Hi, everyone. My name is Doctor Rob Schmidt and we are very fortunate enough to have Doctor Jeff Bostic join us for this. Number six of our webinars through the course of this school year. And today's topic would be the signs and symptoms and treatment options of child and, child and adolescent depression within the school age population. It's a pretty large topic to discuss within an hour or so. If I sound like I'm talking fast, I probably am trying to talk fast to get as much information as we possibly can into this conversation for our parents and some of our staff. So just a brief background with Doctor Jeff Bostic, who likes to be called Jeff, is pretty cool. Is a child psychiatrist, faculty at Georgetown University Hospital, Department of Psychiatry. He provides school consultative services to or within the Maryland through MSDE and Virginia schools. And he still remains, despite being so busy, a part of the Harvard Mass General Hospital staff. Is that right? And is an active, is an active member of the American Academy of Child and Analysts and Psychiatry committees and is one of the assistant editors to their actual, their journal. And they have a, each state has a chapter. I know, right. So I remember giving a talk to the Baltimore chapter many years ago. He has extensive professional experience and publications from journal articles to books to chapters in books. So we're really, like I said, really fortunate to have Doctor Bostick, and probably most importantly and selfishly, to have Doctor Bostick, a part of the Talbot County Public School consultation staff for our school teams. And he provides monthly or as needed, you know, on paper, formally it's monthly. But Jeff is so flexible. He's pretty much within the phone call or an email, and he provides consultative services for all of our school social workers within our eight schools and has been for, I'm guessing about a year and a half now. Yeah. So we're going to go ahead and take it away and probably through MSDE just real quick. Jeff is a part of the Maryland School Mental health response program through MSDEV, and they have had that contract over the past year and a half. That's how fortunate we have been able to meet doctor Bostic. So let me back up a little bit. So we keep hearing now that the United States, we were in such a child and adolescent or child mental health crisis, and it took me back thinking about today. We heard the same thing in the nineties with our former surgeon general, Doctor David Satcher. He talked about that and, you know, it was a crisis then. I don't know if there's a similarity or a difference between from the mid or late nineties to what we're seeing now, because now we're hearing the same thing that through the surgeon general, that we are in a child and adolescent or child mental health crisis. And I just wanted to get your thoughts related to that. Like, what are the differences? Is there any difference? Well, you know, my perception is, is that actually back in the nineties, there was just growing awareness that kids could be depressed. It used to be, even back to the eighties nineties, that people were like, kids can't be depressed. It's like, that's just part of being an adolescent. And they'll be moody and that'll all get better. And ultimately, people recognize, like, no, some kids really, like, get impaired and they can't function for months at a time because of, like, distressing moods, whether it's depression or sometimes it could be something like bipolar disorder, which is much less common and certainly with anxiety and stuff as well. So that was kind of one of the things that went on back in the early nineties was the recognition that really kids and youth can get depressed and we need to respond to them. The way that they present is differently. The treatments for them have to be modified so that they fit their developmental kind of place, if you will, so that all was really relevant. More recently, I have to say, the surgeon general, now, Vivek Murthy, has done a really great job, in my estimation, also, like his predecessors and kind of taking this forward a step. And specifically, Doctor Murthy has really focused on coming out of the pandemic, but also on loneliness and everything that that seemed to entail with making everybody, and particularly youth, more vulnerable to everything, like depression, anxiety, all kind of psychopathology, if you will. And so the thing that I see that's different, that I really personally like, is more of a focus on are we dressing the natural things out there in our environment that are potentially contributing to people's vulnerability to, if you will, psychopathology. Can we do things about that structurally to make things better? Can we address poverty better? And kids who are under resourced, we know that they're more vulnerable to depression and suicide, everything bad. And so he's really taken a good step forward with that. And this is the big thing. In my own estimation, we've moved from, in the nineties trying to diagnose kids. Oh, this kid seems like he has ADHD. Oh, that kid feels like they have disruptive mood dysregulation disorder or bipolar or major depression. It's like, no, no, no, no. And I think one of the things that you and I particularly probably share Rob, based on our conversations with the meetings that we've done, is everybody's kind of on the spectrum. I don't mean just the autism spectrum, probably relevant, too, but more specifically, like, with mood, some people are much more moody. They're more vulnerable to, like, having negative moods or being despondent, whatever. Some people are more like, anxious. We all talk about people, or they're kind of wound tight, if you will. And the point is that these things are not so clear cut as, oh, you meet six out of nine symptoms, so you're over in this box. And the other people who only have five symptoms, like, well, that's fine. We don't need to worry about them. And I think Doctor Murthy specifically has been good about helping us to think about this more along the continuum. So whether it is your degree of distractibility, ADHD, we're all on various places on that spectrum. Whether it is your social skills, your ability to, like, read between the lines and social interactions, stuff that's been historically more associated with, like, autism. Like I said, everybody's different in that regard, too. And then the same thing again with mood and also with, like, being able to, like, resolve and navigate, like, conflict or difficulty. So it's a much more proactive approach, I think, in recent times to recognize the significance and severity of it, but to do it early. And, you know, our bad metaphor here is trying to build better brains rather than, wait, two dadgammets, someone is really impaired in multiple of their domains before we say, well, I guess we should do something now. So, yes, the numbers have gone up as far as the numbers of kids diagnosed with depression and who have described a depressive episode in the last year, if you will, between even 1980, 1990, ten, even in 2020, the numbers have gone up. But I think our approach is shifting more to, like, being early, uh, you know, involved with this kind of stuff and trying to be more preventative or early intervention rather than waiting until things are really in a bad, bad spot. Yeah. So, yeah, so the. It is like, kind of like the old evil cave was ramp. Since then, you know, it's gone. It's going a good percentile up. But, you know, as a parent, what does depression even look like in kids now? I know it's. It's. It's. Can be complicated, of course, but say, can kids in elementary school, can they have depression like. Or is it more like situational, or is it like. It's not so much the biologic? I don't know. What would you say? Like what would it look like in elementary school? Well, I'll just think there's two different questions there. One is what does it look like at different ages? And two, does it really happen like