 All right, we're back. This is now Senate Health and Welfare. We've completed our meeting with Senate Judiciary and we're moving on to a concern that we each have and that is around the mental health of kids, particularly after and after and around the pandemic. And we understand that some of the issues around mental health have escalated for children during this time. So we're going to hear from Commissioner Squirrel first and then we'll move through some really important witnesses. So thank you all for being here. Thank you Squirrel. Yes, thank you Senator Lyons. Good morning everyone. It's nice to see you all. I hope you're doing well despite that snow outside, which we'll all just pretend isn't there, except for those of us that might enjoy some spring skiing or snowboarding. I do want to just take a moment and introduce other members of the DMH team who are joining us today. Laurel Omlund, who was our director of our Child Youth and Family Unit, and then Dr. David Ratou, who is our medical director for the Department of Mental Health. Good morning. Good morning. And I think, Nellie, if it works for you, Laurel is planning to share her screen. We do have a presentation for the committee this morning. So Laurel, if you want to tee that up, then we will get started. And just for the chair to be aware, I do have to hop off at about 10.55 to join the governor's press conference. So just so the committee is aware. That's fine, thank you. Of course. Okay. Well, certainly as the chair so eloquently noted, our focus on child youth and family mental health is absolutely critical from the department's perspective. The social, emotional and mental health needs of children and youth are critical. We are all aware that children or youth are setting long-term health trajectories in their earliest years. And we have an opportunity to focus our mental health services and supports upstream. We all recognize that the earlier we can intervene, the better the outcomes. And we certainly have great assets to leverage in Vermont to support that work. Just in current terms of, I think we have one of the highest rates of children and youth who are insured, as well as an incredibly robust school-based mental health system that we can continue to build upon. Focusing our promotion and prevention activities, particularly on our youngest from honors, is a key priority of Vision 2030. This is something that the Department of Mental Health takes very seriously. And so today we will discuss the child and youth system of care, some key initiatives that we're working on, and then to illuminate the committee on some of the impacts of COVID that we're seeing and some of the steps that we're taking to mitigate against them. So there are a few key takeaways. You're going to hear a lot of information, a lot of data. Here are some of the key pieces that we really think the committee should be focusing on. Number one is continuing to double down on our efforts to fully reopen schools. We know that public health emergencies can have both short-term and long-term impacts on the mental health, well-being of children and youth. This pivot to hybrid and remote learning has left many of our Vermont children and youth lacking some of the benefits of access to school, the social interaction, the personal connection, the structure and the routine. And so when we think about healthy development for children and youth, we think about promoting protective factors, which is social connection, concrete supports and building social and emotional competence. One of the most protective factors that we can offer our children and youth is access to school. So that is certainly something that we continue to focus on. It is where many of our children and youth access mental health services, particularly for those who are most vulnerable. The second area that we also see is absolutely critical. It was critical pre-COVID, it is even more critical now, is our ability to be more proactive and responsive to children and youth and families when they are experiencing a crisis or even to intervene before there's a crisis. Mobile response is a critical initiative that the Department of Mental Health is putting forward. We have a real opportunity to provide supports to children, youth and families in their homes in a more proactive way. Mobile response is a way to achieve that. It was put forward as part of our governor's recommended budget. We are proposing a demonstration site in the Rutland area will provide more data and information in terms of the need. But again, we really need to turn our attention to supporting children and youth more proactively to prevent them needing to go to these higher levels of care, such as emergency departments, residential treatment and inpatient. The last big key takeaway, which I know this committee and the chair is very aware of is support for workforce recruitment efforts. What is fundamental to having a strong mental health system of care is our workforce. So we are thinking about and looking at creating a task force to really articulate a five year strategy to strengthen our mental health workforce. It is articulated as a part of Vision 2030. I think we really need to outline what exactly are we going to do to advance and support our mental health providers, create a pipeline and support for new folks coming into the field. So again, that is another area that we are focusing on as a department. And I think at this point, I'm going to turn it over to Laurel who is going to walk us through just an overview of the system of care to make sure that committee members really understand it and then we'll be diving into some of the data pieces as I noted as well. Laurel. Thank