 Okay. Good evening everybody. Welcome to the latest installment of the Let's Talk series from the Bedford Playhouse Virtual Playhouse. My name is Dan. I am the Director of Development and Programming and we're very pleased that you're taking some time out of your schedule to spend it with us this evening for what's going to be a very important conversation. A couple of things that I just want to mention before we start is that there is a Q&A button, which you should all be able to find at the bottom of your screen. If you are on a laptop or PC, there's also, if you're on a phone or iPad, I think it's at the top of your screen on Zoom. Please, at any point, if you'd like to post a question, do so. The moderators will get to as many of them as we possibly can in the time that we have. Please try to refrain from using the chat feature. The chat tends to confuse a few things with regard to the Q&A, so please post all your questions in the Q&A. We have some good news that the Bedford Playhouse is no longer completely virtual. Per the governor's permission, we have reopened as of this past Friday with limited capacity and observing all of the necessary safety protocols for social distancing. Please check out our website. We are starting some live programming back up. If you are comfortable and if you're so inclined, you may find something on there that appeals to you. I would also just ask for those of you who enjoy these types of programs, if you would consider making a donation to the Playhouse, you can do so also on our website before you shut your devices down tonight. If you would be so inclined to do that, that would be great. I would like to now introduce our moderators for the evening, so please welcome Angela Alvarado and Tamara Tribble. We're going to take you the rest of the way. Hi, good evening. My name is Angela Alvarado and I'm the student assist counselor at Fox Lane High School. I'm a licensed social worker and this is my counterpart. Hello, my name is Tamara Tribble and I am the student assistance counselor at Fox Lane Middle School. We work with the student assistance program and we specialize in alcohol and substance misuse prevention and early intervention for the middle school and high school students and their families in Westchester County. We have the pleasure this evening to collaborate with three of our community doctors from Silver Hill Hospital. Tonight is about coming together as a community and learning about how we can help our teenagers to make healthy decisions. We will be discussing how vaping marijuana and alcohol has had an impact on our youth and what we can do to prevent it. We're hoping that this evening you will walk away with information on what we can all do to help our youth make healthy decisions so that we can move forward on a path to help them feel successful. We want to also take a moment to just thank those who made tonight happen. Let's talk effort was conceded in 2019 by Christine Biddle and Vanessa Smith and Audrey Zinman who proposed establishing a community conversation to start addressing mental health and substance use disorders. So they were hoping and what they are doing tonight is bringing in leading experts to share their resources and information so we can have encouraging conversations on how to end the isolation and stigma associated with mental health and substance use disorders. The Befford Playhouse as you know joined in this conversation and they established the less talk series which has consisted of films and panel discussions by our leading experts and shared resources recognizing that healing begins with sharing experiences, honest conversations and leading edge knowledge. The Befford-Lewisboro-Poundridge Drug Abuse Prevention Council also known as a DAPC joined forces with the less talk in 2020 to forward the shared missions. The DAPC is a three-town cooperative effort that works to implement science-based prevention strategies that focuses on increasing protective factors and decreasing risk factors associated with alcohol drug abuse in individual families and communities. Thank you so much for making tonight happen and we look forward to future events on helping individual families and our community. I'm going to turn it over now to Tamara Tripple to introduce our panel of experts. Hello and to second everything that Angelus has said we are really grateful to have you all here with us tonight and grateful for our guest speakers as we continue to learn about substance misuse and to shed some light on what trends they are seeing firsthand as professionals in the field. So to start Dr. Frank Bartolomeo is the director of adolescent services at Silver Hill Hospital. He oversees inpatient transitional living and intensive outpatient program for adolescents as well as the design and implementation of new and innovative clinical programs and services. Dr. Bartolomeo believes that increasing resilience means having the capacity to bounce back from adversity through the support of meaningful relationships with friends, families, or community. This has been a guiding principle for him over the course of his 30-year career working with 13 to 18 year olds as well as emerging adults. Our next speaker is Dr. Rocco Morado. He is the service chief for the adult transitional living program at Silver Hill Hospital. He heads up the extended stay hospital-based highly structured program for adult patients from all across the hospital centers of expertise to Dr. Motolo healing people as a mission, a vocation, and a calling. He says the mission of healing has been paramount within the hospital's institutional culture for generations and scrumptiously passed down. He and his team have had strong resolve to never give up and uses every means possible to help patients and their families. And last but not least, we have Dr. Elizabeth Ortiz-Schortz, who is the service chief of the adolescent transitional living program at Silver Hill Hospital. She and her team treat patients with multiple psychiatric diagnoses, borderline personality disorders, reactive attachment disorders, mood disorders such as depression, anxiety, and bipolar illness and co-occurring disorders. She strives to give adolescents and their families the tools to manage challenging behaviors, regulate emotions, better understand their difficulties, and improve their communication in order to set out on a different course. Dr. Ortiz-Schortz believes in going the extra mile to understand where her patients are coming from. So thank you for all being here. At this time, we will view a 15-minute video that was put together from our panelists, and it will be speaking about vaping, marijuana, and alcohol. Again, please use this time if you have any questions to direct your questions into the Q&A tab, not the chat room. We will get to as many questions as we can. After the video is done, be mindful that this will be recorded. So if you miss something, you will have the opportunity to watch this again when we send you the recording. Once the video is complete, we will begin right away with our Q&A portion. And now we get ready to watch the video. Today I want to talk about vaping, nicotine, addiction, and it's a really important subject because of the high number of people who are using it at younger ages and what problems it causes. Very few people start using nicotine thinking about future consequences. It is only once they