Issue 1 | First Quarter | 2016

Mary Christie Quarterly A publication of the Mary Christie Foundation

Robert Meenan:

The Kids Are Not Alright p. 9

Q&A with John Sexton, President Emeritus of New York University p. 3 Exercise & Eating Disorders on Campus p. 20

Issue 1 | First Quarter | 2016

Mary Christie Quarterly The Mary Christie Quarterly is a publication of the Mary Christie Foundation, a thought leadership and philanthropic organization dedicated to the health and wellness of young adults.

STAFF Publisher & President Editor & Executive Director Treasurer Research Associate Communications Coordinator & Staff Writer

Robert Meenan Marjorie Malpiede Amy Feldman Dana Baarsvik Ashira Morris

BOARD OF DIRECTORS Chair

John Sexton

Vice Chair

John P. Howe, III

Vice Chair

Michelle Dipp

President

Robert F. Meenan

Secretary

Marjorie Malpiede

Treasurer

Amy Feldman

Member

Frederick Chicos

COUNCIL OF EXPERTS Chair: Susan Windham-Bannister

Terry Fulmer

Lawrence Bacow

Dr. Paula Johnson

Lynne Bannister

Dr. Derri Shtasel

Grace Fey

Ellen Zane

CONTE NTS 03 Q&A: John Sexton, President Emeritus of New York University 06 Opinion: Smashing Stigma and Confronting Addiction 09 The Kids Are Not Alright 14 Dr. Paula Johnson to Head Wellesley College 15 Opinion: Race Issues on Campus Rooted in Opportunity Gaps Early On 17 Q&A: Dr. Judy Platt, Student Health Director of Boston University 20 Exercise & Eating Disorders on Campus 24 Young Voices: We Need Help Asking for Help 26 Science Summary

Cover art and spot illustrations by Emma Roulette

Q&A: John Sexton John Sexton believes that helping young people discover who they are should be a primary goal of higher education.

Interviewed By Marjorie Malpiede

John Sexton may know college students better than they know themselves. The 73-yearold former high school debate coach and President Emeritus of New York University has kept his illustrious academic career as close to the classroom as possible. For 14 years, he was both professor and president at NYU, hosted annual student retreats at his home on Fire Island, and presided over the development of one of the strongest student wellness programs in the country. His interaction with his students is as intentional as it is exhilarating. Sexton believes that helping young people discover who they are should be a primary goal of higher education.

Weeks before his retirement as president (he still teaches at NYU’s New York, Shanghai, and Abu Dhabi campuses), Sexton strolls through the university’s Global Center for Academic Life, stopping for selfies with admiring students and asking a cluster of prospects what they want most out of their university experience. When we sat down to discuss the health and 03

wellness of tomorrow’s leaders, he sounded more like a philosopher than a university president. Here’s what he had to say.

dents, including stress-related anxiety and depression.

What might be contributing to this?

MCQ: Why is health and wellness programming on college campuses so important?

JS: There has been a shift in the way we view the role of higher education in America today. Students come to college keenly aware of the large investment they and their families are making in terms of time and resources, and that forces a more utilitarian view of college, one that sees college as primarily preparation for a career.

JS: We need our youth to be healthy and well-educated to address the challenges that our generation is leaving them, from climate change to ensuring a world economy that provides a decent life for all. This is best achieved when we educate the whole person – mind, body, and soul.

My view is that unless we make wellness deliberate in some form, a component like reading and writing, then a comprehensive essential element of higher education is missing. We need to be asking ourselves, “What do we want to come out of the development of this person?”

MCQ: We hear a lot about the increase in behavioral and emotional health issues facing today’s college stu-

This creates all kinds of conscious and unconscious pressures that I don’t think we yet fully understand. They feel pressure, for example, to decide what they want to do very early on, and then hyperextend themselves into internships and job preparedness. Graduation is no longer a rite of passage. It brings with it a fear they might not be well-started in their career path.