you, Sarah. Good morning, everyone. I'm Laurel Omland. I'm the director of the child adolescent family unit at the department, as Sarah said earlier. And we thought it would be important to start with some laying foundation about our system here in Vermont. And so a really quick history lesson for those who might not be as familiar with it. So this is the early timeline of our child and family system of care in Vermont. And I guess just to reflect on this, when I was my daughter, the age of my daughter, the age that my daughter is now when I was her age, if I had experienced significant mental health difficulties, the only options for my family would have been outpatient therapy or inpatient therapy with nothing in between and pretty limited at that. So I would anticipate my parents would have felt fairly isolated, struggling to figure out what supports I needed as many parents did at that time. And it was that that really drove the leaders in our state to look at how to expand options for children across Vermont. And so we were one of the first states to have the system of care grant from the SAMHSA and the federal government to establish a child use and family system of care. We also, I think have a proud history here in Vermont about our Act 264 legislation, which really established a commitment in Vermont to coordination of care across the different entities who serve children and families here. And I'll talk about that in a little bit. And then we've continued that work in additional innovative partnerships through the Success Plan 6 program with schools. Again, we'll talk about that to some extent and then additional expansion of system of care lens around the early childhood world, the transition age youth. And now we're continuing to focus on infusing concepts around trauma-informed care and resilience development as well as integrated care. Really trying to assure that we have structures to connect to mental health services in places where children and families typically are. So in schools, in primary care, in early childhood settings and in communities, especially for our transition age youth. We know that providing quality mental health services in places where they can have lasting outcomes. And so that is one of the goals of our system. But it's important to understand that that system of care really established some of our core values that continue today, the concept of working together, the concept of having family voice as paramount in that effort and expanding what service array we have available to meet the needs and the changing needs of kids and families. So a little bit about Act 264, if you're not familiar with it, it is the foundation of our system of care for children and families, not just for mental health, but across child welfare, juvenile justice, education, and then it expanded under the Federal Interagency Agreement to all disabilities. So that includes our Development Disability Services, Entity Vocational Rehab, et cetera. So what this did was it really established some core components for our state that continue to function today. As I mentioned, it meant that families are at the table as an equal partner in talking about what their needs are and informing how our system is established and develops. There are common values across those entities I mentioned. And then there's a problem solving pathway, which starts at a treatment team or a team level of those who are already working with the child, but can also bring other partners to the table to really help ensure that we're leveraging all the potential resources that are available across our system to meet the needs of that family. And that can happen through the local interagency teams that are in each of our 12 human services districts, as well as a state level interagency team, which has all those partners at the state level together. And there's a mandate to provide coordinated services. And we have a coordinated services plan that can be a useful tool as teams work through this with families. I think what's important to understand is that while we strive to function as a holistic system and really strive to uphold these values, we each of our departments in our parts of the system have our own mandates, our own rules and regulations and our own resources. And so that's often where some of the challenges arise, but it is still a helpful structure that guides us to come together to figure out how to best meet the needs of children and families across Vermont. So for mental health, this is just a quick visual about the division we have here at the department for children, Child Youth and Family Mental Health in Vermont. And this is really a public health approach. If we were to start at the bottom to understand this, it's really thinking about how our mental health system can promote mental wellness for all children, youth and family. How do we provide targeted supports to reduce risk factors and increase resiliency and protective factors? And then what can we offer for intensive or intervention and treatment services for children, youth and families who have identified mental health needs? And we'll be talking a little bit about some of the specifics of what is offered at those different layers within that public health triangle. If I could just add real quick, I would say that DMH sees its purview or its lane, if you will, as the entire spectrum. Certainly we have obligations for people who are more severely affected with mental illness, but we really wanna look at the entire spectrum, especially when it comes to kids and youth. Absolutely, thank you, David. And I think it's notable that many of our resources are focused on that intervention layer. And