Child and adolescent psychiatrist Petra Steinbuchel, MD, discusses the ongoing behavioral fallout from the pandemic, presenting the evidence on increases in mental health problems among adolescents. With practical guidance, she focuses on how to support stressed kids by fostering connections, nurturing resilience and building life skills – as well as how to structure a return to “normal life.” Bonus: Learn the 4-1-5 breathing exercise you can use anytime to calm your nervous system.
thank you for joining. And um I really am eager to talk about this because I know we've been experiencing covid in lots of different ways and actually just want to talk about the collective mental health impact. Um, and in particular considerations in adolescent patients. Um, and um, and potentially also family members and um, and then think about some tools for the transition as we anticipate. I'm going back to school in the fall and as we're going back to work. And so with that I just wanted to share this. Um, that was put out by an organization called Trauma transformed, which is a seven county bay area initiative that was started in 2015. And um, it really wants to um, to help us kind of understand trauma better and the impact on ourselves, our patients, the systems of care in which we find ourselves. And um and so this was put forth just at the beginning of quarantine last year, we acknowledge that we're in the midst of unprecedented times. We acknowledge that we're each holding a multitude of feelings, responsibilities, fear and Joyce at the same time. We acknowledge that there are many responses to stress and uncertainty. Each of them valid. We acknowledge that there is no better opportunity to practice compassion and collective care than right now. This is the work we acknowledge the critical need for reflection, inquiry and prioritization of the most critical needs always moves me to read that because I kind of really compelling. We certainly have been in extraordinary times. And and really I think wanting it to be behind us and still not quite there. So COVID 19 has been this wrecking ball that has really disrupted our usual routines and schedules and a lot of Life's kind of natural rhythms, including Neil Times, our sense of kind of weekday vs weekends, the punctuation of seasons, knowing that the school year is ending, may have felt that way a little bit more so this year, but certainly not in 2020. And it's also disrupted our connections to loved ones for so many people say. I finally got to see my my mother and my father for the first time in over a year. Um, and that's led to a lot of isolation in particular for older generations and communities and um as well as socially professionally. Um it's been a challenge in a number of ways. Um, so not only have we experienced this pandemic, but for those persons with, with kids or who care for Children. Um the experience of distance learning has been quite an experience and there have been um multiple impacts of structural racism and racially motivated violence and murder that has happened. And it's been really highlighted in the media. It's not necessarily a new phenomenon, but it has been very much out there in the news and very much in people's awareness in addition to a number of other collective traumas and that includes also the impact of climate change and impact of wildfires that are across across the west and that we have certainly experienced six of California's worst wildfires in the past four years and we're all metabolizing a multitude of diverse feelings in response. Um, I want to acknowledge also that we have been weathering the same storm but have been in different boats. We have different access to resources to care to even the ability to work depending on our means and our geography and what type of insurance we have and so wanting to call that out and have us take a moment to reflect on that. Um The collective impact of COVID-19 may be calling out these inequalities and the disproportionate effects on persons of color and also enhancing the type of other in that's been happening um in particular for health care professionals. So nurses and physicians and other health care providers have have data to take extreme precautions to think about, you know, how they interact with family members. Um, And for a period of time, pediatric practices were really struggling to figure out how to adapt to virtual workflows and to increase revenues and be able to survive in the midst of the COVID-19. And um, and then the question of moral injury occurring, So thinking about how best to help and what are the available resources and um and where do I put forth my efforts heard so many colleagues talk about, you know, wanting to help more and feeling guilty for not being able to do more when in reality. Um, you know, many people have never been working harder in their lives and then amidst all of this, you know, we've been um to varying degrees more on screens than ever before and up late at night potentially reading about everything that's going on and um, and wanting to look into that crystal ball and know what the future holds. Um, and I really want to highlight the impact of what we call that curious trauma. So experiencing something second hand can be as impactful is actually experiencing something firsthand. For example, a lot of people who, who witnessed the The crashes after 9 11 experience significant symptoms of PTSD. Similarly, people