That said, I think it’s very easy to have a conversation about student wellness that

Photo by John Gillooly

John Sexton in discussion with Susan Windham-Bannister and other council members at the first Mary Christie Foundation Council of Experts meeting. is defensive about the various challenges and issues that students face. But this easy conversation misses the more affirmative aspects of student wellness.

Viewed affirmatively, student wellness prepares students for a life that is joyful, useful, fulfilling, and balanced. Seen this way, a core part of the education we hope to impart includes the skills of general wellness – not just physical exercise and good diet, but also the importance of contemplative time and setting a balance between the personal and the professional.

MCQ: How do institutions make wellness more deliberate?

JS: I believe that if we are to develop in students a life of wellness, which in my view is everything from healthy lifestyles to behavioral and emotional health to respectful interaction with one another, we need to do so both defensively and affirmatively. First, we need to be there for students who are facing various wellness challenges and let them know, easily and transparently, what supports are available to them so as not to let their challenges becomes obstacles to their education.

This is critically important today when we are experiencing the positive phenomenon of students with psychological challenges who can manage their diagnosis such that they

can be admitted to and succeed in college. There are obstacles that we want to get out of their way, or at least make less daunting, so that they can learn and thrive. On the affirmative side, even as we demand that they stretch themselves and move beyond their comfort zones, we must provide safety nets so that their intellectual and experiential risk-taking does not endanger their well being.

Thus, At NYU, I wanted people to know that we accepted an obligation to be as aggressive as possible in providing wellness programs for students. We have a growing array of tools and resources on campus including in-person and online programs on stress, 04

substance abuse, sleep, and relationships. We have a student wellness exchange that supports students by phone 24/7.

And I make a point of linking this back to the fact that our tuition is among the highest in the nation. I say to parents, “If this does not mean something to you, you should realize you’re paying for it anyway!”

MCQ: What advice would you give other college presidents?

JS: The answer to this really depends on the objective of your institution. Not every college or university is going to accept wellness as part of its mandate, because in this vast category of institutions—that is, American higher education—some are very narrow-

On the other end of the spectrum are small, liberal arts colleges and research-intensive universities that supplement academic life with extracurricular activities. The most comprehensive offer studyabroad experiences that open new worlds. When students at these institutions encounter an environment or human beings who are different from them, we want them to see this as a great gift instead of a great terror. But often they need sophisticated programs to help them get to that point.

Overall, I really do think there are powerful reasons to name emotional wellness and address it, because there is a powerful interest in families about it, especially if your school is going to challenge

“Viewed affirmatively, student wellness prepares students for a life that is joyful, useful, fulfilling and balanced.” - John Sexton ly focused. On one end of the spectrum, you have institutions that seek only to impart existing knowledge at as deep a level as a student can handle in a very narrow area or discipline, largely unconnected to other disciplines. You take competency exams that judge your mastery of that body of information. That is your environment.

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students to think differently. I think it is very comforting for families to know that you will provide a safety net for all students, and certainly for those who come with a history of challenges.

The critical element here is understanding what kind of institution the student is entering, what kind of educational frame it provides, and how the

mental health and wellness of students will be supported.

MCQ: How do students and parents get that kind of information?

JS: This is currently a challenge. What we really need is a dashboard of indicators – just like we do with other indicators like job placement, statistics, or SATs – on an institution’s approach to health and wellness. Does this particular institution make this a priority? How so?

MCQ: Will providing more information about supports really help address behavioral and emotional health issues on campuses?

JS: Yes. Because you can match the student to the right environment, you know what’s missing. If emotional health and wellness of students is one of the things that an applicant and his or her family are seeking, it may affect the selection of a college or university. And if the college or university I attend is not addressing wellness issues, applicants and parents who know this must attend to this need in some other way.

John Sexton is the President Emeritus of New York University and the Chairman of the Board of Directors for the Mary Christie Foundation.