I think there's been a strong effort to try to ensure that we do have resources and offerings that really address mental health illness and how do we indicate about what that means for children and families? And I think some of the partnerships that we have with our schools can be really important in that avenue. So taking those levels and think about what are the different aspects of our current system. Let's give some examples of those. And I think it's again, noting that our mandated service population are in youth with serious emotional burdens in their families. But again, we really want to provide as much promotion, early intervention as possible so that we can support them earlier in that need. So here we have some promotion prevention activities around mental health consultation. Am I the only one hearing problems with your audio? Oh, thank you, I was muted. I was trying to say the same thing. So yeah, so Laurel, is there just be aware that your audio is spotty? Okay. It's going in and out, but it seems okay now. Okay, sorry. But apologize for that. I think if you turn off your video and that might help a little, sometimes turning off your video helps. Sure, if I can figure out how to do that when I'm screen sharing, I'm just not as sure how that works. Just go to stop video. You got your three little dots. You got video down at the bottom. You can just hit stop video. Got it. Okay, thank you for that input. And please interrupt again if it continues. Is this okay? You're fine, go ahead, you're fine. Great. Okay, so as you can see here, we do have promotion prevention activities. This is just a short list representative. We offer some child psychiatric consultation within primary care. The school mental health role that we play with the agency of education around their broader school environment activities with the multi-tiered system of supports. So I'm not necessarily targeted to particular individuals, but really looking at that broader population level of need. And then for the earlier intervention or supports for families, we do recognize that respite is a really key component of that. We can offer some additional support of counseling, care coordination that can happen in different settings, including school and primary care. And then at the intensive level is really thinking about that much more intensive level of need where there might be some intensive home and community-based services or even some out-of-home treatment including crisis supports in patient, et cetera. So I think it's also important to understand how as our system has evolved over the years, the number of children and families that have been served has also been on the increase. And so this is a quick representation of that. And this does reflect all children served through the designated and special service agencies in Vermont. The reason for this increase, I think we all can understand is multifaceted. There are many contributors, some of the social determinants of health that you may be familiar with, the opiate and substance use issues that our communities have faced, exposure to trauma, et cetera. So it's also, I think, a recognition that people are seeking assistance and wanting to help address some of the challenges that they're experiencing. I would also say that Vermont is good at identifying the needs for children and being responsive. So those are all contributors to this. If you were to overlay, I'm sorry, Dr. Richard. Go ahead, please. I just was gonna say if you overlay the level of acuity with this graph, what would we see? I think we would see an increase in the acuity. And that's something that, especially as we get into talking about the school-based services, we have heard as we've traveled around the state where numbers of kids might not be that significantly drastic, but the level of need of the children and their families has had quite an increase. And so that means that there also is a tremendous need for not just mental health services alone, but really that partnership with our other system partners is essential in trying to address those needs. Dr. T, were you gonna add something else? I was just gonna make the comment that if this graph isn't dramatic enough, also keep in mind that the absolute number of kids really hasn't changed much and has even dropped, I think in recent years. Thank you. So to zoom in a little bit onto our school mental health in Vermont, we've had this structure as noted on that timeline since the early 90s where there's a partnership between local schools and our community mental health agencies or our designated mental health agencies and a structure by which the school district can contract with the designated agency and the designated agency can then leverage mental health Medicaid to provide the services within the schools. And the local match, if you will, or the way that Medicaid works is we need to put forward a state match to draw down the federal match. And so that state match essentially comes through the local school district. And then we're able to enhance that with the Medicaid federal component of it. And it was started in the 90s as an attempt to reduce the cost burden on education to meet the needs of Medicaid enrolled students in their schools and address the mental health supports with the goal that students can then be available to learn in the school building. So the past 10 years, I think again to speak to what we just noted, the population of students served hasn't changed that much. I think we're all aware that the actual population of students in schools has reduced over the years. And again, as we've been talking with principals, superintendent, special education directors as