Stephanie Ruhle: Good afternoon and thank you all for being here. Welcome to the Child Mind Institute's Summit on Telehealth and the Coronavirus. We all know why we are here. This has been an extraordinarily challenging year for individuals, for families, most notably for children. The need for mental health services has never been greater. If you think about the last year for adults: we are creatures of habit—days, months, weeks where we might not have contact with others, we might not be able to go to work. It is challenging. But for children, for teens, exploring life experiences is everything, and they are going without them. We do not know what the long-term impacts of this pandemic will be. One of the—dare I—I won't say silver linings, but I would say a bright light, is how we have seen the rapid change in some health care deliveries, specifically mental health services, and that is through telemedicine. The hope is, even long after this pandemic, telehealth will be delivering services to some of our most underserved communities for years to come. So, I want to start our conversation, as Kimberley said, with two extraordinary guests. Hopefully, many of you know him. He is the president of the Child Mind Institute, an extraordinary New Yorker, Dr. Harold Koplewicz, who just released the Child Mind Institute 2020 Mental Health Report focused on telehealth. We also have with us the extraordinary Surgeon General from the State of California, Dr. Nadine Burke Harris. In addition to being an acclaimed physician and researcher, she is also an advocate for one of the most serious, expensive, and widespread problems that face our children today: childhood trauma. Thank you both for leading this conversation. I know we are all excited to learn from you. To start, I want to ask both of you—but Dr. Harris Burke, to you first—you have studied and been a physician and focused on children's mental health your entire career. How bad is what we are facing today, from what you have seen?
Nadine Burke Harris: What we are seeing today is extraordinary. As we know, the pandemic is a—not just a once-in-a-generation, this is a once-in-a-hundred-years phenomenon that is happening right now—and it is putting extraordinary hardship on families, on individuals, families, and certainly on children. And what we are seeing is that not only does the pandemic, in general, increase the amount of stress that our kids are experiencing, but it also reduces the thing that we know to be an antidote to the effects of stress, which is the number of caring, buffering relationships that they have access to through school, through afterschool programs, through faith communities, and so we're really seeing very, very significant risks for children at this time, which means that it is up to us to rise to the occasion in providing them with the support and buffers that are effective in reducing their long-term risk.
Stephanie Ruhle: What do you think, Harold?
Harold S. Koplewicz: I was here for 9/11, and we lost 3000 lives during that event, and it took years for us to recover, especially kids who were around ground zero or who lost a parent or an uncle, or an aunt, or a neighbor. The word “extraordinary” that Nadine used is absolutely correct. This event is transformative. And what I am very concerned about is not only how much of a loss kids are experiencing academically this year, and for teenagers and college-aged students, the social ramifications and the inability to have romance and contact with people, but I'm quite concerned that after COVID we are going to see an epidemic of anxiety disorders. We are going to see a whole bunch of kids who currently are not being exposed to social interaction which might make them nervous, or kids who are separation-anxious are not being forced to leave their house, and I think we are going to see a huge amount of posttraumatic stress disorder. As a nation that is exhausted, we still need to get prepared and really prevent this onslaught of anxiety, which can have a terrible effect on kids. Anxiety is truly the precursor of depression. It disables people. So, for young people who are going to be—next September—able to go back to school, try to deal with the ‘new normal,’ we should be prepared as a nation to help teachers, pediatricians, and parents recognize the signs and symptoms and what they can do to alleviate the stress.
Stephanie Ruhle: Harold, when you compare it to 9/11, which was obviously devastating, that was a one-day event. The fact that the coronavirus continues to rage on and we do not know when we will be getting to the other side of this, how much does that impact increased anxiety?
Harold S. Koplewicz: There is something called COVID anxiety or COVID uncertainty—that really describes what we are going through. With 9/11, for the weeks and months afterwards, we had posters up of people who were missing, but if you flew to Florida, if you went to Boston, if you went to Los Angeles, you did not feel it. COVID is truly this global pandemic. There is no escaping it. There are children who are living with food insecurity, housing insecurity, school disruption. This is very real, and this is going to have a scarring effect that for a briefer event, we can get over much quickly. And so, as a nation, we have to get past this. I am really pleased that the Biden administration is taking the vaccination so seriously, the supply, and putting these vaccines in people's arms, but simultaneously we still have to save our strength to take care of the kids' mental health needs, which could be devastating if we ignore them.
Stephanie Ruhle: When you help us understand the state of California, a huge state that has obviously been hugely impacted by the coronavirus, what have you seen in children and families? I mean, most of the people on this call can say, “It is challenging doing virtual, we have had to change our life around, but we are also in a position where we have the technology, we can support our children and sort of become de facto teachers' aides.” Many families do not have that.