watching a lot of news around Ebola virus when that was very prevalent About 10 years ago, that that was, they were experiencing a lot of symptoms of PTSD. Um, so want us to think about how much we're consuming media at what times of day and um, and trying to pick just a couple of trusted sources and then limiting your exposure during times when it's not going to be really activating and interfering with sleep. Um, there has been a significant impact on kind of difficulty sleeping, given that we're just constantly on edge. Um, thinking about our response to stress. Um, usually in terms of response to stress, um, it's something that is time limited, that is meant to be kind of activating. We all have stress in different ways, otherwise you feel motivated to get out of bed in the morning and um and so some amount of stress in life is normal. Um for example, you know going to school on the first day or when you're getting shots but that can be time limited and positive and then more tolerable stress responses can be activated when um you know, there's a natural disaster that is generally more time limited than the impact of Covid has been. And this elicits a kind of stronger response, but it still felt to be somewhat tolerable um With a caveat here that if you have experienced multiple other traumas in the past, that your threshold for becoming activated in the face of a new stressor can be lower and it can be easier to activate that stress response. Um And then what's called a toxic stress responses when there's a heightened or sustained stress response over a long period of time. And this includes exposure to adverse childhood experiences, prolonged financial hardships and an ongoing um more chronic stressors. So what's happening in our bodies during this time um Normally we have a usual kind of fluctuation in our stress response systems that um you know, we become activated when our sympathetic nervous system are kind of fight flight response system experiences some kind of threat. Your alarm goes off. You know, I have to be at work in an hour or I have to do a paper for school, so I'm going to get aroused and activated. And then I'm gonna do the work of getting ready or do the work of getting the paper together and then after I'm finished I can um settle down and that's activated by our parasympathetic nervous system or our rest and digest response. And this is really happens pretty automatically in the face of stress. Um when we feel kind of normally aroused, then we get a certain amount of adrenaline that helps us to kind of focus more and and also, you know, mobilize. We feel a little bit of increased heart rate and oxygen wanting to breathe in a little bit more deeply and maybe your muscles kind of tense up. This is all kind of a preparation to fight a perceived threat. And um when that thread becomes really, really strong then you can have this kind of phenomenon here where you're getting really, really high levels of activation that actually kind of hijack your ability to think clearly and then your body tries to compensate by having a really strong rest and digest or break response. And you get this fluctuating here fluctuation. So some of the symptoms of ongoing over activation of that sympathetic response can include anxiety, panic, difficulty sleeping, feeling, restless, fidgety, difficulty concentrating and so that is what a lot of people are complaining of feeling in the past year and a half. Um we can't sustain this level of fight flight response forever. And so eventually our nervous system gets tired and really activates the parasympathetic response. And so these are some of the symptoms that you can experience after prolonged threat exposure. This can include some of the kind of fatigue numbing, really feeling kind of what's called dissociation. And it's a protective mechanism um to help you manage that really extreme threat response. One thing that we can do to actually manage our stress response and I'm going to invite everyone to to do this right now is we cannot control the automatic kind of heart rate going faster, but we do have control over our breathing and when our sympathetic nervous system gets activated, it motivates us, our bodies naturally to take in a lot of short shallow deep breaths because we need to take in a lot of air to run away or to fight. Um I want to invite you to actually do something called 415 breathing. That's going to activate your parasympathetic nervous system so you can take whichever hand you want and place it on your belly button and take a big deep breath in and really think about moving your belly button forward. You want to engage your diaphragm and feel that moving forward and then Exhale and we're going to do this together on the count of 415 With the breath in for four. Hold for one and out for five. And here we go, Deep breath in 2, 3, 4 Old out 2 3, 45 In 234 Hold out 2, 3 for hi And in 234 holes out 23 for five. I want you to just notice how your body feels after doing that. Notice if you feel any even small release of any tension that you might have been voting on two. And the reason for doing that is actually where activating our parasympathetic nervous system by having the out breath feel longer than the in breath. Um because we're signaling to our bodies, it's okay to exhale. We don't need to take in all that oxygen and get ready to fight. We actually can exhale a sigh of relief as the expression