are addicted to it that they recognize the drawbacks of their decision. Nicotine is one of the most addictive substances in the brain, more addictive than heroin. And what it does in terms of withdrawal, in terms of increase of anxiety, cravings, the need to obtain the substance to maintain that feeling of normalcy, and the need to continue using in spite of all the consequences can lead to serious problems. Nicotine can get into the system in a variety of ways. Cigarette smoke is extremely deadly. About one out of two people whose smoke in their lifetime will die of related illnesses, cancer, lung diseases, etc. For most people, that is a given and is a very well-known piece of information. But vaping is something that is considerably of concern because since vapes started being produced and massively used in 2011, people felt that this was not a big concern. So the availability and the feeling that this are not harmful substances has created a false sense of it is okay to use. So in vaping, there is water vapor that in and of itself is not carcinogenic. But there are additional toxins, including the metal coils in e-cigarettes that can also release substances that are possible toxins to the brain and to the body. There are oils and scents and these are poorly regulated industries. In 2019, there were multiple pulmonary emergency admissions and deaths that for individuals, even very young ones who needed oxygen therapy and that was related to vaping, primarily things that were modified and contained vitamin E acetate, which was particularly toxic to the lungs. It's something that we can ingest and it's in popcorn and other oils that are mass produced. When these things are absorbed into the lung, they can create significant problems and numbers of people were affected, hospitalized and ended up with significant problems related to that. So that is a concern. In terms of other issues beyond the health aspects, which is that a lot of younger people are using. You see it more often than not and people would have never used athletes and students as early as in the area have encountered kids in third grade that are already experimenting with vaping. So it is a concern. Financially, there is an aspect where people will spend $1,000 or more a year just to maintain the habit. And there are concerns in terms of hygiene, in terms of sharing vape pens and other paraphernalia, in terms of how transmitting other things like herpes and mononucleosis and potentially now COVID is something that just sharing these devices can be problematic. So yes, I think that the fact that these substances are poorly regulated, that we do not know what beyond the nicotine other chemicals that are being absorbed into the lungs, the nicotine itself can be problematic to the brain. And there are a lot of other health economic impacts and social impacts to you saying it's really important to consider whether it is a wise and safe decision. Some of the lung damage that we're seeing in people that are smoking vapes for even a couple of years are similar to some of the lung damages that you see with people when people are smoking for a longer period of time. Because again, vapes have been around for a shorter period of time and we can recognize that they can cause more problems quickly. I was asked to speak this evening on the effects of cannabis on the behavior and well-being of young people. When I was younger, I worked mostly in the city. And what we saw was really agitated people. Young people ages 16 to 21. And at first the cocaine seemed to be a really powerful thing. We didn't think so much about the marijuana as being part of the problem. But as the years went by, it seemed to me that the use of marijuana was a very potent, very powerful effect on young people and not on everybody by a long shot. But there seemed to be a subgroup, especially young men who were particularly vulnerable to smoking marijuana. And it seemed odd to me at first since my generation would smoke and we didn't see big problems or we didn't think we did. And those of us working with young people began to notice something else. And there's not a lot of data on it, but this is my experience, which is that very often privileged and highly intelligent young people, really, really bright young people would be admitted with psychotic disorders, which were also resistant to conventional treatment. And interestingly, when you did cognitive testing on them, they were intact at the same time they were incapable of functioning reasonably. And that this would continue even after they stopped using marijuana. And over time, we had to develop new techniques of dealing with them. And so you have to say, well, is it everybody who smokes marijuana who has this problem? No, it's not at all. There are people who are vulnerable and people who aren't. So in my own mind, the vulnerability seems to be much more so in boys, but it might be that boys use drugs more and take greater risks than girls do. So that it might be a matter of dose. I mean, one thing that's changed over the years is that marijuana is now much more potent than it used to be years ago. It may be four to five times more potent. And there may be a threshold for it doing damage. And so there may be a crossing point where if you're exposed to it for an extended period of time, you have more risk of having problems. So that's a kind of the important thing. It also could be there are some people who just because of their family background and the family history are more vulnerable. So it might make sense that if you came from a family where there was schizophrenic illness, that you'd be more likely to show schizophrenia using drugs. And maybe it's simply that if you were using marijuana, it would come on earlier than before. So that doesn't necessarily seem to be true from the data. But it could be something like say if you had a family where there was a history of depression or bipolar illness, that the use of cannabis might make you much more prone to develop something that will closer to a schizophrenia that would be called technically a schizoaffective disorder of some kind. And again, that's my suspicion to what we're seeing. There are 33 states, and I think Puerto Rico and the District of Columbia that allow the use of marijuana for medicinal purposes. And what I see is many, many people now who are being treated with marijuana for anxiety disorder and other issues. And which also leads to the general acceptance. And it's a mismatch between federal law, which makes marijuana a class one control substance, and the states which make it generally available. And what's sold in most states is not regulated, you don't actually know what's in it, which is another interesting phenomenon. So I've given you my plea that people should be more careful that my experience as a physician is that it could be relatively dangerous. And that we see in this country a fairly high degree of morbidity that can be ascribed to the use of marijuana and cocaine and alcohol. And we're maybe not focused on it in the way we should be. And that is to the detriment of our children. So underage drinking, particularly binge drinking is a serious public health problem in the United States. For adolescents, they consume more than 90% of their alcohol by binge drinking. So nine out of 10 adults who suffer from addiction to nicotine, alcohol, or other drugs, began using