A Conversation About Children’s Mental Health

Good evening and welcome to a conversation about children's mental health.

It's easy to know when your child is sick if he has a fever.  A child's mental health problem may be a little bit harder to identify.  It may involve anger, fear, sadness or anxiety.  Sudden changes in a child's behavior can signal a problem.  Mental health problems can disrupt daily life at home, at school or in the community.  Without help mental health problems can lead to school failure, substance abuse, family discord or more serious conditions.  Our panel of experts tonight is here to answer questions and to offer recommendations.

We are here in the studio of WCVE Public Radio in Richmond, one of the sponsors of tonight's event.  We're joined by our fellow sponsors, Richmond Magazine and the VCU Department of Psychiatry.  I'm Bill Miller of WCVE and I'll be one of the moderators, along with Tina Eschelmann, of Richmond Magazine.  Good evening, Tina.

Eschelmann:  Good evening.  Thank you, Bill.  As editor for Richmond Magazine's Health Pages, I've worked on a couple of articles related to mental health recently; and, we became aware of how difficult it can be for families to find the resources that they need.  So, we thought that this conversation would help to give people an opportunity to get their questions answered.  In addition, I'd like to mention that our July issue includes an interview with Alex Slusher, who's one of our panelists tonight.  And in the article she talks about the death of her son Stewart, and about her efforts to spread the message of suicide prevention; and I'm sure you'll hear more from her this evening. 

Thank you, Tina.  Our panelists for tonight include Dr. Behla Suud, who is Medical Director of the Virginia Treatment Center for Children at VCU.  Dr. Suud specializes in development disorders, in child and adolescent psychiatry.  David Gould, M.D., is psychiatrist at Tucker Psychiatric Clinic.  Dr. Gould specializes in child and adolescent psychiatry.  Alex Slusher is a mother and activist for suicide prevention.  Mrs. Slusher founded Hold Hope.com, and is building a Suicide Prevention Resource kit for K-12 teachers and administrators in regional public schools.  And Vivian Mann, licensed clinical social worker, is Clinical Director for Child Savers.  Ms. Mann has served children in need of mental health services for over 15 years. 

Questions for the panel have been submitted in advance via email and on cards distributed to audience members.  Each of our panelists has been asked to prepare a two-minute introductory statement and we'll begin now with Dr. Suud.

Suud:  Thank you, Bill.  Thank you for responses, VCU Department of Psychiatry, Richmond Magazine and Public Broadcasting System.  It's not often that one gets an opportunity to speak about something that one feels passionately about.  I've lived in the Commonwealth of Virginia for the last 22 years, and have served as a provider of care for children and families, along with being an educator of people who inhabit the world of child mental health; as well as a researcher.  And I look at that role versus my role as a part of the largest system of mental health within which our children and families reside.  On a daily basis, we are a witness to the successes, but, also the trials and tribulations of the system, which is largely fragmented.  Virginia as a Commonwealth is known for its innovative work in being the creator of the Comprehansive Services Act in the early 1990's; and then, has also fallen short of the way it provides care to kids.  As far as child mental health is concerned, we are very aware of the fact that children don't exist in a vacuum.  It's their own emotional problems, but how they interdigitate with the larger system within which they function--their families, the juvenile justice system, the Department of Education, and so on, so forth.  And, hence, we are looking at a very textured and complicated, complex system, which I hope that at the end of this dialogue today of an hour and a half, with the contributions of our distiguished audience, many of whom are friends and coworkers, that we will develop an appreciation for this complexity and this textured nature of such a complicated issue.  I'm glad that we've had this opportunity to start the first dialogue of many, I hope, within the Commonwealth, which will allow us to start trudging this very difficult road in creating a system of care for child mental health of which we eventually will be proud of.  I'm glad to be here today and I look forward to talking with you all.

Vivan Mann with Child Savers is our next panelist.

Mann:  Thank you.  I'm thrilled to be here.  Thank you Bill and Tina for inviting me and I'm thrilled to be representing the social work field at tonight's discussion.  At Child Savers we are involved in several different areas of mental health as an outpatient clinic.  Also, in working with trauma, which is huge in children's mental health.  It can be traced, for many of the children, to the beginnings of mental health issues.  And also in working very much with child care centers, where so many of our children spend so much of their week.  And these people are so key in the system that Dr. Suud was speaking about; and the system of care that is offered to our children in trying to bring childcare, schools, parents together and make that complicated system work for these kids and have everyone on the same page, offering the same thing.

Alex Slusher, the founder of HoldHope.com, is our next panel member.

