Early Childhood Mental Health_ What Does Indiana Data Tell Us About the Mental Health of our Youngest Citizens
Description of the video:
Just a reminder as well that you have captions that are an option at the bottom of the screen if that is helpful to you. Okay, so here's what we're doing today. I'm kind of excited. I'm kinda I'm partially excited because I love this topic. I love infant-toddler mental health. I love talking about early childhood mental health. I think it's valuable, it's timely, and it helps for all of us to have these conversations so that we can be on the same page with what we mean when we're even using these words and what it looks like in Indiana. So I'm excited. I'm also excited because I'm a data nerd and I enjoy data. And today is gonna be about sharing some of the data that we've pulled together from various sources and talking about how it relates to infant-toddler mental health. But I will try to not drown us in data. I wish we had the chatbox because that does help with allowing folks to kind of put their human experience onto the data. I'm hoping that you all, as we go along, will feel comfortable enough that you will raise your hand and unmute and talk a little bit about some of the numbers that I'm talking about and what that looks like for you all. Because I have a feeling, we have a variety of folks here with a variety of experiences. Alrighty. Cool, cool. Well, before we get started, I do want to share a couple of quick thank yous. These webinars and this is part of a series in case you didn't know, there's four webinars in this series. They'll go through June. They are part of a series that is a culmination of a grant that we received here at the Early Childhood Center from the Centers for Disease Control and Prevention, the Association of University Centers on Disability and Infancy Onward. We just want to thank them for the funding of this project. We wouldn't have had the time and the resources available to do it without their generous funding. I also want to thank a couple of folks, Dr. Walton at the IU School of Social Work. Wendy Harold, who's the Executive Director of the data strategy, Data Strategy at DMHA, because they were willing to share a database with us, which we're not going to talk very much about today. I'm going to just skim the very surface of it. We'll share more in the summer and fall as we continue to have these conversations. But they were willing to share some data on infant-toddler mental health that I think not everybody gets to see. And that helps to round out the picture that we're talking about today. So grateful for all of those folks and we're gonna go ahead and dive in. I wanted to start today because we're talking about infant-toddler mental health. To take a moment to ground ourselves in our own mental health in this moment. So there are a bunch of little yellow people on this tree. Hopefully you all can see them. And they all are showing a variety of emotions. From one of them is falling out of the tree to lying on the ground looking tired or possibly sad. I like number 20. I hope I aspire to feel like number 20 on all days standing at the top of the tree do and the power pose, right? But you all can take a look. And since we don't have our chat, I'm going to have you just think for a moment which one depicts how you're feeling right this instant. If you want, you can hold up your fingers. I don't know. If you've got 20 or 21, it might be hard for you to do that. I was kinda thinking I was 15 earlier maybe like I'm sitting maybe not full energy but had kind of a smile on my face. So feel free to share if you'd like, but otherwise just kinda ground yourself. What I was struggling with and I'm just gonna be honest about this is that I was, I kept thinking about I have a hard week from Wednesday through Friday. So I kept thinking about what I was going to feel like then. And I kept having to ground myself and note when we're talking about our mental health right in this moment and how somebody feels right in this moment, we need to focus on right now. And right now, I'm doing okay. I'm having an okay day, I'm getting things done. And so that's where I landed on my 15th. But whenever we're going to talk about infant-toddler mental health, you're going to find throughout this entire presentation that what I keep coming back to is it's not really infant-toddler mental health. It's adult mental health because those connections between the parent and the kiddo are everything. And so if the parent or the caregiver or the child care provider, if if you all are not feeling your best, then that's going to translate into how things are going with the kiddo. So I ask about you because that's very important. Alright? Okay, Well, everyone's gotten the chance to look at the banana pupil is one of my kiddos calls these little guys. And we're going to keep rolling along here. I want to take a moment to introduce myself. I'm Dr. Katie Herron, the Director of the Early Childhood Center here at the Indian Institute on Disability and Community at IU Bloomington. And what we do is as the Early Childhood Center, we are a research to practice center that focuses on zero to five for the most part. And we are part of IUs Indiana Institute on Disability and Community that really spans the entire life range of people with disabilities. So we try to be inclusive of all. We start with early childhood. We have a center that looks at school age kiddos. We have a center that looks at transition from high school into adulthood. We have a center and health equity. So we really tried to span the range. But today we are going to focus in on early childhood and in particular early childhood mental health. We're research to practice center. So our goal is to pull data that is existing, find gaps, identify them, pull them together into something that makes sense for practitioners to use and benefit from. So that's the goal. Myself. I have been the director here for about a year. I've worked here for about a decade. I have two kiddos. One of them has mental health challenges and we have gone through the systems of care around that for most of his life. And I have some personal lived experience as well as experienced around really looking at our families that are starting their journey with young kiddos and how mental health challenges, both for the adults and also the kiddos can really impact their trajectory. So that's who I am. We are now grounded in where I'm coming from and we're going to dive into some content here. What I'd like to do today is talk a little bit about what mental health and early childhood is. Because I do think that there are some common misconceptions around that. I'm going to talk about why we might be worried about it. I mean, presumably I'm doing a webinar because this is an issue, right? A problem that some of us are thinking. We need to address this. We're going to talk about why that might be that some folks are worried about mental health at all in early childhood. We're going to share some data around Infant Early Childhood Mental Health. Based on Indiana data from a variety of needs assessments. We pulled together over 20 needs assessments and data sets and attempted to create a picture of mental health with that existing data as well as some data that we gathered just for this purpose. Then we'll end talking just a little bit about what services might be needed and where we need to be looking into in terms of addressing these challenges down the road. And then as I remind you of the other webinars that are coming, you'll be able to see connections around what we talked about today and the resources and opportunities that those webinars will be focusing on. So kinda hopefully will build on itself. Okay, so that's our plan until 03:00. So let's talk about what it is to start. And I would have put it in the chat if we'd had a chat, but since we don't have a chat, we're rolling with it. Would anybody care to try to define Infant, Early Childhood Mental Health, anyone feeling sassy today and want to jump in and give it a shot? That's a lot to ask. I recognize. I get it. I get it. There had been a chat. You guys would have been all over it. It's cool. Alright, here's the definition that we're gonna be using today, and it is 0-3. So this is, this is what we're going to base all of our data around. What is Infant Early Childhood Mental Health? The developing capacity from birth to five years old. To form close and secure adult and peer relationships. Experience, manage and express a full range of emotions, and explore the environment and learn. And all of that in the context of family, community, and culture. Okay. Don't worry, you're not going to have to memorize this. I'm going to show this slide three more times because we're going to keep coming back to that definition as we talk about the data throughout. So if that's how we're defining infant-toddler mental health, I want to point out that there are some things that are missing from this definition. Do you see the word diagnosis anywhere in there? No. Okay. Let's talk about what infant-toddler mental health isn't. Mental health in young children in early childhood isn't generally focused on diagnoses. That doesn't mean that there aren't a subset of kiddos that would benefit from a diagnosis and the services that the diagnosis might make available to them. So I'm not saying that we never diagnose kids in early childhood, but it's not the focal point when we talk about mental health in early childhood. We're not talking about which child we're going to label as depressed or schizophrenia or PTSD. That's not, that's not what this is about. And the goal is not to add an additional category or label for young children because we don't want a box those kiddos in either, you know, that young children can have characteristics of some of the disorders that we think about more in older kids and adults. So we can see characteristics of anxiety, depression, PTSD, neurodevelopmental disabilities. We can see those things in young children. But young children are tough because they don't look like adults. Those symptoms of those things don't present the same way they do in adults and kiddos. You're muted. Sorry, can you all hear me? Thumbs up if you can hear me? Yeah. Anybody can. Because I got a message that I just want to make sure that I'm not I got a thumbs up. Thank you, Marlene. Appreciate it. Okay. I'm going to keep going. So the focus is not on assigning a diagnosis to a kiddo. So when we're talking about infant-toddler mental health, I don't want your mind to go there. Now, again, I'm not saying that that never happens. We do have ten to 16% of young children that do receive diagnoses. And some of them may, that may be a very beneficial thing for that subset of kiddos. And especially because often we need diagnoses to unlock the doors to our systems of care. But the main focus is on that definition that I just shared with you a second ago around the relationships that our young children have with the adults in their lives and also the peers, siblings, peers and childcare, etc. And how they are learning to identify and manage their emotions. And how are they are able to get, explore, and learn in their environment. That's really what we're talking about when we're talking about mental health. I like to have our definitions down solid because sometimes there are misconceptions about what it looks like. It can even get political. And I just want to make sure that people understand what we're talking about. Okay, Cool, cool. So let's talk about how many kiddos, we're talking about in the state of Indiana, when we think about early childhood, we've got about half a million children from birth to age five. In Indiana. It's about 6.3% of the total population. We have about 80,000 babies born each year. So we're talking about a lot of young children that we need to. Um, be thinking about and watching and thinking about how to support and not just them, but the caregivers in their lives as well. So what do we see when young learners are mentally healthy, when they have good, strong positive mental health. What we see is that babies and toddlers can learn to identify and begin to understand their feelings. I want to emphasize this is a process because if any of you think that you're perfect at identifying and understanding your feelings, I want to have coffee with you because I'm not there yet. So it's really important for us to remember that this is what we're talking about. Beginning to do these things, beginning to manage strong feelings and expressing them in appropriate ways. Again, I'm almost 49, is still working on that one. Beginning to manage impulses and behavior, learning to recognize feelings and cues and others. So we started out talking about identifying their feelings and being able to express what they're feeling. And now we're talking about they also need to be able to understand what feelings look like in others, in their peers, in their adults that are in their lives. Because that's essential to making friends. So when we start to talk about those peer connections that we hope that kiddos can start to do in childcare and in preschool, They've got to have that capacity. And if they don't have these things that we have above that, It's gonna be really hard for them to do. And then ultimately, that gives them the confidence, the ability to cooperate, the curiosity, to be successful