before the age of 18. About half of all American high school students are using addictive substances. So binge drinking is really for males five or more drinks in a two hour period. The consequences of underage drinking, heightened risk for addiction, accidents, injuries and death. So the fatalities from automobile accidents, alcohol poisoning, we hear that happening with hazing. And there are about 190,000 visits to emergency rooms that are alcohol related. And those are related to falls. They're related to particularly, aggressive behavior, a lot of male on male violence involves alcohol. And there's an increased risk of being victimized when alcohol is involved. It can also contribute to mental health conditions, like depression and anxiety. In some cases, there was a preexisting, for example, depression. And then someone began to drink alcohol in parts of this called the self medication hypothesis, begin to drink to sort of feel better, but can also work in reverse. You can be using a substance that's having an effect on the central nervous system that can lead to the development of a mental health disorder, like depression. We know that alcohol affects the adolescent brain differently than it does adults. Because the adolescent brain is in a state of growth, it's impacting the development of the frontal lobes and the prefrontal cortex. And it has an effect on learning. So people probably heard of all of this information about the neuroscience of the adolescent brain. And what we know now, based on increased technology, is that our brain goes through different periods of growth and change. And the highest amount is from birth to really three years. And then it goes through another period of what we call plasticity, reaching a height of at 15 years. And what plasticity refers to is really that our brains can change in response to environment and in response to kind of what we're putting into our bodies. So adolescence has been described as both a period of opportunity and risk. So I often compare it to being able to open up a window and you can either let fresh air in, or if it's smog or other kinds of things, that's getting in too. And that's having an effect really on the development of your brain. Aaron White, who's a researcher at Duke, and he's noticed that there are actually changes and differences in the brains of adolescents who binge drink versus those who don't. He makes the statement that if you're binge drinking in high school and college, it's like a self-induced learning disability because your brain is having difficulty forming new memories. And there's a lot of research on what we call parenting styles and the effect on children. There's at one end of the continuum, the permissive parent. At the other end of the continuum, I call the drill sergeant parent. And we have found the most effective parenting style is really kind of the middle path that incorporates elements of both sides, that there are limits and boundaries and safety, but it's also done in the atmosphere of love and warmth and flexibility. What we're really trying to do in terms of brain health is to give our adolescents as much time as possible so that their brains can mature and evolve in a healthy and the most effective and skillful way. And putting in substances, whether it's cannabis, nicotine, and alcohol, which is also a very addictive substance, is literally shaping and affecting brain development. Thank you. So please direct your questions to the question and answer tab on the bottom of your screen. Okay, so the first question we have, anybody can answer, are the schizoaffective type conditions you're observing with marijuana use reversible? This is a, Dr. Murata, can you hear me? Yes. Yes, we can hear you. Yeah, I mean, there's something on my screen. So, yeah, I think often they are, especially the kinds of things I see that I believe are part of the exposure to drugs like marijuana and alcohol and young people. I think some of the things that Frank just said, some of his ideas are absolutely critical because he's talking about critical periods of growth. And along with the critical periods of growth are periods of enhanced vulnerability. And so when young people are exposed to drugs, and when it leads to a maybe a misdirection of development and learning, right, there's still time to try to get things back into place. And so they can be reversible, but not necessarily with the kind of conventional treatments that are sometimes spoken about. So there's all, you know, you have to like invent in quotes or develop a prescription for each individual person because, you know, the prescription is a recipe, right? What's the recipe that will help that individual? And that takes a lot of intense work. That's just not out of a cookbook, you know, it's not that this is the diagnosis. This is exactly what you do. It has to be thought out carefully for each person. But I'm very helpful for people, you know? We've seen incredible, incredibly important changes for the good in lots of these kids, lots of them. To add to that, I'd like to say that when we treat adolescents, a lot of the times they come in with such levels of impairment, and even after a few weeks as they continue to do better, it's still a concern that the fact that they were able to get impaired so much to begin with. And for a lot of kids, it's the first beginning of concern that might lead them to, you know, to experience what Dr. Morales sees with the older young adult patients in terms of just the first sign of deterioration. So I think it's really important to, you know, to consider that the kids look extremely disturbed. And as they start clearing their brain starts, the folks that start lifting, they look better. But it's still a concern that the brain was spread out to begin with to be under, you know, to have looked so terrible at a period of time. Thank you for your response to that. One of the questions that came up is, you know, when we're talking about these different issues with teens, you know, where would you redirect the teens for help? Do you oftentimes, you know, begin, would you recommend individual therapy or group? And I know when Tamara and I are working in the high school, oftentimes it depends on this, you know, on the student. But if, you know, we're talking about a student that has what looks like a severe substance use disorder as well as mental health, like a co-occurring mental health disorder, what would some of your input be for our parents? I would say that it has to be a combination of, you know, intervention at the individual level that you're seeing at the school. But to really be effective, there has to be a family intervention as well. Because really, the parents who once outside of school will set or determine the boundaries, provide the, you know, the methods of accountability. And so treating the adolescent in isolation without that is generally not going to be very effective. And then sometimes they're just what we call environmental interventions where, you know, we essentially make substances harder to get in the home. And so that can have an impact. So if there's, you know, lots of alcohol in the home, in some cases, we have to ask parents to lock it up or, you know, do what they need to do to make it difficult to get. So there are different levels of intervention. So the environment changing things in the environment, the individual