Slusher:  Thanks, Bill. First off, let me just say it's HoldHope.org.  That will make it a little easier to find the website.  As Bill said, my name is Alex Slusher and it's been my pleasure for the past twenty--almost 22 years to be a full-time mom and I really had a great job; was very involved in PTA and, ironically, was the one who put together parent information programs at a lot of the schools.  But, one of the issues I never, ever considered talking about was suicide.  Last May, on Mother's Day, as a matter of fact, my son Stewart commited suicide.  And, in that moment, our whole lives changed and I realized that there is an issue that we are not talking about that we need to talk about.  And so I've basically dedicated myself to spreading the word and educating people about suicide and helping other parents so that, hopefully, they won't have to go through what we went through.  I've seen so many people affected by Stewart's death--the community, his friends, teachers, obviously our whole family; and I had no idea until I started looking into all of this what an epidemic teenage suicide is.  It's the third leading cause of death amongst teenagers.  Fourth for kids ten to fourteen; and we just need to talk about it, we need to encourage the kids and the families to get help and to get help that is working for them.  I've created Holdhope.org in the hope that we can put together a website that can provide resources for the community.  It's in the building stage, so, right now if you go there, what you're going to find is a place finder.  There's also a grant that we're trying to get from the Pepsi Refresh Company.  They are doing grants and we're trying to get fifty thousand dollars, under the health category, for suicide prevention training and education in the Richmond area.  Right now, the teachers do a self-test online and we want to be able to do hands-on training and that's what that grant will go for if we get it.  If you go to www.holdhope.org, you will find the information on how to go online and simply vote--we don't need your money, we just need your votes.  And I want  to thank you for the opportunity to be on this panel today.  Thank you, Bill.

Thank you.  And, our fourth panelist is Dr. David Gould, with Tucker Psychiatric Clinic. 

Gould:  I'd like to say I'm sorry for your loss.  That's the worst tragedy in child and adolescent psychiatry.  I'm terribly sorry.  (Thank you.)  At this time, I would like to thank Richmond Magazine for your strong interest, coverage of medical matters and for inviting me to be here tonight.  I'd like to thank VCU and MCV Department of Psychiatry.  Your missions of education, research and treatment are vital to our region and the science of psychiatric medicine.  I'd like to that WCVE, which is my favorite radio station, which I am a member of, for hosting us tonight.  My thoughts about health care have evolved over the nine years I was in medical school and residency and in the twenty years I've been a member of this community serving in the private practice of child and adolescent psychiatry.  I think about these lines from our nation's Declaration of Independence, 'We hold these truths to be self-evident:  That all men are created equal.  That they are endowed by their creator with certain inalienable rights.  That among these are life, liberty and the pursuit of happiness.'  We're reaching that part about all people being equal.  I believe that pursuit of happiness is terribly hindered if you are too psychotic to grasp reality; you're too depressed to engage; too anxious to leave the house; too inattentive to even remember what you're pursuing.  Should mental health care and health care in general be a right in this great country?  I think so. 

Thank you very much.  Tina, I'll let you ask our first question.

Eschelmann:  Alright.  I had two questions that were a little similar, so I'll just read them both.  One says:  "If an interested citizen wanted  to communicate concern about child mental health services to his or her legislator, what would you recommend that they say?"  And that was kind of echoed by another one that says:  "There are so many families suffering in silence, which is made worse by the fact that elected officials never talk about these issues.  They talk about school reform or health care reform, but, never children's mental health.  How can we let our legislators know that this is a problem for many families that  we want addressed?"  Dr. Suud.

Suud:  This, indeed, is a very complex and complicated problem.  However, we are really at the cusp and the brink of really pulling together the resources of the Commonwealth in a new campaign, which has been launched in Virginia; and, hopefully, that will serve as a platform by which we can let our legislators hear about the complexities of children with mental health.  And, this is the Voices for Virginia's Kids, Campaign for Children's Mental Health.  This is something which was concieved last year and the campaign was kicked off in November of 2009; and this is a three-year campaign, which is really pulling together the different, disparate voices of the different systems, so that our legislators can hear, in a unified voice, what the needs of children's mental health.  So that would be a very good thing for the citizenry to also join in; and I believe there's a website for it that is called Oneinfivekids.org.  And that's something that you can log into and sign on and create some strength in the voice that our legislators can hear.  So this is an example of that, as well as the National Alliance of Mentally Ill, the Virginia chapter, which can serve as a major support for families who can converse with each other, can support each other, and these organizations really provide a unified voice, whcih legislators can hear. 

I don't want to spend too much time on legislators or legislation, but, a question I received seems to hit on a similar topic; so, I want to use this as a kind of a follow up.  And this is directed towards Dr. Suud or Dr. Gould.  The questioner indicates that the past two State budgets proposed significant cuts in inpatient care for children's mental health.  They mention specifically the Commonwealth Center in Staunton.  The question is: "What are alternatives, what kinds of alternatives to these cuts can you recommend and how would an increasing level of cuts affect pediatric mental health care in the Commonwealth?" 