well as our designated agencies, everyone speaks to the fact that even though the actual numbers haven't changed, the acuity level is more intense. And there's just a significant need that we're all trying to meet within for students in schools. The way that our SuccessFantasy School Mental Health is structured is essentially in three categories, if you will, those are listed here. We have school-based clinicians. So these are more master's level, often licensed clinicians who can provide clinical services but also can be partners with schools and thinking about at a school-wide level, how is the mental health, social-emotional needs of students and educators being met? And it can provide some consultation around that. We also have behavioral intervention programs that can provide more intensive behavioral supports for students who might struggle to be present in their learning. And then we have what's called Concurrent Education Rehabilitation and Treatment, or CERT as we often call it. And that's really layering this SuccessFantasy Medicaid therapeutic service within a therapeutic school, alternative school setting. And so those are a small number of programs, but again, an intense level of supports for those students. And I should note that for the behavioral intervention program and the CERT program, these are also serving students who have autism spectrum disorder and have those intensive needs as well. I think it would also be helpful to note that about 32% of youth who are served through our designated and special service agencies receive some of those services through this SuccessFantasy School Mental Health component of our programming. It is about a $72 million Medicaid spending authority that we have for this, although our actual spending has been somewhat under that, especially in this past year with COVID and the shifts with school. We did for this current fiscal year in the contract contractual partnerships between the local schools and the designated agencies. There was about a 27% reduction in FTEs that were contracted for this school year compared to last school year. And I would say the majority of that reduction was within that behavioral intervention programming. And that is likely due to more of the remote learning that was happening. However, it's important to note that all of these services continued when COVID hit and when schools did go to either remote or hybrid so that the clinicians, the behavioral intervention staff, were still providing supports to those students even when they were learning from home. It was a reduced amount of supports, particularly for the behavioral intervention folks, but it was still an important component of helping those students access through the remote platforms to manage some of their challenges and to work with the families and understanding now how to support that student when they're learning in home. So there's quite a bit of coaching of families during that period as well. As far as what this looks like across the state, I will say it varies and there are regional differences. And that is something that's of interest to both us at the Department of Mental Health, as well as to the Agency of Education to understand what those are and where are there areas that we want to strengthen and where is that really due to kind of local decision-making. But essentially our understanding about those regional differences is that it's partly due to a school or district's own resources, meaning they might have their own folks within on their staff who are addressing some of the mental health needs. And so they're determining what additional needs they might have in whether to partner with their local designated agency. But it also might mean that they are making decisions somewhat based on what resource, funding resource they have available to help to put forward in these contracts to leverage that Medicaid. There's also historical just what is the relationship between the district and the designated agency and that can contribute to what some of those decisions are locally. And then I think a really significant component is the workforce that's available. And I think you'll be hearing some throughout this that it has been a challenge to continue to have the workforce to fill the level of need that's needed. So that can also impact what those regional differences look like. Laurel, this is so enriching. But we're gonna run up against a time crunch in about four minutes. So, and I know that you have information about what's going on, what has happened during the COVID landscape and so I'm gonna ask that if you can summarize a bit more broadly for us and help us move through. And then at some point we will be coming back to this. Okay, sure. I apologize. I think we had understood we might have had one more time. No, don't apologize. Our agenda is so full and that's what happens at this time of year. Okay. So I think some of this can be referenced. You do have the slides. This is a bit of a picture of what's been happening with school mental health during COVID. And as I noted, it did those supports and services did continue. And we continue to hear concerns about the level of anxiety, mood, challenges, family stress and the impacts of social isolation on students. So I will pass this on to David at this point and then we might come back. And David, I think you're muted, sorry. Just gonna turn really quickly to how kids are doing right now. And I know people wanna get to COVID but it's good to look a little bit about how people were doing before COVID. And I think the bottom line here if you look at some of these statistics is that unfortunately for a lot of our youth, their mental health really