his primary wish
• 01:00:07is to reduce suffering from
• 01:00:08symptoms
• 01:00:09and interrupt the
• 01:00:11accruing developmental deficits. And as
• 01:00:13providers, we can feel challenged
• 01:00:15by the reality
• 01:00:17that the time in which
• 01:00:18we have to work with
• 01:00:18the child might be very
• 01:00:20limited including
• 01:00:21and maybe especially in the
• 01:00:22context of a brief hospitalization,
• 01:00:25and we can potentially feel
• 01:00:26ineffective or helpless we can
• 01:00:28help. And what I love
• 01:00:29about what you're saying that
• 01:00:31I so agree with is
• 01:00:32that it can be easy
• 01:00:33to forget
• 01:00:34that any of our efforts
• 01:00:36are in a broader continuum
• 01:00:37of care, and there's incredible
• 01:00:39things that can be done
• 01:00:41within that
• 01:00:42hospitalization
• 01:00:44that also can be, up
• 01:00:46then there's the follow through
• 01:00:48to referrals for the evidence
• 01:00:49based treatments at the child
• 01:00:50study center.
• 01:00:52So I love both your
• 01:00:53recommendations of what we can
• 01:00:55be doing and also what
• 01:00:56we need to steer clear
• 01:00:57of. So,
• 01:00:59thank you so much. At
• 01:00:59least at least we shouldn't
• 01:01:01do the wrong thing. That's
• 01:01:02right.
• 01:01:04And as my my one
• 01:01:05of my one of the
• 01:01:06previous chairs in my place
• 01:01:07that used to say, Glenn
• 01:01:08Sachs, who's a trauma guy,
• 01:01:10What does it mean?
• 01:01:11Yep. I know Kelly. So
• 01:01:13what does it mean if,
• 01:01:15you have
• 01:01:17trauma problems
• 01:01:18and someone gives you a
• 01:01:19pill?
• 01:01:21Right. It means the problems
• 01:01:22are biological,
• 01:01:23which of course they are,
• 01:01:24but you know, because everything's
• 01:01:26biological, but and they're the
• 01:01:28pill
• 01:01:30can fix what's wrong with
• 01:01:31you,
• 01:01:32as opposed to allowing the
• 01:01:33child to externalize
• 01:01:35what has happened to them.
• 01:01:37And That's why the psychoeducation
• 01:01:38is so important.
• 01:01:40We just share the stairs
• 01:01:41stuff with you and the
• 01:01:42care stuff with you in
• 01:01:44a teaching the kids like
• 01:01:45in an educational way. This
• 01:01:46is why you're the way
• 01:01:48you are is very important.
• 01:01:50And then they can go
• 01:01:51out with their diagnosis and
• 01:01:53protect themselves
• 01:01:54from the mental health world.
• 01:01:56Thank you all. It's great
• 01:01:57to be here.