Mental Health and Gun Safety in Pediatrics - Catherine Neyer - APP Conference 2026

All right. And with that, we thank you all for attending today. Let any of the committee members know if you need anything at all throughout the day, and I'd like to welcome our first speaker, Kathy Mayer, to the stage. If you want to just leave, let's leave the agenda. I don't know who he is. There she is. Hi everybody, thank you for being here. My name is Kathy Meyer. I am an inpatient psychiatric mental health nurse practitioner at College Hill, and I want to once again thank you all for being here. This morning, I'm gonna talk about a topic that sits at the intersection of youth mental health, safety and clinical practice, which is firearm injury prevention. The session is designed for advanced practice providers working in diverse settings. My goal is to give you practical evidence-based tools you can use in your clinical encounters. Oh, wrong way. I have no financial disclosures. This is, um, our first question, uh, which of the following statements reflects the perspective on asking about firearms in healthcare settings? Give it a few minutes for people to respond. So, um, it looks like the, the majority of people are responding, and yes, um, this, uh, uh, excuse me. Asking about firearms should be as routine as asking about medications, substances, um, or seatbelt use is the correct answer. Risk factors for firearm-related harm include untreated medications, mental health conditions, trauma exposure, adverse childhood experiences, bullying, and family conflict. Social isolation is also a major contributor. Access to an unsecured firearm is a risk factor all on its own. When we assess risk, we need to consider both psychological vulnerability and environmental access. Firearm access is a modifiable risk factor. We cannot intervene on what we do not assess. Routine non-judgmental inquiry normalizes the conversation and reduces stigma. So, um, we're gonna look at some data. Firearm injury is not just a criminal justice issue, it is also a public health issue. Um, this video is gonna walk through 5 key facts that shape our clinical responsibilities. So I have to hit something to play it. Just that. Rates of depression and anxiety have been surging across the US in recent years. More than 50% of gun-related deaths in this country are suicides. The Bipartisan Safer Communities Act signed into law in June, includes new gun safety measures and funding for a range of mental health services. Here are 5 facts on mental health and gun violence. Number 1. Each day, 111 Americans die of gun-related injuries. Of those deaths, 65 are suicides. 20 years ago there were 15,045 gun-related suicides in the US. In 2020, there were 24,292. Suicide attempts with a firearm result in death nearly 85% of the time. For other common methods, the success rate is less than 3%. Number 2, the National Alliance on Mental Illness reports that nearly 20% of high school students have had serious thoughts of suicide and 9% have made an attempt. Suicide rates are rising among teenagers, and COVID made things worse. Suicide rates among teens increased by as much as 50%. during the pandemic on top of the 57% increase in the decade before among adults, the depression rate hit 32.8% in 2021, up from just 8.5% before the pandemic began. Number 3, in 2018, just 43% of Americans with some form of mental illness received mental health services. Rand. Data show that among those with serious mental illness, defined as a diagnosable mental, behavioral, or emotional disorder other than a developmental or substance use disorder that substantially interfered with or limited one or more major life activities, just 64% received mental health services. About 14 million Americans have been diagnosed with a serious mental illness. Number 4, Penn Medicine Children's Hospital of Philadelphia Research shows that a proximity to violence and multiple exposures increased the risk of pediatric mental health distress. Nearly 1 in 3 mental health related juvenile emergency room visits during the weeks after a neighborhood shooting were linked to the event. Those living with mental illness are more likely. To be the victims of domestic violence, 23 times more likely, according to Angela Kimble of the National Alliance of Mental Illness. Number 5, the Bipartisan Safer Communities Act includes nearly $2 billion in mental health funding. The new funding includes $500 million through the school-based mental health services grant program for school-based mental health. Service providers $250 million for the comprehensive Community mental health services, $150 million for the 988 Suicide and Crisis Lifeline, $120 million to prepare and train community members and first responders on how to respond to individuals with mental disorders, and that's what you need to know about mental health and gun violence. Rates of depression and anxiety have been surging across the. I apologize. There we go. OK. Um, so why is this topic important? Firearm injuries are now the leading cause of death for children and adolescents in the United States surpassing motor vehicle accidents. The shift happened