Nadine Burke Harris: That is right. And when we think about the challenges that many children are facing during this pandemic,—for myself, for my household, for my husband and I and our four boys—the biggest challenge is managing distance learning while we are trying to do everything else. But we recognize it. A big part of my background as a researcher and as a physician is recognizing the impact of what the CDC calls adverse childhood experiences, which include things like abuse, neglect, or growing up in a household where a parent is mentally ill or substance-dependent, or where there is intimate partner violence. There were 10 specific criteria that the CDC looked at, and one of the things that is really powerful is that, for an individual who has four or more of these adverse childhood experiences, not only do we see the things that we would expect and the things that Dr. Koplewicz rightly pointed out—dramatically increased risk of anxiety, dramatically increased risk—we are talking about four and a half times the risk of depression; we are talking about dramatically increased risk of suicidality—the international data shows 30 times the risk of suicidality. But there is also double the risk of developing diabetes, double the risk of developing asthma. It is important to remember that the brain and the body are connected, when children in particular experience high doses of adversity, it can have profound effects on their mental health but also on their brain development and the development of their immune system and hormonal systems. The traditional adverse childhood experiences that the CDC identified as being a major risk to health, intimate partner violence, is increasing. Mental health conditions among adults are going up. Substance use and dependence are going up. So, all of those things also have a profound impact on this generation of children who are also having the experience of having parents who are extremely stressed and who are manifesting their own symptomatology as a result. So, we see that the long-term outcomes are likely to be substantial both on mental and physical health. That is why in the state of California we have launched a first-in-the-nation initiative called ACEs [Adverse Childhood Experiences] Aware, to train all our health care providers—we have trained over 15,000 health care providers—on screening for adverse childhood experiences, recognizing how that can lead to overactivity of the stress response, and then responding with trauma-informed care which includes, when appropriate, connection to mental health services.
Stephanie Ruhle: How do you connect with those children, those families right now, in this time when we are so disconnected? Oftentimes, children who are at risk—it is the school nurse, it is their teachers—who see those red flags and then pull in services. Right now, with kids home, is that even happening? How can it?
Nadine Burke Harris: You are exactly right. At the start of the pandemic when the shelter-in-place order went into effect, in California, we saw a 50% decline in reports of child maltreatment. Now, we know that child maltreatment did not suddenly fall off a cliff the minute that families are exposed to a really stressful pandemic and are forced to stay at home together with their kids. We are fairly certain that is not the case. Rather, it is just not being reported, because kids were not coming into contact with those teachers, those coaches, those rabbis, or whomever it is, with a trusted adult who might recognize that there was something concerning going on and then make that report. And that is why, to answer your question, how do we solve this? It really takes a village. And that has never been more true than now. What we strongly encourage everyone to do is to check in, right? To check in with their students. We encourage teachers, educators, even who are doing distance learning, to schedule one-on-one time with the kids in their classroom just to check in and see how things are going, because it really requires all of us to do that.
Harold S. Koplewicz: It really has required us to be more innovative. In New York City, the Child Mind Institute worked out a program that we provided Digital Wellness Kits for every one of the 1.1 million students. We also did webinars for the 75,000 teachers. Now, the problem is that it was not mandated, so we only got buy-in from only 25 or 30%, but the idea is exactly what Nadine is talking about. The Digital Wellness Kit is talking about checking in with yourself and then being able to check in with a teacher if you had signs and symptoms that were different, whether it was sleep, whether it was your appetite, whether it was your ability to concentrate, or your general attitude about optimism versus pessimism.
Stephanie Ruhle: We have some breaking news from The New York Times—it is as if we are on an actual news broadcast here—and I want to get your thoughts. CDC officials urged a return to classroom instruction as soon as possible, citing evidence showing it is safe with the right health protocols. In the report they write, quote—basically they say there is enough available evidence indicating that it can be carried out, meaning schools can be opened safely, as long as mask wearing and social distancing are maintained. Researchers at the CDC wrote this in a journal, but local officials also need to impose limits on other settings like indoor dining, bars, and poorly ventilated gyms. Do you agree that it is urgent; that it is time to open schools? Dr. Burke Harris?
Nadine Burke Harris: What I would say to that is: I have seen that data from the CDC, and it is totally consistent with all the other data that I have seen, that with the right protections—so that includes high levels of testing, PPE, masking, and distancing—that it can be safe to return to school. That is a big part of the reason that what many states are doing, what we have certainly been doing in California, is being very focused at trying to bring those resources to our educators so that our schools can safely reopen.