in really younger kids? So here's the bottom line as best I can understand it. Again, this is an evolving thing that I don't know. I know what I, what I think at this point based on being in this field for a spin and watching how things have evolved and whatnot. But my perception is, is that, yes, there are people who are vulnerable to depression even at early ages. And in fact there was research published in 2022 looking at like five to eleven year olds, again, who had not only been depressed, but suicidal. Suicidal. And so we don't ignore that anymore. But again, that's not the preponderance of people. Most people under the age of twelve, for whatever reason, are less bolder depression than after that. So there's a couple of really interesting facets to that. One is that we know puberty has changed in the last hundred years. Girls used to go through puberty when they were about 1617 in 1900. Better nutrition, more stability as far as around. Both nutrition and other kinds of things have improved that, such that girls now go through puberty at average age of around twelve. So it's dropped four years in one century. Boys start now in puberty at about ten, where it used to be a little bit later, although boys sometimes finish puberty a little later, a little bit more like 30. Right, exactly. But the result of all that has been that, again, people seem to be more vulnerable earlier, partially because of just some biological changes that thrust them into puberty, which has all kinds of like, adversities, is probably too strong a term, but I'll just say factors that are associated with that, they can be complicated. Girls are, who are older or more, who go through puberty quicker, are more vulnerable to be depressed than those who go through a little bit later. And that's of course because they're oftentimes foisted into situations where older boys are trying to engage with them or romantic relationships are pursued more aggressively. And the girls aren't necessarily psychologically ready for that. So there's all kind of factors that go in there. But, so the big point is that life has changed in the last hundred years, not just in the last 30 or 40. Biologically that's made us probably more vulnerable to some of these things as well as against sociologically and psychologically as well. But so therefore, how does it present? Well, the two most sensitive predictors of depression specifically are one, does your mood change? That is, do you report that you're spending more of your time either depressed, most commonly, particularly with girls, or irritable, more common with boys and particularly younger boys? They won't say, oh, I feel sad. They'll be like, you're bugging me, or that person's. Is that the internal external facet? It can be. It certainly can be. And that's always been the joke, is that it's easy to spot anything in boys because they just, they immediately, like, blame other people or they're lashing out. And so those things are, like, picked up more readily than someone who's, like, actually thinking inside and not expressing something so quickly. So again, I don't mean to stereotype or anything like that, but just we know that in an honest way, that when kids describe mood changes, and again, those are manifest again externally by, again, oftentimes irritability or like crying and sadness, but also internally asking, how are you feeling? How did your day go today? I know those seem simple, but those are important. That's the first most significant predictor of depression, if you will. The second most sensitive likely to pick up depression variable is withdrawal from previously enjoyable activities. I don't mean to sound that so psycho babbling, like rolling off here, but it's a really big deal, which is when kids have engaged in things and then they withdraw, they just don't want to do them anymore. That is really like, cause for awareness or concern. Now, let's make a distinction. If a kid is finally getting out of music lessons that they have not wanted to take since the get go. That's not what we're talking about. We're talking about when a kid has enjoyed playing video games and then just suddenly stops and retreats to the room and sleeps or whatever, or when a kid has played sports. And so I just don't want to do it anymore and there's no good reason for it, so to speak. And same thing again with music, you know, playing, you know, bands or just playing your violin or whatever. So those are the two biggest things. And again, they show up differently, you know, in younger kids, they're more likely, just, as you said, to be external. The kid may not articulate, wow, I'm really feeling sad. They may just be like, you know, and I don't want to engage. And it may be more external stuff you pick up on, but you can also ask about it. And of course, we're always encouraging not just parents but teachers, you know, to make sure that kids are drawing because so much of the time, whatever they're drawing can be tainted with things that kind of signals like this seems a little different than what the other third graders, nine year olds, etcetera, are doing. So that's a good way to kind of, like, distinguish some, some of the kids who might be struggling with that. Yeah. And we see, and we see that. We see that a lot in our teachers at Tawba County Public School, especially English. Our teachers pretty much have a trained knack to pick something up like that in self expressive papers, art class, young kids drawing things that, you know, you know, head is detached or in mid air floating. You know, they do calls just for further explanation or inquisitive. So our teachers, you know, since kids spend most of their time during the course of a year in school, you know, it's, you know, sometimes our school staff are the first identifiers of some things that may be shifting or the child may not have the skills to deal with. You know what? We see a lot like reasons for school mental health referrals or counseling referrals, you know, related to the social piece. And that's not understanding maybe why mom and dad aren't together. It could be a loss of a dog, elementary school, or a pet or even my show, my show lamb that had passed away, that we spent the last four years, you know, showing all of a sudden something or loss of a grandpa or someone like that, that we see some situational kinds of things. And our teachers pick that up or refer to the school counselor, and the school counselor does, you know, further inquiry to see how they're doing and talks with mom or dad or grandparents. So. Yeah, and I think Talbot is very good at this. You have, you know, social workers involved in each of the schools. So they're part of the school. They're part of the matrix of adults that look out for kids, and they've got mental health savvy. So again, they're better positioned sometimes to interpret stuff than just people who are not familiar with any of this kind of stuff. But that said, we've increasingly been working on, quote unquote, mental health literacy with school staff so that they're better positioned also to let go. This feels a little bit off. And again, we're not interested in waiting until someone has got all the symptoms of depression or adhd or anxiety or whatever. But, like, hmm, I can already. I mean, they typically have 30 ish kids per class, and they're looking at these kids relative to each other. It's like this kid's like, he's doing differently than he was previously. What could be going on? And this is the big factor, I think. So often parents are afraid or they feel, like, blamed, and it's not deliberate, but when they get a call from the school, it's like, oh, God, what do they want me to do now? What are they imagining that we're doing or not doing at home? That's rarely, in my experience, the circumstance. And so it certainly works way better when you've got the kind of network of good adults around the kid, the school staff, the mental health clinician at the school, and the