recently and dramatically. At the same time, we're seeing rising rates of depression, anxiety, trauma, exposure, and suicide among youth. These aren't parallel crises, they do overlap. When mental health symptoms meet easy access to firearms, the risk of fatal outcome increases exponentially. Understanding this intersection is essential for effective prevention. According to the Centers for Disease Control and Prevention, firearms surpass motor vehicle crashes as the leading cause of death for youth. CDC data showed a steep rise in firearm deaths among youth aged 1 to 18. Homicide is the leading category for younger adolescents, while suicide dominates among older teens. We also see some significant disparities. Black youth experience disproportionately high rates of firearm homicide, while rural youth have higher rates of firearm suicide. These patterns reflect broader social determinants poverty, community violence, limited mental health access, and cultural norms around firearms. Youth mental health concerns continue to rise, higher rates of depression, anxiety, trauma exposure, and behavioral dysregulation. These trends intersect directly with firearm access. When mental health symptoms increase and access to lethal means is present, risk escalates quickly. Exposure to gun violence, whether direct or indirect, has profound psychological effects. Youth may develop PTSD symptoms such as hypervigilance, avoidance, and intrusive memories. They may struggle with grief after losing peers or community members. Even witnessing violence online or hearing about violent acts such as school shootings can create chronic fear and emotional dysregulation. These experiences shape brain development, behavior, and long term mental health outcomes. Over 90% of fatal suicide attempts involving youth occur with a firearm. Firearms have an extremely high lethality rate. 9 out of 10 firearm suicide attempts result in death. Most youth suicide attempts are impulsive, occurring within minutes of a triggering event. If a firearm is accessible, the likelihood of death increases drastically. Safe storage and lethal means counseling are powerful evidence-based strategies to help prevent suicide. Earlier we discussed risk factors and the importance of assessing risk factors. Protective factors matter just as much. Strong caregiver relationships, consistent supervision and supportive school environments reduce risk. Safe firearms storage, locked, unloaded, and separate from ammunition is a major protective factor. Access to mental health services, early intervention, and community support systems all help buffer against stress and trauma. Our role is to strengthen these protective factors in every clinical encounter. So I have some more questions here. A teen endorses passive suicidal ideation. What should the APP do next? I'm gonna go ahead and move to the next slide. Um, so that is correct. The correct answer is asking directly about access to firearms and medication. So passive suicidal ideation still requires a safety assessment. We cannot assume low risk. Assessing for means is important. Despite the myth that it might increase suicidal thoughts, the evidence suggests otherwise. Means assessment does not increase suicidal thoughts, instead it increases safety. So for our next question, we have a 13 year old with increasing irritability and recent school suspensions. The caregiver reports he's been hanging out with older kids who have guns but insists he's not like them. What should we do next? So yes, the correct answer, as most of you got. Um, is, ask about the youth exposure to firearms, access points, and supervision routines. Behavioral changes, risky peer groups, and caregiver minimization can lead to elevated risk. This is a moment to use trauma-informed assessment, not avoidance or minimization. And we have case 3, who's a 16-year-old, reports worsening anxiety and trouble sleeping. The caregiver casually mentions they keep a loaded handgun in the nightstand for protection. What should we do next? I'm gonna go ahead and move on. Um, so yes, the answer is C. Introduce lethal means counseling and discuss secure storage tailored to the family's context. When discussing firearms, it is important to be sensitive. This is a topic that can be polarizing to many people. Providers should avoid extremes, neither ignore the issue nor demand immediate removal. Instead, we can explore what the firearm means to the family, the family safety goals, and practical feasible storage options. This non-judgmental approach helps to build rapport and increase adherence. For the next question, a caregiver states, we have a gun, but it's hidden where the kids can't find it. What should we do? Yes, so the majority of the answers, I'm gonna move ahead. So yes, we want to explain that hidden firearms are often found by youth and discussed secure storage options. The American Academy of Pediatrics states that 39% of parents erroneously believe their children do not know where their gun is stored, and 22% wrongly believe their child has never handled their guns. For the provider, this is a teachable moment. And this is the last one. A 14 year old presents