piece, and then the family piece. And to add to that, I think it really varies depending on the circumstances, the family history of substance use. We have had some individuals that come in and it's the first admission and we discover by virtue of the assessment that the concerns married a higher level of care, longer term supports, whereas they're another person that might be using consistently, but they may be dabbling. So really important part of it is to just get a good assessment. It may start with we went up with the pediatric assessment and then obtaining and following up with referrals to other mental health practitioners to help understand a little bit more the depth and the needs as they pretend to each individual and family. Yeah, I mean, I would think about it of, you know, on a continuum. So there's use, abuse, and then there's what we might call addiction or dependence. And sometimes those things are not interchangeable. So there are some substances or some behaviors that are addictive in nature, but one doesn't develop dependence, physiological dependence. So I really take a look at what is the relationship to that substance? You know, how involved is the adolescent with that substance? How much has it taken over his or her life? What are they willing to trade in exchange to preserve their relationship with their substance? And so when we do assessments, we're really looking at where someone may fall on that continuum. And one of the things I look at for, you know, people who are really abusing and moving towards serious trouble, I look for a couple of things. I look, is there continued use despite lots of adverse consequences? And they keep using and so that suggests they're not learning from mistakes. And the other I look at is, you know, have there been attempts, unsuccessful attempts, to control the behavior? You know, promises to cut down on nicotine or promises to reduce pot smoking, but not able to do it. And then if there's evidence, the third see is, you know, what I call cravings. And if you have all those things three things together, continued use, attempts to control and cravings, you usually cross that line into, you know, with the adolescent or adult can't can't control the behavior. It's now a question of, you know, not able to versus I want to. Yeah, I thought Angela was also asking something that's embedded in all our answers, which is what's the best treatment? How do you know what to do? And I think that critically calls for, you know, real evaluation, right? A real assessment of what goes on. This treatment should emerge from the differential diagnosis to use, you know, medical talk, right? We got to know what we're up against. And we're mostly up against the situations, a very complex situation. Thank you. You actually answered the next question, which was, do you see more benefits in directing teams for individual therapy or group therapy? And it sounds like in all of your experiences, it really depends on that specific family in the case and the complexities of that addiction. But again, for Dr. Bartola Mayo, the question for you is, what aren't your thoughts on the use of naltrexon and other medications for treatment of alcohol abuse in adolescence? This is something that we're hearing more and more frequently. But do you have a perspective or have you seen certain cases where you feel like it could be beneficial or can you talk a little bit about that? I'm going to defer that one to Dr. T. Schwartz and Dr. Morata. They're the two physicians of the three of us. Go ahead. Thank you. So I think in general, we are not using a lot of naltrexon in terms of some of the substance use disorders at the level that we see in this setting. In some communities, there is some usage and we have used naltrexon for other addictive behaviors, including self-harm in different circumstances. It can come as a handy tool and that's only one small tool in addition to all the other therapeutic interventions. So again, not an approved for kids or teens specifically for substance use, but it can be used occasionally. This is not our first two modality. Thank you so much. One of the questions that just came through is, and this really could be any of you that could answer this question, when you're thinking about signs and symptoms, what are some things that parents could be looking for as signs that their child is in trouble and that they may be abusing substances? What are some different things that they could be looking for at home? Do you want to start with that one? Well, I think in terms of the home behaviors, any changes in behavior, sleep habits, etc., any changes in friend group that it seems to be dramatically different from the previous peers, any mood issues such as irritability, oversleeping, undersleeping, etc. Again, there's a variety of physical signs in terms of redness of the eyes and smells and other things like that, even though now with certain compounds to vaping marijuana, etc., it's a little bit harder to detect certain of the THC as directly as you would if the kid came smelling as much of drugs. Slurred speech and changes in behavior, those would be some of the more significant things to consider, as well as changes in spending habits. The kid working and they don't have money for food or other things that they might want to purchase. Where is that money going? Unexplain items in the home as well could be a sign of problem behavior, as well as just general loosening of some of the other household rules and responsibilities that could certainly be a problem, skipping school, etc. Yeah, I tend to look at if there's also a gradual or sudden restriction of activities that the teen had previously been involved with. So suddenly they were involved in band or chorus or a sport and suddenly their interest seems to be waning and their lives are getting smaller. That sometimes results of having this develop this relationship with a substance and generally a corresponding peer group that is consuming more and more of their time and treasure and their money. What always strikes me is that some of them are obvious because the kid comes off track and then you have the kid is going to the Ivy League schools and running the drug racket at the local high school sometimes. Sometimes it's not obvious at 17 but at 20 it is. You see terrible things and my analogy is it's like what happened when TVs became little computers and you had to go to your kids to turn on the TV on. I think they're so good at, the kids are so much smarter at so much than we are that we can get fooled very easily. So it's like you have to have a high degree of suspicion. I get fooled all the time. And I think to talk about vaping, I think it's important for parents to be aware of what the devices look like. They look like USBs or small pens and other things that computer mouse and things like that. So it's important to know, and if you find one of these, to have the conversations and be able to see what it looks like. It's much, much harder to detect which makes it even more attractive for kids and teens and just continues to increase that feeling that it's not as dangerous as these things actually can be. Dr. Ortiz, one of the questions that you're talking about vaping says, what would you recommend in terms of medication or nicotine replacement therapeutics when dealing with teens and vaping? There are not a lot that are approved