parent, like, going, let's just put our heads together and think about what could be going on here, rather than who's to blame for this, because rarely is it like someone's to blame. Most of the time. It's like the kids perceptions have increasingly gotten negative. And so no matter what it is, whether they're playing sports and stuff outside of school or whether they're talking with their family, whether they're having peer conflicts or whatever, that stuff's usually going across several places. And so it's just so important to coalesce information so that people work together. That really makes a huge difference in turning things around more quickly. Yeah, just, you know, I'm just thinking, like, you know, having, maybe having a child in school and to school calls or the therapist, if I'm in my child in outpatient mental health, and they all of a sudden they give this diagnosis because of course they have to bill, so they have to diagnose of some sort, you know, when they throw diagnoses around, typically in a school age population, mood dysregulation disorder, major depressive disorder, what is dysthymia? You know, those kinds of things. Can you just touch on that? Because they're typically at school age. You hear that for kids or middle, high school that are referred or seeking treatment, maybe not even going through the school. And the parents sometimes are not always, it's not always explained to the parents what these even are by our mental health practitioners. Yeah, so, like, yeah, this time me up. Mood disorder. So a couple of things in terms of the disorders, you're totally right. People have to assign a diagnosis so that they can bill insurance to get paid. That doesn't mean, and this is what's most important. So often I'm encumbered with families will say, so, Hubert has now been diagnosed with MDD, with major depression. So will he need to remain on medicine now for the rest of his life? And of course, the answer is typically no. That's not the norm, if you will. But the entire point is that we would never want an illness, depression, anxiety, whatever, to define a kid. The better metaphor for this, in my own experience, has been diabetes. People have diabetes. They get that typically not in elementary school grades. Most people who get diabetes get it much later. But the point is, you learn to live with it and you learn to not be defined by that. Similarly, all of us have times when we have rough times. We have a breakup with somebody, we have a loss, like you said, a grandparent or somebody else. Nobody does well with all that kind of stuff. I've met no individuals in my life who are like, nope, no adversity for me ever. It's like everybody has those. And so sometimes people need some support. We would always wish that they get support at school. I've spent much of my life in addition to working in schools professionally, I've been much more likely to do that, starting back in Boston when I finished up at Mass general and just stayed on there for like 25 years. I work in community mental health there, and we had social workers and case managers and stuff, and we preferred that over, like, kids being in the hospital. We wanted to fight, how can we get them sucked into being on a t ball team or playing softball or whatever else it might be so that they can get back into the game of life and how could they be successful at school and all kinds of stuff? So our focus has been much more on trying to, again, keep people in the game and not let their illness define them. Oh, they need to go to the hospital for a month or three months or whatever. It's like we really. That's really kind of like not the game plan the vast majority of the times. So that partnership stuff, again, is real important with families to do, you know, with the school staff, because this is the other really harsh thing. Lisa Jacox and other people did research going back, like now, 1015 years, showing that if you're really going to get mental health support, it's going to most commonly occur at school. You alluded to this a second ago. Michael Rutter, this guy in England or the UK, somewhere in the UK, wrote a book some number of years ago called 15,000 hours. And he was a psychiatrist, child psychiatrist, even. And his focus was like, schools have 15,000 hours to work with kids from basically kindergarten to, like, what we would call 12th grade. At this point. There's no therapy model where you're going to go see a therapist once a week or twice a week or whatever that's ever going to approximate the density of intervention that you can get, for example, at a school. And so Lisa Jacox's work similarly was like, the vast majority of kids who do outpatient stuff don't even make it to the second appointment. So if you're going to get even six, like, visits in with somebody over the course of time, that more frequently happens at school. And I'm just telling you, that's the model that we're seeing increasingly embrace. That doesn't mean that we want to neglect academics or anything else, but that's just such an important place for us to make sure we're providing stuff, because, again, clinicians working with the workplace, you know, school like that is whatever they're seeing in the groups that they may be doing with these kids that can be extrapolated. Like, how are we going to make sure that this kid can now be successful and function in math class, geometry, whatever it might be? So that's really changed the way that we look at treatment stuff. The big thing on diagnoses that's really shifted is major depression, again, has been, like, redefined a little bit to better account for, like, differences in childhood versus adult and all. But the bigger thing has been bipolar disorder. It used to be kids who were up and down, their lids are up and down. They'd be fine for 15 minutes, and then they'd blow apart, and then 2 hours later, they'd be like, calm or depressed or whatever. They used to get diagnosed with bipolar disorder a lot. That diagnosis went up a lot in the nineties. What was interesting was there was a study done in Appalachian, and they just followed kids for years, kids and adults, actually. But they had a big cohort of kids, and we're talking thousands here. And they looked, and certain of these kids, they didn't even call it disruptive mood dysregulation or bipolar. They said, man, they have some kind of serious emotional, like, reactivity here. And so they monitored the specific symptoms of bipolar disorder and the serious emotional stuff. And the whole entire point was they found that these kids who were like, quote, ultra rapid cycling, or rapid cycling, like every day or every hour, seemed like they were like moods were changing. They didn't turn out to have bipolar disorder when they grew up. That is, they didn't have intervals of, like, mania that would last for like, three or four days, and then intervals of depression that might last for a week or two or three months, like classically bipolar adults tended to be. Instead, these kids grew up, and it turned out that their symptoms were most consistent with major depression and with adhd and impulsivity specifically. So it was like, our treatment for that has really shifted. So that when we see kids who, like, parents come in and they're like, my kids, bipolar, you wouldn't believe. Their leaves go up like this, then they're down every day. You don't know what to expect. It's like, that's not biologically what they probably have. And when I say that, it's like, we've got a few things that we can't do. A blood test or an MRI scan or whatever for such. Well, anything really, in psychiatry, but particularly bipolar disorder and schizophrenia. Yet when you see that as a clinician, it's not particularly subtle, particularly as kids get to be about 15 to 25, which is usually when bipolar disorder or schizophrenia show up. With bipolar disorder, it's really pretty conspicuous. People will, like, go days without sleeping, and they'll be really bizarre, and they're