goes and let our bodies calm down so that can be a quick and easy way to activate um that parasympathetic kind of slowing down response. Um so I wanna just invite you to take a moment to reflect yourself on where you're feeling right now on the stress continuum. Whether it feels like it's positive, tolerable, toxic and where things have been for you. What are you noticing about your own trauma exposure response? Thinking about some of the folks who had checked into the chat and feeling kind of cloudy and what is happening inside your body. What's happening for you right now personally? And I am. Can you speak from personal experience? I have young Children and I have and an older parent and um and then work and managing a household and managing kind of all of the different uncertainties that have been continuing to come. And it is really challenging to stay even in the tolerable range a lot of the time. So this is um this is a slide from the Kaiser Family Foundation who released some data in um in May as part of an overall summary on the impact of Covid and mental health. And um and so I wanted to highlight here um the places where there's been a major impact and kind of disproportionately. So, so amongst 18 to 29 year olds, there's been a major impact, and if you think about what many 18 to 29 year olds are doing, they are um either meant to be in school and or starting um perhaps a trade or starting their lives, figuring out who they're going to be in the world and and you know, their job security may not be fully established, and so there's been significant stress and impact here. Um and then uh so the first bar is, you know, there's been a major impact, 31% and then a minor impact. 30%. Um mothers in particular have experienced significant impact in terms of their mental health and then looking at um household incomes that are on the lower end um that there's a significant impact here. Um and there's also a significant percentage of um of racial breakdown here um In total, you know, that 25% of adults say that they've had a major impact on their mental health and additional 22% have experienced a minor impact. So what does this mean for kids they feel are stress and respond accordingly. And that can be true if you have Children to be true with the Children that you encounter clinically. Um This is another survey that was those put forth in october um looking at the number of people who experienced trauma and stress related disorders, um and then another looking at anxiety and depression rates. Um There's also a household pulse survey that that surveyed across the country and that these rates of anxiety and depression were fairly consistent and um three times as much as what they are prior to covid. It's a substance used to seem to be somewhat increased and also rates of suicidal ideation. Um Additionally, thinking about the impact, a number of households experienced loss of employment, um income, and 61% actually reported difficulty paying for usual household expenses in late March 2021. Um what's been the impact on kids. Um And in particular in um with regards to school. So I do want to highlight that there have been some potential benefits um that kids have been able to sleep in a little bit more, that they've practiced some more independence and also kind of self pacing around their learning. Um They've experienced decreased academic demand and um and really less social pressure in particular for kids with social anxiety and I think it's also really brought to light How highly prevalent mental health conditions are. And if you think about those statistics around anxiety and depression around 30%, I think it's really helped to highlight how universal this experiences. Um It also has brought a significant degree of isolation across all ages and there's been a lot of grief around loss of rituals. Um lots and lots of ongoing uncertainty. Um You know, even for the fall, I mean, I think we're all planning and hoping to return to school and then there's still uncertainty about what the impact of the delta variant is going to be. Um and then of course increased screens and with that less physical activity. And there have been concerns for increased obesity and also kind of non nutritious food. A number of Children actually rely on um schools to receive lunch and then a significant um slightly lower percentage rely on schools to receive breakfast as well. So thinking about adolescent. Um and what are the kind of usual social and emotional milestones that adolescents go through. And so in the kind of younger adolescents um phase there's a lot of um you know, trying to test out kind of more logical thinking, testing new ideas, um new identity and um and with that they may be more moody and need more privacy and separation, which they're not getting right now because of, you know, having been to varying degrees at home more. Um And then for older teens, they're really striving to be more independent and may start kind of distancing a little bit more and with limited more limited ability to do that. Um In terms of kind of rates overall of mental mental health concerns. So even prior to covid one in five U. S. Children present with a diagnosable mental health disorder. And we know that 50% of mental illness onsets by age 14 And 75% on sets by age 24. However, it often takes between two and four and sometimes even 10 or 11 years between the onset of symptoms and then the time