to urgent care for a sprained ankle. During triage, they endorse feeling down a lot lately. What should the provider do? Yeah, so you all pretty much got it. Um, so the correct answer, yes, is C, conduct a brief validated screener and ask safety questions. Even in a fast-paced clinical environment like urgent care or emergency room, mental health screening should not be deferred. It can be hard to focus on mental health symptoms when a child is coming in for a physical injury, but youth often disclose depressive or anxiety symptoms when at a routine checkup or visit for a physical injury. There are several strategies with strong evidence behind them for prevention. Routine mental health screening, trauma-informed care, lethal means counseling, and family education are essential. Let's take a few minutes to examine each component a little more closely. Routine screening is one of the most powerful prevention tools we have. This means screening every youth, not only those who present with behavioral concerns or mood symptoms. This may look like integrating the PHQ-9 or GAD 7 into annual well child visits in primary care. In urgent care or at specialty visits, it means asking a few brief validated questions even when the presenting problem is physical, because youth, as was said before, often disclose emotional symptoms in unexpected settings. In mental health, screening helps track symptom change and identify emerging risks. Routine screening normalizes mental health conversations. It communicates to families that emotional health is just as important as physical health. And importantly, it creates a natural opening to ask about safety, including access to firearms and medications. Second, trauma informed care. This is not a specialty, it is a universal precaution. We should assume that many youth and caregivers have experienced trauma, including community violence, domestic violence, or prior losses. I will discuss trauma-informed care in more depth here shortly. For now, it is important to remember that trauma-informed care reduces defensiveness and increases the likelihood that families will engage in safety planning. Lethal means counseling is the 3rd approach. It is a brief evidence-based intervention that reduces suicide risk by increasing the time and distance between a person in crisis and a lethal method. This is not about confiscation or judgment. It is about safety during periods of elevated risk. A key framework clinicians may use is calm or counseling on access to lethal means, a nationally recognized training developed to help healthcare providers have effective collaborative conversations about firearm safety and other lethal means. Effective lethal means counseling includes asking directly about access to firearms and medications, exploring how firearms are currently stored, understanding the family's context surrounding firearms, such as safety concerns, cultural values, or other reasons for firearm ownership, offering practical, feasible storage options and collaborating on a plan that feels realistic for the family. Finally, family education is where prevention becomes sustainable. We want caregivers to understand not only what to do, but why it matters. Key messages to share with families include youth often know where firearms are hidden, even when caregivers believe they do not. Older teens are at the highest risk for suicide and unintentional injury. Safe storage is not just about preventing suicide, it also reduces accidental injuries. Impulsive behavior and access by peers and mental health symptoms can fluctuate quickly. And safety plans need to be revisited regularly. Education should be tailored to the family's literacy level, cultural background, and concerns. We can provide handouts, demonstrate lock devices, or connect families with community resources. Family education can be a daunting part of this conversation as this topic can be viewed as controversial for some. It is critical and important that it isn't completed, however. The American Academy of Pediatrics reported that parents who received education and counseling on safe firearm storage were more likely to report adopting one or more safe gun storage practices. So we have some safe storage myth or facts, um, hiding a gun is enough to keep kids safe. Older teens don't need firearm safety conversation, and clinician counseling doesn't change storage behavior. These are all things that I have heard in my practice, and of course they are all myths. As we discussed previously. When we talk about safe firearms storage, we are talking about a set of practices that significantly reduce the risk of suicide, unintentional injury, and impulsive behavior among youth. The evidence is extremely consistent. When firearms are stored securely, youth firearm injuries drop dramatically. Safe storage includes 3 core elements firearms unloaded, locked in a secured device, and ammunition stored separately. But in practice, families need more than a definition. They need options that fit their daily routines, their safety concerns, and their cultural context. Families often assume safe storage means getting rid of firearms entirely. That