at exploring and learning in their environment. So these are the things we hope to see if we've got good mental health in early childhood. This is what it might look like or what we may see if children are struggling with their mental health and early childhood, we may see a loss of developmental skills and sometimes that goes along with having experienced trauma. So a child may be developing and then something happens that is really challenging for that child and their brain. And we see that they may lose some of the skills that they had previously. You may see separation fears, Macy challenges around sleep. We'll talk a little bit later about percentages. We have some data on how many children get as much sleep as they need to. We may see play that represents some of the things that they've experienced. So if they've had some challenging experiences in their lives, are some adverse childhood events. We may see that demonstrated in their play. We may see challenging behaviors. We may say lower social and emotional functioning. Really, what that means is all those things we just talked about when we have good mental health around identifying feelings and being able to express, again, just beginning to do those things. We're going to see less of that. And we're going to see less ability to explore and learn because really you've got to feel pretty secure and you've gotta be able to identify and understand what you're seeing and other people around you before you're going to feel confident enough to go out and do that. Now those of you who are in preschool or childcare settings, I wonder if these lists seem familiar to you. So e.g. if you were ever, if you've ever been asked, gosh, what do you really want your kiddos to be doing before they go off to kindergarten? Is it probably that list of mentally healthy things that we just went through? I mean, it's not always exactly what they know in terms of academics, right? I mean, we want them to know certain things, sure. But those social emotional skills that are listed there, That's the critical stuff that makes kiddos be able to go into kindergarten and integrate well. So it's really important that we're addressing them and looking at them as soon as we can because it gives those kids that much more of an ability to go into school and be successful. Okay. I wish I could talk to you all in the chat. I'm missing my chat, but that's okay. We're going to forage on. I just said forage for John. We're going to forge on. Alright, why are we worried about mental health in early childhood? So we talked about what it is. We now I hopefully have a shared understanding of what mental health is. Let's talk about why we may have some concerns or why early childhood mental health in particular, may be something that we really want to understand. This is a quote by Steven bouquet. I'm not sure if I'm saying his name right. He's a professor at Brown University and I really liked this quote. So let's just listen. The early years are viewed as a time of heightened neuroplasticity, punctuated by specific sensitive periods which represent key developmental windows during which the physiologic effort to rewrite neural connections is lessened. As such, prevention or intervention efforts during those time periods are likely uniquely powerful windows of opportunity for correcting early deviations from mental well-being. Potentially shifting mental health trajectories for life. Now he wasn't aiming for small words there. That was a lot of big words in one quote. But what I like about it is there's this keyword there, neuroplasticity. And I think that's a really important word for us to understand as we're talking about early childhood. Because what we know is that brains are always changing. Brains are able to adapt based on negative experiences. And they can also adapt based on positive experiences. And when kiddos are little, they can adapt so much more easily and quickly and fluidly than say, my brain or an adult brain can adapt. Our brains can still adapt. Older kids brains can still adapt. So it's not like we're giving up on anybody ever, but it's so much easier during those windows. He calls them the sensitive periods where there are these windows where we can rewrite and make shifts so easily. And you all working in early childhood, you've got kiddos during those windows that time. And so you have a special opportunity to make positive changes. So having said that, let me show you visually what that looks like. So these are things that can change your brain. And we would probably say they would change your brain in a negative way. So if a child experiences trauma, if they can't move the way they could typically move for a period of time if they are neglected, they experienced abuse, heightened stress for long periods of time, our brains are meant to experience very quick bits of stress like, okay, we runaway stress over were meant for that, were great with that. If we have prolonged stress, prolonged negative effects, that's when it really starts to shift our brain chemistry and cause problems. What I just want to emphasize though, is the flip side of this, which is that we can also change our brain through things like movement, music, nature, good nutrition, laughter, loving, secure, close relationships. So just as we can take advantage of the neuroplasticity in kids at a young age to shift them. I mean, just as we can worry about the impacts of these negative things, we really can take advantage of that in order to heal, right? To rewire that brain and in good ways. Okay, So here's another quote for you. Most potential mental health problems will not become mental health problems if we respond to them early. Okay, so that's why mental health is important always, but we're going to jump onto it nice and early. So having said that, let's go back. I know I showed you this definition already, but I want to hone in on one part because what we're gonna do is we've pulled data from all of these different sources, all these different needs assessments. I have everything cited at the end. So if you're curious which needs assessments we have used, they are all cited at the end of the presentation, which I'm more than happy to share. But we're gonna go through part by part of this definition. And then we're going to put in some data from those needs assessments to show you what we're seeing in Indiana. So the first part of this definition is good mental health. We have close and secure adult and peer relationships. Okay? Alright, so let's get into that. What do we know? Well, tell you what, I'll tell you what we don't know. We don't have data that tells us how many parents, caregivers and their young children are doing amazing. We don't have general population data that says, hey, you're killing it. You're connecting, your, There's a trusting relationship. You're getting back-and-forth communication, all the wonderful things we hope to see in early childhood. We have no idea. That's a gap. We don't really know. What we do know is when we can identify barriers. So when there are barriers to trusting, secure, close relationships, those are things we can sometimes capture in the data. So some of the potential barriers that we can see, our, we know that about 30%, so about a third of adults in Indiana households with children reported having little interest or pleasure in doing things more than half the days now that's a sign that's indicative of depression. We can't diagnose anybody based on one of those symptoms. But 30% of folks that were surveyed said that yet they had experienced that. About a quarter 24% of adults in Indiana households with children reported feeling down, depressed or hopeless, which is another symptom of depression. Again, we're not saying that, that many people have major depressive disorder. We're simply saying they are experiencing that symptom. Again, about a third, little over a third of adults with children in the household in Indiana report feeling nervous, anxious, or on edge more than half a day. Now that's a symptom of an anxiety disorder, doesn't mean that that many adults or it could be diagnosed with a disorder, but that symptom is present in about a third of adults. Only about 16.8, almost 17% of Indiana adults with children received mental health services in the last year. So it's not to say that a third of adults necessarily needed mental health services. But if we've got about a third of adults who are expressing some of these symptoms of depression or anxiety, it might make us a little nervous to know that only a little more than half of those folks had received mental health services. So there might be It's possible that there could be a little bit of a gap between folks who are struggling with mental health and those that are receiving supports around it. A lot of this, we have to do a little guesswork, so we're not going to say anything conclusively. We're not saying anything causes anything else. We're just pulling from these various needs, assessments and census reports and things like that to start to paint a picture. Because what we know is that if adults are struggling with their mental health, it makes it so much harder to connect positively and consistently with young children. Doesn't mean you can't do it, but it makes it harder. It's a barrier. More than 1.1 million adult Hoosiers experienced mental illness every year. And 56% of adult Hoosiers with mental illness do not receive treatment. At least that was in 2022. Untreated mental illness costs and Deanna least 4.15 billion annually. So we know that's an expensive cost from a systems perspective. We know that about half of our adults that are struggling with mental health, well, a little less, a little more than half aren't receiving treatment that might be helpful for them. Finally, as I alluded to before, mental health is a particular concern for infants and young children in low-income households. So we have an equity issue here. Mental health is obviously a challenge and a barrier to strong parent-child relationships across the board. But what we know is that mental health is a larger barrier when we're, when we're also dealing with the stressors around poverty and around the mother's living with depression in those households. Okay, so mental health is a particular concern for infants and young children in low-income households. More than half of infants in low-income households live with a mother experiencing some form of depression. And I point these things out, I'm going to try to really highlight when we see something that really is inequitable. Because then we've got to look at what systems and supports are available for our families that have higher income and what are we missing? How can we be more supports around those families that have less and therefore experiencing more stressors in addition to that depression. Okay. The other thing that can potentially be a barrier to forming those close and secure relationships. That's part of the definition of mental health is adverse childhood events. Now, there was a huge study done on adverse childhood events since then, there have been a lot of other studies that have replicated those findings in different ways. But just as a reminder, I know you've probably all had lots of trainings on this, so I'm not going into a lot of detail. But just as a reminder, these ten adverse events that you see depicted on the screen were the ones that really stood out as as differentiators in the study. There are other adverse events. This does not encapsulate all the adverse events that there could be, but these are the ones that really stood out as, as differentiating groups. And so what we see is there's abuse, there's physical, emotional, sexual abuse, there's neglect, physical and emotional, and then there's household dysfunction. So that can be mental illness of an adult or someone else living in the household, incarcerated relative, a mother being treated violently, substance abuse, divorce. So these are the biggies, if you will, from that original study. Since then we've found that certainly things like race, race biases and things like that have also shown to be important in some groups and in some studies. But I'm just going to stick with these ten for now because this was the original ten that kind of floated to the top in that study. What I'll share is that we know that 21% of Indiana children under the age of 18 have experienced at least two adverse childhood events? We don't have I don't have it broken down. I don't know if anyone does for just our early childhood kiddos. So this is children in general. But what we know is that early childhood kiddos, our youngest kiddos, are most likely to be removed from the home. And so we have to imagine that this is I mean, if I had to imagine, I would guess that this is the same if not more, for younger children, but we don't have data on that to share today. We know that 91% of child removals in Indiana in 2021 were due to neglect. There's a great studies if you want to get into the brain chemistry and trauma around aces and neglect. But neglect seems to have a particular impact on the brain. So I think it's notable to see that neglect was a common reason for child removal because we know that it has a particular impact. Okay. Just to reminder, I feel like I have to save us anytime I talk about aces, Adverse childhood events, that adverse childhood events do not equal trauma. So