to assessment, diagnosis and treatment, suicide is the second leading cause of death Amongst persons ages 10- 34. And um and the rate of depression and teams is on the order of 7%. Some studies show more than that. Um. Mhm. During and post pandemic, we've seen lots of increases in anxiety symptoms across the board. Um This first bullet point here is around uh A study in um the Shanxi province of China and that more than 30% of kids experienced increased anxiety symptoms that showed up in a number of ways including behavioral problems, regression, difficulty sleeping, increased cleanliness and separation anxiety. The study here looked at um multiple um over 1000 families and with kids ages 2-18 and found that most of these kids in particular, the older kids had at least one area where they experienced elevated depression, anxiety, irritability, attentional problems and there has been an increase in in O. C. D. Um Some kids however have done better in certain areas and um and that's not to be kids who may have experienced bullying or may have significant social anxiety or ways of learning that they actually learn better through just concerning. Um This study here is from summary from the Kaiser Family Foundation that a significant number of high school students reported worsening emotional um and cognitive health and a great number of parents reported that their Children experienced worse mental and emotional health. Um loneliness is one of the biggest factors in this in particular for older Children and teens and the duration of the loneliness is the single biggest factor that contributes to this. Um And that contributes significantly to not only current depression but also potential for longer term mental health concerns. Mhm. So um in terms of you know, what do adolescents need and they need to be able to have some increased autonomy which has been challenging. Um They want to engage in risk taking. That is a normal adolescent phenomenon and um and sometimes that means you know being maybe cavalier about masking or being around people who have had exposure to covid and um and that that can feel very upsetting to parents, caregivers or clinicians but it is a normal developmental process. And so just to try and have some empathy for that. Um They really do want to separate more and have been kind of varying um going be able to do that. They also really need honesty and clear expectations and um and so thinking about you know what happens when we feel more stress back to that stress continuum. Um Irritability can be a significant expression of of a lot of stress. And um and so if you think about what looks like anger on the surface can actually mean many different things often. Um Feeling anxious, stressed, rejected, nervous, exhausted, I'm sure offended. Um And so I think I like to hold this iceberg in mind when I'm interacting with with family in particular. We can tend to kind of take our feelings out the most on the people that we really care about and thinking about. Like being curious what's below the surface before getting angry back what we see on the surface is behavior but actually what's underneath that are a complex city of thoughts, feelings, expectations, values, yearnings and your true self when um when kind of idea or concept that I wanted to um to invite you to think about our kind of how our thoughts, feelings, behaviors and bodily sensations are all connected and that we can impact one of them by altering kind of another. We can't really change our feelings very much, but we can try to change our thoughts. We can try to change our bodily sensations and we can try to change our behaviors. So this one is kind of the thought. I should read more about Covid so it can be prepared and feeling underprepared. It might cause anxiety, fear stress. Um And then that results in staying up more meeting, not getting enough sleep which then sets things up to feel badly the next day as well. That amount of stress can cause some of that stress response that we talked about earlier and then it goes on. If you can alter this by telling yourself maybe at 11 pm I've done everything I can do today. There's nothing more I can do right now and I'm gonna breathe a little bit and just try to go to sleep. And that could ideally help decrease your feelings of anxiety, help you get more sleep um and helped to change that body's stress response. Um Other things to take care of or just the basics around Eating. Um you know being careful about how much caffeine you're consuming and when that caffeine can stay in your body for up to 12 hours. Being able to you know to eat regularly enough to keep your body going in order to feel satisfied and also to feel calm when we're hungry. We can feel much more irritable. So I want to highlight here some what are called cognitive distortions. These are the thought component of this and and they are meant to be protective, but sometimes they can really activate this cycle here. So um in particular, you know this thought I should be more about covid. So it can be prepared is one that I think health care providers are very vulnerable to. Um these should statements, I should do this, I should do that, I should do more and that actually can just set off this whole cycle. Um Also feeling like I really need to be the one to do this and having that kind of personalization. Well if I don't do it then who's gonna do it? Um some of these other ones um maybe