is not the case. There is a menu of options that maintains both safety and the family's sense of security. Some home storage options include lockboxes for quick access but secure storage, gun safes for long guns or multiple firearms, cable locks that prevent the firearm from being loaded or fired, and trigger locks that block the trigger mechanism. Some families keep firearms in their vehicle and storage options there include a console safe for secure storage during transport or a cargo area lockbox for larger firearms or when traveling. In addition, some families may choose off-site storage options such as with a trusted relative at a gun range or storage facility where the youth would not have access. The goal is not perfection. It's about increasing safety in a way that is realistic for the family. So let's talk about some trauma informed care. When we talk about firearm safety in clinical settings, how we communicate is just as important as what we communicate. Trauma informed care gives us a framework that reduces defensiveness, increases engagement, and helps families feel respected rather than judged. These principles apply across all care settings, whether the youth and family have presented to their primary care provider, mental healthcare provider, specialist, or urgent care provider. Our first priority is creating a sense of emotional and physical safety for the youth and family. Many youth and caregivers have experienced trauma, whether it is community violence, domestic violence, discrimination, or prior negative healthcare encounters. When we ask about firearms, we want the environment to feel calm, predictable, and non-threatening. Example of trauma-informed safety language can include, I ask all families these questions because the child's safety is important to me, or you are not in trouble, this is just a part of keeping kids safe. Safety also means being mindful of tone, body language, and pacing. A rushed or abrupt approach can shut down the conversation before it begins. The second foundation is trustworthiness. Trauma often erodes trust, so we need to rebuild it through transparency. Families deserve to know why we are asking about firearms. Some examples of how to phrase this conversation include, I ask about access to firearms, the same way I ask about medications or seatbelts as part of routine safety. Or I want to be clear about how this information is used. It helps us create a safety plan that fits your family. Trustworthiness also means being consistent, following through on what we say, explaining next steps, and avoiding surprises. This is especially important in inpatient mental health settings where youth may feel powerless or unsure of what will happen next. The third foundation is choice. Choice is a core trauma informed principle that often gets overlooked in safety conversations. Families need to feel they have options, not mandates. Trauma often involves loss of control, so restoring a sense of autonomy is essential. Some ways to give choices can include, there are several ways families store firearms safely. Would you like to hear a few options? And you know your home best, which approach feels most realistic for you? Choice reduces defensiveness because families do not feel coerced. Instead, they feel respected and involved in the decision making process. The 4th foundation is collaboration. Trauma informed care avoids a top-down approach. Instead of telling families what to do, we work with them to find solutions that feel realistic. Examples of collaborative language include, let's figure out a plan together that works for your home, or what storage options feel doable for your family. Collaboration increases buy-in. When families feel like partners rather than recipients of instructions, they are more likely to adapt safe storage practices. 5th 5th is empowerment. Trauma can leave youth and caregivers feeling powerless. Empowerment means helping them recognize their strengths and reinforcing their ability to keep their child safe. Some ways to empower families include positive praise, such as you are already doing a lot to protect your child, let's build on that. We encouraging families to take an active role in safety planning. You know your home best. Your insight is essential to making this plan work. Empowerment is especially important when caregivers feel judged, overwhelmed or defensive. When we validate their efforts, they become more open to discussing changes. The final foundation of trauma-informed care is cultural humility. Firearm ownership is deeply tied to culture, identity, geography, and lived experiences. Cultural humility means approaching each family with curiosity rather than assumptions. One way to phrase this could be families have many different reasons for owning firearms. I want to understand what they mean to you so we can talk about safety in a way that fits your values. This final principle is critical. When families feel respected instead of stereotyped or lectured, they are far more willing to engage in meaningful safety planning. When we combine these principles, we create a space where firearm safety conversations feel supportive