hasn't been good even prior to the COVID pandemic. And the trends here in Vermont are similar to trends that we are seeing nationally. If you look at some of these statistics, I find in particular the idea that six and a half percentage of our youth say that they actually had a suicide attempt in the last year is quite troubling. And this is all really important because I think the research pretty convincingly states that one of the strongest predictors of how well people do after a major stressor is how well they were doing before a major stressor. And these statistics would indicate that we have a lot of kids at risk. And in the interest of time, maybe I'll we'll move to the next slide and Commissioner Squirrel. Yeah, I can walk us through these quickly. This is really getting at kind of current state as David, Dr. Ratu noted even before the pandemic we were seeing concerning trends and the mental health needs of children and youth. There was a study that was conducted by the University of Vermont and VDH for youth ages 12 to 17, kind of comparing where they were in terms of the fall of 2020 versus 2019. And you can see from this slide significantly more depressive symptoms have been reported increases in anxiety. And around 70% of the youth reported that the pandemic made their anxiety, worry, mood, loneliness a little or a lot worse. And we recognize that this was the compounding impact of isolation due to COVID-19. And then for young people in particular, this is a time where social connection is so critical to their development, they should naturally be connecting and orienting more towards their peers. But I guess I wanna underscore for the committee that this is an age group that we are very worried about. The next data slide is really just looking at some of our child and adolescent needs and strengths assessment data in terms of children and youth who are identified as lacking community connection, optimism, needs related to anxiety. The final bullet here is the rate of ED visits for mental health related concerns has increased. I can tell you today, last week, we had 16 children and youth waiting in our emergency departments. And you compare that to about four last year. So we are seeing just increases in acuity, increases in need that we need to pay attention to. The next slide really gets at what our pediatricians and community partners are telling us. Primary care pediatricians have extreme wait lists, 75 to 80% of what they see are referrals for mental health and just underscoring that the children and youth are not okay. And again, you see this age group of 12 to 17 really emerging as a priority area. And just also recognizing that we know there's diminished capacity in caregivers. Everyone's been in such a tremendous state of stress and we know how that impacts children and youth as well. And then finally, I guess this really underscores why access to school really matters. School is where we see children and youth. It's where we can assess what's happening, provide treatment. This data was even startling to me in calendar year 2020, almost 50% of children and youth who are on Medicaid received their mental health services in a school setting, meaning that this is a place where children and youth really access the services and supports that they need. The last bullet on here is just again, a data point from the department for children and families has seen a 21% decrease in calls to their centralized intake and emergency services, thus indicating that some children and youth may be suffering in silence because we know that schools are where we see children and youth and can assess that need and risk. And I think finally we can kind of, these are all trends and data related to just overall increases in pediatric ED visits. You can look at this data a little bit more at your leisure. And this is really the data that is driving our putting forward mobile response. Mobile response is an opportunity for us to respond more proactively at the community member level for children and youth and their families who might be experiencing a crisis or ideally before they're experiencing a crisis. It is an evidence-based approach. Other states have implemented mobile response and seen significant reductions in use of higher levels of care, such as residential ED utilization. We are targeting and proposing to do a demonstration pilot of mobile response in Rutland. That is a very data-driven decision. You can see here that when we look at ED visits among high utilizing children and youth, you can see that Rutland has one of the highest rates of ED utilization. This is something that is very supported by Rutland Mental Health, as well as their local hospital system. We have an opportunity to implement mobile response now to really test and demonstrate its efficacy in Vermont and then to look to scale it up statewide. The other opportunity we have with mobile response is that we are currently looking at a potential enhanced F-MAP for mobile services. So as we look to implement this over the next few years, we'll have a real opportunity to leverage that enhanced F-MAP. So again, just underscoring for the committee how urgent and important this particular priority area is. And I think we can probably leave it at that. There's more information on mobile response, how the system is really an ecosystem in terms of points of care. But I know in the interest of time, we should probably wrap up. Yes, thank you. That's terrific. I think this gets us the information that we need as we're talking about any recommendations, either to appropriations or for policy recommendations here. So I'm going to ask, that would be great. There we go. Thank you. You're