thinking grandiose, doing all kinds of things they wouldn't ordinarily do, and then they're like, I had no idea it was doing that. And then maybe they'll be depressed, but maybe not. But then they'll function sometimes for, like, months and years, fine, no problem at all. And then, boom, they may have another episode. Again, that's very different than trying to manage someone whose moods go up all the time that you see sometimes in school, which typically necessitates, again, a different type of intervention where you work on, like, how to manage your impulsive, like, perceptions or actions or whatever. So the diagnoses are important and we're trying to evolve them. And I can only apologize. We're struggling to try to find good markers for those. There's multiple ones that are coming up now, and I'm joking about it because it's like there are things like inflammatory response markers that also suggest inflammation, like whether it's your intestines, your gut, if you will, or other parts of your body. Those are like, wait a minute, we're seeing that those seem to be associated with people's vulnerability to developing depression or anxiety. That's really paralyzing for them, etcetera. But we don't have any markers yet or any MRI test yet that can definitively say, this is what you got. So instead, it's like, whatever you got, let's target those symptoms and do interventions to get those better. And if we can do that in school, all the better, because that's just a better place for us. To really measure how it's impacting your interpersonal relationships as well as, like, your academics, you know, progress, same as your work stuff's going to be in coming years. Yeah, you know, I hear a lot from colleagues and parents especially, and, you know, does every child that has maybe depression or has or presents with depressive type symptoms that may be not even in treatment, does every child have thoughts of suicide? Or is that just a myth, would you say? Or does that vary? Well, it depends on who you talk to. Kids who are exposed to things like that, both environmentally and I don't mean this is a criticism of parents for, like, not better regulating all the screen access that kids have to pretty much any kind of thing, but rather that, you know, some people have had family members or other circumstances that have made certain things, like, visible on their radar screen. And it's not, of course, unusual to look up and go, hmm, I wonder what it would be like if I were not here anymore. Like, again, even passive suicidal thoughts, no active plan. But just like, what if I'm not here anymore? So it varies again by people's past experiences in one facet, but some people do feel it. So a real important distinction to draw here, though, has been self harmful behaviors as opposed to, like, suicide plans, if you will. There are people, not just kids out there, who will scratch on themselves, cut on themselves superficially, and they'll tell you, oftentimes it's like, it allows me to at least not feel numb. It allows me to feel like I'm alive and stuff like that. And. Or it releases. Sorry, endorphins. Right. The things that diminish your receptivity to pain so that you can. So it kind of combats those painful kind of things a little bit. It is not the approach that we suggest or encourage for anybody, but it's important when a kid is, like, cutting on themselves that you're like, do you feel better when you cut? Because some of these kids will say, yeah, I feel better for 15 minutes or 2 hours or something like that. Versus are you hoping to. Is there a plan here to bleed out and die? Which is, again, indicative of, like, suicide suicidality versus self harm kind of stuff. And that puts us in a jam in schools because it's like, you know, because even though the intent is not to die, it is to feel alive again. But the more you do it, it sound. It seems like in working with. Used through the year, the last 30 years, is that they tend to go deeper. They get a more euphoric type feeling. And so accidentally. You know, kids across the country do die because they. They have to. They have to cut more and they have to go deeper, and they don't realize it. They're going deeper. And so that's the. That, you know, that's the word. That's what, you know, we see scratches and, oh, my cat did it. Right. Or something. You know, I scratched it with this. And there are varying tools or instruments used to scratch. It. Could be, you know, a paperclip. It's. Could be. What's it, a bob in your hair of the bobby pin. Bobby pin. And, you know, razors. It could be anything like that. And then, you know, and we know they don't want to die, but we still have to take the steps, you know, to ensure safety. That's put schools in a jam across the country. Yes. And at the same time, that's so important, though, and I agree with you, because either way, it's a. It is a signal for need, for intervention. So whether someone is cutting, trying to feel better, or whether they're trying to cut so that they can die, if you will, either way, it's like, we got to do something. And the biggest point is that, you know, again, they're not. They're not mutually exclusive. There are people who sometimes are like, I don't want to live anymore. And they will self cut. There are, again, people who don't feel suicidal, who do self cut. But the point is, anytime that happens, we have to respond to it. That's not something. And this is my bad joke again. We're talking about building good brains, but the whole thing is people have this perception that practice makes perfect. And to the brain, that's just not true. To the brain, practice makes permanent. So whatever you get used to doing, that tends to be your default go to kind of, like, response to things, and we want to move that away. And so backing up to, like, an uber simple, kind of, like, little mnemonic we use here when we have kids who are. Who are experiencing stress. And again, this is done even proactively. We don't even wait sometimes for kids to, like, describe depression or cutting or any of this stuff. It's like you're going to have stress. And people who live the longest, this has been studied, believe it or not, recognize that stress is a normal part of life. You should feel stress when you go out on the football field and you're the quarterback or the defensive back, whatever, you should feel a little bit of tension and stress so that you're, like, up to your, like, optimal, like, performance kind of level, but you don't want to be paralyzed by it. Right. So similarly, you should anticipate that you're going to have stress, know that it's a regular part of life and you should have coping skills for it. And that's how we're trying to even like with early, you know, age kind of stuff. It's like a simple one is quote unquote harps, you know, when you start to feel stressed, you should do a healthy alternative. So for adults, that's like, instead of like taking substances or whatever to blunt their, like, distressed feelings, it's like. No, like exercise. Do things that you, like, paint. Exercise is proven, right? Exactly. Yeah. Now how about this? Because you brought up something actually said when I was thinking about, you know, the chronic youth, chronic students that maybe, you know, when, when their first maybe struggle with any sort of adversity, the go to. The first thing I have in my toolbox is I just wish I wasn't here, you know, just having that as a go to, is that, would that be considered, even though it has to be addressed, is that considered like a inappropriate coping skill? Like, that's my go to? Yeah. I don't know. Right. No, but I'm with you all the way. And our attitude about this at this point is you can't tell people to stop doing anything. Don't think about suicide. Don't think about not being here. I mean, don't walk on the right side of the hall. You have to instead replace. It has been a more effective strategy. And that's why again, like this silly harps, like little