knowing that kiddos have experienced two aces does not mean that what 21% of Indiana children had been traumatized or have Trauma. And the reason for that is that we don't know the impact, the longevity of these aces. So something happening one time. And having, you know, there might be protective factors such as a supportive adult or being having that only happened once and then that child goes into a safer environment. There are lots of ways that that can have a bigger or a lesser impact. So I just want to remind you that a says don't necessarily equal a traumatic outcome or impact. Okay. Here we go. Another potential barrier to children forming close relationships could be their place where they live, their neighborhoods. So 40% of Indiana parents report that their child does not live in a supportive neighborhood. And as far as I can tell, supportive neighbourhoods taught include things like, are there parks and playgrounds? Are there sidewalks or their community centers? Do the residents feel safe? It's kind of a compilation variable of multiple things to make that supportive neighborhood variable. And that percentage is higher for black and Latinx families in Indiana. So again, talking about equity, that's something that's going to be more of an impact for some of our families than for others. Okay, we're gonna go onto the next piece of the definition and share some data around that. I do want to pause and see if anybody feels strongly enough about anything I'm saying or has something to add that they would like to unmute. I highly encourage you to do so, but I know that's a high bar on a Monday afternoon to expect. So I'm just going to pause for a moment in case somebody would like to. If you're planning to come back for the other three webinars that will be hosted by different folks at different times while share those at the end. We'll have a chat function working for those much quieter, mouseY way. That's how I like to contribute, at least in webinars, you can quickly type in your thing and you don't have to be put on the spot and unmute because that's just, you know, we're not all mentally prepared to do that. Right. So okay. I'm going to keep going. If anyone does feel strongly, I will pause again after this next piece of the definition, you'll get another chance. Okay? So here's the definition again. You remember it. Okay, so what we're going to focus on that we just talked about some data that speaks to barriers to that close and secure adult and peer relationship. So now we're going to talk about some data around experiencing, managing, and expressing a full range of emotions. So here we go. First of all, you remember how I said that if anybody had figured out how to fully experience, manage, and express a full range of their emotions than we needed to have coffee. Yeah. So this is something that is absolutely a spectrum and we're all working on it. I got this tweet because I really like it. It says, how do I teach my body that my fight or flight response is supposed to be for life or death situations, not answering an email. We're all struggling with regulation and with keeping ourselves not in that constant, agitated state. And children need to learn that too. And children can't do that unless it's modeled. And they get to see it regularly from the adults that they trust to teach them and model things for them, right? So what do we know about how children experience, manage, and express a full range of emotions? Unfortunately, you remember how I showed you that big question mark before around that happy mom and baby. We don't know when it's going really well. When it's going really well. What we see is that those kiddos, remember when I showed you that list of things that kids can do when all is well mental health-wise. That's what we see. We see the kiddos that don't need a ton from us. They need us to be there and be that secure, trusted adults when they're in childcare and preschool. But they're doing okay, right. We don't have data on that. Particularly, what we have data on is when there are challenges seems to just kinda be the way it is. So from a bunch of needs assessments, let me show you some of the things we do know 26%. So almost a third of Indiana children. Now this is not just early childhood because I couldn't find it broken down. If anyone knows where there's better data than what I'm showing you, please e-mail me three to 17. That's what we're talking about for this one, have one or more emotional, behavioral, or developmental condition. So 26% in Indiana compared to 22% nationally. Okay, so a little over a quarter. What we know is that 17% of Indiana parents reported that their child was anxious or clingy. We know that 12% of Indiana parents reported that their child was sad or depressed. Again, I'm not saying these kids have anxiety disorders or depression. Just that they have those symptoms that their parents or caregivers are reporting that they have those symptoms. 13% reported a change in their child's ability to focus. 10% reported more anger or outbursts, and 5% reported more problematic child behavior. Spark, which is our learning lab for childcare providers, early childhood educators, reported that when they get referrals, about a quarter of their referrals, 24% were around behavior concerns. So when childcare providers or early childhood educators are calling in and saying, Hey, I need some help us, something about a quarter of the time. It's for child behavior, right? So this is when things are challenging. These are the numbers we're seeing. Now, this next part I'm going to, I'm going to share more about in the summer and in the fall and I'll share how I'm gonna do that, but I'm lucky enough to have some access to some data from the child and adolescent needs and strengths. Comprehensive multisystem assessment. It's called the cans, if you've heard of it. And it's an early childhood version of that. And it's given to kiddos when they are brought into a community mental health center setting. And it's also used by DCFS when kiddos do that intake process. So we have a nice big dataset there because one of the things we're really seeing when we look at needs assessments, if there's not a lot of data on how children are functioning. And obviously that's an outcome of mental health is how kiddos are functioning. And so we felt like there wasn't a ton of that data available. So this is a great dataset for us to explore and we're gonna be doing that over the summer. We've got some statisticians. They are going to help us to really tease that out and break it down by demographics and things like that. So just to give you the tiniest little teaser from that dataset, what we see when we do this kind of big overview look is that kids in early childhood, when they come in, remember this is not a general population sample. This is coming into community. Mental health centers are coming into DCS. So these are kiddos that may have some things going on. We find that chil, children are more likely to have moderate problems with parents, siblings, and family members. So these are the things that tend to pop up and be a little bit bigger concern on this assessment. So problems with parents, siblings, and family members. So that goes back to that close and secure relationship. Part of the infant-toddler mental health that we talked about the definition. Moderate problems with social relationships, often has problems interacting with others and building and maintaining relationships. So again, talking about that social piece, about that relationship piece. Then the final one is around managing the stress of the child, that the caregiver is struggling to manage the stress of the child or the children's needs. It really speaks to that interference and the relationship potentially between the child and the caregiver. So this is just the very beginning. Look when we start to look at these datasets and I'll be excited to share more with you all later on if you stick with us around infant-toddler mental health. Okay? So another place where we have data is from the Spark I mentioned Spark is the place where you can get support and training for early childhood educators, childcare folks. They did a professional development needs assessment in 2022. And they asked some great questions around mental health and around behavior. One of the things that I thought really stood out was talking about preschool suspension and expulsion or childcare suspension and expulsion because this is a real issue and it tends to be an equity issue, although I'm not sharing data around that because we don't have that data right now. But what it did show was that we've got about 21% of folks who responded to that survey who have suspended a student. I think. Oh, now I'm forgetting off to go back to my notes. I can't remember if it was in the last three months or six months. I'll have to check on that. But it's suspended. A student in a certain period of time prior to the survey, 17% had expelled a student, and 17% believed that a suspension and expulsion weren't effective way of handling behavior. So that's something that's important for us to think about as we're thinking about how do we come alongside families and children that are struggling and support them to get what they need as far as those secure relationships and as far as managing and expressing those emotions. And we know from the research that suspension and expulsion is usually not gonna be our best strategy. And it's interesting to see how that breakdown looks across the different types of childcare as well. Because we see that we've got different percentages in ministries and centers and child care homes. The other piece of data that suggests that we may have some challenges around this, managing and experiencing and identifying emotions is we see first steps referrals going up and often when kiddos are struggling, they will be referred to first steps. We do see a gentle upward trend in first steps referrals. Even though first steps is a developmental program focused on all kinds of milestones for kiddos. They do they can address behavior. I mean, they do have psychologists and social workers in the program. On the other hand, it's not their primary purpose, right? So it's, it's one piece of a much broader developmental system. Okay. Alright. So we've got about 20 min left and we've been sitting here for a moment and because I can't chat with you all in the chatbox, you're doing a lot of listening and not a lot of getting to talk back to me. So if it's okay, Let's do a little bit of breathing. This is something we do in childcare is increased bulls because they like it because it's related to an animal. But it's basically this physiologic breathing, which is very good for us to do, to expel extra carbon and get more oxygen into our lungs. So what we do is we do quick to two quick breaths in and one long breath out. So if you would like to breathe, take this moment to breathe. I'm gonna do one more. This is something that you may notice that you do after you cry. The next time you have a good cry, which hopefully we all do occasionally. You'll notice that your body does that. It needs to get that extra oxygen in and release that long breath. So we do that, that we sometimes they'll do it before bed. You may notice that you're doing it before bed. But it's a, it's a common way of I'm breathing and relaxing. And when we have too much of that shallow breathing, we can get agitated. We can feel like it's where agitated and that's just because we need to get more oxygen in there. So having that nice deep breath in through the nose and then out through the mouth can be. So feel free to move around to stretch, turn off your camera and do something embarrassing, whatever you need to do to kinda get your brain back. And we'll keep going. Okay? So you're gonna get sick of this definition. I warned you at the beginning, but here we are again, okay, I don't want anyone to forget what this definition is. We talked about relationships and we talked about some possible barriers that we see in the nana data around forming those close and secure relationships. Talked about experiencing, managing, and expressing a full range of emotions, not mastering it, but just starting the journey. And then now we're going to talk about exploring the environment and learning. Because when we send kids off to childcare and preschool, would we hope for them, we hope that they're going to explore their environment and learn, right? So we wanna make sure that that's happening and if there are barriers to that, we want to be thinking about those. So what might we know from the data? What we know is that young children are not always safe and secure in their environments. And if they're not, it's gonna make it much harder for them to explore and learn. So when we look at the rate of referrals made to child welfare agencies in Indiana, it's 110.1 out of 1,000, compared to 45.2 out of 1,000 for the United States as a whole. So infants and toddlers, zero to three or more likely to be referred than other age groups referenced that earlier. But we know that generally it's this young kiddos that get those referrals. And we know that some kiddos aren't safe in their homes. We know 20% of Indiana households with children who rents, so families that are renting, our report being very or somewhat likely to be evicted in the next two months. Now, all of you can remember as less hierarchy of needs, we've got our triangle. If they're worried about being evicted and losing there their home, then it's gonna be much harder to worry about some of those other things like sitting down and reading a book with your young child or something else. Okay. Indiana had 15,523 people in families with children experiencing homelessness. 