Stephanie Ruhle: Dr. Koplewicz, what do you think?
Harold S. Koplewicz: There is no doubt that the lack of socialization is having a negative effect on kids. Let's set aside the group of kids who are socially anxious, and who are separation-anxious, and appear better today because they're not forced to be exposed to those things that make them anxious. But if you look at the other 80% of the population, those kids thrive on the social interaction. You see photos of a kid with his head on the desk and the screen opened up, and they cannot engage with their teacher. And remember, many public schools are not doing synchronized learning; they are doing asynchronized, so they are watching a video of someone teaching them history or math or art or English, which is more challenging than if they were in a classroom. But the other part of school is hearing other people speak, of learning how to share, learning how to wait your turn, being able to hear another person's point of view, which gets lost on the two-dimensional screen versus the three-dimensional person. Clearly, we need safety, we need social distancing, we need people to wear masks, which is being done in many public schools and many private schools in the United States, and they are successfully containing the virus and simultaneously keeping kids in school. I would tell any parent, though, who was watching that this is a good year to reassess your expectations for your kids' academic productivity, no matter if they are going to school on a regular basis or if they are doing distance learning. This is more stressful, and when kids are under stress, it makes academic productivity harder. And if you are a teenager or are a college-aged student, I would tell you that you have to reassess your expectations for romance and socialization. It is just more difficult when you have to wear a mask, when you have to do social distancing. So, if we can readjust our expectations, I think people will be under a lot less stress. But I do not think we can underestimate the power of social connection, particularly for school-aged kids and for adolescents.
Stephanie Ruhle: Dr. Burke Harris, what do we do about all these crucial life lessons beyond academics that kids and teens do learn? When Harold says that we have to change our expectations, do we then say, “Oh, I guess they won't learn those lessons”? When you think back, you do not need to go to high school for four years to learn all that stuff. It takes four years because it is all about the entire process and maturing. Not having that for a year plus, what is that going to do to our kids?
Nadine Burke Harris: We want to keep in mind that the vaccine is being rolled out right and is now becoming available to portions of the population and that really is the light at the end of the tunnel. One of the big things I want to encourage is that, for all of those who are eligible to get vaccinated as soon as they are able, and to do it as soon as they are eligible and have access to the vaccine. At the same time, there is a lot that we can do to support the health, well-being, and development of children even during this challenging time. One of the things we know from the research on how stress affects children's developing brains and bodies is what scientists and researchers characterize in three ways. There is positive stress—the kind of stress that helps folks be able to muster the energy to solve a big challenge. There is something we call tolerable stress, which is a more severe or intense stressor, but with the right support from caring, nurturing adults, and caregivers, children's brains and bodies can recover from the impact of that stress. And then there is toxic stress which leads to long-term changes for children's brain development, their immune system, their hormonal system, and even the way our DNA is read and transcribed. That is what leads to increased risk of both physical and mental health consequences. What we hope to do is—we recognize that there is tremendous increase in stress right now because of the pandemic—but we aim to keep it in the tolerable zone as opposed to the toxic zone. That means we have to perform the interventions that we know make a difference: things like regular exercise, good nutrition, good sleep hygiene, nurturing relationships. Nurturing relationships are the strongest antidote against the effects of stress on the brain and body. Additionally, things like mindfulness, like meditation, and mental health interventions, and particularly now with the pandemic, the rise of telemedicine, to increase the accessibility for mental health service is very important. I want to stress and emphasize that these things are treatable—the impact of stress on health and development are treatable—and they are recoverable. So those are the most important things for people to understand.
Harold S. Koplewicz: We did a study that looked at the mental health effects of COVID on kids. We had 6000 subjects. Half of them reported on themselves as adults, and half reported on their kids. It was very important for us to see what the most important factors were that affected someone's mood in a negative way. What was interesting is that adults were more concerned about COVID worries, and kids were more affected by a change in routine. Their life circumstances, the fact that they couldn't go to school, the fact that they were worried about their parents' finances, the fact that they couldn't play outside—many of those things were the kind of stressors that parents could diminish. A parent who can recognize this and says, “Let us make sure we go to sleep on time; wake up at the same time. Let us have some routine in the house…” Not every parent can do mindfulness. “Let us do gratitude once a week and talk about why we feel thankful. Let us make sure that we are taking a walk together, that we are able to throw a ball or go to a park in a safe way.” The power of parents to influence the environment and to make it less toxic is very important. Now, in my opinion, parents have so much extra to do. Not only are they parents, but now they acting as teaching assistants and playmates. And they are workers, but there is positive data about what affects kids most during COVID is the life circumstances that are negative, and parents have a lot of control over being able to make them less negative.