for, I know for students under 18. So I know this is a question that we commonly get at the high school all the time from parents and we oftentimes will refer them to physicians. So this is a great question, I think, for a lot of us. Dr. Ortiz, thank you. Yes, I think we traditionally used nicotine patches in addition to the lozenges and nicotine gums. Occasionally, if a kid is about 17 years old or so, the insurance companies and others might approve of label use of chantix varincycline and other products like that. So it is possible to prescribe some of the adult medications of label for teenagers as long as they are a little bit closer to 18 than not. Otherwise, really abstinence and again, nicotine replacement patches, gums and lozenges tend to be sufficiently helpful for the gradual decrease. Thank you. Thank you. So this question, I think, I'd like to direct towards Dr. Morata. We have a parent that is sharing that they have a bright 16 year old who does well in school but is hiding his marijuana use and it says we have intervened early and got a therapist involved. What boundaries do we put in place other than limiting time alone away from our home and with friends? They have a zero tolerance in their home. Can they drug test and how often? What do you suggest? I mean, it's a 16 year old so they still have a power but there's going to be a power struggle. The culture is lined up against them. The family is going to be looked at as being too intrusive. I mean, the kid has a therapist, the kid has a problem. The question is, is this sort of a quote, normal situation or is there something going on that's going to go very badly? You need to handle on that. That's why Frank is right about you need family therapy. You need to get into the family system of what's going on. Now it's playing out. I mean, if somebody asked me how often you want to test, you could say well you want to test every couple of weeks at least, right? But I don't think that's where the money's at with this kind of thing because there's always ways of tricking us. Quite seriously so. I mean, we've had patients in hospital, patients in prison, right? Using drugs and not getting caught. So you have to understand that parents don't have as much control as they may think they have. Young people know a lot more than we do about, you know, pharmacokinetics and masking. And so we have to look at this very carefully. And I think that it shouldn't, it's not something you can easily say on a screen in front of everybody. I think this is calls for a consultation. You know, they should speak to, you know, one of the staff, you know, Dr. Schwartz, I mean, they can give real advice on how to behave for other people in the community. Absolutely. I do agree. I think that just testing in a vacuum can create its own difficulties. There is an opportunity for testing at home for some individuals that, you know, but it still is within the context of a larger family support and to look at models that are more more supportive, more of a harm reduction model necessarily. That means that you really are basically contracted with the kid that if the urine is negative, then they have all this privilege that they can participate and partake. And if they have a positive urine, it's not going to be like, okay, it's the end of the world and you're going immediately into treatment, but it merits a conversation with a therapist and with them and so forth. And I think that in the right therapeutic setting, a lot of therapists will, you know, will do some form of testing or will have availability to do, you know, to do that through, you know, through the medical providers. And I think that that strikes the balance and takes some of that responsibility away from your child because you really want to be able to connect in a way that relationship and improving that relationship actually decreases some of the harm longer term harm more than anything that educational piece and really supporting that. So I think that to get to the that role of policing the child versus helping the child and supporting them and giving them education will be really desirable to move away from from that and the testing can sometimes be felt as intrusive. If somebody else can do that and if that's needed, that's great. There is room and opportunity for parents to have to do the testing themselves, but that would be on their very specific, you know, consultation and support to the entire family system. What I liked and I heard in that question is that the family seems, you know, crystal clear about their values and has given an unambiguous statement about use. And many families don't do that. Many families will give more of an ambiguous response to use in terms of, you know, experimentation, that kind of thing. And I haven't met an adolescent yet who didn't take an ambiguous message about that as a green light to go ahead. So, you know, I like the fact and, you know, embedding it in the family values. So, kids will get into, you know, fruitless, you know, debates about it's legal, it isn't legal, it should be legal, everyone's doing it. And I think just staying with in our family, this is what we do and this is what we stand for. And in terms of testing, you know, I wouldn't use it as a first line intervention. Again, if there have been repeated instances in which family trust or parent trust has been violated, now you're moving into a place where the testing can be positioned as actually trying a way to rebuild trust as well as accountability. So, what I'll, you know, I'll say to families is every time there's a negative screen, your son or daughter is making a deposit into the trust account. And usually by the time you get that, get to that point, you know, the trust account is either empty, you know, or overdrawn. And so framing it in terms of, you know, we need to rebuild trust. And this is one of the ways that we'll do this and hope, you know, help them be accountable. Thank you. One of our next questions, given the circumstances of COVID and our environment that we have forced to adjust to, what do you all suggest or have you had experience with virtual help? Have you had any positive experiences with virtual help for a student or anybody who might be using substances? And have you had any experiences with some of the apps for cessation? No, I was treated virtually for COVID. And that was a good experience. I did well. And because I was sick, I had to treat my patients, you know, virtually for a while. And I was surprised by how well it seemed to work. I'm sort of my old age blown away by this part of it, that there seems to be this ability to make these connections and see more clearly. Although there were some things that I do, that I feel I cannot do well virtually, that I can't read someone's eyes or, you know, I mean, I'm an old style kind of position. So I need to tap the reflexes and have a sense of the person physically. So there are things you can do and things that are not so easy to do. But that's just my own personal experience. And, you know, maybe, maybe the others have different. This has been very hard. This is, for me, the virtual modality has been demanded a great deal of attention that kind of level that was automatic, because it was learned over a long period of time and had to be learned to more effort. It's doable. But it has problems in my mind. For me, I think that the experiences that