5,950 children were removed from their homes in 2022. Infants remained the highest age category for removals, and neglect remains the most frequent reason for removal. It's 60 child deaths due to maltreatment in 2021, 35.2% of children ages four months to five years old slept less than the recommended age appropriate hours during 2020, 2021. Remember when we talked about sleep earlier as a sign that a kiddo might be struggling with mental health. Here we see that often we do have kiddos that aren't getting what they need while lack of sleep doesn't always indicate a lack of safety, it does suggest that they may not be getting their developmental needs met in the environment that they're in. We also know that 70% of children in Indiana have all available parents working. And only 23% of children, zero to five are enrolled in some form of childcare. We know that when we have both families, parents going out to work or whatever who's ever is in the household meeting to go out to work, to earn an income that there are gonna be children in the home that aren't always, then in the most safe and secure environment. 39% of three and four-year-olds are not in preschool. Children in care only 47% are in programs that are rated paths to quality level three or 450, 5% of Indiana families reside in a childcare desert. In other words, an area where there aren't high-quality options. 72% of families in rural communities have little or no access to licensed childcare. And from our mic, the needs assessment respondents, 79% of those respondents expressed a need for childcare or expressed that there was a need and Indiana for more better childcare options. I'm sure I'm not blowing your mind here. This is not anything that's going to surprise us. And some high poverty counties have less than 40% of children in funded care receiving see CDF vouchers. Most counties with high poverty and low percentage of children receiving funded care are rural. So in other words, there's a disconnect between what we think is needed in a particular county versus what's being received. All of these things can limit the way that a kid I was able to explore their environment and Lauren, potentially, not necessarily, but it's a possibility. The thing is when we gathered data from a bunch of needs assessments and what the data wasn't gathered for the particular purpose, we're pulling together to try to paint a picture. So one of the things that I'm going to ask, I've mentioned it already, but if you have data or have questions about the data that I'm presenting, as I said, all the citations for where the data came from or at the end of this PowerPoint. But I'm also very open to hearing if you think you have different data or better data. And we can continue to perfect this picture as we go. As the title said, this is preliminary data that we've pulled as we continue to work over the summer to complete that report and prepare for the infant toddler summer that we're going to have in the fall, which I'll tell you about here in just a minute. So based on all of that data and based on the needs assessments that have been so painstakingly done by a variety of systems around the state. What do we think Indiana needs? One of the things that multiple needs assessments stated, that there's a need for mental health supports for adults. And hopefully, if, if me showing you that definition over and over again has done nothing else, it's emphasized that infant early childhood mental health is not so much about the child as it is about the adults in that child's life, right? So if we aren't providing those dolts with enough mental health care and supports, then that's going to trickle down to the young children in their lives as well. So we know that the needs assessments show that there's a need for parents and caregivers to have mental health supports, for pregnant people to receive mental health supports while they're pregnant and also immediately afterwards. And we see that those mental health needs do differ based on demographics as well. We talked earlier about the higher rates of depression when families are also struggling with having low incomes. And there are other examples of that as well. We know that multiple needs assessments state that more home visiting services are needed. And there's also been conversation about not only do we need more home visiting capacity, but we also need to think about ways that we're connecting families to home visiting so that they get into the program that's gonna be the best support for them at the time that they need to be. And I know e.g. we're gonna be talking about resources and in future webinars, but I know e.g. that might help the baby from Indiana Department of Health just came out recently. And that's a way to try to funnel kiddos who are families who may be in need of home visiting, but aren't sure which program is going to work for them, to funnel them into the program that's going to be the best fit. So that's a great example and lots of systems have attempted to create family navigators that can help families navigate all of these different systems. So that's something that's trying to address these needs. One of the things that I think we all have to think about is that sometimes we go forward trying to address the issues that we see within our own system and all the systems do their own thing. So how do we get all of those systems to talk to one another so that we're truly giving families the most seamless service that they can possibly get. Systems need to consider how they're communicating families about home visiting options. We just talked about that and then thinking about how they're reaching underserved populations. So e.g. needs assessments talked about the concern that we may be missing families experiencing homelessness. And so that's, that's an example. I saw that there was a hand raised and now it's gone away. I hope I think it was Jill. Jill, I just was going to finish that slide, but I'm done. So. If I covered it and that's why you put your hand down. That's cool. If you just got tired of having your hand up, I would love to have you jump in if you'd like to. So open invitation. Oh, sure. I thought well, I was just I can't hear you. Sorry. Can you hear me now? I think I may have my I think other people can I'm having trouble hearing you, but I think that's because my volumes that hold on just a second. Let me get that fixed. Okay. Go now. Okay. Can you hear now okay. Sorry about that. That was my computer. No, that's fine. I was just wondering because I was watching some of the dates that the data was collected or pulled from. And it was right there in some of the height at COVID times. So I didn't know. Is there a previous data or data after that to just took away? I would just be interested to see what impact of COVID had on some of that as well. Yeah, We tried to pull host COVID when we could when we had it and there were some that we, that's the most recent data that we have. I did not go back and look at previous years pre-COVID to see if that was an anomaly. So that's a great suggestion. Yeah. I was just curious because I think now we are definitely experiencing the need for children. And so it was interesting also that report for the influx of first steps referrals. And I also wonder on that just from my own personal professional experience is I feel like sometimes we tend to start there. Especially like maybe some behaviors are starting, but we're also contribute to a language delay or the that child is having some trouble with their language development. And so we start that as a first avenue of trying to support that child's behavior as well? Yeah. And hopefully getting them into a system that can then support them to find other systems if that's a better fit? Exactly. Yes. Yes, absolutely. Yeah. Other thoughts while we have well, we have the slides off for a second and I don't know if anybody else here is working in childcare, but I'm with an Early Head Start program. And so we are the children that are enrolled in our program are children who were born during the pandemic. And there is a real huge difference between the social emotional health of families now versus pre-COVID. And we're not seeing an improvement yet. Okay? You guys are also experiencing the same because that's my own little anecdotal bubble. But we're not seeing significant changes yet now that we're towards the end going into the endemic rather than the pandemic. We're not seeing a lot of change. I love how every single head nodded at the same time when you said that, Robin? Yeah. That is certainly what I've been hearing anecdotally and I'll tell you how frustrating it was when, when pulling all this data together and not being able to show it in the data. What I hear from all of these early childhood educators. You know how hard it is and how it's different and how it's. But there's it's hard to not be able to show that. You know, I'm hoping we can, we can continue to work on gathering that data. But other other thoughts at this point, I know we're about to wrap up. I was I've got a couple more slides. Unless I've got a hand up melody. I'd just like to add in the DCS and employment. I think all of us here are kinda holding our breath. During the pandemic. The school is our number one resource as far as calling and reports. And those came to a halt. Almost. I don't know the numbers. I just know what I witnessed in my region in so as an internal in the melody, I think we lost. It's scary, but I do fear what the, what might be the answer. So if I lost you a little bit in the middle, but am I right to summarize by saying that we might see higher numbers once we are. That's my concern is going and monitored for so long. What the effects on he said these younger children as they come into the school system might be. Yeah. Yeah. Then I certainly hear that from school age administrators and teachers as well. Yeah. Okay. Real quick, we've got 6 min. I'm going to zip back in here. Show you just a couple more slides and then we will, I'm going to show you what else you can look for if you're interested. What we know is that, and this is, none of this is gonna be a surprise to you. We really just talked about it, so I'm gonna go quickly. But we know from needs assessments that stakeholders say that social emotional is the thing that we need, that you all are seeing the challenges there and that is the priority. It's the third biggest priority that was listed in that assessment and fourth most important priority for babies and children with disabilities in particular, we've got 52% on the Spark needs assessment. Sharing that they're not using a developmental tool currently. As we get these kiddos who have been out systems coming into systems, having that consistent developmental screening tool. I think it's gonna be really important. And so working with childcare and preschool is to make sure that that's happening. We know that there is less collaboration between childcare and preschools and community organizations that could support mental health than we would like to see. I mean, it would be amazing to start to see more of those connections being built. We also know from that needs assessment that the childcare providers and preschool providers aren't necessarily feeling super confident in their knowledge around early infant and early childhood mental health consultation and the ways that they could find services to support the behaviors and the challenges that they're experiencing in the classroom. There's a lot of stress, but they're not always sure how to make the right connections to find services. Then priority topics for professional development. When we ask on that needs assessment, you can see it's mental and social, emotional health, it's discipline, it's challenging behavior. It's all the things that you would expect to see based on what we just talked about. One of the things I wanted to share around the community mental health centers situation in Indiana, and also around the infant and toddler endorsement registry is that we've got endorsed providers in 52 52 counties don't have endorsed providers. All the ones with stars do have endorsed providers. And what that means is that you've got a provider who's gone through additional training and is particularly skilled at working with infants and toddlers around mental health. I will say based on a relatively small poll that I did because I didn't get a ton of responses back. Of the responses I got back only 15% had current openings. So even when we know that there are things available in some counties, the challenges, are they really available? And then how do we handle waitlist and crises and things like that? We have 24 community mental health centers in Indiana. Only eight of them see children under the age of four, and only two of them see children under the age of two. So I called all of them. And what I found is that none of them really had referrals to there was no place to really send somebody with a young child except for 211. And I call T11 and they sent me to first steps. So it's a real challenge to get people connected with what they need. And I just think we all have to be aware of that. So just as another note, in terms of talk systems talking to one another, none of the community mental health centers offered referrals are mentioned. The infant toddler endorsement or the registry that shows where providers are. I put the link here in case you haven't visited the endorsement site, but you can find where providers who have that training are in your county and give them a call and contact them. So what's next? I know we're at the end here. We're going to finalize this data. We're going to add new data based on all of the stakeholders around the state who are contributing to this process. This is preliminary data based on what we've got so far. I welcome your input. I also welcome input. I'm gonna be presenting at multiple different places to start the conversation of what else do we need to know? Is there other data out there that we can share and highlight to get a better picture, the whole goal is to have a good enough picture that we can start to spread awareness and an effective way to legislators, to others in the community who need to understand what this is. That it's not a scary thing. It's not about diagnosing babies, it's simply about supporting healthy relationships. So babies get the social emotional, the emotional stuff that they need so that they can go on and be successful and learn when they hit childcare, preschool, and beyond.How Knowing Social Emotional Milestones Can Support Infant Toddler Mental Health