Nadine Burke Harris: That is incredibly true; there is a lot of data on that. It has huge implications in terms of how we take care of ourselves as parents. As I mentioned, as a mom of four boys, one of the most important things I have to realize myself is that self-care is not selfish. My ability to not get so overwhelmed that I cannot be available to my kids to spend that time, or to do that snuggle, or take that walk around the block—my kids will even tell me. The other night at dinner, my 8-year-old said to my 4-year-old, “Uh oh. I think Mama lost her giggle.” And it was just such a bright light to me, and I thought, “Oh my goodness, my child is telling me,‘Mama lost her giggle.’ That is my sign to me that I have to put aside some of my stressors and worries and really be present and engaged with my kids. As it turned out, five minutes later, he said, “Oh look, Mama got her giggle back!”
Stephanie Ruhle: But what about when it is more than ‘losing your giggle’? When we talk about the power of parents—the pressure on parents right now—in good times we are very focused on our children's well-being. I think about myself sitting in the Child Mind waiting room, and when my child needs support, all of my attention and all of my focus is on that child. Right now, we are seeing what parents go through is crippling. So beyond just the “take the time,” for self-care, what do we do for those families who are truly in crisis?
Harold S. Koplewicz: If there is any opportunity that has come out of COVID, it is telemental health. America has a problem with mental health services. Sixty percent of all the counties across the United States do not have a psychiatrist. Twenty percent have one psychiatrist. So, we have a problem in the way we have distributed our mental health services. The Child Mind Institute closed its doors on March 15, 2020 to the physical sites in San Mateo and New York, but on March 17, we opened as a telemental health service, and today we are seeing 300 kids a day remotely, when pre-COVID, we were seeing 200 kids a day. We are offering services to kids in more locations, particularly rural areas, and kids who typically would not receive it. My feeling is that telemental health could actually democratize child mental health services if it is done properly, but that also is something that parents have to be aware of. In the same way that a kid is aware of whether ‘Mom loses her giggle,’ parents really must be aware that there are signs and symptoms that your child is suffering from potentially more than a demoralization, but it is a real anxiety disorder, or depression, and the fact that you can get help on a screen relatively quickly, without the waiting list, without the transportation, without the danger, is really important. And remember, on a good day in America, only 40% of kids who have a mental health disorder ever get any help. So, we were not even starting in a great place. This should be that opportunity to say: “I am watching my kid more carefully. I am spending more time. I am concerned. They are not sleeping, or they are not eating, or I cannot get them to play Fortnite, or I cannot get them to throw a ball with me.” That is a warning sign.
Nadine Burke Harris: Similarly, the same is true for parents as well. When the pandemic started, I switched to seeing my therapist by FaceTime, and it was fantastic. It worked, and that is what we have been doing. It is equally important for us as parents and caregivers to be attuned to our own mental health—how we are doing, how we are sleeping, our intake of substance—watching those things, because there is a symbiosis, there is an interdependency between a child's well-being and the well-being of their parent. As I told my patients for years, and their caregivers, that the most essential ingredient for a healthy child is a healthy caregiver.
Harold S. Koplewicz: So therefore, self-care is really child care. But more importantly, we need to stay on schedule. It is so easy for parents to get up in the morning and not start the day the way they usually would because we're not running out of the door. But to say we have regular hygiene, we eat breakfast together, we put a change of clothing on, we eat meals together, we have time for exercise. I know how hard that is, but it is essential to keep that going. I was watching a TV program and Ray Romano was on, and he jokingly said, “Oh, this is the first time I'm wearing pants in the longest time.” And I thought, OK… everyone should be putting on pants every day. Whether or not anyone sees anything from your bellybutton up, it keeps that routine going. It is essential. I mentioned gratitude before—that once a week, families sit down together and say why they are lucky. There is so much to be grateful for, and you can find so much to be angry about and to complain about, but there has got to be a moment once a week where your children see that there is something more important than them, and more important than you, that you are grateful for that, whether you go to church or not.
Stephanie Ruhle: Do you think telehealth is here to stay after the pandemic? You were just talking about your own therapist, Dr. Burke Harris, in a very joyful way. I could hear in your voice the feeling of: I do not have to get in the car, I do not have to drive over there, I am saving an hour. In some ways, do you think it is better than it was?
Nadine Burke Harris: I do think that telemedicine is here to stay, and that it works particularly well for certain things. It is more challenging in other areas, but I believe particularly when it comes to mental health, that it is a place where I think the rapid, the large scale switch to telemental health—not so much the speed as the scale—is a significant benefit for many, many people. And I think one of the places where it is can also helpful is in consultation for primary care providers who are asking, who need to ask a question. Rather than sending someone in with an appointment, they can get guidance from a colleague. So, I do think that particularly when it comes to mental health, telehealth is an advancement for the field.