I hear and I know is that kids are particularly responsive and they don't struggle as much in terms of making a connection virtually, because by nature, they are involved frequently with face-to-face contact, I mean contact through a screen, to friends and others. So they're able to make the transition fairly robustly. Also, it creates a lot more geographic flexibility. For example, we have an intensive outpatient program. And in the past, we could only refer within an hour's distance, because people couldn't drive. You know, the program is virtual now. So we have people traveling from, you know, from nearby areas and communities that they wouldn't be able to avail themselves of that opportunity. So in some ways, the geographic flexibility, the fact that the teenagers are able to respond to that medium does have some advantages, some of the disadvantages, especially when you're trying to have some of the group contact is that you miss out on some of the peer interaction and some of the lightness and some of the other things. So it feels a little bit more like some of the kids who are strolling with some of the virtual classrooms and so forth. And we have a lot of kids who have not responded to those supports who need in-person support. And those are the ones that we have to connect them with, you know, with face-to-face support. So not everybody responds in the same way. And there are many kids that are actually taking advantage of that. Also, because of the decreased stigma that, you know, the visits have, you don't have to necessarily go to an office or go through a bigger procedure. It feels a little bit more less intimidating for teens. So that's one of the other advantages. Thank you so much. That's very helpful because I know how challenging it's been in the school. Just learning how, you know, I like how you said, you know, the things that were so natural as a counselor to be able to read someone's face expression now with a mask is you're looking at all the different body language and everything that you could imagine to try to read eyes more than anything and expressions underneath. You know, one of the questions that also came up that was sent in prior was, you know, a parent had asked, what do you do if you discover that your 16-year-old has smoked marijuana and eaten edibles on more than one occasion and really enjoys it? You know, what are some things that you could help this parent with what they could say to their child? I know oftentimes right now because of the society's current perspective, you know, a lot of the adolescents don't believe there's a lot of risk involved with THC use or marijuana use. So it would be great, you know, to hear from you guys what your thoughts are. An election year, that's a difficult question. I mean, I, you know, I'm, I was actually at Woodstock. I always tell people, it's not a joke, you know, and I was at Berkeley in the summer of love. And so I grew up with a very different ideology. So it makes perfect sense that if you're a teenager, your 16-year-old, you know, smoked or at an edible that it would be a pleasurable experience because, you know, that's the way the vast majority of us are wired to find that pleasurable. So it's hard to imagine the dangers that will emerge over time, especially when it's not everybody, right? It's, and it may be the one in nine that things get very bad for. So it, it's a tricky bit of business to negotiate. And I think what Frank said about the family values, they're very critical, right? I mean, because the values of the society, especially liberal northeast society, is such that it's totally acceptable behavior. And it's odd to be opposed to it, right? It's really odd to take a stance against drug use, you know, especially what's looked at as being relative with the nine drug use. So the family has to say, what are our values? What, again, as he said, what do we stand for? And how do we want this to go in our family? And I also think it helps for families to get together. You know, I really think that groups of mothers and fathers talking about these things is really important. And that they need input from school personnel, from teachers and from others, right? And I think they need access to other information to help them do it, because I rarely see information in the general press about the dangers of marijuana, which is interesting to me, right? You see much more information about the dangers of cigarette smoking, at least as I read it, than marijuana use. And I think it should be a general conversation. And again, that comes from my clinical experience. But I mean, guys, how, you know, in our own experience, we have to go to lectures, you know, we had doctors have to go to school for the rest of their lives, which is a good thing. I mean, how often have we gone to a grand rounds or required lecture on the danger of marijuana? Right? Yeah, a couple of times, right? But on alcohol, all the time in comparison, right? And I mean, we're required to monitor people with cigarette smoking, that's almost a requirement of everybody, whether you're a retinal surgeon or a psychiatrist, it's like, we can't discharge patients without having, you know, there's things we have to fill out, we have to attest that we discuss these things, right? That we're not, we're not mandated to take so seriously other things. So it's not strange to me that the general culture, we're a reflection of the general culture's values. And remember, sorry, Rocky, yeah, it's the parents have the earliest influence on kids' relationships or attitudes towards substances. So that in terms of nicotine, alcohol, other drugs. And so that's being shaped very early, not by what we say, but by what we do. And certainly with alcohol use, it has become such an ingrained part of our culture. It's an, now kids regard it as an entitlement. I'm entitled to drink and, you know, get wasted, because that's what we do in this culture. And that's what I'm entitled to do at college. So pushing against that is very challenging because it's so ingrained into, you know, our mores. And that's taught very early, you know, growing up, you know, my father's been a seasoned ticket holder for the Patriots for 50 years. And when I was a kid, he and his friends would drag their sons to the football games. And what did I see when they were tailgating? I saw lots of men, also women consume large amounts of alcohol. And so what are the message that I get, about what men do together when they get together? That was something that was communicated to me nonverbal. And it took me generations to really appreciate, you know, that men can get together and it doesn't have to involve a beer or substance. So that's being shaped very, very early. And, you know, kids see us when, you know, you come home from work and have a cocktail. Right? That's saying something. You know, kids are wondering why when you go to weddings, everyone's drinking. You know, that's saying something. And those are the kinds of discussions that kind of, you know, as Rocky said, it makes sense that they want to use a substance that makes them feel good. And, you know, there has to be sort of a broader dialogue about this. Thank you. Just being mindful of the time before we wrap up. You did answer a little bit of this question. What, as parents, what kind of behavior should we be concerned to respect of leading a good example for our young