self explanatory. You're also welcome to read more about them here. So how do we re regulate? Um We we can do it by trying to focus on these key things and in particular in this border. So starting with creating safety so we can kind of calm down. That stress response and safety means having rhythms, routines, reliability, predictability. We know that that's all been disrupted. Um personally my kids have been in camp this year, which has been really welcome, you know, kind of activity based distraction for them, but there's also not been a lot of routine around it and the routine before that was really that they were home a lot of the time and um and so that has been stressful and as much as we can create routines um and then also creating connection through relationships. Um really pausing to listen with the intention to understand even if it's just for a few moments, but really making sure that we're trying to connect and listen to the important people in our lives, to our patients, to our colleagues. Um and then from there, you know, being able to work towards a sense of purpose. What I'm hearing a lot from young people is that um, they've been feeling like, what's the point of a lot of things, especially older adolescents, younger adults, you know, feeling like, well, yeah, I'm gonna go to college, but it's all distance anyway, or I don't get to see my friends. And so what's, what's the point in that we really do need to help establish a sense of purpose and we'll talk through that a little bit. So creating safety by finding these rhythms and routines and having a schedule as much as possible. Um, for families, I really encourage families to create a family schedule that is visible, visual and and that way you can't argue with a piece of paper or a dry erase board or whatever it is, it's written down on. Um, so then when it's time to go or, you know, it's your turn to make dinner or your turn to do the dishes or whatever it is that it's on the schedule, everyone's agreed to it. You've seen it all week and now it's your turn rather than making it relational in the moment I need you to do the dishes, but I don't want to, I want to keep playing Minecraft or whatever it is. Okay, so having that and part of that can also foster connection. Um, and we, you know, create this and cultivate this in any number of ways, but um, but I do want to emphasize the benefits of in particular family dinners and having that predictability, reliability, eating a nourishing meal together and knowing that that's going to happen at the end of the day and it's going to be a time to come together. Um, one of my former teachers and facial who is that best general, she's a family therapist and psychologist and she sounded the family dinner project and from this, she studied this for quite some time. We know that the benefits are cognitive that kids who have family dinners, their vocabularies are better and they're doing better in school. Um, there's also physical benefits or lower rates of obesity and, and eating more fruits and vegetables and then also psychological benefits in terms of lower rates of depression, anxiety eating disorders, substance use disorders and fewer behavioral problems in school. Um, thinking about purpose and meaning and um, you know, there are many adolescents now who have been vaccinated and who are really starting to engage more in the world and um, and going and getting their driver's license and being able to spend more time with friends, which is great. Um I think what I have seen a lot of is a lot of kids having stayed home for a long time and and with that maybe not necessarily contributing to the community that is the family home. And there are lots of skills that adolescents need and to survive in the world and thinking about kind of the basics and that it's okay to have that expectation and even if a team is depressed or anxious actually doing something that develops a skill, develops confidence, confidence and um and more of a sense of purpose and that it is not only okay to expect that, but it actually can be really helpful developmentally. And so thinking about teens who are um, you know, either close to or even before getting ready to transition out of the home, you know, do you know how to do laundry? Do you know how to manage a checkbook or checking account. Um how do you pay your bills, How do you um make phone calls to order pizza? Um Let's work with someone who was going to a major, I make school on uh athletic scholarship that felt so uncomfortable about actually just calling and ordering a pizza on the phone because that was something that was really stressful. So developing those basic skills, um getting asked a lot what what does all this mean? How impactful will this be and I really like this um this graphic that is in a recent article in pediatrics in february of this year, um that is by tomboys and several other colleagues, looking at how kind of the interplay of genes, environment and time and what happens in terms of the biology of managing adversity and fostering resilience. And the reality is looking at um at what we know from past studies from past collective traumas, that the majority of kids are going to be okay. There will be some number of kids who do experience various challenges and and may have long term mental health impacts from this, but we need to look at that um and provide the supports um one of the biggest kind of modifiable