rather than confrontational. Trauma informed care does not make the conversation softer, it makes it more effective. It helps families stay engaged, reduces defensiveness, and ultimately increases the likelihood that they will adopt safe storage practices that protect their children. When working with youth who are experiencing mental health crises, trauma exposure, or elevated risk related to firearm access, one of the most important decisions we make is determining the appropriate level of care. This decision goes far beyond symptoms checklists. It requires a holistic understanding of the youth's safety, environment, and the caregiver's ability to provide consistent supervision. Inpatient care becomes necessary when the youth cannot be safely supported at home or in the community, whether due to imminent risk, inability to restrict access to firearms or other lethal means, or inability of the caregiver to provide adequate supervision. Outpatient care is appropriate when risk is present but can be managed with structured supports, reliable follow-up, and a home environment where safety measures can be implemented and maintained. To make this determination, we assess the youth's current level of distress, their impulse control and coping capacity, the presence and security of firearms, and the caregiver's willingness and ability to enact a safety plan. These factors together guide us toward the safest and most therapeutic setting for stabilization and ongoing care. The important takeaway when determining level of care is that this is a dynamic, not static decision. Risk can change quickly and our assessment must adapt with it. Inpatient care is reserved for situations where youth cannot be safely supported in the home or community, even with enhanced outpatient services. This level of care is not just about symptom severity, it is about immediate safety, environmental risk, and caregiver capacity. When these factors converge in a way that compromises safety, inpatient treatment becomes the most protective and therapeutic option. So how do we know who needs this level of care? Inpatient care should be considered when any of the following are present. Intimate risk. The youth expresses suicidal intent, has a plan, or shows behavior suggesting they may act impulsively. Intimate risk also include escalating aggression, severe self-harm behaviors, or inability to commit to safety. A plan or intent is present. Even if the youth appears calm in the moment, the presence of a specific plan, especially one involving a firearm or other lethal means, significantly elevated risks. Firearms cannot be stored safely. This is a critical factor. If there is a firearm in the home that cannot be immediately secured, removed or stored safely, inpatient care may be the only way to ensure safety during the crisis. This includes situations where caregivers are unsure how to secure firearms, disagree about storage, or do not believe the risk is serious. Caregivers cannot maintain safety. Sometimes caregivers are overwhelmed, exhausted, or unable to provide the level of supervision required. This may be due to other children, their own mental health needs, or lack of insight into the youth's risk. In these cases, inpatient care may provide the temporary structure and monitoring that the home environment cannot. Once admitted, inpatient care focuses on several immediate priorities stabilization, rapid intervention to reduce acute distress, manage suicidal thoughts, and address severe mood or behavioral symptoms. Observation by staff 24/7 ensures the youth is safe during the highest risk period. This is especially important when impulsivity, agitation, or access to lethal means is concerned. Inpatient teams can quickly evaluate psychiatric symptoms, substance use, trauma exposure, and environmental stressors. This helps refine the treatment plan and determine what supports are needed after discharge. An important part of inpatient care is working with families to ensure firearms and other lethal means are secured before the youth returns home. This includes reviewing storage options, exploring temporary off-site storage, and confirming that safety measures are in place. Families often need guidance on supervision, communication and safety planning. Inpatient teams can help caregivers understand risk and build confidence in maintaining safety after discharge. Outpatient care is appropriate when a youth is experiencing mental health symptoms or stressors, but can still be safely supported at home with consistent supervision and a solid safety plan. This level of care is not low risk, it's manageable risk within a structured, well-supported environment. Outpatient settings allow for continuity, relationship building, and long-term therapeutic work which are essential for recovery. We consider outpatient care when several conditions are met. Risk is present but manageable. This includes passive suicidal ideation without a plan or intent, emotional distress that the youth can still regulate with support, or trauma symptoms that are impairing but not escalating into crisis behaviors. Caregivers can reliably supervise. Caregivers must be able