Gould:  OK.  I'm in private practice--I work in an office and I also work in a hospital.  Our hospital has twenty inpatient beds for child and adolescent psychiatry mixed.  Besides our hospital, in private practice there's not really another Richmond psychiatric service.  In MCV, they have some beds, but, we really have limited beds.  When I came here in 1990, there was Psychiatric Institute of Richmond, there was Westbrook Hospital, there was Tucker, where I set up a unit, there was  MCV, that had inpatient beds.  There were a lot more psychiatric beds.  All those places have closed, except for us and MCV.  There's some beds down at Poplar Springs, but, there are times when people will come to the emergency room in serious need of hospitalization and be unable to be admitted to the hospital because all the beds are full.  At that point, you start calling around the State looking for a place for the child to be helped, not because they're a nuisance, not because they're a behavior problem, but because they have a psychiatric illness and are not able to be managed safely in the home.  At that point, people stack up in emergency rooms unable to find a proper bed for their care.  We need every bed we have.  Closing Commonwealth, closing beds for child and adolescent in the State system, I think that's totally inappropriate.  Those beds are definitely needed.  If we need to put more services in the community, we need to find other ways to do that.  But, psychatric illnesses do  require hospitalization from time to time and there's no way around that. 

Suud:  Yes.  And I would echo what David has said.  I think that beyond the fiscal reality, the issue really needs to be from the needs of the children and the population.  So, in principle, the idea of de-institutionalization, reduction of inpatient beds, really needs to be supplemented by appropriate community resources.  So if you have step-down programs, or if you have community-based services, those replace those high-end services like inpatient care, which is usually the argument that most legislators make when they think of funding opportunities.  There really needs to be a pulling together of like-minded people to look at how you can develop a system of care which can meet the needs of the kind of children that David is talking about, so that we are not dismantling, just like we did in the '60s--the De-institutionalization Movement--which then led to homelessness and a variety of different other problems.  And so we really need to put our heads together to figure what are community-based resources and what are step-down resources that can be pulled into place to supplement the dwindling inpatient beds that we have.  The other issue that I really want to bring attention to is that often times, places like the CCCA in Staunton has a very different mission than, say, private practice beds, and those reflect the insured, underinsured or not insured populations; and each of those have a place.  The sweeping changes across the nation upon the privitization of public mental beds is, I think, a problem.  The solution is really pulling together the public, academic and private sector and getting all the players at the table to say, 'How can we approach this problem?'; rather than marginalize one population from the other.  The other issue also is that often times, children, their families, have very tiny voices with the legislature and the lobbyists.  And we really have to be cognizant of how do we keep those issues on the front burner, as to safety-net beds, as well as public psychiatry versus the private sector and the academic sector and pull all of them together as partners to be solution to the problem, rather than close down the public sector beds. 

Eschelmann:  The next question is:  "How can we investigate wait times for appointments with child and adolescent psychiatrists?"  We were hearing that, in some cases, the people who we interviewed for our article said that it would take months to get an appointment for a child; and it sometimes is hard to know how urgent it is.  Did anyone have any thoughts they'd like to share on this question?

Slusher:  Well, yeah, I wanted to mention that in our case, Stewart did ask to see a therapist and I could not get him in to see one.  He specifically had heard one speak at a community forum and he asked to speak to him; and I called and the therapist had no openings, even two months out.  And by the time I was able to track somebody else down, my son said he didn't want to see anybody; and I thought that he was doing better.  But, we  need to do something where we're providing more care for our children.  There're just--I can't tell you how many parents I talk to who have a similar problem where they just can't find the proper help or they don't know where to find the help.  I do speeches to parent organizations, student organizations and one of the most often-asked questions I get is:  " How do we find a therapist?  Where are the resources?  How do we match this?" And so I agree with what Dr. Suud is saying, that we need to start working together--private, public sector--and pooling our resoruces.  I have found a lot of different people trying to do the same thing in small groups or individually, and I think that  if we start working together, we can actually create what we need for these children. 

Gould:  Also, Dr. Suud spoke at the Psychiatric Society about expanding the child psychiatrist's reach into the community, of being more responsive to primary care physicians, social workers and families.  I've been running a little experiment in our office.  Dr. Chas Hall joined my group.  He's a child psychiatrist and the two of us decided to send out letters to primary care physicians, psychologists, licensed clinical social workers' referral sources, and say, ' Hey, look, we understand it's hard to get a kid in.  We understand when they have problems, you can't wait.  You can't wait a month, two months.  That's not being helpful.  So what we're trying to offer is same-day calls.  A physician has a patient in the office, a psychologist or social worker or therapist has a patient in the office that needs to be seen right away, the person can call us, we'll get on the phone and offer advice.  At that point if the decision is made the patient needs to be seen right away, we're trying to take care of those referrals within 24 hours.  If they're not an emergency, but, need to be seen soon, we try to offer within a week.  This is an initiative that we've come up with and it really matches what you're trying to do throughout the Commonwealth.

Suud:  Well, I have trained Chas well.