ones, adolescent model, good and bad behaviors? Should we be concerned about keeping our drinking in check? Or how do we balance making it appropriate but still educating our students that that's not something that we want them to be involved in? And I think that you all mentioned it again, it goes back to values and having those conversations and building relationships and having the student understand and have a perception of harm before they want to argue about the laws. So I definitely see that in the middle school as well, just focusing on good decision-making skills so that they have the tools to make the right choice. So can any of you speak to how parents, if they should monitor their behavior or how to go about that? I mean, the research is clear that, you know, kids who binge drink tends to have a parent who is also binge drinking or is more likely to binge drink if they see a parent doing that. So again, the parent may not regard it as binge drinking, but if you think about, you know, five drinks in a two-hour period of time, that also depends on what you're drinking. And so, you know, wine tends to have a greater, you know, alcohol content than certain beer. So if they're watching, you know, parent consume, you know, many glasses of wine at dinner, that's again communicating how people drink. So I think paying attention to that is enormously important. And in some cases, you know, we have to go back and acknowledge when we made mistakes. You know, we've had kids, I've worked with kids who parents have in some ways given them the green light to experiment and then things got very bad. And then they started having, you know, fruitless debates about how much is too much. And in some of those cases, I think the parents had to go back and say, I made a mistake. I gave you some very mixed messages about using. And, you know, I'm sure that confused you. You know, we had a kid recently at the hospital who, you know, in response to her heavy substance use, the father would say, oh, I did what you did, but many times over. And, you know, she began to see her father as a potential risk factor in her, in her relapsing. Because in some ways he was, he wasn't acknowledging or giving the reality of what, what she was doing. But I actually was saying, well, that was nothing compared to what I did. He loves his daughter, but gave her some very confusing and dangerous messages. Thank you. In addition to go to addressing the confusing or problematic messages, I think, and setting a good example, I think it's really important to engage the teens and individuals in the dialogue and discussion that does not seem to be too directive. So it really is about asking questions, not just telling them what to do with trying to understand what kind of pressures the kids are facing. Well, you know, what are some of the things that the peers are doing, you know, asking questions, you know, is there, there are a lot of kids vaping in your school? How are you feeling about vaping if you see somebody vape and eventually teaching them the language so that they have a plan? So if they encounter these things, how can they avoid them? How can they really manage without looking, you know, silly or foolish or missing out on some of the social, you know, cash that goes with, you know, with doing this, this substance is nowadays. So it becomes part of the process, part of the ongoing conversations. And the more that parents can learn, you know, the about, you know, the use and the tools and what's going on around their, you know, their neighborhoods, what happens when they're visiting another friend's house and all of that, the more they can help support their child specifically to their situation while upholding their own family, you know, values when it comes to what is healthy, what is safe, and what is appropriate. Yeah, I mean, it's very difficult when we're anxious about our children to approach them with curiosity rather than judgment and approaching them with curiosity and exploring what would it mean for you if you didn't use substances in your school. Often it comes with significant social costs. And often the highest, the kids with high social status are heavy partiers. And being able to empathize with them because we all have a need to belong for adolescents is even more intense. So they're often caught between these competing drives, if you will, one hand, I need to connect and belong, but then also I also adhere to the values or the beliefs my parents are putting out for me. It's a very difficult dilemma. And I think approaching that with empathy and appreciating, you know, what would happen, again, if you go to the party and you're the only kid who's not using, what would that be like? And I've heard other kids tell me, I won't get invited to the parties. Okay, so now there's going to be a social cost associated with it. And how are we going to deal with that? I think you're absolutely right. Students really appreciate the honesty and not just saying no, because I said so, but having a further understanding of why, so that they can make those decisions and feel confident when, you know, they're approached in a situation that's not safe. So awesome. Thank you. Just to add to that as one of my final comment, comment is to recognize that, you know, the brakes, the impulsivity part of the brain and the ability to just pump the brakes is not there yet for, you know, for most individuals until they're early to mid 20s. So to understand the context of, you know, it is not as easy as telling somebody don't do this. I think that the temptation in the moment is going to be much more significant. So the fight is going to be, you know, we have to be cognizant of that in our supportive and educational efforts. I mean, I feel so strongly in agreement with everybody, but also this idea that the school is a central place in this, the setting, you know, is trying to set a different set of values, because we're just occasional, you know, advisors or viewers of this. And also what I saw with my own children that they were other people in the community took on the parental role in a way that we didn't understand that, you know, that we were odd parents. And but our children became identified with other people's parents. And there's some pretty wild behaviors going on in Fairfield County and Westchester County. And I think that has to be addressed on some level at some point. I'm actually in Charleston, South Carolina on vacation, and I got to head off again. It was a great pleasure. Thank you for having me. Take care. Thank you so much, Dr. Marata. Thank you. Thank you for everything that you have all mentioned tonight. I think it's so important. I think parents often times can feel so alone dealing with each one of their children's and feel like their situation is so unique. And it is to it is very unique to them. So we just so much appreciate, you know, all of your input and everything that that you guys have shared tonight. And I think, you know, being professionals in the school, we usually are the first line of intervention. And we're, you know, always trying to figure out what's the best way to intervene with this family and help them in the moment, you know, with some of the questions that they've been asking tonight. We do have, you know, two final questions that we were hoping to get to. One is, you know, it's about it's for, you know, families, there's a