risk factors that we have in terms of mitigating the impact of trauma is through relationships, relationship with caring nurturing adults, we know from World War Two actually from the operation pipe piper um that was done in England, where it was thought that Children could be should be safely removed from their homes and sent to the countryside in in England and and then retrospectively taking a look at that actually, the Children who stayed with their parents in London amidst the bombings fared better from the mental health perspective than those who were separated from their parents. So thinking about the really helpful um and mitigating effect of having those nurturing relationships. So in this like to think about a strengths based approach, this is from vessel Vander Kolk who who is a leading author and researcher on trauma and so thinking about um instead of what's wrong with you, especially when you're seeing kind of regressive behaviors or maybe you know failure to make academic gains in the same ways um to reframing that to what has happened to you and then also thinking about what's right with you and having this type of approach can be helpful um and personally it can be helpful with our patients, it allows the person who is responding um to the question to feel known and understood and it also gives a fuller picture if you're using this approach with patients for example then if you think about what is what has happened to that person rather than just seeing what's on the surface in terms of maybe feeling angry or frustrated or sad or difficult to be with to be curious about that and what's going on with that person who has happened to them and then also to look for what are the strengths, wow that single mom was able to get these appointments get here at eight a.m. With two young Children and she didn't really have enough money to get here but she made it here and she's only 10 minutes late rather than thinking about it of like You're 10 minutes late and now you're upset and I don't want to deal with you. Yeah it really also helps to leverage those strengths in terms of the service delivery process and um and helps people to feel more understood um Okay, this is just, you know, thinking about building resilience, this is true across all ages. Um but looking for for ways to develop real skill sets in order to feel competent, this includes communication, self advocacy, peer negotiation, academic skills, and um when when we tell our Children what to do and actually undermines that sense of confidence because they're not able to um to generate those problem solving sets themselves. Um Mhm. Thinking about confidence, you know, in ways to develop that, that comes from from the the confidence and feeling like I can do it connection with peers, connection with trusted adults, the more the better. Um thinking about character and how we're modeling character um for our kids and really holding that accountability, holding those strong values um in all ways that are possible um contribution means, how can I think about serving others um that really builds a lot of resilience and um and I think it's very important for us to to help our kids not only think about themselves, but think about what they're doing to help others. Um and then coping, you know, this isn't to say oh you shouldn't you shouldn't focus on the stressful moments, but how can I get through them and then what what is it that I actually can control, what can I let go of, what do I not have control over and being able to let go of? Um here I wanted to share um that this was, this was a family that actually implemented their own kind of team school spirit days during quarantine and um and we're able to just kind of showed tremendous heart and hope in the face of a lot of challenges. Um and we really need to start with empathy for ourselves, for youth, for parents and parents and caregivers um also for administrators, including school based administrators and um and having clear expectations remaining curious and then thinking about, you know, having a tuned communication, meaning you're noticing what someone is saying not only with their words but also the nonverbals and responding to those in kind. Um This may be familiar to many of you, but there's kind of increasing evidence looking at spending time in nature and also spending time unplugging from our devices that um there have been some studies to show improve mood, improve concentration, decreased stress with spending time in nature and also unplugging from devices. Um I also wanted to highlight the importance of meaning making. Um we have been asking ourselves a lot, when are we going to to go back to normal? We all really want things to go back to normal and the reality is that we're not quite there yet and it's likely that we're going to have some amount of impact for some time. Um It's still important to adhere to safety measures and then also to be able to talk about what's happened and answer questions and provide support um in offering a meaning making channel for grief. It helps us to process and deal with mass trauma on its own scale. And so this can be done in any number of ways, but I think, you know, when when kids try to talk about it, or um if you can just kind of ask open ended questions like what has this year been like for you in different ways, that that offers an opportunity to help make some sense of it. Because when we can explain