Gould:  Yes, you did very well.  Yes, so we're happy about that and understand that in any field of medicine, if I'm hurting, I fell off a ladder last week and broke my ribs.  I need help now; I don't need somebody telling me, 'Well, I can see you in two months.'  My ribs, hopefully, will be fine in two months and I won't need a doctor at all.  But when you're in a crisis, hearing 'I'm going to see you in a month; I'll see you in two months--we don't have any openings' is not the  answer you need to hear.  So we're working on that.  Dr. Suud's working on that more over at the Commonwealth.  But it's a program that also Dr. Cohen, who's in the audience, has been setting up.  So, I'm excited about that.  I think we do need to be more responsive.  I think when somebody has a problem, you need to be there for them.  You can't just say, 'Oh, well, you know, I'm busy today.  Maybe I can see you next week.'  I don't think that's providing a service in your community.

Suud:  If I may just kind of dovetail on that.  This particular program is called the CAPPEDS Program or the Collaborative Program for Pediatrics and Family Practice, which is  something that we have tried to institutionalize.  But I think what Dr. Gould is talking about are the home-grown projects which follow that model, which indicate that if practices took up this kind of a model, it has a great chance of success because it does not produce that much of a burden and, actually, works quite well.  And if we can  amplify that within the Commonwealth and institutionalize it within practices, as well as CSBs, and so on and so forth--meaning that we embrace that as a State--we have some chance of dealing with the workforce problem that exists.

Eschelmann:  I was going to ask if you or Ms. Mann would like to elaborate at all on plans for the Child Mental Health Resource Center and how that might help solve some of these problems.

Suud:  OK.  The Children's Mental Health Resource Center is something--is an initiative that has been started by multiple stakeholders who really care about children and families.  And this is an organization which has pulled together a variety of different stakeholders and I can't even begin to name all of them, but, essentially it is really removing your barriers and coming to the table and looking at what the needs of children and families within the Commonwealth are.  These could include a variety of different direct clinical services, along with really developing a knowledge of all the different resources which are available in the Commonwealth, which we can really serve as a clearinghouse for letting the consumers know what is available in the State.  And so this would serve as a clearinghouse of all of that information, provision of direct care and this is a fledgling kind of an effort at this point in time, requires a great deal of funding and help.  But this is a start in the right direction.  Would you like to add anything?

Mann:  I think that clearinghouse idea is just extremely important in the education.  Because right now, for parents, when they first receive a diagnosis, perhaps, of their children there's very little out there in terms of trying to educate themselves, find support groups for the parent.  The different types of parenting techniques that are really needed where the average parenting skills are not working and you have to become Super Parent for a child who has specific needs, because of particular disorders and diagnoses.  So, I think having that one stop that you can go to to be able to then find that that's the right door to find your network of services, no matter what your child is diagnosed with.  And help for the caretakers, as well, to not forget those people taking care of children--that is the hardest job in the world, and to do that as a mother, father, parent, guardian, that support will hopefully be there through the system. 

Miller:  You're listening to a panel discussion recorded before a live audience at WCVE Public Radio on Children's Mental Health, and our panelist include Dr. Behla Suud, Medical Director of the Virginia Treatment Center for Children at VCU; David Gould, M.D., psychiatrist at Tucker Psychiatric Clinic; Alex Slusher, a mother and activist for suicide prevention; and Vivian Mann, Licensed Clinical Social Worker and Clinical Director for Child Savers.  I've received a couple of questions that seem to be related.  One asks what State has a model child mental health program.  And, another asks what communities, perhaps in the country, are doing child mental health well.  Where can we draw some examples, how can these serve as models for our own community programs? 

Mann:  One thing that is being worked on by many different agencies in the Richmond area now is called "Promising Neighborhoods", or "Richmond's Promise".  And many agencies have come together to look at the holistic system in the East End of Richmond, where there's a lot of poverty, trauma, violence.  And they are looking at the Harlem Children's Zone, which is a program that was developed in Harlem, which started, I belive, within about a ten-block radius of wrap-around services that were provided to families in that area; and has just proven to be such a best practice.  Had such success in working with children and their families through the school systems, with mental health through their housing communities and really, that  systemic approach.  And so these agencies are now looking at grants opportunities and a grant has been applied for to plan how Virginia, how Richmond could duplicate, replicate that model, particularly in the East End of Richmond at this point in time, to be able to bring that here and work on that systemic approach that's worked before. 