psychiatrist that is in private practice that often encounters early substance abuse in patients, particularly with ADHD. And first question is, how do you balance the need of ADHD with the needs to treat the substance issues? And then the second question is, how do you work with families to treat any underlying codependency family structures that can also be a large part of reinforcing part of the substance issues? So on the question of stimulants, the studies have shown that when a person has ADHD and they're enter the enter the teenage years, if they're not properly treated that they're at a higher risk of additional substance use. And it's typically not addiction to the the stimulants themselves. A lot of the times the stimulants help to, you know, to kind of like help normalize and decrease some of the, you know, hyperactivity impulsivity. So not having those things, not having the, for example, the stimulant medication to treat hyperactivity impulsivity has shown that the risk of substance use is higher. And when kids are properly treated, it's not that the risk goes low, but at least it's even it levels the playing field with other kids that do not have attentional issues. So I think it is important to balance it out. And if there's concerns that the kid might be diverting the drug, meaning like utilizing their medication to sell it or give it to other kids, obviously that needs to be addressed on a very careful basis. Assessing there are occasional kids that do have ADHD that will want to abuse their own stimulant medication. That is rare and it still merits limiting the amount of medication, making sure that they're taking it consistently. Sometimes drug testing them, but reversely, not to find that they have other substances, but to make sure that they're taking the medication as prescribed. So there are ways to manage that. And I think that on a general on a general sense, it's important to treat more often than not. And to have agreements with the adolescent patients in terms of having conversations that if you suspect that the medication is being diverted or misused, then they're not going to get that medication. And for the most kids, they want to do well in school. And that's the one that helps them the most. And thinking about switching to non-stimulant medications with which might be less effective, you know, it's less of a it's not worth it. So they will, you know, very often respect the those agreements that they have made with you as a as a treater or provider. And the second question, I don't, I don't recall, but I'll take a stab at that one. Okay. I think it was regarding codependent dynamics and families, you know, codependency and, you know, what am I call enabling, you know, I really regard as misplaced love. And what I mean by that is this, we are hardwired as human beings and as parents that when we see our child struggling or suffering, that we're going to move in and protect them. We are hardwired to do that. What can happen with a substance use issue is that the parent keeps doing that in such a way that allows the person to be able to under function. So they develop what we call an over functioning, under functioning relationship. So and it becomes a dynamic so that the more you over function and allows the child to continue to under function or continue to use the substance. So again, it comes out of a place of love initially. And again, at a very deep, deep level, and, you know, being able to stop that and see that actually what you're doing is contributing to the problem or allowing continued use takes a lot of work and effort on the part of a parent because you have to use your, you know, your, your cognition to pull back your heart because the heart is going to want to rescue. And it's a very difficult dilemma for parents. Thank you. And I think this is the perfect question to wrap up. What at the end of this discussion, what is the most important takeaway for parents and kids who might be listening to this zoom call? What is the most important takeaway that you have to share with us? I think in terms of substances, that it's important to really know, know the risks to understand that the brain is developing. And you really wouldn't put things in your body, you know, it wouldn't eat things or put things in your body if you don't know what's, what's in there. And it's the same thing with, you know, substances, alcohol and other things that, that really can impact, you know, a lot of things down the line. And then the most preventive strategy is education and relationships. And if you build on those, those are the most important things to, you know, to consider. Yeah, to build on what Liz said, you know, there's an expression that the opposite of addiction is not sobriety, it's connection and relationships. And so this idea that I talked about where someone is developing a relationship with a substance or a behavior, and that beginning to drive a wedge in between people and children and parents. So paying attention to that connection that also means for parents, you know, we're often under enormous stress, and also feel particularly alone and isolated with this. And I think to the extent that parents can kind of get also get together, connect, have a group that you feel sustained by, you know, is enhancing and can focus on helping you to maintain that connection, that relationship, so that a substitute like a, like a substance doesn't interfere with that. Thank you. Thank you so much. You know, as we're coming to conclude for the evening, I just think that everything that the doctors have shared with us tonight is just so helpful. I think it's probably helped Tamara and I also in the work that we're going to be able to do moving forward with our, you know, the teens that we intervene with this year. You know, one of the things that I think about all the time, and to say to parents also is just to remember that you're not alone. Even oftentimes you can feel like that when you're dealing with your child and that you have local resources. We have Silver Hill, which is an amazing hospital. I've had a lot of students that have attended and been in part of their programs in patient and out. And they're really great at treating our students and follow through and they've been so helpful to so many of our families. And you know, I also you want to say that Tamara and I are available to you also. Oftentimes parents don't know where to turn and it's important for you to know that the schools do have confidential services to be able to help walk you through some of the experiences that you may come up against. So we just want to thank our panelists for doing an amazing job tonight. And as Tamara mentioned, this is recorded. So if you feel like there was something that you missed or any questions that you would like for us to forward to the doctors, we can definitely do that and have some questions answered. And this will be available on a link to YouTube. So if you have any friends that you think could really benefit from hearing tonight's discussion, please pass that along and that will be emailed to you within the next day or so. Thank you so much for having us. Thank you very much. Thank you everyone for the questions in the chat. This was a really good conversation. And thank you to everybody for participating. This was really great. Thank you. Bye bye. Have a good night everybody. Thank you so much.