our narratives um including the impact of trauma, then it helps that to be just more of a chapter in our lives, but not the kind of longer term governing force around it. When you don't talk about it. When you try to quickly move on or bury it, then it can show up in other ways later thinking about about this also, um really want to highlight the importance of caring for ourselves and that it's not self indulgent. Although if you get too much into those should statements, then it can certainly begin to feel like it's self indulgence. Well, I should be, you know, reading more, I should be making my kids lunch right now or I should be doing any number of other things. Um if we don't take that time to just pause and take care of ourselves however long or short. Um, then we won't ultimately be able to preserve ourselves. Um, we will experience a great deal of burnout. Um, just looking at the time. And so I want to just highlight a couple of pieces around around school. Um, so school is a place for academic instruction, but it's also a place for all of these other pieces. So developing social and emotional skills and um, in a sense of safety, we know that there have been increased concerns for rates of child abuse. Um, but with that still decreased reporting of child abuse. And and a lot of that is felt to be because kids have not been able to attend school and be around other adults who are going to be observing this as well as of course they increase stress it of being home and alone together. Um, and sometimes being cared for by older siblings who don't really have the skills to do that mm source of reliable nutrition. Um, and it may be a source of a lot of different services. Physical occupational speech therapy, mental health services, um, physical health services and opportunities for physical activity um, in a safe place. And so for these reasons, the American Academy of Pediatrics is really advocating strongly that all um, schools try to have kids come back in person and keeping students safe and physically present in school as much as possible. Um, that said, so they're recommending that all eligible individuals should receive the vaccine and that all students older than two years and school staff should wear face masks. Um, at school, unless there's a reason not to um, Being back in school really requires a lot of good communication about next steps. Um, what when and how this is going to work and then really emphasizing the need for training on how to talk with students and how to support them and anticipating that students may be experiencing any number of stressors including um financial impact. Um, we know that the economy is still in a lot of flux right now and that a lot of people are still struggling financially and there may be new struggles that emerged once some of the government funding changes in the coming months, anticipating newer advice needs, around academic accommodations. Um, Some students have done better with the distance learning. Um, We expect that in preliminary data have shown that students have failed to make the same expected um advances in terms of their knowledge base over this past year and so to not expect that, oh, we're going to hurry up and catch up and try to cram everything in there is not going to be the level of readiness to do that for any number of reasons, including the experience of stress, including increased mental health concerns and also kids needing to get re adjusted to being back in person. Um There may be ongoing concerns around grief and loss. Um, it's very likely that any student um their life has been touched by losing someone to covid um and your job loss. Um and then continuing to think about the digital divide that affects um you know, different SCS differently and communities of color disproportionately. And so I think we need to think about um scaffolding and how do we get there and that that we um may expect to see some changes in behavior. Um And with that kind of more regression and and an irritation with things that seem to be kind of out of proportion. Um you know, to to I didn't get the right mac and cheese. Um It's not really about that, it's about I have experienced a lot of stress and uncertainty and change this past year and I don't know what to expect moving forward. And so I'm going to pick on the one thing that I can name right here and that is that it's not the right back and chief. Um So with that, you know, thinking about how do we help build this stepwise kind of ladder to get to a feeling of more confidence and confidence and um in terms of key takeaways, mental health disorders are highly prevalent and we're so prior to covid um the post quarantine data are scarce. That suggests that a lot of a lot of youth are doing worse, but some are doing better in discreet ways and that we as a species are resilient. Um and we can be hopeful and cautiously optimistic, but we do need to be attuned to potential for increased mental health needs. And we really need to put equity and inclusion at the center of our responses. Um back to school doesn't mean back to normal, even though that's all our deep desire. Um and hope is that everything could go back to normal right away. Uh huh. And then also that we can look at additional models for care delivery. And this includes um telehealth which has taken off more post pandemic, also more consultative and brief interventions, including digital interventions.