Description of the video:
I'm so pleased to have Steve Viehweg with us and he and I, mostly Steve will be chatting and I might just chime in occasionally and ask some questions or comments as we go along. But as we think about infant toddler, mental health and it's all about relationships. One of the things that can throw off relationships is having expectations for young children that are too hard, right? Or not developmentally appropriate. And then what happens is we get frustrated. Kid gets frustrated because they can't do what it is that we're hoping that they'll do or we're expecting them to do. As we learn more about social emotional milestones, the goal here is to think about how can understanding these milestones help us to better form solid and secure relationships with these kiddos. Because that's what they need in order to be able to learn how to manage emotions and all the other things that we want them to be able to do at home and in school, et cetera. That was more than a sentence. Steve, I'll turn it over to you. I was going to say that was an amazing sentence, but well said, I love that you brought up how this all came about because we have a longstanding partnership anyway, Katie Heron and I, in this work, and we both have this burning desire to understand better mental health and what can we do as providers. Whatever role we play to better help those young kids that goes across things like not only service but even thinking bigger and widening our lens about what do we do programmatically? What do we do around training and understanding? What do we do about policy? How do we get folks that make decisions about where resources go to understand the complexity of this and to think about the youngest kids, and they need us to do that. We have to be a voice for the babies. That's something we always try to say, is that we invite you to be a voice for the babies if we don't know each other. I am Steve Viehweg. I have a lot of letters after my name. I do that on purpose for a couple of reasons. One is so that you know I'm a licensed clinical social worker, but I'm also endorsed as an infant early childhood mental health provider. And you too, likely, could get those letters after your name, if you don't have them already. And that's one of the other webinars that's coming up is to learn more about that. Learn how you too could get those letters and please check it out. The goal is that folks that have knowledge, experience, and understanding about early childhood social emotional development would embrace this competency driven endorsement so that you too could have letters after your name. But really the big reason is that we're trying to create a community of practice so that wherever there's a kid that needs help, we could identify them and get them connected to folks that have a clinical background when necessary, to help them out. The CDC has learned the science. I'm the Act Early Ambassador to Indiana. And that's another connection that Katie and I have, because she's now the Mental Health, I guess, Ambassador, we could call it. Katie as she'll introduce herself. But the CDC is interested in trying to get information out about early childhood development. We're going to focus on that today as Katie was inviting us to think about the developmental piece around this. And we acknowledge that the social emotional domain is the hardest one to describe, to understand, to assess, and to deal with. But we have some information that could help us standard in my day job. I work for the Indiana Lend, which is our Leadership Education and Neurodevelopmental Disabilities Training Program at the School of Medicine in Indianapolis. And I'm also the Associate Director of the Center for Translating Research to Practice. We do like to let you know you mentioned Angie Tomlin who's a coauthor with me in a book called Teching Tough Stuff. It's aimed at home visitors that support families. But really, it's a practical guide that can help anybody. And some of this material is in there, like understanding the behavioral pieces that might connect with development, invite you to look at, so that's who I am. And the question is, what about the other one? Katie? Who are you? Okay. I'll chime in quickly here. And I have your book on my shelf. By the way, I am the director of the Early Childhood Center at the Indiana Institute on Disability and Community. So I'm located at Iu Bloomington on campus. For the last year, I have been the CDCs Mental Health champion to Indiana. We have been looking at ways to connect these milestones with mental health. It was interesting looking at those social emotional milestones on these slides, and I'll ask when we get there, but it's interesting me, there isn't more emotional stuff on those milestones. Yeah, I don't know if you have thoughts on why that is and we can get there. But I thought I was really reflecting on that when I was looking at the definition of mental health and then looking at the milestones. I thought it seems like there was maybe a little disconnect there. And the other thing that we'll naturally observe, we'll just throw out before we get there, is that when you look at the other domains that sometimes I look at, maybe something in communication and go, doesn't that look like social emotional development for young kids? There's a lot of crossover. I think that's an important message, right? That it's messy and complicated. But we can use the evidence. The other thing we'll say about these milestones that we look at today is that they are evidence space. The CDCs only put out milestones that they could say comfortably, we have evidence that this really is the thing, and that most kids, 75% or more would have this skill, this activity, by that age. That also helps, I think, answer your questions like why are there more things? But we don't have evidence for them, But here's what we have evidence for. It's a high criterion to become a stone makes a lot of sense. We all have to work on this, right? We all have to work together to keep building the evidence space about what's behind this. Yeah, that's true, because mental health and early childhood, we're pulling pieces from a lot of different places to try to build that base. And it's not always there yet. That's me, we can keep going. Well, the other thing you said that was really key in the long introduction sentence was that's all about relationships. And that's a good place for us to start as we just reflect back on a definition of infant, early childhood mental health, which you can see coined by zero to three, The National Association of Zero to Three. If you haven't visited their website, go do it. Just type in zero to three.org and you'll get there. But look, this was in 2002 and has remained the go to definition because it's just good. When we talk about infant, early childhood mental health, we're talking about the child's developing capacity to do three things. One is to form close and secure interpersonal relationships. And you can think about how that happens, right? That's the babies are born experience expectant and they need adults to help them navigate the world that begins at birth. Is that connection with hopefully with a secure interpersonal relationship. Which by the way, is something we need throughout our lives to be able to do that. And second, to experience, regulate, and express emotions. When babies are born they're learning this skill and it comes with lots of practice. The adult caregivers help them understand and calm down and learn how to get needs met. But also like how to regulate, how do I do this in a way that's not so disruptive? Then third, to explore the environment and learn another skill that turns out to be really important for later on. All of that is within the context of family, community, and cultural expectations. The nuances of how that might work, I like to always throw in that I think all of us could share this idea with folks that do public policy, that make decisions about where dollars go. Because the work that you and I do in early childhood, it turns out, is very important for something you need later on. If you're in Indiana today and we may have folks from outside the state joining us, I don't know, but Indiana is a state that works. I saw it on the side of a building downtown. We value work and you think about what employers want. They want people who can do these things. They want them to be regulated, dependable to be able to solve problems, to interact with others, and to do what they're supposed to do. We are at the beginning of making that happen, we are today thinking about kids in the context of relationships and social emotional development. Another way to look at this and maybe more simplified way is comes from our colleagues, our friends in the infant early childhood mental health world at Fitzgerald. And Debbie Weatherston, some others. They say that this directs our attention to the well being of all infants and toddlers within the context of secure and nurturing relationships. Just think about that, but what happens and why relationships are important. And then the role that we all might play in supporting those caregivers in whatever way we can to build those connections with kids. You might have come to this today wondering, can babies and toddlers have mental health problems? And the answer is yes, they can. There is evidence that would say that kids even under the age of five, can experience what we might call grown up feelings like all those listed here. Extreme fear, grief, sadness, hopelessness, intense anger, even rage. Now, it might look different, right? So we have infants and early toddlers who aren't able to articulate these things using words. But there are ways that they can share some of their big emotions and you can imagine why kids might have these big emotions, right? It could be lots of reasons where there could be traumas or things that happen in their lives or things that interrupt their connections with adult caregivers. We just need to become better at knowing what to look for with those young kids and to try to understand, hence our conversation today. Trying to understand what this might look like, what does mental health look like? And young kids ways we might figure this out or begin to wonder it is if there are delays in development. I think this group is probably really good at observing young kids and being aware of when things are not on track. We might not always have the ways to explain what it is, but we have a sense, right, of when we're observing kids. We might also notice kids that are having trouble regulating in all the different ways. That might be whether it's through sleep or other behaviors or eating or the things that they're doing notice might have particular fears or they might be in emotional distress. Have you looked at kids? Sometimes and you can tell that they're not feeling comfortable. It's not comfortable for me to see that, but we might observe that and be aware there's a lot of talk about attachment, how kids connect with those adult caregivers. And there's a whole literature about attachment. Most kids have what they call a secure attachment, but sometimes they don't. They might have what's a disordered attachment? And there are some descriptions about how we might understand that and try to intervene and help kids get better attachment. And it could be for lots of reasons. Certainly we know about kids that have difficult behaviors, including aggression. And we can begin to wonder what's going on, and that's what we'll explore. What could be behind this, Maybe feeding or sleep problems, or even physical problems. They're growing, they're not growing in the right way. Lots for us to think about, but think about how some of these symptoms might in fact be related to mental health. The mental health and well being of kids. We could say that these