Opinion: Smashing Stigma and Confronting Addiction Instead of being paralyzed by the cultural connotations of addiction, we should approach it like other health problems that people can and do recover from.

By Dr. Leslie Adair This can create a “perfect storm.” The intersection of coping with intense stressors and the freedom to make decisions can lead to alcohol and other drug use, misuse and addiction.

Photo courtesy of the Hazelden Foundation

Going to college and living on a campus can present unique, often difficult challenges for young adults. As they transition away from high school and the safety net of their home environment, they may encounter life-changing situations.

They might have underestimated the stress of college. There are worries about fitting in and concerns about living in a dorm or on their own. On college campuses, alcohol and other drugs are often more accessible than at any other time in a young person’s life.

Some students are not prepared for the realities of college life, and their parents are not able to protect them from every unexpected challenge. Students may choose to attend college across the country from their hometown and then discover that they don’t have the skills necessary for survival on their own.

At this stage of their life, young adults tend to view themselves as invincible and often discount the seriousness of high-risk behaviors. This com-

bination can turn a seemingly benign situation into a dangerous one.

The fact is that most of us can get hijacked by unexpected obstacles. The sudden realization that “this is really much harder than I expected” can derail anyone.

A young woman I know shared recently that she was absolutely devastated by receiving a “B” grade in one of her first classes at college. As a high achieving “A” student, she couldn’t wrap her head around the expectations of college professors in comparison to her high school teachers.

When this derailment occurs, it’s not a big leap for young adults to turn to substance

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use to make the uncertainty and insecurity go away. What starts as maladaptive coping can spiral into a constant need. And once control is lost, substance use becomes a full-blown addiction or disorder. That’s when we start to see falling grades, damaged relationships and negative, risky behaviors.

Stress also plays into the cycle of addiction.

Being in an unfamiliar environment away from the home support system can cause anxiety, which may

and addictive tendencies coming together.

While the student may self-medicate in hopes of feeling better and avoiding more stress, this may also be the critical time when the light switch to addiction gets flipped on.

Those with a predisposition for addiction or addictive tendencies may now find that they are struggling with a co-occurring disorder like anxiety or depression along with an addiction to alcohol or other drugs.

handle challenges and not fail. As addiction develops, their first reaction may be to isolate and pull away from relationships with family, friends, teachers or mentors who might be able to help. This, in turn, exacerbates the problem.

In our society, there is a definite gender bias between males and females struggling with alcohol and other drugs. The “boys will be boys” mentality still exists, and while parents may be tolerant of their sons drinking,

“While the student may self-medicate in hopes of feeling better and avoiding more stress, this may also be the critical time when the light switch to addiction gets flipped on.” - Dr. Leslie Adair escalate to panic attacks and depression.

A typical reaction is to “self-medicate.”

This is also when we see both stress

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For college-age young people, there is also a tremendous amount of pressure to “hold it together”– to be able to show family, friends and others they can

late more than men.

When we get a college-age woman into our residential treatment, she often has been hiding it for so long that she is much sicker than her male counterparts.

For parents, it may also be extremely difficult to take that first step and admit that their son or daughter has a problem. This is where the stigma of addiction really becomes apparent. Parents of a child who is struggling with alcohol or other drugs may be experiencing intense feelings of personal failure, blame or guilt.

they don’t want to admit their daughters have a problem or are addicted.

In reality, we need to look at addiction as a health issue. People of great character and great success have substance use disorders, too. And even the best, most well-adjusted parents have children with substance use disorders.

Women with addiction issues tend to iso-

It’s important to not be paralyzed by stig-

ma, but rather to look beyond it and see addiction for what it is: a health disorder that is dangerous, even deadly, but one from which many people can and do recover.

Breaking through the stigma and voicing concerns to a qualified professional – whether clergy, counselors, school administrators or school health care providers – is essential. Early assessment and treatment of the addiction can make a tremendous difference in the recovery process.