to monitor the youth, restrict access to lethal means, and follow through with safety planning. Their insight into the youth's risk and willingness to engage in treatment are important. Firearms and other lethal means can be stored. This is non-negotiable. If firearms are present in the home, they must be stored, unloaded, locked, and separate from ammunition or temporarily removed during periods of elevated risk. When caregivers can implement these measures consistently, outpatient care becomes a safe and appropriate option. Outpatient care provides a therapeutic environment where the youth can work on underlying issues while remaining connected to their daily life, school and family. Key benefits include continuity and relationship building as regular sessions allow clinicians to build trust, monitor progress, and intervene early when symptoms worsen. Evidence-based trauma-focused therapies such as CBT, TFCBT, EMDR, and DBT informed approaches can be delivered consistently over time in the outpatient setting. These modalities help youth process trauma, build coping skills, and reduce symptoms. Outpatient care also allows for family therapy, parent coaching, and school collaboration, all of which strengthen the youth support system. To ensure safety and therapeutic process, outpatient care should include regular follow-ups. Frequency should increase during periods of heightened stress, transitions or symptom escalation. Weekly or twice weekly visits may be appropriate early on. Risk is dynamic. Even if a youth initially presents with passive SI this can shift quickly. It is important that we reassess suicidal thoughts, coping capacity, and environmental safety at every every visit. Even when risk appears low, we revisit firearm access because circumstances change. New firearms enter the home, storage practices lapse, or stressors increase. And finally, collaboration with schools and community supports. School counselors, coaches, mentors, and community programs can reinforce coping skills and provide additional monitoring. This creates a broader safety net around the youth. The goal of outpatient care is to help the youth stabilize in their natural environment while building long-term resilience. We want youth to develop coping skills, strengthen relationships, and maintain safety over time. Outpatient care works best when it is proactive, collaborative and grounded in ongoing communication with caregivers and community partners. So here is an example of coordinating care across settings. 15 year old discharged from an inpatient unit after a suicide attempt. Before discharge, the inpatient clinician completes a handoff to the outpatient therapist and school counselor, sharing the updated safety plan and confirming that firearms at home have been secured. At the first outpatient visit, the therapist revisits the safety plan with the family and coordinates with the school to ensure daily check-ins. This this scenario highlights what ideal coordinated care looks like for youth returning to the community after an inpatient stay. Transitions between levels of care are some of the highest risk moments for suicide, relapse, and safety lapses. When we coordinate well, we close the gaps that youth often fall through. A handoff includes more than sending discharge paperwork. It means direct communication between providers, ideally a real-time conversation. The inpatient team should be sharing the updated safety plan, recent risk assessments, triggers identified during hospitalization, interventions that were trialed, and what did and did not work, and any concerns about firearm access or supervision. This ensures that the outpatient clinician is not starting from scratch. It also lets the family know that the inpatient and outpatient care team is aligned and paying attention. It is important to include schools in post-discharge conversations. Schools are often the first to notice changes in mood, behavior, attendance, or peer relationships. In this scenario, the school counselor was looped in early, which allows for daily check-ins, monitoring for academic or social stressors, a safe adult at the school, and coordination around accommodations or reduced workload. This is especially important after hospitalization when youth may feel overwhelmed returning to their routine. Safety plan continuity across settings is important for discharge planning as well. A safety plan is only effective if every environment the youth enters understands it. The same plan should follow the youth from inpatient to outpatient, outpatient to school, and school to home. This continuity prevents mixed messages and ensures everyone knows the warning signs, coping strategies, and steps to take if risk escalates. It also reinforces to the youth that they are supported by a consistent unified team. One of the most important steps is confirming that firearms in the home remain secured. This is not a one-time conversation. It must be revisited at every transition. The youth and families should be asked if anything has changed with firearms storage since discharge, if firearms are still locked and stored separately from ammunition, and if the