problems can be serious chronic. We need intervention for them, but we can do that. We know that we could successfully treat these things and be able to help kids and families who might be having these challenges. You wonder how common is this? Well, the data would say the best estimates of serious behavior concerns in kids ages two to three might fall 10-15% That's enough kids that we should pay attention to that parents in pediatrician report says that behavior problems, there's 10% of one to two year olds. Even those really young kids, they're reporting behavior problems. We might flip it around and wonder like how many kids are being kicked out of preschool because they have behavior problems? Right? I'm not sure what the data would say about that. That's hard to collect, but our own experience might be it's too many. What could we do to help kids stay in the environments that they're in? Some more data, up to one in four kids under the age of five are at moderate to high risk for developmental, behavioral, or social emotional delays based on the National Survey of Children's Health. And these reports are like the incidence concerns of older kids. So it's similar, it's about the same. We should be paying attention to this and trying to understand when parents are reporting challenging behaviors. They're also sharing that there might be delays in social emotional competence. When we're listening to what they say, they report being worried about their kids behavior. And certainly they're telling us that the behaviors interfere with family activities. That's some clues for us that gets us to thinking about the developmental piece, about this. The CDC, the Centers for Disease Control, is they've been putting together for a long time now. They've had the materials out, they learn the science, act early materials. What prompted them as an agency to think about this was understanding that developmental disabilities are common and not usually identified before kids get to school. But the data would say that 1.6 kids between the ages of 3.17 ends up with the developmental disabilities. That's a lot of kids. What could we be doing ahead of time to better understand that? The latest data that just came out of the CDC through their Atom network, their autism and developmental disabilities monitoring network, says that 1.36 children age eight meet the criteria for having autism spectrum disorder very quickly. The way they figure that out is they have teams of researchers looking at medical charts, eight year olds, and seeing if kids meet the criteria based on what's documented there. That doesn't mean all those kids have that diagnosis, but it means a large number of kids would meet the criteria. We also know that early intervention ahead and ask you a question. Sure. Or maybe it's a it's a comment and a question. I'm looking at that list of ways behaviors that we might see when a kid might be struggling. You shared that list then you shared that slide. Yeah, that's the one. Yeah. I was thinking there's probably some things on that list that are going to be Really stand out to childcare providers or teachers as potentially disruptive in a classroom. Or we've got our externalizing behaviors that are, it's hard to ignore those. And then we've got our internalizing that are a little quieter. So I'm looking at that and then I'm listening to you talk about the kiddos that actually need clinical intervention or may have a disability or delay. I'm thinking about a teacher. A couple of preschool teachers I was talking to the other day that were saying that they have an inclusive classroom where they have kids with Ip's Right. So that are getting special education services. And then typical kids in their class and the behaviors of the typical kids were so challenging that they were having trouble serving and providing the specialized services that the kids with Ip's needed. So I guess I just wanted to point out that it's so interesting to think about all of the ways that it's important to identify when kids are struggling because it doesn't always reach the need for clinical intervention and it doesn't always become a disability. But if we identify when we see some of these behaviors, even in smaller doses or in certain situations, I think we're seeing it so much at lower levels that I don't know what my question is. I guess I just wanted to point out, it's not like we're only talking about the kids that get a diagnosis. We talk about this stuff. You're making me think about all the things that have happened. Let's talk about we had a pandemic, in case you didn't know, we're still all learning. Like what the impact of that was. I hear early care education providers talking about the kids that were in settings and then out because we were all at home and then came back. Or we have kids who were never in and now we're coming in. There's lots of things that could influence that. Then I think you're right, it's probably helpful for us to just step back and understand what's going on developmentally, for all kids to try to understand like what's behind the behavior, what's going on. Because there could be any number of things. It could be serious. It could be not so serious, but it's impacting my behavior. Now if I understand it, maybe we can find ways to help with that. I also was thinking about how people have been embracing self care, ideas like mindfulness and yoga. Or how all the meditation and applying that to very young children as another tool to help them with some self regulation. When those things occur, like when we're all getting out of control in our classroom. But we can learn as a group of kids like, well, when we get like this, we got to use our whatever skill to help us calm down instead of becoming a behavior problem. Sure, Yeah, I have good observation. Yeah. When we have Crystal and Nancy and Shannon come on June 15 to talk about some of the initiatives that Costal is doing. They're going to talk about how the call map is available and free to all childcare providers now as well as teachers. I hear a lot of providers saying that they're using it in their classroom. I think they're using it for themselves as well as using it in their classroom with these littlest learners learning to be calmed by music, mini meditations, things like that. When I've heard examples of when that's been introduced into classrooms, where when things get out of control, then the kids themselves go, okay everybody, we're getting a little bit, whatever the word is, it's time for us to use this skill so that we can calm down and they can do it themselves. And isn't that what we want? Right. And then built at home. Exactly. Yeah. Yeah. Somebody just commented in the chat that they worked in a school as a therapist and they had built in mindfulness into the school. And then I think this is interesting, they added one mindfulness session after a code red. If something stressful happened in the school, they worked in a procedure. They had a process where they were automatically going to take a few moments to calm down. I love that. That's a great idea. Yeah, this ties into this notion that earlier intervention is better, right? We're just throwing out lots of examples of when we notice things that need attention, then we should do it as early as possible and get whatever support services are necessary. But at the same time, it's never too late either. Like we don't have to say, oh, you missed that birth of three window or birth of five window. So there's no hope. I think we should always be trying to do but the earlier, the better. Hence these conversations. Now one aspect, how do we just look at development to better understand that? I don't think we have to sell you on the idea of early intervention. Everybody's here is like, yeah, let's do that. So let's focus now on looking at the CDC materials and understanding just how they set these up. And then we can play with some of the materials that they have to dig a little deeper. But the CDC put together these materials because there was a piece missing, they felt. That whole umbrella of understanding child development. And what do you do when there's a concern? They are on the end of keeping track or monitoring and looking at milestones which they would just define as things that kids do by certain ages. How they play or how they learn or how they speak or how they act, or how they move. The things that you and I see every day and looking at those milestones give us some clues about where kids are developmentally. Parents may need our help in understanding what those are. If any of us have kids or grand kids, we didn't just automatically know everything that kids are supposed to do, we might need a resource to help us. Cdc said, well, we'll put together materials that are aimed at parents. They're in parent friendly language, they're sensitive to the culture, and they're evidence based. They're written in accessible language and presented in ways that makes sense to people that everybody would have the ability to have some common language about what kids do at certain ages. But also understanding that kids develop at their own pace. And some are going to reach certain milestones earlier or others. This is not scientific in the sense that it's not a measurement. It's just a tool to help us begin to understand and communicate about it. And tracking again, go ahead. Yeah, my lens, I'm a parent of a child with a disability, and then I also have done a lot of work in this field, particularly in early intervention. And one of the things that I hear from parents when they have kiddos that do have delays over and over again, is that milestones can be a bummer. They can be sad because if you're so far behind, if your kiddo is so far delayed in a particular area, it can just be a sad conversation. I've heard a lot of really skilled professionals use them in lovely ways with kids that do have delays and disabilities around. Not so much focusing on how behind a child is, but talking about what's coming next and what did you just accomplish. It's this individualized thing. I love that you talk about how kids develop at their own pace. And then just thinking about how, beyond that the messaging works when kids are developing at their own pace, I think is really important. You'll see in the materials that the CDC is developed that alongside the milestones is a lovely list of activities, things that we could do to encourage development at that stage. You're right. If we can separate out the age piece, we have to start somewhere. Like if we're trying to identify where kids are and if there's a delay, then we start at age 30 months. And yet we could use this tool still in a sensitive way that's supportive, as you're saying, when we identify a problem. What I hope we all take away too is I hear a lot from providers that they're hesitant to talk about delays with families for lots of reasons. It may be that we're not diagnosticians, so we don't feel comfortable saying there's a concern. But I also understand, and I say again, we're all observers and how many of us are constantly watching kids wherever we are. And when there's something that doesn't seem right, we're right, that doesn't look right. And how do we know that? We know that because we have this experience. We have this knowledge. It's okay if we were to bring this up and support families. The other thing I would tell you is that in our research with these materials, is that families would say that they trust their early care education providers to tell them about what their kids are doing and when there's a problem more than they would their doctors. And why is that? Because as Katie said, it's all about relationships. We develop relationships, partnerships with families. They're expecting us to tell them. You could use these tools as a way to help build that language and that opportunity to talk about it in ways that makes sense. I think what you're saying is that when you have that relationship, it's much more likely to be strength based. Whereas in a pediatrician's office or something like that in 15 min, you may end up with this deficit based approach accidentally from any attempt to be mean, but just it's quick, it's straightforward. But when we build relationships, we really can use this tool in a strength based way. Well, think about the opportunity of partnering together. When we're looking at what kids are doing, we're understanding what's happening. Then we have that opportunity to go, oh, what do we do here? Here's what we're trying in the program, here's what you can try at home. And when there's a bigger question, then we can have that conversation about what do we do next? We screen, right? So if we're monitoring and keeping track when we have a question, then the next thing we might do is get more information. And that's exactly what Elmira says in the chat. She says that teachers also observe longer and have more take it away. That's a perfect segue. It is. We wanted to just set this out there, but today we're talking about monitoring and just understanding, develop, and keeping track of all of us do that. And we're looking at milestones, the things that kids do from birth to five. It just helps us look first, celebrate what kids are doing. So that's what we could use this with everybody. And then it helps us talk about progress with everybody that's involved. It helps us know what's next. Also helps us identify if