Harold S. Koplewicz: Also considering there are 8300 child psychiatrists in the United States and that there are so many states that have so few of them, this is terrific. People who traditionally were stigmatized by it, now do not have to be seen in a waiting room, they do not have to take public transportation, they have the privacy of doing it in their own rooms. We do have a problem, certainly, that there is a part of the population that does not have access to broadband, and does not have enough interconnectivity with the internet, but that is fixable. There are so many things that will be gained by keeping telemental health as an option. For some people, it will be the whole option, and for others it will be a hybrid kind of deal: see the doctor one or two times in person to receive your initial evaluation, and then the follow-up treatment will be done on a screen.
Stephanie Ruhle: Dr. Koplewicz, are you seeing parents asking to get prescriptions for their kids? It is so hard for any child to focus right now, and at a normal time, parents might not be seeking a prescription to help their kids to focus. But are you seeing that change right now?
Harold S. Koplewicz: We are seeing that parents have become much more observant. The school was complaining for years about how inattentive or how anxious or how disengaged the child was, and then all of a sudden the parents are noticing it because they are there, their school is there, so that learning disability becomes very obvious, or that attention deficit becomes very obvious. I do not believe anything has changed in the way we still evaluate a child, or whether medication should be added to the treatment, but we are seeing parents having new insight into how their kids work. Remember, kids work at school. I will take a teacher's evaluation—if a teacher says to me, “This third grader is definitely more hyperactive than the average third grader,”—I'd take that with a lot of value because she or he has had 30 third graders for 10 years, that is 300 her sample size, or his sample size. My sample size is always skewed, and parents' sample size—at best they have four kids, three kids, two kids, so all of a sudden parents are getting a snapshot of what it is like to watch their kids work. And that is helpful. I do not think anyone is asking for medicine; I think they are being a little bit more receptive to adding medicine to the treatment program.
Stephanie Ruhle: Dr. Burke Harris, one emotion that has been displayed especially among teenagers, that we have not talked about, is anger…angry that their year, their friends, their sports have been taken from them. How does one address that?
Nadine Burke Harris: I will tell you how I have addressed it with my two teenagers. It is around helping them have greater insight into the reasons behind it and to make meaning of the situation. One of the important things is, number one, to start by validating those feelings. You are a senior in high school, and you have worked your entire time, and you have gotten really good at lacrosse and this is your final season, and you are going to miss the entire lacrosse season because there are limitations or restrictions on school sports.
Stephanie Ruhle: Are you able to convey to your son how to find new meaning?
Nadine Burke Harris: I am in a unique position because we sit down and Mike could say, “Oh, well, it is terrible that there are these restrictions,” and I say, “All right. Well, I am the Surgeon General; let us talk it through. How do you think that the policy should be?” “Well, what about this? Well, what about that?” “How do you feel about the idea that there are many people who are becoming ill? Do you want to…” “How would you feel…” My mother has been ill, unfortunately. She has been hospitalized several times in the past year, and the idea that there was a hospital—and it was not related to COVID—but the idea that there was a hospital bed available for her because of the sacrifices we make, and that that is the piece that I emphasize to them, and recognizing that these are some of the sacrifices that their generation is being called to make, and generations before them have been called to make sacrifices for the benefit of the many, and for them it is a sacrifice. It is hard, the fact that they cannot play sports. They have worked incredibly hard, and now they are in this position. But by making that sacrifice, what it means is that other people get to live.
Harold S. Koplewicz: That is a great point that you started with, also: validation. The worst thing a parent can do is saying, “Oh, it's not so bad.” It is bad. Particularly if you are in high school, particularly if you are applying to colleges—if you are in eleventh grade, it is bad because it counts for college. If you are in twelfth grade, and a whole bunch of kids did not go to school in September, so there are less spots available for people applying to college, that is bad. For those of you who are a freshman or sophomore in college, and you are essentially doing Phoenix University, but you are at M.I.T., or at Yale, or Berkeley, that is bad. Parents have to say, “As bad as it is for me, it is worse for you.” When parents admit that, it makes it so much better. I always tell the story that my parents were Holocaust survivors, and my mother would say, “Oh, what are you complaining about? The Holocaust is over.” “I am delighted the Holocaust is over. I still had a miserable day at school.” Do not take away how bad my day was. This is awful—I hear about kids getting rejected from colleges that knew they were going to get into, and the numbers are not working. And for us grownups, this going to be a bad memory. It is certainly going to be like the Depression; people talk about the Depression endlessly. But it will just be a tiny bit out of our 50 or 60 years of life, very different than when you are 16 or 17 and, by the way, kids feel everything so intensely…they are always boiling or freezing. I hate you! I love you! This is really a hateful situation. You validate it, and then you say, “OK, how do we make it better? Because lacrosse is not coming back.” Or: “What can we do—how are you going to keep your body fit?” You can certainly keep jogging, you can certainly keep running, you can bring more equipment into the house. There are solutions, but at the end of the day you cannot fix this. This is an unfixable problem, and it is going to leave a scar, and that's OK, as long as we are not pretending it was good when it was really bad.