Suud:  That's wonderful to hear of a home-grown project.  But, perhaps, the general thinking these days about mental health, child mental health in particular, is a model which we call "Systems of Care".  And, basically, Systems of Care is something that has eluded Virginia.  We've probably been one the the states which has had just one Systems of Care grant.  These are federally funded grants which come from SAMSA and really espouse the notion that there is no wrong door of entry once the child comes in; because, as I alluded to earlier, a child does not exist in a vacuum.  They're constantly interacting with different systems, be it education, be it juvenile justice, be it the housing world that they live in--the neighborhoods and so on, so forth.  And, so the needs are many; and it becomes very difficult to pinpoint whether it's a mental health need, whether it is another type of need.  The Systems of Care philosophy really espouses the notion that children and families are the best judge of what the needs are.  And they work with the professionals to educate them about what these needs are and then are able to work through the system to obtain these needs in the best possible way.  And the system is set up in a way which allows that to occur almost intuitively and that the wheels are oiled in order for the bus to move forward.  There are various programs in the country, such as the Milwaukee Wrap-Around Project, which has won numerous awards; and, basically, here, whenever a child or a family has an identified problem, the system works effortlessly to move them from place to place to get their needs met.  It is a child-driven, family friendly, family-centered type of a model, wherein the child and family are considered the experts in their own care, with the professionals merely aiding and abetting that process of wellness.  And, that is said to be one of the more progressive models, and there are many such in the country.  We hope that in Virginia, we are successful in creating a Systems of Care model with the help of technical expertise from the federal government, from SAMSA and we move in that direction, because that model will allow us to do what we have already articulated.  That is the collaboration between the different players, so that we are working towards what the kids and the families need. 

Mann:  One of the other, I think, huge issues that we haven't really discussed in mental health is the issue of trauma and children's exposure to traumatic events and violent events.  And, one of the things that we're doing in Richmond now that we started four or five years ago with Child Savers is the Trauma Response Program, where we have a partnership with the Richmond Police Department, Richmond Ambulance Authority, MCV, and second responders through the Department of Social Services.  And, all of these agencies have come together so that trauma specialists, social workers who have been trained to do trauma focus work with children, are called out 24/7.  And, this is based on a model out of Yale University that is, again, also a best practice.  And we have not replicated that here--it needed to be changed, in terms of how the Richmond system works.  But, it is a very close model and the same therapist goes out at three in the morning after a child has witnessed a murder, works with that child to help be the eye of the storm in that situation, helps calm them, physically, to help calm them down; does follow up in their home or wherever they are in the next 24 to 72 hours, and even weeks, if that's needed.  And then that same therapist will see them for short-term treatment up to twelve sessions, to deal with the trauma focus--the trauma that has occurred--and then, they will go in for longer-term treatment, if that's needed.  But, I think that the understanding of children and trauma and having all of the systems, not just the mental health systems, but police departments, school systems, really involved in this, because so many of the diagnoses children are getting, when you trace it back, it goes back to traumatic events that were not taken care of at the time that then turn into depression and anxiety and post-traumatic stress.  So, I think that is also an important program that is based on a best practice out of New Haven.

Miller:  Thank you, Ms. Mann.  A number of questions from our audience members have to do with the involvement of schools in dealing with these problems.  And I'll try to summarize them.  One asks:  "What assistance can be offered through the school setting?"  One asks:  "How can the lines of communication be open between schools and mental health providers?"  And another simply notes that there can be difficulties even when a professional school psychologist and a parent are in a cooperative relationship, there is a challenge sometimes to getting the care that the child needs.  Any views on that issue or areas of success?

Suud:  School mental health is, perhaps, one of the best possible venues wherein there can be a wonderful relationship between the child, their needs and the professionals coming in to work with the child in the place.  Because the office setting is a very artificial setting; when you go into a physician's office or a therapist's office, that really takes the child away from the natural setting.  So the school setting really provides an excellent venue for really looking at the child within their natural setting and seeing what are the kinds of problems that eminate.  School mental health by itself is a very large system and it really depends on the openness of the system to have professionals come in, where there's a collaborative relationship between them and the school personnel.  There are great opportunities, yet, there are great challenges and the importance is really importing more evidence and best practice type of models within schools.  Oftentimes, psychologists and other professionals from outside can really develop good partnerships in looking at classroom management and really, I think perhaps the most important thing is early intervention in identifying when problems are about to happen; and preventing things from escalating to the point where they get into the clinical realm.  And I think that that's a great opportunity within school settings, as well as involvement of parents within the schools--how do you bring them in in a non-adversarial way and really make them partners in the process of recovery and wellness.

Eschelmann:  And, Ms. Mann, you wanted to respond to that?

Mann:  Also, just wanted to add that if we're waiting for school to be kindergarten, we're too late.  We can help there and we need to be working there, as well.  But, when we're also talking about that birth to five-year-old child care setting and preschool and all of those programs, because having children be ready for school and really putting emphasis on a child's health emotional development early on in that birth to three setting.  And working on attachment issues and all of the things that you can do in an early intervention in a natural environment and bringing child care providers and parents together more; because I was shocked to find out in Virginia you're more likely to be expelled from pre-school than you are from any other time in your school life, including high school.  And that makes no sense, so getting involved much earlier.

Eschelmann:  And there is a question for you.