there's any concerns. Materials we could use that we'll look at today are the free CDC materials. When there is a question, then we would talk about doing some screening. That is a more formalized tool. Again, it's not scientific, it's not a measurement to say you have a diagnosis or a delay. But what a screening tool will do is also looking at milestones, but in a more organized way, is going to tell us if things are okay or if we need to go to the next level and get a child and family connected for an assessment, that would be done by whatever provider. It could be a psychologist or a speech therapist or any of those folks that have their even more refined tools that could get to a diagnosis. You see we're not doing that. We're just talking about what kids do is on track. If it's not, we should get more information that would help us know how to support that child, where they are, and to keep them going. I hope you're taking away from this, that tracking is important, keeping track of what kids do. It gives us a chance to know where we are, catch early signs of development, et cetera. That gets us to a place like, let's play with this a little bit and we always like to start with when we talk about development, to know what are the five domains of development. Here's the quiz portion. Tell us what they are. You can unmute, you can go ahead and type it in the chat. I'll see how fast you could do that, but okay, social, emotional. Yeah, cognitive. Somebody that motor. In the chat I see physical, adaptive, problem solving. Someone said problem solving, Language and literacy. Fine motor. Oh my gosh. We got way more than the number you said. Well, let's talk about that, Katie, because they're using some words that might be in the same categories. Definitely. So what we're going to show you is what comes out of part C of Idea, the Individuals with Disability Education Act. So these are the five domains, here they are. And Elmira, you win the prize if there only were one to say social emotional first. And that's my bias, it might be Katie's bias. That one is what we should be putting at the top for lots of reasons. Not just because I'm a social worker, but because none of the other stuff happens. A child doesn't have a good connection with an adult. If they're not connecting, then they don't grow. Their brains don't grow, they don't grow physically, et cetera. Then the second one here is called communication, and that talks about both expressive and receptive. That's a second on my list because a lot of the issues we might identify that are behavioral might be related to communication. Right. When kids are having trouble with either understanding or expressing what they're looking for, then we had cognitive, some of you listed that as problem solving. Okay, that's fine. Adaptive is in here, I will say, is that the materials we look at today from the CDC and also like in the ages and stages screening tool leaves out that domain because like we've said earlier, there's so many crossovers for this young age group, it's not necessary to include that as a specific category to look for. Then the last one on our list here is physical, which by the way, includes both those motor things, the gross motor and the fine motor, but also a focus on nutrition, hearing, and vision as part of that physical domain. Now we have that background. The Cdc's milestones are available in lots of different ways. What we'll look at today are the check lists they have put together. And you can see in the middle here of this screen an example of your child at 15 months. What they've done is this is something that you can access online, you could print, you could use it a variety of ways. And it has just a few of the milestones from each of those four domains. And it's in a checkbox format. You could use this tool, talking with a family or a caregiver, and compare, does the child do this or not? Are all these milestones are the ones that have evidence? And the CDC would say that at least 75% of kids or more would have these milestones by this age. Then in a little bit down there, you can see that pink area are some open ended questions, and that's designed to get at the nuances of some of this. There's some questions where you could talk about just to get a better understanding of what the child does, what do they do together, et cetera, to have more conversation and a better understanding of where this is. Now I will say on the left, you can see that there's a picture of a phone. Because all of this that we're looking at is available on an app that's free and downloadable. But of course it's also available if you look at the right and a nice little print edition because some people like little booklet, they've made it available in lots of different ways. And see it's available in Espanol, all of this in Spanish and English. You can download it, get it, et cetera. Enough of that. We thought we would spend some time looking at some of the social emotional milestones in some of the areas. I pulled out the social emotional milestones from the 15 month checklist. Here's the five things that they show. By the way, if you look in the Or if you just do the check in the app. The question would ask you, is the child doing this? Yes, not yet or not sure. So that gives you that choice. Now, the beautiful thing is in the app, or if you go to the milestones and actions at the CDC website, is if you're not sure what these things are, then there's either a picture or a video clip and they're trying to get more video clips. What it looks like, here's what it looks like. If you go to the CDC website where the milestones and actions are. These checklists, here we are on the checklist page for 15 months. And we can scroll down, here's what most babies do by this age, social emotional milestone here. There's pictures for some of these. And then there's a video. You can just click on the video and it'll pull it up eventually. Now we're in super slow. Sorry about that. So it's just a short video clip that shows you what that looks like. Okay. Or there's a picture, you can see a picture of copies, other kids and what this looks like. So how did these sound to you? I mean, that was Katie's question. You're like, looking at these, do you have any comments about what these things look like? I think we have to know the parents that we're working with. So like for example, if we have parents who like to be perfect, having a list might be overwhelming and could be like, oh, my kid doesn't clap, but they do other things just knowing the parent and the kid. Yeah. Yeah. That's a piece of this, isn't it? Is. How do we use these tools in ways that are accessible to families based on what we know about them? Yeah, One of the things that I was thinking about when I was looking at this list and thinking about all of the times when I hear about challenging behavior right, with our little kids, is something like copying other children while playing. Right? Taking toys out of a container when another child does. If we had somebody who wasn't as familiar, a parent that was less familiar with developmental milestones, they might be really frustrated to watch a 15 month old child because maybe is playing with something and another one comes over and wants to do the same thing. That could look like trying to take away the toy, or not playing nicely, or not sharing. But we know that taking turns and sharing takes a lot of stuff that those 15 month olds don't have yet. But really what they're doing is showing you something that's developmentally appropriate, which is showing interest in a toy that another child has, and trying to do something similar. Thinking then about one, if we're always frustrated by that, even though it's typical that's getting in the way of the relationship, then also, what could we do instead then we don't want to sit there and ask them to take turns, right? Because they're not quite ready to do that in 15. Right. Could we provide two or multiples of things that the kids are interested in or what are the ways that we then handle that differently? Well, I was thinking about we pulled up the one here, that's 15 months, so think about how that's a one year old with a couple of months afterwards. Right. So what does that look like? And by the way, also the CDC, when they revised and updated all of the milestones, added a 15 month and a 30 month checklist that used to not be there, but there's enough of a difference between a 12 month old and an 18 month old to have a 15 month old check list. And it is interesting just to see what these things are. And I like what you were saying, Katie, about how we present, so how we understand it and translate this could be really important, right, about this child at this age. The other thing I was reflecting on is when we participated in the CDC and helping look at the one year old book that they created called Baby's Busy Day. We test drove it with groups of parents and have them read it and look at it. I remember the Spanish speaking families. A couple of them remarked that there was little note in there that says, shows imagination, and families, like one year olds are imaginative, had not thought about it that way. And what a delight to see them like. That's really cool that my one year old has an imagination. And this is what it looks like, right? To have a way to understand it. I think it is important for us to think about that. To look at what these are and how do we explain them. Which is why it's nice to have a picture or a video clip. To just talk about what it looks like and then how does it translate to what we're trying to do within our classroom. Always remembering that the pacing is different for individual kids. And then thinking about if you do have a kid with a delay or a disability, how they may be doing some of these things but in slightly different ways. You mentioned earlier, which I thought was such a good point that yeah, we're focusing on social emotional, but all these domains impact each other. When my child who had a disability was little, he couldn't walk until he was six and he didn't have a wheelchair until he was four. Imagine not being able to move, which is a primary way of imitating or interacting with other young people. And imagine the impact that might have. So if everyone is jumping and my son couldn't jump, how is he trying to do what you be like, what the other kids are doing? And are there ways of adapting that and recognizing the impulse though? It's just it's tricky and it's good to keep an open mind. I mean, these are super helpful. But also keeping an open mind, right? Yeah, right. Well, and keeping the lens wide because I think I appreciate that you brought up earlier like this is, this is good for everybody. I mean, everybody benefits parents, caregivers, teachers. He's interacting with the child to have a sense of like, well, what do kids typically do at this age, even if there's no delay? Because when we're learning about it, we can celebrate it. And it helps us to understand how could we include this child over here who's not moving, and why, why would we do that? Because it does relate to some of these other things. I think that's a good point. And you can see on this checklist that we're showing here, the language milestones And the cognitive milestones. I always admire looking at these and sometimes think like how does this not fit like a social emotional thing, because they tie together. Right? And that's a good point. Okay, let's see here. We pulled out a couple of the older ones now like to just take a speed through the 30 month and maybe the three year because probably more of the time that we're all experiencing questions about behavior is when kids are 22.5 Three is when we're seeing that. Here's the 30 month one. This was the new one that they added. Here's the social emotional milestones. You can see the difference here. In the 15 month, what did it say? Copies other children while playing, like taking toys out of the container. Here at 30 months is the milestone, says plays next to other children and sometimes plays with them. So what does that look like? Shows you what she can do by saying, look at me as a social emotional milestone. Follow simple routines when told, helping to pick up toys. And you say it's cleanup time again, we can go to the website and you can see what this page looks like. And by the way, this is designed. If you go to the website and Katie put in the chat with the Urls, but I always just put Cdc.gov slash act early and you'll get right there. That's what I can remember, Cdc.gov slash act early, then you can easily find the milestones. And by the way, there's also like a whole video library of all the pictures and the video clips that they've put together by age and domain. If you wanted to just go find that to show a family or a staff member what this stuff looks like, you could easily find it and download them and use them however you like. Here's at the 30 months, what your baby does by 30 months. And there's more videos here and they're trying to get more in there, but we could look at this video. This is their example of what it looks like for a child playing next to just doesn't exam. Again, I'm thinking about what this might look like in a classroom of this is 30 months. So 2.5 year olds. Yep. 2.5 year olds at 2.5 having everybody come to Circle Time to do ring around the Rosie or something. It might work for kids and it