It’s equally important for colleges and universities to move beyond stigma and not deny that alcohol and other drug problems exist on campus. The healthiest institutions offer, and even promote, addiction care and recovery support services. That requires acknowledging that such care and support is needed.

The first step toward helping a son or daughter get help is to go through a comprehensive assessment of the problem. If depression or anxiety is suspected, an assessment of both chemical dependency and mental health issues is warranted.

It is also important to seek out the services of a trained professional and follow through on the treatment recommendations. We know the longer an individu-

al stays engaged in the treatment and recovery process, the better the outcome. A common belief is that this issue can be “fixed” in a month.

However, the fact that a college-age youth completed treatment does not mean they will be successful once re-immersed in the same environment, with the same stressors. In some cases, the decision has to be made to put college on hold for a while, in order to get the care and establish the stability one needs.

A promising development is the rise and growth of collegiate recovery programs (CRPs). A CRP is a supportive environment within the campus culture that reinforces the decision to disengage from addictive behavior. It is designed to provide recovery support along with the educational opportunity to ensure that students do not have to sacrifice one for the other.

Hazelden Betty Ford Institute for Recovery Advocacy is a strong supporter of collegiate recovery programs, and it’s our hope that one day, every campus in America will have one.

Leslie Adair, PhD, LP, LMFT, is director of Mental Health and Family Services at the Hazelden Betty Ford Foundation in Plymouth, Minn. Her areas of focus include co-occurring disorder assessment and treatment; couples, family, and relationship counseling; abuse and trauma issues; integrating Twelve Step philosophy into mental health treatment; and cognitive assessment. She is a 2010 graduate of Fielding Graduate University in Clinical Psychology.

More than 150 colleges and universities now have CRPs either established or in the process of being launched. The

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The Kids Are Not Alright Why the health and wellness of today’s college students need further examination.

By Robert Meenan

Every generation understands that the future belongs to the young; that the youth of today are the leaders of tomorrow. My boomer generation believed so strongly in our future as leaders that we looked suspiciously at those over 30 and thought songs such as “Our Day Will Come” and “The Kids are Alright” said it all.

Today, our young people live in a more insecure time when even the kids themselves doubt how alright they really are. The youth of today, who will be the leaders of tomorrow, are facing challenges that in many ways are more difficult and more daunting than those faced by prior generations.

The prominent sociologist Robert Putnam (“Bowling Alone”) has documented this difficult new reality in his latest book, “Our Kids: The American Dream in Crisis.”

His book describes how the social context for today’s young people has been fundamental-

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ly altered by major changes in the economy, in family structure and in technology.

them develop into the leaders that they want to be and that we need.

While the youth of today are far safer than were prior generations from the classic four horsemen of famine, pestilence, war and death, they are more anxious and less resilient. They are also more depressed and more financially indebted that any previous generation of American youth.

In a recent edition of The Economist, the youth of today were labelled “Generation Uphill”. We’ve come a long way – in the wrong direction - from “The Kids are Alright.”

However, as a public health expert I recognize how little attention has been paid to the health and wellness of this seemingly robust segment of our population. For some time the health and wellness of young adults has been a low priority for both public health experts and for the kids themselves. That has to change.

As a nation we need to focus more attention and resources on understanding the health and wellness needs of people entering adulthood.

health and wellness needs of young people which, as Robert Putnam makes clear, are being played out in a social environment that is increasing fraught with risk and stress.

The foundation is particularly interested in the physical, behavioral and emotional health of college students as they are truly our future leaders.

Institutions of higher education offer unique environments and opportunities for addressing student health and wellness issues as part of an overall learning and maturation experience.

“For some time the health and wellness of young adults has been a low priority for both public health experts and for the kids themselves. That has to change.” - Robert Meenan

However, higher education is not one system but rather a diverse set of independent entities with their own approaches and agendas. Ivy League universities and community colleges have many similarities and many differences.