mnemonic thing. It's like, what can you do if you feel like sad or distressed and sorry. One of the big things that humans do that lights up one of the pleasure centers of the brains is be nice to other people. Altruism, that's a really healthy thing to do. So when you're feeling sad, if you can, if you're able to think about other people and reach out to them and look out, you know, to do things that would like engage them, throwing a ball, you know, doing music with them, sharing tunes with them or whatever, that kind of stuff is good. But in addition to, like healthy alternative stuff, some people can't think of that in that second, you know, reframing stuff. People who are spiritual, like, look it up. It's like, I wonder why this situation is in my life right now. What am I supposed to do with this? You don't have to believe in some specific tenet or ideology. But it's like just recognizing that things can happen in your life and you can do left or right with them, you can go good or you can, like, let those things really become overwhelming. So that's kind of the. So you're on the r part of this problem solving, you know, what are my options here? What are the likely consequences in terms of my reactions to this thing? If I cut on myself, what's that going to do? Well, my other friends are going to be afraid of me. They're going to be wondering whether they should talk to my parents or not. It's like those are not really consequences that most people would want to inflict on the people that they, like, their peers or whatever. So oftentimes there's a better alternative, and that gets to the last one, which is social support. You know, when we get scared or we feel weird about stuff, it's like, first thing to do is like, look around. You know, our joke is like, if you're on an airplane and there's turbulence, you know, rather than just like, assume the crash position, if there's turbulence, you just look around. If everybody else is not freaking out, you're like, he's probably going to be okay. Getting kind of a reality check from trusted others. And so, you know, doing those kinds of things, looking for social support. Like, when you feel bad, do other people feel bad? Is everybody bummed about how they did on this test or what happened? You know, in a ball game or in a musical, whatever it might be, those kinds of things are really helpful practices to get used to instead of, I just wish I weren't here. That's really not going to lead to much, that's going to be beneficial for most kids. And those are your reasons. Yeah, I'm sorry. Go ahead. That's okay. I was just going to say one thing, which is people are always like, why would human beings ever experience depression in the first place? That's got to be bad. Bizarrely, there's been research on this, and it turns out that human beings, when they, when they feel like negative moods, it makes them feel like that they're, the width, the depth of their mood is positive, that they're not like robots all the time. So there seems to be some benefit, particularly in artistic people. But that's the entire point. If you have moods that are pretty, like, I feel great, or I feel really awful, or even if I feel awful more of the time, it's like, write about it, draw about it, paint about it, write songs about it, make music about it. It's like those things are helpful to other people. And you can't believe the number of times that all of us hear about students who say, I really felt awful and alone until they heard certain music or they read certain stories where the people are like, I'm not weird. This is like other people experience, like, different kind of sensations to different degrees and depths that I do, but that's not a bad thing necessarily. So that's kind of like sharing my pain, share my sadness that this is the reason. So I'm getting it out. And we're looking at this, like, neutrally on either through music or through a drawing and then working together. Exactly. Yeah. And you're talked about the last ten minutes, probably, about protective factors and how important they are. And for each and every one of us, first of all, life is hard for all of us, and we share that with every time we get. Get a chance to talk to our parents and kids. It's hard. Everybody goes through challenges. So, you know, you look out, like, your, your. Your protective factors, what are they? You know, what keeps you going? You know, is it something spiritual? Is it. Is it, is it, you know, playing ball? Is it, you know, being a part of it, just feeling like you're connected or belong to something is. Is priceless. A pet. Pets are in priceless, you know, having my pet on my dog, my dog sleeps with me every night. So, hey, I get to talk to them. And so kids, you know, drawing music, you know, finding out all of these things and just listening, and that's one thing, you know. You know, we talk about our school based mental health clinicians and our social workers and parents also on here that, you know, thinking about all the good things that are going on. But when I get stuck, my go to is here. That's the bottom out. But what do I need to be reminded of to get to at least mid group, mid midway? Right. I'm thinking what you're saying is. Yeah, I mean, just the support thing is so huge. And I have to say one of the things, again, I just love about the fact that you guys have embedded people in your schools. Sometimes schools will have one mental health worker who will bounce between three or four schools, so they're there on Monday and Thursday and somewhere else, and that's harder. And the fact that you guys have people who are there and part of that culture, like, they understand kind of what the rules of engagement are there. That makes it so much easier to, like, have someone who can individually help a kid and or a teacher like, you know, make the interaction between the staff or the academic course and the kid more valuable. And there's so many times when we look up and it's like, you know, the kids failing everything, but pick a class, english, art, whatever, and you're like, wait a minute, what's going on in that class? And you learn something so valuable from the teacher who had the kid last year or was doing something this year where they found a way to connect. And then that stuff can be spread across, you know, to other people. And so there's a lot of opportunity for density, that is multiple interactions with multiple kinds of people that exist in school kind of settings. That, again, is so important because, again, I don't mean to be negative about it, but just honest about it, which is the limitation of hospital settings are people are frequently there for short intervals and then they're back out into the real life of school, and they don't necessarily have the connections that they have that they made in the hospital transfer very easily. We're working on that. We're trying to get better, like, ensure that there's communication from the beginning, let alone at the end with hospitals and schools. But again, we're always thinking from day one, anytime a kid's like being in treatment, what else can we do? Which I'll take another quick tangent on. Sometimes parents with the best of intentions will say, you know, we're not going to tell the school that we're going to have Hubert treated by somebody specifically with medicine, which psychiatry people often do, or with therapy. We're just going to see if they notice. And I'm just going to say that, in my experience, doesn't work very well. It works way better. I appreciate the intention of, well, this will be a blind trial. They won't know. But it's like they're managing so many different things that it's difficult to, like, look at what they need to look at. So again, concretely, on the medicine end, they're going to start a medicine like, it's helpful if the staff is, like, looking for. Wait a minute, is this kid sleeping more in class now? That is exactly. Exactly. Yes. Versus like, well, they seem like