Stephanie Ruhle: Go back to California with us, Dr. Burke Harris. Beyond your teenagers, you are thinking about all the young men and women in your state. How do you address when their anger does turn to hate? They are susceptible to misinformation, conspiracy theories, that can quickly bring you to hate groups, which basically just starts with: I'm not going to school, that stinks, I don't want to wear a mask, a website that says it is not really a virus, it is not really going to …on and on and on and on. How quickly do young people who are angered, who might not have supportive parents at home, how vulnerable are they to get to a very bad place at this point in time, given where we are?
Nadine Burke Harris: Well, there is certainly a lot of misinformation out there, and that's something that is very important for all of us to be part of that effort to be combatting misinformation. Young people are susceptible to misinformation. I raise my eyebrows at some of the things that I hear even in my own household. Some of the work that we can do to combat that is to engage young people and listening, being engaged with them, hearing what they are thinking, finding out what they are reading or what they are coming across online, and not just pooh-poohing it but walking it through with them and say, “OKN well, wait a minute, tell me more about that. Oh, so they said what? Now, what do you think of that? Does that jibe with what your experience is, or do you believe that, or what would make you think that that is a good idea or a bad idea?” That has been the piece that is very important here in California. Our superintendent of public education has had numerous forums engaging youth, youth-led forums—one of the big challenges for young people right now is that they feel so powerless. We were just talking about sports being cancelled. We were just talking about changes in routine, whether school is in person or distance learning. For a lot of young people and especially adolescents, that sense of powerlessness, that sense of frustration, especially with the events over the past summer of really coming to grips with the impact of racial injustice and racial tensions in the United States. There are so many things that are bubbling to the surface, and that just lifting up those conversations and empowering young people to lead some of those discussions, explore their feelings in a way that is engaged is really important.
Harold S. Koplewicz: I believe it is two-pronged. For teenagers, the peer group always becomes more influential than it had been in childhood, but parents still remain the most influential force in their lives, and parents have a tendency to stop talking. They hear that, oh, everyone is doing it, and so they keep quiet. So, if there was ever a time where parents must speak up, it is now. But I actually believe that the Feds and the states have to start counteracting some misinformation with really powerful and digestible information. It would be terrific, for instance, if we had athletes and we had movie stars and TV influencers getting vaccinations in front of everyone and saying, “It's cool to get vaccinated,” and how cool they are, and how great-looking they are with a mask on. It seems simplistic, but if people are out there saying something else, and they say it too many times, people start believing them. We have to balance this. Our silence is giving volume to the other people.
Stephanie Ruhle: Dr. Burke Harris, I want to go back to telehealth. Because it is just seeing a young man or woman on a screen, Does it give you sort of a window into their home, their lifestyle, the distractions in their life? When a young person comes to your office, or a doctor's office, most likely they have their hair brushed and their teeth brushed, and things are in order. But when you are doing that telehealth visit, and maybe it is 4:00 in the afternoon and you can see that the room is a mess and there is food there and they are still in their pajamas, does that actually help in understanding the condition?
Nadine Burke Harris: Last spring, at the start of the COVID pandemic, we had a webinar for health care providers in California about addressing adverse childhood experiences through telemedicine, and that one of the things that we heard from many of the providers who participated in that webinar, was being able to see what folks are experiencing in their home really brought them closer to understanding the challenges and experiences that their patients are dealing with. So, that is absolutely right. It also helped to, in some cases, identify resources that they can lean on. That certainly is one thing about telemedicine that, again, can be a useful tool.
Stephanie Ruhle: What are the things that school can do so teachers are better educated or equipped to help when it comes to emotional wellness? I know teachers do not necessarily want to take on another responsibility, but is there a social/emotional program that comes to mind that educators should start to think about?