always bring in comprehensive and detailed information and we can use it. Not to worry, we will use it. I'm going to turn to Danielle Lindley, who is here from the Northwest Counseling and Support Services Center. So Danielle, thank you for being here. No problem, thank you for having me. I really appreciate you taking the time. So I'm going to speak a little bit about the current gaps in the children's system of care. I mean, it's really interesting because when you think of our March children and families who are experiencing long wait times in the emergency department or waiting on inpatient mental health care, it'd be natural to conclude that you would think one of these gaps is our hospitals or residential beds. And it's actually because we have a lack of capacity in our community-based system. I can just give an example for here at NCSS. Many people assume that a lot of the services we provide are outpatient and psychiatry, but actually 93% of our services are delivered in the home and the community. I oversee about 300 staff here at NCSS and the Children's Division and 20 of those are actually only office based. So most of our services are provided in the home and the community or we're embedded in the school and pediatric settings or other stakeholders. So I think it's really important for people to know that that is a system that we really, really rely on. When we have these services and we don't have these services, it impacts our ability to provide wraparound services to youth in the community. So a little information on what is impacting this is really around, and you've heard this earlier, is workforce retention and recruitment challenges. We just don't have the capacity and the workforce to be able to provide the level of need that our families are experiencing. COVID definitely has impacted this. Children that weren't on our radar before are definitely on our radar. We're seeing an increase in referrals. And with our workforce challenges, currently most of our staff right now are holding caseloads anywhere between 15, somewhere's up to 30, which is not typical and not setting us in a place where we're able to provide the quality of care that we want to. The other thing that is important to note that when we have these vacancies, a typical FT is able to hold between 12 and 20 cases. So those are 12 to 20 children and family that are not receiving services that we're then having to triage on our already strained system of care. Another impact of this is really around our, another contributing factor to this is the disparities and pay between mental health clinicians in the community and compared to healthcare schools and state government. And we often lose our workforce to those other providers. And another piece around that is that part of our system of care is just not what the DA is providing, but we're seeing also, we're having the inability to recruit for foster families, home providers, respite providers, mentoring programs. And so those are all things that are really integral to keeping children in their local communities. We also have a lack of community supports for mobile crisis intervention and stabilization. Sarah was speaking, our commissioner squirrel was speaking about that earlier. And so that's something that's really vital to keeping kids in their community. Also, because of the nature of the acuity and so many people needing services right now, we really have the inability to focus up-stream and invest in some of our prevention to prevent families from being able to access or need to access long-term supports. We'd rather get them earlier in the door so we can identify what the need is and hopefully be able to discharge at a sooner point. And we just at this point are having a real inability to do that. So who are some of the youth that are being impacted by this? These are typically children that are in DCF care. We have a number of kids that we're really struggling to be able to keep in our community. We've seen some of our rates within across the state of kids that are in care increase and we just need to be able to provide the services to keep them. We have a high number of kids that are diagnosed with sexually reactive behaviors. This requires a very specialized care and we wanna keep these kids in our community. So we need to be able to have the staff to be able to do that. We're also seeing a trend with kids that have co-occurring kind of developmental disability challenges and mental health. And our system is just not equipped right now. There was an influx of children that have been diagnosed with autism. And as they're growing and transitioning, our system does not have the level of support that is needed to keep those kids. And so I think the nice thing is that at a state and a local level, we're coming together to look at that and talking about developing programming and work groups to look at this, but it is definitely a need in communities across the state. And we just continue to see kids with significant trauma histories and attachment disorders. So take all of that and then couple it with COVID. And it's just kind of a recipe for disaster and we're just really struggling to meet the need at this point. So I know that we're short on time. So I don't want to lecture too much or speak too much. Danielle, this is a great portrait of what's happening in your life and in the world of the kids around you and families. And so we really appreciate it. If you have written testimony, that would be helpful to send that into us because we do have a, we have a couple of folks waiting to testify on the next bills. But I know that Senator Hardy has a question for Commissioner Squirrel. And Commissioner