they're doing, oh, it's like they don't know what to look for. So that's kind of an unfair thing to impose on them. So my experience has been things have worked significantly better whenever the school is aware of and looking for, seeing any kind of changes that are going on. And frankly, the communications with the outside providers is, in my experience, Uber helpful because the parents can't be expected to know what goes on for the 8 hours that the kids at school every day they're not there and we're good reporters back to them so they can share that with their treating physician. Right. So I mean exactly. We're all a part of that same team so we will notice changes probably quicker during the week than they would at home because the, Johnny's only home for a few hours and he's sleeping or not sleeping. I don't know. And the demands are not the same. You know the demands at school are really very much what a kid's going to have. We don't see this at home. You only see that at school and we hear that a lot and it's like okay because there, there aren't like you just said, the demands are quite different. Right. So. Well and everybody's tired. The poor parents are typically tired too. They've come in, they've worked typically much of the, the day and, or they may be working morning. It's like I'm just trying to like get my kid fed and like situated and ready for bed. It's like nobody's looking for. Well you know what, let's sit here and go over your algebra equations. Like some parents can do that but that's, that's, that's a heavy load for everybody. So again, the whole point is is it's harder to gauge that stuff after school much of the time relative to like in school. So it's just another helpful piece of evidence or information to have when you're talking with your, your, your clinician, whether they're prescribing or whether they're like just providing therapy. It's really helpful if they have that input about this is what we're seeing when they get out in the real world, so to speak, because it's going to resemble when your kids working in McDonald's or Walmart or whatever else, you know, coming up when they're 15. 1617 you know. Right. Just, just backing up a little bit when we're talking about depression overall and like when that's explained or if it's observed and it's identified. You know, a lot of the studies that talk about the greatest predictors of depression and later grades high school is our students that say that in the first few grades, preschool, kindergarten, first and second grade, if they say it then it's a greater predictor of, you know, of later thoughts and acting actually as they get older, if there are no preventative or supportive or interventions in place and I kind of was taken aback by that because it's. We see that. And when we assume the presumptive assumption is that when you do an assessment that this is not the first time, Johnny, at age 16 is having these thoughts. So let's go way back. Let's do a timeline way back when this was first said, if we can get that information right. So. So it help. It helps us out. Yeah. There was this, this big study done. It was a national study by a bunch of different, like, you know, clinicians across the country, and they looked at a national database, and they were talking about how, particularly when you go backwards, little kids looking exactly what you said, were there signs of, like, mental health or mental illness kind of symptoms back there? And there were a couple that were really important, certainly the mood kind of stuff, but also impulsivity, which sometimes it was like, oh, these kids look like they were ADHD. They may have had some ADHD symptoms, but the big prominent ones were that they would be impulsive. And that was a real particular problem. Another interesting facet to it was also that family history. Now, often we don't know what the family history is, but sometimes we do, and we know that sometimes there have been multiple people in the family who've had depression or whatever else along the way. And it's tricky because I totally respect that. Families are, like, very conscious about it, and we try to be, whenever we're working with people, we don't need to disclose details. So typically, we're like, there have been three people on the maternal side of the family to experience depression going up the family tree. We don't need to say, mom is in treatment for extra wires. No, exactly. Yes. Right. So it's just important that that stuff be clarified so that families feel comfortable and open about, like, describing stuff to recognize the vulnerabilities that kids have, but yet not like, oh, well, this is just something, you know, it's like, we want to be thoughtful and sensitive to that kind of stuff when we're working with families. Yeah. And some of those studies, they call them, like, a subtype of impulsive traits, you know, and it was like, wow, okay, so I didn't know that before. So, you know, we're looking into the studies, you know, years ago. It's like, okay, so there's the. The impulsivity, the subtype is impulsive traits. So it's not. So it's pretty. It's pretty incredible. And, you know, families need to know that, you know, everybody wants the same thing. I mean, we want their child to have a great quality of life, living, do well in school, you know, least amount of referrals for disruption or suspensions. We want great attendance. We want them to do well, whether it be through, you know, college or a career, you know, we all want the same thing. And, you know, and I get this a lot, you know, when, when our school staff, our mental health practitioners, whether it be the social workers or our school counselors, which do an amazing job, you know, when they first identify and call the parent, a cold call. Right. And I try to, when we talk about this in our groups is that, can you imagine you're the parent on the other end of this line and your school's calling. First of all, like you said earlier, the school's calling, okay, it's not good, man. What did he do? What happened? You know, is he sick or she's sick. And then you talk about mental health things. It's like, wait a minute, you know what? Why are you telling me this? And so it's easy. When we do these trainings at the beginning of the school year, the defensiveness is a natural response. And I would be too, like, what are you talking about? You know, he's, that I know of. He's fine, you know, but in school, because of the different setting, academic setting, social setting, it's really intense. And the safeguards aren't maybe like free roam as they maybe would be less structured at home. Yeah. So we understand parents. You know, we want the same thing. You got every. We're parents, too, so we want, we want the same thing you want, you know, at the, at the greatest level. And, but to do this, maybe we have to put some things in place. That's all. And that's, you know, that's the piece that. And, and I'm going to speak for you here, Jeff, because sometimes there are no quick fixes. Right. Right. I mean, whether there's no quick pill, there's no magical pill. There's nothing magical about a hospital setting other than it allows for cooling down period. Doctor Schneider talked about years ago, a couple days just to escape maybe, but there's nothing magical. So what would you say collectively when you think about treatment options, where you think about from the mild, which will be minimal supports in school, and to more intensive kinds of treatment, maybe for our older students. Yeah. So the first thing is that, again, we're trying to move away from mental illness and toward mental health. And this is not a small thing. And the good side of this has been we wrote a paper. This is like around, I don't know, around 2000 or so. And it was about the number of celebrities who had come out to talk about having bipolar disorder, depression, OCD, a variety of things. And there were like 65 or so who were, like, really pretty out about it. And they