Harold S. Koplewicz: Almost every school system in America in the past decade has started to think about social/emotional curriculum. The idea that now it is needed more than ever is really—this is the moment. Whether it is a moment to teach them classroom management, or signs and symptoms of mental health disorders—not that they become a diagnostician, but they become part of the ‘army’ to protect kids, to know when there is a problem, would really be helpful. But I think there has to be a quid pro quo. They have to receive continuing education credit for it. There is a limit to how much you can keep just piling on and saying, “Now you are going to do this. And you are doing reading and writing and arithmetic,” so there has got to be a way of reinforcing them with something that's valuable to the teacher to take on yet another task.
Nadine Burke Harris: You asked how do we move forward? How do we support this generation as we move forward from this pandemic? My office created the first California Surgeon General's Report called Road Map for Resilience, and it really focuses on how we take a cross-sector approach to addressing the impact of adversity during childhood. Part of the key piece is a recognition that the answer cannot only be in our health care system to diagnose and treat every child, or every adult, but rather that it really has to be a cross-sector approach. So, for our educators, there is a whole chapter in the report about what can be done in the educational sector, and that includes trauma-sensitive and trauma-responsive school environments—again, training educators on how to look for signs of stress and adversity and their impacts on children, but also how to create an environment where we create, where we increase the cumulative dose of buffering. That is one of the things I talk a lot about: increasing the cumulative dose of these nurturing, buffering relationships that actually help to mitigate the impact of stress and adversity on children.
Stephanie Ruhle: How do school systems and teachers do this when they are going through distance learning? A teenager knows how to think—they do not want to get caught, they do not want to get found out, necessarily, if they are in distress. But there was a New York Times report over the weekend of a school system in Las Vegas, one school system, seeing this increased number of suicides. With distance learning, how do you start to look for those signs?
Harold S. Koplewicz: If we go back to what Nadine was talking about, the chapter on buffering. Even on a screen, maybe it is time for teachers to say, OK, I am allotted 45 minutes, 60 minutes for a class, but I am going to have to start making a systematic 2-minute to 5-minute check-in with kids on a regular basis. In the same way that a teacher would notice that someone is more disheveled, or someone is sleeping on the desk, or someone just does not seem to be as engaged, they would ask them to stay after class, or they would say, “Can you see me at the end of the day? I want to chat with you.” We have to figure out ways that, as overwhelmed as teachers are, that maybe part of the classroom is individual windows where you can see a student for five minutes, just to check in. Most kids would find that very rewarding, getting that kind of buffering attention.
Stephanie Ruhle: Dr. Burke Harris, with so many kids and teens under some level of distress, because we all are, how do parents start to look for signs that maybe their child or teen needs professional help? Or is this just part of the process we are all going through with loss and COVID?
Nadine Burke Harris: Dr. Koplewicz, as the mental health professional, you probably have some immediate ideas on how to answer that question. But I would like to say a couple of things. Number one, as we have talked about noticing differences in your child's mood, in their level of engagement, if they are sleeping all the time, if they seem more anxious, or in their level of hopefulness, if you are seeing symptoms of depression, certainly those are concerns. So, those are important things for parents and caregivers to watch for. At the same time, for some kids it will show up in their mood and their behavior, and in some kids the stress shows up in their bodies. They have asthma, and their asthma is getting worse, and their asthma acts up every time—I had a patient whose mom told me that her asthma acted up every time her dad punched a hole in the wall. For some kids, it is reflected in their sleep, for some kids, it is reflected in their weight, or their appetite, so these are some of the changes we can see. A big part of that is just checking in regularly, being engaged. And if there is a concern—and this is one of the things I think is very important—do not wait for the wheels to fall off the cart. It does not have to. Kids—or adults—do not have to be in a dire situation in order to seek mental health support. In fact, more and more we see as a society and as a health care system moving more towards preventive mental health. When I decide that I need to talk to my therapist on FaceTime, that is entirely preventive, so that I can be the best mom that I can be. I know I have a stressful job, and rather than being in a situation where I end up getting overwhelmed by it, I want to practice, the same things I do for my physical health are the same things I do for my mental and emotional health, which is to be proactive and preventive, which is really important. And hey, guess what? It is a pandemic! It is dreadful! There has never been a better time to reach out proactively and say, you know what, it would be great to just check in with someone or talk to someone. Or my child is struggling, if they are struggling in school, if they are struggling in their relationships or in social situations, it does not have to be terrible. We can just do it so that things can be better.
Harold S. Koplewicz: I would just add one thing: regression. If, for young kids who might not be able to tell you something is wrong, watch how they behave. If all of a sudden they are sucking their thumb again, if they are visiting you at night and want to sleep in your bed when they were comfortable in their bed, when they become too quiet in situations where they were chatty before, anything that looks like a child is acting younger than their stated age or the way they were behaving before, is a red flag for parents to pay attention.