family still feels confident maintaining safety. If the family struggles with storage, this is another moment to problem solve. Transitions are high risk moments. Risks often spike during transitions because structure decreases, supervision changes, symptoms may fluctuate, the youth may feel overwhelmed or misunderstood, and families may assume risk has resolved after discharge. When inpatient, outpatient, school, and family symptoms communicate clearly, we create a safety net that holds the youth through the vulnerable post-discharge period. Collaboration ensures that no one is working in isolation and that the youth receives consistent trauma-informed support across all settings. As we wrap up, I want to leave you with three core messages that anchor everything we have discussed today. These are the principles that should guide your practice no matter what setting you work in. 1, firearm injury is a leading cause of youth death. That reality can feel overwhelming, but it also means that healthcare providers have a powerful opportunity to intervene. Every clinical encounter is a chance to identify risk, strengthen protective factors, and prevent tragedy. Our role is not political, it is clinical. We are addressing a major public health issue that directly affects the youth and families we serve. 2, firearm safety conversations should be as routine as asking about medications, substance use, or seatbelt. When we normalize these questions, families are far more open to discussing them. A trauma-informed approach grounded in the principles of safety, trustworthiness, choice, collaboration, empowerment, and cultural humility helps reduce defensiveness and build rapport. Families are more likely to engage when they feel respected, understood and supported rather than judged. Our tone, language, and curiosity matter just as much as the content of the conversation. 3, lethal means counseling is one of the most effective evidence-based interventions we have to reduce suicide risk. It does not require a specialized certification, long sessions, or complex tools. Just a brief collaborative conversation about access to firearms and other lethal means and how to increase safety during periods of elevated risk. This is well within the scope of every advanced practice provider. When we help families secure firearms, even temporarily, we create time and space between a youth in crisis and lethal means, and that time can be life saving. Ultimately, our goal is simple, to keep youth safe. By asking the right questions, using trauma-informed communication and integrating lethal means counseling into routine care, we can make a meaningful difference. These conversations save lives and you are uniquely positioned to have them. Thank you for your time. Hi, thanks so much for your talk. Um, I have a lot of friends and colleagues in primary care, um. So Is should there be a one on one conversation? I'm not sure that always happens here at Children's anyway, when the kids are inpatient, um, with the primary care, or is it just with the therapist? So it's typically with the therapist or the medication management provider. Um, sometimes the one on one, like in-person conversation or real-time conversation isn't happening so much as like. Handing off the discharge paperwork, but we are trying to move more towards like trying to have those conversations with providers. That's great. Um, and then something I learned recently, this is more of a comment, but like, it goes so far to say, like when you're in a, because I'm not in, um, mental health, uh, a mental health area, like whatever you're seeing the kid for, um, it goes really far to say, you know, I know you brought Johnny here because you want the best for Johnny, right? And so do I. And so that's why it's important for us to have this conversation about. Whatever it is, you know, whether it's vaccines or guns or anything that could be construed as political, um, in this day and age that you can say, you know, I know you want the best because you brought them here, you brought them to see me for this, so I really want to make sure that we have this conversation about this other thing. Yeah. Thank you, thank you. Thank you for such a nice talk. Um, I don't know if you can answer this, but I'm just curious, what do you, what do you think is like the root cause of such an increase in the, um, suicide and the gun violence, just given that I feel like maybe many years ago when, you know, my parents were growing up, there was probably just as much access to the guns in home. Um, but not necessarily an uptick in the suicide and, and the gun violence. So what, what would you say is the main contributor to that? I think some, and I'm no expert, so, but in the, some of the research that I've done is like there is more, um, acknowledgement of what's going on, um. And that can contribute to, you know, there's more, we know more about mental health, we know more about gun violence, and potentially, I know there were some studies that have said that like, um, We didn't talk about it very much, right? It was still happening. We just weren't really talking about it. Thank you. Thank you, everyone.