were, like, doing all kinds of work with it. So they asked us to revise this paper. Like ten years later, we're like, okay, we'll see if we can give it a go. When we just did our preliminary search, we immediately came across over 300 celebrities who were like. And so the big thing is that this is much more talkable, aboutable. Yay. We're happy about that. But now what that means is that we want to do stuff from the beginning because again, these people function at a very high level. And just like they did that. The other funny, one of the funny roles that we see ourselves mental health conditions in now is with sports. And so every team, I joke about this all the time in baseball, Major League Baseball, in the NFL, the National Hockey League, even the NBA, all of them have mental health professionals that work with the team. And it's not because the players are mentally ill. They're typically not. But you want, just as you want them nutritionally in a good place, as you want them, like, again, muscle wise to be in the optimal spot for themselves. You know, you want them also psychologically to be in the best kind of place. So we, I think this is a big thing moving from the stigma of, oh my gosh, I've got, my kids got a mental health thing to like, hey, we're dealing with our anxiety this way. We're dealing with our mood regulation stuff that way. Because like you said, they're going to have it to work with for spans of time, whether it's weeks or months or years. But this is the other thing that I've seen over the course of my long life. I've seen kids do great and then I don't see them for five or six years. And then sometimes when there's changes, they get married or they pair off with somebody, they have children, sometimes they'll have a struggle again and it's like, so they need those tools. And sometimes all they need to do is talk about it literally once or once or twice, and it's like, oh, right, this is how I step it up from when I was in the 9th grade to now that I'm 27 or whatever. So the whole notion of understanding that your mental health will vary a little bit, but the tools are so important to have now that that makes a lot of difference. So, being very concrete, again, with everybody at school, you know, we're really focused on a couple of things. One is building good mental health. We know that practice makes permanent. So getting in good patterns of doing things is a helpful thing for everybody to do. Whether it's like problem solving, whether it, again, is like how they socially engage with other people. All that thing is hugely important. We really have to stay on top of that because it really matters a lot in terms of your human happiness and satisfaction down the road. So that's kind of the tier one stuff we do. Like, the stuff I mentioned a while ago, like that chorps kind of approach. Again, we do a lot of stuff now, again, around, like, small grouping kind of stuff where kids will engage so that we can work more on that. They do projects that way with academics, even. So, we're trying to match this stuff better with academics, which is more like real life stuff now anyway. So, again, I want to be real clear. I'm not one I owed interested in reducing, like, time that kids spend in math class or learning how to read or taking fine arts away or physical, you know, physical health or pe, if you will. Those things are all huge, but they are not walled off from psychological stuff. They're integrated. And again, whether it's sports, I'm telling you, all teams have performance psychology people working with them now for a reason, and that's because it's important. And the same thing is true with academic support and all that kind of, as well. So at the tier one level, you know, like, for everybody, we just want to make sure that we're empowering them with ways to look at stress. It's a normal part of life. This is how you manage it. Don't be afraid of it. Here are tools to use. Which ones work for you? The next. So, tier one, we all have problems universally. I mean, I don't know of anyone that does not have problems or is diagnosable. We all are at different stages. So those. Those are your supports? Finding those supports. I can manage life. I can get over this hump. I can carry on. And then we're getting into tier two. Yep. If those aren't successful. So the one one kind of, like, conduit between, like, the everybody universal tier one, as we call it, kids. And then the tier two are learning to gauge kind of where you're at. So, you know, sometimes people use, I'm in a kind of a red zone. I'm not good. I can't function right now. I can't focus on math or I'm in a yellow zone. I'm kind of like a little bit. I'm about halfway there, you know, but I'm not really good green. I'm good to go. Sometimes it's that for elementary school kids, sometimes it's like numbers one through five for, like middle school. And the whole point is that kids start becoming aware of thinking about, how am I doing right now? And then, depending on whether I'm red, green, or yellow, or whether I'm one, three, or five, what am I going to do to get myself at the right mental place where I can do what I got to do? So learning which skills work for you, like, depending on how severe or minor your stuff is, is real important. That segues into the tier two stuff, which is vulnerability stuff. That is, we know that some kids are. They just lost someone, someone close to them is died. Again, nobody typically does well with that. So it's like, what are we going to do for those kind of kids? The other thing we've been working with a lot has been kids who relocate, kids who come in from another place. It's tough to come in from another place, even if you're coming to a better place. It's not familiar and it feels weird, and it makes us all anxious when we do that. So we've worked increasingly on soft landing kind of stuff. So we oftentimes do groups with kids again who've either relocated, they've been exposed to trauma at some point in time, or they've had some acute thing going on, so that we reduce their vulnerability to like, oh, this is a rough time for them. They may not know what to do. And so instead of going down that depressive or anxious or some kind of, like, not helpful kind of direction, we can early intervene and equip them with tools instead. And it's funny you mentioned it a while ago. The first thing that we do with people who relocate, there's a real big program on that that Sharon Hoover at the National center for School Mental Health has developed actually for people in Ukraine. And then she'd been over there four times in the last year to work with in that area, to work with those people. But it's like looking at your inside strengths and your outside supports, and so your inside strengths are like, I'm good at sports, or I really am, like, I'm tough, you know, things don't bother me in the same way that they do other people. You really have to focus on that. And we do that with kids again, whether they're seven years old or whether they're 13 years old or 17 years old, and then again, outside supports again. Sometimes people get that from a teacher at school. Sometimes they get it from people in spirit. It could be having a conversation with a custodian. I mean, we see that that's the male figure. That's who I have, I talk to every Monday about what happened to the Ravens yesterday, you know, but that's so important is having connections with people who have mutual interests. You know, our joke with this is, if it ain't good for both, it ain't good for long, you know, meaning just uber concretely, that it's like when you find kids that really both want to play a certain sport or both like the same kind of music, same thing with the custodian, where they, they want to talk about the ravens, it's like, that's just low hanging fruit. And those are things that make people feel good. They don't feel alone. They're combating that same thing that the surgeon general has talked about. So those