Squirrel, when Senator Hardy asks that question, perhaps you can let us know what your timing is on H46 and H104 and if Morning Fox is able to stand in on your testimony for those two. Yes, Deputy Commissioner Morning Fox will be covering both of those pieces. I do have to hop off in four minutes just to call into the governor's press conference. So Senator Hardy has a question. Great, thank you. Thank you, Madam Chair and thank you, Commissioner. My question actually is pretty relevant to probably what you'll be discussing in the governor's press conference. And I am the mother of three teenagers. So I am living right now with the stress of mental health issues and school issues. And I'm really concerned about us reopening schools when we have not prioritized vaccinations for our youngest people who are eligible. Students over 16 are not yet eligible and won't be till Monday. So most of them will not have been able to get vaccinations by the time schools are going to be reopening for all students in the high school and middle school age. And I know that under 16, there can't get vaccinated but I don't understand why our state did not prioritize getting students who could be vaccinated vaccinated so that they were had the opportunity before high schools were reopened fully. I'm really concerned about schools being able to maintain protocols. And there's a lot of anxiety and stress about going back to school under the circumstances with rates of infection, the highest right now among youngest Vermonters. And so I know that's not necessarily in your purview but I don't understand at all why we didn't prioritize vaccinating students if we are gonna reopen schools. Yeah, it's a great question, Senator Hardy. Thank you. And I certainly appreciate the anxiety that the school reopening does bring on all fronts. I think that's very real for many families, for teachers and for our incredible education workforce. I think in terms of how the state deployed the vaccine program, it really did utilize the age banding to ensure that those who were at most risk of death by COVID that they were prioritized. Certainly for children and youth, the data and scientific research does indicate that those health impacts are less. And I think that was the rationale and logic in terms of let's utilize and implement the age banding not to say that it isn't a priority as well to ensure that our youngest Vermonters who are eligible can. And I think that's why you saw the administration really pivot to, unfortunately once the J&J became available but then unavailable, that pairing that vaccination deployment with the gradual school reopening was exactly what they were trying and we were trying to accomplish. So that was- I understand, I've talked to Commissioner Levine extensively about the age banding. And I think to a point it was useful and then it became very problematic. And I just think that trying to reopen schools right now without having this age group vaccinated is really challenging and is adding to the mental health and stress and anxiety levels that we're trying to prevent by reopening schools. And I just want you to know that message and hope you can pass it along to others because the students will not be vaccinated and would not have been vaccinated even with the J&J was still online because of the late timeline for providing the vaccinations for this age group and trying to reopen schools. I think it's very problematic and I appreciate all the efforts to try to reopen schools. I absolutely do. And I know that it's crucial that we do so but we need to do it safely and I'm not confident that we are if we haven't prioritized vaccinations at this point. Okay, Senator Hardy, thank you. Commissioner Squirrel, you know, your follow-up and but then this is taking us away from the topic at hand but obviously a topic related to stress and anxiety induced as a result of a possible disease. Yeah, thank you Senator Hardy for your questions and concerns I participate in the governor's task force on school reopening. So I will make sure that your thinking is provided to that group. So thank you. Okay, Danielle, thank you so much as well for being here. And I don't know if you're hearing from kids about any concerns about heading back to school at this point. For sure, I think across the board for a variety of reasons. I think there's a lot of students who aren't even engaged in school. So the thought of stepping back into school is just so complicated and so anxiety provoking for a number of reasons. I know that, you know, I have two younger children and I think just for knowing what the virus is they're still scared that they're going to get the virus and how long is this going to happen and when will things be back to normal? So I actually don't know of too many kids where the thought of being in school full-time isn't anxiety provoking or provoking some sort of emotional reaction. I think schools, I will say I am impressed with schools and how they're coming together with the recovery teams. And so I'm very appreciative of that. I think a lot of community partners are coming and partnering with them so that we can be proactive and try to provide a lot of service to make this transition a little bit smoother and less anxiety provoking, but it will take some time for sure. Thank you. Thank you for being here today and Dr. Ritu, thank you for being available to us. And I think at this point we're going to move on to the bills and Laurel, I'm not ignoring you. I just couldn't see you. So thank you Laurel for also for being here. Your testimony is always spot on and really very much appreciated. And we will get back to this issue pretty quickly going forward. So thank you.