might not work for others. Or in that moment, some kids might want to do that with everybody and some kids might not want to engage and thinking about ways you can have some options for a child who doesn't feel like doing that particular game. Because at that age, sometimes they play with others and sometimes they may feel more like just being nearby or watching and thinking about that and then look at the language. Right. So as you mentioned earlier, are our expectations realistic? At 30 months, we're saying that kids, 75% or more kids would say about 50 words. So that's a fairly limited number of words around doing what you just suggested, right? Offering choices. And like the next activity, I might not have the ability to process all that right away. And then if I'm doing something I like and you're telling me to do something else. Might my behavior look like? I might not be able to say, you know what, I'm really enjoying this activity right now and I prefer to play a few more minutes, if you don't mind. Could we change your agenda? I can't do that at each start, but I might throw the toy at you because I'm mad because this is one way to let you know that I wanted to keep doing this. To keep it in perspective. Yeah. No, I think that's really important because again, if we think about all of this as the bottom line is we want kids to be successful. We want families and caregivers to feel like they're successful as well. So for example, if you need to transition activities and the kids enjoying themselves, you say, okay, go ahead and put away your toys, Come over to the carpet and sit quietly. Now, it says here follows simple routines. When and under cognitive, we can get to two steps. There you go. And what did I just say? I said toys. I counted three. Go to the carpet and sit quietly. Yeah. Those kids are going to forget to sit quietly or forget the carpet or go to the carpet first because they saw somebody else do it and forget about the toys. Right. We're already setting ourselves up to be frustrated if we don't have a sense of where we need to be with the milestones. Melissa's got a long comment and here about challenging piece of going to daycares where there's a wide variety of expectation in settings. It's hard for the little ones that we're working with is their developmental level doesn't always match the age, right? But they required to be separated based on age. That is an interesting question. They push for a circle time which includes a Bc's counting colors, et cetera, which may not always be a good match. You're right, those are things to think about. Using these tools might help us have some of those conversations at every level. Whether I'm the parent caregiver or whether I'm a teacher, maybe I'm asking those questions because I'm in that setting and wondering about this or wherever we might be able to have that. If you're a preschool director or childcare director, sometimes having these milestones available for children or for families can help you to explain why you might not be at Circle time for 10 min doing a Bc's for 2.5 year olds. Right? Because sometimes parents they'll see a very strict or regimented preschool or childcare and think, yes, they're getting ready for school. Excellent. Really, that's not a developmentally appropriate space. Right. It depends on the age of the child and what we're working on. Ideally, all spaces, even going into school through regular school, should be looking at the, looking at learning from the idea of offering options. It's called Universal design for learning, and it is the most accessible way for kids with disabilities, for kids without disabilities to acknowledge that kids learn differently and sometimes need options. But that's a whole other. So then six months later, here's three years. So look at the two that have evidence, right, for social emotional milestones. And it's the first one says calms down within 10 min after you leave her. Like at a childcare drop off at three years. We would expect that most kids would be able to calm down after 10 min when you leave them right now. Now that's interesting to me when I think about, you know, dropping off your kids and what that might be like even earlier. We're hoping by age one that I can do a quick drop off and not have the trauma that we think might happen. But this is a milestone that we don't expect until three. Then the other one is for social motions, notices, other kids, joins them to play. Just to take a quick look at what that might look like, you can see there's nothing yet for the calming down. That means they're working on it. They're working on getting these videos and pictures. But here's the video clip of noticing other kids and joining them to play. Maybe, there you go. So think about how you could use a video clip like that, right? To have a conversation either with a caregiver, a parent, or staff. And just what you could parse out from that. And sometimes I think about these videoclips could look at not only a social emotional, any of the other milestones and how they fit together about how these kids were communicating or how they were playing, or what they were doing. In addition to, in this example, what the social emotional milestone would be. And then let's do it this way, just so you can see comparison of one year later here. And the Cdc's materials will go at three years, then four years, then five years. There's a gap in there once we get going along. But they have several more under social emotional of what this looks like. Another. Other way you might use these. Sometimes I'll create questions with polls to say, when does a child pretend to be something else during play? And give people choices like is this a 30 month, is a three year, four year, five year. And then let them see, then show them the video clip. Then you can have very nice conversations about, well, why did we think about that? Well, it may be because most of the kids I'm working with already have that skill. That's my experience with my own children said that that was the case. But others may have different experiences. You can use it to have nice conversations and to get some insights and learning about how that looks. Here's the example. We'll go to the CDCs website. Again, you can see there are some of these videos, but now we're looking at a four year old. And here's what social emotional milestone might look like at age four. And you'll see that this is a little bit different from age three. Well, maybe you will. What are you going to do? You're going to put out the fire. We'll wait for ten fire a firefighter will. Yeah. Okay, so that gives you an example. And we might even just for a moment, flip down to what are the language communication milestones. And now there are fewer here in this one that have the evidence behind them. But says sentences with four or more words, that's something we'd expect at age four. The majority of kids would say sentence with four or more words. What does that look like? Something out. I hear a lot when we're talking about communication and when we're thinking. Talking also about challenging behaviors. That saying a sentence with four or more words, that's when we're in the frontal lobe, that's when we're calm and we're able to think, right? But sometimes if we're trying to negotiate about a toy or a child is tired or upset about something that can go away. Right? This context specific. And I think it's really important to remember because one of the things that can really challenge a relationship is if we try to reason with a kiddo who isn't in that part of their brain. If they're upset and they're in that more active emotional part of their brain, they just can't do some of those things in that moment. If we get frustrated and say, I know they're capable of saying these words and they're not, then are they being naughty or no, Or are we acknowledging that there could be trauma and other things going on and we have to let them calm down and regulate before we can see some of these things. That makes me think too about when there might be discrepancies between what kids are doing during the day and what they might be doing with us at home in the evening. Because I know my own kids, they were very attentive, very busy during the day, and then they would come home and they had used up all that energy I think, and so they weren't able to be in that space anymore, and they were more in the reactive space. When we would have the parent teacher conferences and they'd say, oh, they're so helpful. Like who are you talking about? But I think that might account for that. Right. They're tired and they don't have the same, it could look different. Yeah. That would be a really important conversation to know like, well, what are the things that work during the day that we might try at night and vice versa? What are they doing at home that might be important for you to know during the day when you're caring for them. And also just knowing that context of what's going on with that kiddo. Of course, that takes us to family engagement in all kinds of things, but I was just talking to a colleague who was sharing that some counties around Indiana have adopted a handle with care program. If you heard about this, where law enforcement is collaborating with schools to share, if a child has had an interaction, if let's say they had domestic violence in the home or something has happened where that child has come into contact with law enforcement, they will reach out to that kindergarten teacher or preschool teacher or whatever and say handle with care. They're not going to share details, they're not going to say what happened, they're going to write handle with care. That way we know that something possibly traumatic happened to that little kid and we can know what emotions we might be seeing and why we might be seeing bigger emotions or fewer of those milestones on a particular day. I've seen that also offered by teachers, just classroom by classroom, where they'll send home a little note to the mom saying, or dad, or grandma, or whoever, saying if something happens, if the kid just has a rough morning and is grumpy, just send me handle with care. You can put it in the folder. You can email me or text me and you don't have to tell me anything more than that. I'm going to know that something's going on. I love that. I just want to well, I hope what we're able to take away from this is based on this conversation or based on our skills and abilities going to be able to diagnose a social emotional issue. That isn't the goal of this conversation today. What we're hoping is that we can take away an appreciation for learning more about what is typical development, what are some clues then that would help us know when things are going awry. And then then another session we can spend more time learning about, well, what do you do then? Where do you refer to? Try to get more assessment or information about whether or not there is some social, emotional, mental health issue going on that we've not been able to address in the ways that we've been just throwing out and tossing around today that might need the support of some other provider. See, there's lots of opportunity here for us in the work that we do to better understand, and that's part of it, I think is seeking to understand what's going on with this particular child and then acting accordingly and doing it in ways that maybe match where they are developmentally. I do want to throw in just to note here that the CDC has other materials that are available that highlight all of these milestones and ideas about activities in some different ways. In addition to the checklists and the print materials and the app, they also have three books. So far, there's a book for one year old, two year old, three year old, They're very interactive. The pages of the book, it just lists what milestones being addressed and maybe a suggested activity. You could use all of these in lots of different ways. They have training on line called Watch Me, and it's aimed at early care education providers. It takes about an hour and you get credit for it. You can print off your certificate if you need that. Then the other list of things they have is something called fact sheets. This is just some helpful information, some aimed at parents like how do I help my kid or how do I talk to my Dr. there's a sheet there for you and me about how do we have difficult conversations, but all of this stuff is available on the website. What we're hoping you're taking away an appreciation that kids have mental health challenges. Yes, that understanding and keeping track of milestones is important, that we've got free resources to help us do this. And that understanding social emotional development in kids can be challenging, but it is possible. We've, I think talked about some practical ways to make that work, just in some conversation. Then we've raised a question that when it goes beyond this, that we need to get more information. That might be a screening or it might be getting connected to a mental health professional that can dig deeper into understanding what it might be. So, I'm aware that we are close to the time. There a slide with a Qr code, Steve? Yes, there is. To here. I just put the link in the chat and that you can fill out a super brief survey and then you'll get a certificate. You can also scan the Qr code with your phone and get to the same survey that way.