are, those are cultivating those protective factors that you alluded to. And then our final level, again is when you have kids who are struggling, they're impaired. Their depression is so bad, they really can't function, both with peers and with school. They don't get along with too many people much at all. And that's where we do more individual intervention. And that's where all the clinicians, the social workers that you have, I mean, they spend time. I know, because we've talked five minutes today, twelve minutes tomorrow, whatever, to, like, help kids get kind of back in place, and also, again, to work things through with the environment, working with other teachers, with the custodian. The kid really likes talking to you about the Ravens. We need to build that into every. That's it. That, exactly. It's priceless. And we're going to start with the Orioles. They're in spring training already, so we're going to get that and they're going to do well this year, by the way. I have to throw that out there. I think they're in a good spot. So it's those more macro things and individual one on one things that occur somewhat with people at those higher levels, but our goal is always to get them back, not to keep them locked there, but how they're going to adjust to managing their situation and then keep them in the game, because too often, you know, kids, they don't, they're not in the game. You know, they're not functioning. They're outside in the they don't feel part. Right. Right. And the problem's not going to wait for them. There was this great story, you know, the Super bowl was recently, right. Joe Fassman, not Joe Thesman. Joe Montana, the San Francisco quarterback, was talking about how he was so sick one time with the flu, and it's like they were going to postpone the Super bowl to the next week. Sometimes you just like, have to learn how to function and use your skills to navigate stuff, even when it's a little bit tough. That doesn't mean we want kids to be overwhelmed with stuff, but we want to make sure that we're still keeping them in the game a lot, that they don't miss the problem, they don't miss the ball games, they don't miss the band concerts and stuff that they want to play on, that we ready? Am I up enough that they can still do some part of that so that they're part of that collective experience? Because that's real protective down the road. It is. You know, sadly and unfortunately, I got to kind of bring this to an end. This is the in depth of this conversation. Could be an all day, minimally conference, breakout session. Like an all day conference. You know, you said it earlier about the culture. You know, if you can build in supports in school that, you know, it goes back to the mid 18 hundreds. John DeWEY but if you can build in these supports in the school setting, it normalizes for kids. And so when they, when they finish high school and you nailed it, you know, you carry, they, they have this message in their head as they, as they struggle in life, because life is hard. It does. And there's different time periods in our lives or events that happen that literally is crushing. It is, you know, things happen. It's called a part of being a lot, being alive, but we don't want you to get stuck. And so what happens is when kids leave school, which they'll never have the greatest amount of interventions and supports after they leave high school, 12th grade, we are so lucky to have the kids and to take advantage of all of the things that we normalize seeking, help seeking behaviors to increase them. So when they're faced with, say, they don't get a job or they're fired, they're going through a divorce or separation or a loss that I just went down a hall to misses Johnson and she was there and we talked through things and those skills come back kind of like CPR, you know, you think you're not getting it, and then when you're faced with something, you act and don't even think about it. It just happens and you did it. And so, you know, that's a life skill that we're embedded in our kids and our faculty, because staff struggle, too. I mean, they're humans, therapists. We struggle at the doctors. Everyone struggles. It's, again, part of that humanistic feeling that happens and learning to deal with it as kids get older. But if we can build this in and teach those kinds of skills at a young age, so when they leave us, you know, they graduate or they, they carry on to a new location that they have these skills and it's all normalized. It's not so much voodoo or stereotyped out, like, I can't talk to these shrink or I can't talk to this person or it's normal. Why not talk to someone? Right? Yeah. So our athletes do. I love, there was a lot of stuff that you talked about. It went back to sports psychology. You gave yourself away there. You did. Well, I'm telling you, I'm seeing with musicians. I was reading stuff from Stuart Copeland, the guy that used to be with the police, like last night. But I totally agree with everything you're saying, Robin. Two real important pieces within that mental health stuff shows up between zero and 20. The majority of people who have any kind of mental health issue will first have it by about that point. Musculoskeletal diseases are next. They occur typically around the ages of 30. Diabetes, I mentioned around 50, coronary stuff around 70. It's real important to work hard on this stuff with mental health stuff right now at school age kind of stuff with the school, because that's also second thing when the brain is most plastic, it is way harder to learn something when you're 30 or 70 or 90 than it is when you're twelve. And so this is the optimal time to deal with something. That's when they're most vulnerable to stuff like this. Yeah. Great. It's well put. I just have to give a quick shout out for our next webinar. Next webinar is going to be March 27 from 230 to 330. It's going to be exactly, Jeff, what you just talked about about 15 minutes ago, what the stress looked like in children. It's going to go back to the stress response model, Han Soli and all the great studies that were done way back in the forties and fifties, and that's how relevant it is today. And kind of like the aces is kind of built on that, you know? So there are responses to trauma and how that affects us psychologically and physically. So I'm going to be doing that on the 27 March. And so I will send out an email out to all of our parents like this one. Should you have any questions, please reach out and call me. 410-822-0330 I'm the only rob in the building. And if you have any questions for Doctor Bostic, you can, you know, you can email me or you can just call me and forward a question and I will pass that along and we will discuss that and get right back to you. And I really appreciate Doctor Bosik. First of all, Jeff, you taking the time out of your day to do this. And I really appreciate our relationship through the schools and through the national center and the MSDE with all the, all of the information you contribute to make the lives of our kids, you know, that much greater and meaningful. And, you know, for a lot of our families, that's priceless. And that's what we all want. Well, it's a privilege. And it's been great to work with people in Talbot. I mean, I'm so grateful for the people that you have there and they've been consistently, conspicuously fabulous, you know, at every juncture. People I would trust my kids with. And that really is something that you love to see. That's great. Well, listen, take care of yourself. I will see you on the next zoom when we have our team consult. Probably within the next couple weeks. I guess. I can't, I don't have the calendar in front of me. But yeah, it'll be very soon. So you take care. Should anybody, anyone have questions again, reach out 4108-220-3330 and you guys have a wonderful hump day. Is it a hump day? Wednesday. Today's Wednesday, right? So we're over the home for the week, going into the weekend. You guys take care. Bye.