Slusher:  Well, I'd like to just add on to what's being said here.  The reality is, I've talked to hundreds of high-school-aged kids in the last year and middle-school-aged kids and counselors; and the problem is that kids don't want to talk to their school counselors.  They really don't see them except if there's an issue.  If they're called on a behavioral issue to meet with the administration, the counselor is there with the student and so is seen as an adversary, so, something has to be done in the education system.  It's very, very difficult when you have hundreds of kids that you're responsible for and you might see them for five or ten minutes.  In addition to talking with the kids, I've been a substitute teacher in Henrico for ten years and so I've seen the classroom situation from a parent point of view, from a teacher point of view, I've talked with the kids; and it's an education problem, in my view, where we need to educate the public, we need to educate the parents.  I thought I was fairly educated and, yet, did not recognize the symptoms that I saw with my child.  In all the teacher conferences that we had over the years with a very bright child who periodically wasn't doing well.  Not once was it considered or suggested that  he might have a mental health issue.  Not once did anybody mention depression, and I think that  we need to work on the public understanding of mental health and the fact that depression is biological.  It's not some amorphous thing that you can control.  It's not something that's going to disappear if you ignore it. 

It's something that we need to educate ourselves about and acknowledge and get help for as soon as possible.  And the analogy that I like to tell parents is if your child had cancer, or as Dr. Gould said, if you fell off a ladder, you would not hesitate to get them diagnosed and treated as soon as possible.  And, yet, when we talk about mental health, we don't do that; or, we say we can do it without medicaiton or any number of things.  But, we need to educate the parents, we need to educate the children, by talking about depression and suicide.  We are not going to introduce these children are not already aware of.  And if I might mention a few statistics:  14.5% of high school students have seriously considered suicide in the past year.  That's according to the CDC.  That means that in the Richmond metropolitan area, if you're talking about Richmond, Henrico County and Chesterfield, over 2,800 students--teenagers--have considered suicide this year.  And, to put that in perspective, we worry about Columbine, where twelve students were killed.  We, and I'm not making light of that situation and I'm not making light of Virginia Tech where  we lost 32 people--adults and children.  But, here we're talking about the potential loss of two thousand eight hundred students or more, and we don't realize what an epidemic this is, mental health.  We need to start paying attention, catching it earlier and seeking medical help and intervention.

Eschelmann:  Do you have any additional ideas or specific programs that you'd like to see for training educators and parents regarding children's mental health issues and suicide prevention?

Slusher:  Well, yeah.  I mean the grant that we're trying to get is really we're trying to do a model training program.  Right now, I can only speak for Henrico County.  We've met with the psychologist in charge there and it's just an online training that the teachers do.  They read something, they look at a CD and they take a multiple-choice test, which is, I'm glad that they're doing some kind of training, but, it's not enough.  The grant that we're trying to get would be to provide two days worth of hands on training for teachers and staff members to then take back to their schools and train other teachers and staff members; and because of funding cuts, education cuts, the schools don't have the money for that.  So, that's what we're looking at doing and providing actual in-person training, where they can do scenarios or they can do situational training to recognize not only a child in distress, but learn intervention techniques.  Because, this is not something that you, I really feel, you can learn from reading an online test.  I mean, hopefully, the teachers, some teachers can do well with it, but I can't tell you how many wonderful teachers we have out there and administrators who knew my son well; who knew other children well (and) want to help them, but don't know what they're looking for.  So I really believe that education has to be paramount.  And also for the parents--the parents don't understand what they're looking at.  I did not understand that anger could be a sign of depression.  We so often say, 'Oh, that's just normal teenager behavior.'  It's not.  I really am beginning to believe it's not normal at all and we need to start looking at what we pass off as teenage behavior, as middle behavior and start thinking mental health much earlier.  Some statistics say depression can start as early as grade school and we need to start paying attention to that and doing something at a very early age.

Eschelmann:  There is a second part to this.  It says:  "I recall receiving a checklist when my children were in elementary school that provided possible signs of giftedness.  Could a similar checklist be provided to educators and parents to help identify potential signs of mental illness?"  Maybe, one of you would like to respond to what signs might be on the list.

Suud:  Well, it is a complicated issue and I think I've become much more aware of it after my work with the Virginia Tech tragedy, in that, what is the role of a university; what's the role of an academic institution?  Meaning, the mission is education and the issues regarding health, which I feel is integrally related to mental health--I think the two are intertwined.  And, what is the relationship of these institutions to having an awareness of those things?  But the bottom line is irrespective of what the mission, these individuals--children--are in the community of the school.  Students, as college students are in the community of the campus, so, you cannot ignore that.  So, given that we have that reality, how do we start the dialog and the culture of education and of awareness, because, clearly educators are not mental health providers.  And they don't have an awareness of what's normal development.  How can we do that and how then can we combine that with the targeted approach towards high mortality situations like suicide.  You know you have to sort of pick and choose and have to really come up with good evidence-based programs which can arm, for lack of a better word, the educators, teachers to be aware of some of these things. 