Stephanie Ruhle: Dr. Burke Harris, you have made it your mission to address toxic shock effects of ACEs, these adverse childhood experiences. Does the pandemic bring out significantly more?
Nadine Burke Harris: Yes. That is the short answer. As I mentioned earlier, average childhood experiences are risk factors for development of the toxic stress response, this prolonged activation of the stress response that can lead to long-term changes for children's developing brains and bodies. In the pandemic, we are seeing higher levels of adverse childhood experiences, the traditional ones that were described by the CDC, things like witnessing domestic violence, that is increasing; having a parent with mental health challenges, that is increasing; having a parent with substance abuse, substance dependence, that is increasing. There was just a very recent report that the rates of divorce and parental separation are going up. All of these things fall under the traditional adverse childhood experiences. But there are other risk factors for toxic stress that were not in the original CDC study that are also increasing: economic hardships, the number of families that are struggling, that have lost a job, the number of Americans who have filed for unemployment and who are really struggling to make ends meet, or struggling to keep their businesses afloat right now is really, really significant. All of the stress that comes along with that and permeates throughout the family, unless there are really strong proactive coping mechanisms to be able to buffer that stress, can impact the health, well-being, and development of children.
Harold S. Koplewicz: Kids who had a pre-existing condition are at most risk. If they already had an anxiety disorder, or you had a mood disorder, or ADHD, that puts them at risk on top of the fact that now they have the extra stressor of the pandemic, of the worry about financial insecurity, about the distance learning, the disruption of your normal life. So those are the kids that we should keep our eyes on. We also have to recognize the kids in poverty, and kids who, again, are living under stressful situations are the other group that are most, if we are going to triage the resources, those would be the two groups that we would have to pay attention to.
Nadine Burke Harris: That is correct. One of the things that we see is that there are some individuals who have experienced adverse childhood experiences but who do not have a mental health disorder, who do not have a physical health condition as a result, but one of the things that we recognize is that the more ACEs that an individual has, the greater the risk that they may be what we call stress-sensitized, meaning—and this is especially true for children—meaning that they may be doing OK right now, but the next major stressor that happens may be enough to tip them over the edge. And so that is part of the reason why in California we are training our health care providers to screen for ACEs and identify who might be at risk so we can provide those nurturing supportive interventions.
Stephanie Ruhle: Dr. Koplewicz, your new book The Scaffold Effect recent came out. What would you say is the top strategy that we can learn from the book, the top lesson for parents, adults, caregivers, in coping with all that we are going through?
Harold S. Koplewicz: It is interesting, because it takes forever to write a book, and then the publisher takes another nine months, so when The Scaffold Effect was being written, Raising Resilient, Self-Reliant, and Secure Kids in an Age of Anxiety, COVID was nowhere in my imagination, let alone in the reality that we are living with. And yet, now more than ever, parents do need to scaffold. You have to think of it as your child is this building, and that there will be times where they do need your scaffold. And it is different than hovering, or being a helicopter, or a snowplow, and it is teaching them that you provide structure, you give them support, you give them encouragement, but at the same time, you are letting them know that failure is an option. So, for instance, it is realistic that what they are going through now is devastating and you cannot fix it, but you can help support them. That is the most important message; that we are there to help our kids grow, whether they turn into a skyscraper or a ranch, or a split level, we just have to make sure that we are giving them enough support, structure, and encouragement, no matter what their developmental stage is, and particularly when there are major stressors in their lives. And Nadine said, it is a pandemic. This is awful. This is the time where we must rise to the occasion to support our kids.
Stephanie Ruhle: One last question for Dr. Burke Harris about rising to the occasion. One group of people who who we are not talking about enough, are teachers. We know how devastating this has been for health care workers who are on the front line every day, and we are talking about ways to give more mental health support and other support to those type of workers, to health care workers, but what do our teachers need—many of whom are parents themselves—dealing with all these issues in their own families?
Nadine Burke Harris: Supporting educators is one of the most important parts of being able to implement any type of trauma-informed or trauma-sensitive educational intervention, because it all starts with caring for the caregiver, making sure that educators have not only the training but also the support that they need to be able to be that supportive adult in a child's life. I often say that educators deliver the daily doses of buffering interactions that are healing for children. It is absolutely true, but in order to be able to do that, we need to be supporting our educators.
Stephanie Ruhle: Amen to that. Thank you both so, so much. And thanks to everyone who participated, people who wrote in their questions. The only way we are going to get through this is together, and we are going to do it with leadership like we are getting from both of you. Thank you so much.