So, it's really a culture change in the way you approach this, wherein teachers become comfortable with recognizing the bell shaped curve of normalcy versus the outliers wherein behavior begins to--and that's the difficulty with--and I would make a statement that it's no different from physical health.  If you had joint pain, for example, you go to the physician and you get an A and A or you'd get your immune status sort of checked out and sometimes you fall within the normal range and sometimes you don't.  And then that determines--that single sort of range of tests indicates whether you belong as a caseness(?) within a certain medical illness.  The same thing is true with mental illness.  Your abililty to determine how do you fall within the normal bell shaped curve versus whether you are an outlier, whether you need intervention or you don't.  These are complicated issues.  But we have to begin to start diagloguing of when a teacher observes abherrent behavior, when do they intervene.  Where do they see creative writing which is dark and which has all of these elements which suggest violence; from being just a creative piece of work or is it part of mental illness.  These are very subtle differences and require a great deal of expertise.  But, we're not asking educators to become experts.  We are saying, 'Pick these up, so, that you can triage them to an appropriate source,' so, that it does not lead to tragedy, like we see these days.  My own particular position is that this dialog and this conversations with students and young people needs to occur in the elementary school.  We need to take into account things like bullying, which really set up kids for all kinds of emotional problems and really trigger responses in the tempramental styles and how they interact with the environment to produce illness.  Those are the kinds of public health and preventive issues that we need to grasp and work on at the elementary school level.  I personally believe, by the time children hit middle school and high school, dialog with them of a substantive nature goes by the wayside.  They're looking to a  different group of people, their peers.  So that they relationship between adults and children has to be looked at at a very early stage--to have a dialog.  Substance use problems, which are--I may say this--the statistics are phenomenal and staggering in what a public health problem substance use has become, which interacts with depression to produce suicide.  Presence of firearms, all of those kinds of things are public health issues that  we need to grapple with in the largest venue.  Two thirds of their lives, children are spending in schools.  Very important place.  How do you make an impact on them is a public health issue that we all need to sort of put our heads together to grapple with. 

Miller:  Dr. Suud, thank you.  Dr. Gould?

Gould:  I just like to say that in the years that I've been involved with psychiatry, I've been really encourged about the decrease in levels of stigma.  More and more and more people are learning about mental illness through programs like this, television programs; I think MTV had something on obsessive-compulsive disorder.  The word is getting out.  There are more and more people coming for treatment.  I'm very encouraged by that.  Now, what else can we do?  I've always been blessed by having great mentors.  The teachers I've had in my life have been excellent.  When I started child psychiatry training, they said, 'David, you are part of your community.  You don't sit in a little office over here in the corner.  Part of your charge is not to just treat mental illness, but to educate.'   And I was given the challenge wherever I went--and fortunately it was Richmond and it's a great place--I was to be a part of the community and give talks to PTAs, church meetings.  I've been fortunate to be affiliated with Dominion Behavioral Health and they set up brown bag lunches and they were teaching school psychologists, school counselors in the Chesterfield area.  We were doing it quarterly at that point and getting together and talking about things.  But I think people that are involved in treating mental illness can certainly help at this point, if they take that attitude and make themselves available to teachers' groups, parents groups.  I just think that's part of what we should be doing and I'm always excited to be invited to come to something like this or to come to a group and to give a talk about mental health issues.  So, I think we involved in the mental health treatment, should make ourselves very available to educate others about these things. 

Miller:  I would want to follow up, if I can.

Mann:  Could I just add one thing?

Miller:  Sure

Mann:  The checklist that you were talking about-- if I can go back to that for a moment.  An article that I read mentioned that one of the best indicators of mental, or early screeners of mental health, could be the school nurse and I think, absolutely, we could do a checklist.  So many of the students that end up with issues down the road go to the nurse with small complaints--headaches, stomach aches, unspecific, unspecified issues.  I'd also, in working together with community servces, I think that if we could work with general practitioners and do a checklist with them.  The more people we can get involved, the more we can work with one another, the more we can dialog.  I think so many of us are seeing different pieces and so, I think if we can get the medical non-psychiatric community involved, as well, with these checklists, it would be a huge help.

Miller:  Dr. Gould, I just wanted to follow up.  You mentioned what you perceive as a decrease in the stigma associated with mental illness.  The stack of questions from our audience members who seem to feel that there is still a stigma to get beyond.  I just thought I'd open it up to the whole group.  If you're, sort of what you're seeing and what you're seeing is ways around that or to combat that way of thinking.

Gould:  OK, when I was a child, when I was a teenager, I don't think I knew there was such a thing as child psychiatry.  I had a neighbor who commited suicide and that was my first thought about mental illness, psychiatric problems.  Later on, when I got into medical school, the psychiatrist were the people that were on the far end of campus; you didn't really talk to them, because they were different.  As things have progressed, and I trained in South Carolina at the medical university, we were integral.  We were on all the floors, we were, we had a big institute in the middle of campus, very visible.  Our teachers were heads of faculty committees, as they are here at MCV.  The psychiatrists were movers in the medical community.  That helped a lot, OK and it's helped a lot here.  One of my most recent mentors, Dr. James Shield, he told me, 'David, we're part of medicine; you need to be available, you need to be there.'  And, that's why we've always had such a close tie between the Tucker Pavilion and the Chippenham Hospital.  We're on the same campus.  We see each other daily.  We're a part of everything.  We're not the odd guys way over on the corner of campus that nobody should talk to.  That's helped in the medical community; that's really improved referrals.  It's not so hard for a family practice doctor to say, 'You know, I think you ought to go see David' if they don't think it's that bad.  If they think, 'Oh my gosh, how am I going to break this news to this parent', it becomes more difficult--becomes more difficult to ask the questions if you don't know what you're going to do when you get certain answers. 

So, from the medical field, I've been very encouraged that the stigma continues to drop.  In the community, fortunately, living here, I've been involved in my children's scouting events, their sporting events, church events, other activities.  I've been able to meet people in my neighborhood and [they ask] 'What do you do?'  I'm a psychiatrist.  'Well, how's that?  You're analyzing me now?'  No, no, no, I'm off the clock. And we start to talk and have conversations; and people can say to me on the sidelines,' So I heard about this; what do you think about that?'  And, being part of the community, the stigma drops.  You know, treating people in this town, they're going to know my kids.  I'll have people walk up to my kids at school and say, 'I'm going to see your dad this afternoon.  You need me to say anything?'  So, lots of people aren't feeling very bad about these illnesses.  A lot of people still do, but it's so much different than when I was growing up.  You know, I talk to parents now and they say, 'You know, I think I had this when I was a kid' when I'm treating their kid.  'Nobody ever did anything for me.  I'm glad we're doing this for my child.'  And I really do beleive we're getting there.  We're not there.  If you have a psychiatric diagnosis and it gets put on a record somewere, all of a sudden people start thinking there's something really wrong with me that might cause you problems in getting insurance, might cause you problems in getting into the armed forces; it might cause you problems in getting into certain jobs.  So there's still that there, but as we continue to educate people.

For instance, at colleges now, when I was in college, if somebody had a depression, they were whisked away in the middle of the night, never to be heard from again.  OK, now, you walk across the campus to the Student Health and you say--and I have patients who do this--'I've been diagnosed with a depressive disorder, I take this medication and my symptoms are returning.  Can you help me?'  And they go, 'Sure.  Sure, we can help you.'  Down at University of Richmond they have a great staff and the people there that need somebody treated actually refer to some of my partners.  Dr. Spanier helps University of Richmond; Dr. Curtis goes to Hampden Sydney.  It's accepted now as part of what can happen to people in their teenage and their college years and people aren't shunned anymore.  And I'm very excited by that.  There is stigma, there continues to be stigma, but it continues to be eroded and I'm very happy about that.

Slusher:  You know I would agree with that.  I mean the most surprising thing for me was shortly after my son died, I thought 'Oh, boy.  I guess we aren't going to have any friends after this.'  But, the surprising thing has been how much support I have.  I look out in the audience here and I see all of my friends and people I've met over the past year and, what's surprising is that talking about mental health is a relief.  Everybody has something.  You all know what my thing is.  I guarantee you all have something and that's what I tell everybody I talk to and I have talked to so many people about mental health and about suicide over the past year.  Everybody I talk to has a story--they knew somebody, they've heard of someone, it's a neighbor, it's an aunt, it's an uncle, it's a father, it's a brother--whether it's suicide, whether it's depression.  And I have yet to find somebody who has been insulted, who has been offended, who has not immediately opened up and wanted to talk about their experience.  And so, I think that what we need to remember is that we do need to talk more and the stigma, it's time for it to go.  I really think it's time for it to go.  People are much more understanding and, as with suicide, I have found in the research that talking about suicide makes it less likely to happen.  We're so afraid that if we mention it we're going to bring up something.  I was afraid of bringing it up with my son; I thought I would give him an idea.  Well, obviously, he already had an idea.  And I've noticed--and I challenge all of you to watch TV, to go to a movie without seeing a reference to suicide.  I will tell you we're surrounded by it; we're surrounded by depression and the only way to make a difference is to begin dialoguing and to talk about it and to realize that we're all in it together and it's OK.  And it's not only OK, but it's essential to ask for help. 

Miller:  And I'm sorry to say that we've run out of time for tonight's program.  But, thank you for attending tonight's conversation about children's mental health.  Our panelists were Behla Suud, Medical Director of the Virginia Treatment Center for Children at VCU; David Gould, psychiatrist at Tucker Psychiatric Clinic; Alex Slusher, founder of HoldHope.org; and Vivian Mann, Clinical Director for Child Savers.  This program was hosted by WCVE Public Radio, along with our cosponsors Richmond Magazine and the VCU Department of Psychiatry.  Thanks to my co-moderator Tina Eschelmann of Richmond Magazine and special and significant thanks to Rupa Merthi, of the VCU Psychiatry Department, for help in arranging and organizing this event.