Having served for two decades as Dean at Boston University’s School of Public Health, I continue to be inspired by today’s students, and I am committed to helping

The Mary Christie Foundation will strive to create common platforms for discussion and problem solving that can foster health and wellness insights and interventions across

The Mary Christie Foundation, which publishes this quarterly, is dedicated to gathering and sharing information that assesses and addresses the

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a range of campus settings for all students – high-achieving students, college athletes, students with disabilities, students of color, community college students, foreign students and those most at risk of addiction, unhealthy behaviors and self-harm.

Attention to mental health and behavioral health will be a critical component of the Mary Christie Foundation’s focus on the health and wellness of young adults, particularly college students. According to the Center for Collegiate Mental Health, college health centers saw a steady and substantial increase in students seeking mental health services over the last three school years, and college counseling centers now report having wait times of two to three weeks for appointments. A 2013 American College Health Study found that over 50% of college students felt overwhelming anxiety at some point in the previous 12 months.

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There are a number of factors that contribute to the increased importance of mental and behavioral health issues for college students, including “good news” drivers like the lessening of stigma around mental health and the fact that many students with mental health diagnoses who have been well supported throughout their teens are healthy enough to attend college.

There are also a number of “bad news” drivers including societal changes, parenting trends, and dramatic advances in technology and communication. We are also putting increasingly high expectations on students, and they in turn are putting higher expectations on themselves.

Today’s college students are also dealing with the challenging double-whammy of high student debt and a difficult employment environment.

Stress and anxiety have become a modern epidemic in

today’s college populations.

According to a study by the American Psychological Association, young adults in America (ages 18 to 33) are significantly more stressed than other age groups.

For college students, typically the youngest members of this cohort, transitional issues compounded by academic or athletic pressures and relationship problems can be overwhelming.

For an already anxious individual, often on his or her own for the first time, the stress can be profoundly unhealthy.

Stress can have an especially unhealthy impact on students with pre-existing conditions and on minority students, including Black or LGBTQ students, who additionally have to deal with stress from overt or subtle racism and bigotry on campus.

A recent study by the Jedd Foundation and the Steve Foundation shows that fewer black students rated their college experience as “good” or “excellent” and were almost

twice as likely to say they seriously considered transferring in their first semester. The report also showed that 75% of Black student responders preferred to keep their feelings of discomfort about college to themselves.

The most recent annual report from the Center for Collegiate Mental Health found that 10% of college students visiting campus counseling centers have made a suicide attempt, 25% have self-harmed, and 33% have seriously considered suicide.

Earlier this year, the MCF partnered with Hazelden Betty Ford’s Center for Public Advocacy on a survey of college students and opioid use. Of the 1,200 young adults surveyed, almost 16% report having used pain pills not prescribed to them, while over 37% said

“Institutions of higher education offer unique environments and opportunities for addressing student health and wellness issues as part of an overall learning and maturation experience. ” - Robert Meenan Chronic stress can lead to a variety of health problems including depression. According to the 2014-2015 ACHA National College Health Assessment, 34.5% of college students felt so depressed it was difficult to function at some point in the past year, and 13.1% of college students have been diagnosed or treated for depression in the past 12 months.

The most extreme and tragic of these statistics is, of course, suicide, a leading cause of death for college students.

Binge drinking, drug use, unprotected sex and other risky behaviors continue to challenge administrators in ways that are far beyond the purview of campus security.

As a contributor from the Hazelden Betty Ford Foundation writes in this inaugural issue of the Mary Christie Quarterly, “What starts as maladaptive coping (to college stress) can spiral into a constant need.

And once control is lost, substance use becomes a fullblown addiction or disorder.”

they would not know where to go for help in the event of an overdose.

The survey also found that opioid painkillers are readily accessible and that young people do not appreciate the lethal nature or addictive power of the drugs. The numbers were virtually the same for those who identified as college students and those who did not.

Risky behaviors can quickly lead to criminal actions, opening up a new set of de12

mands and challenges that colleges and universities are not equipped to adequately address. In the spring of last year, the Campus Climate Survey on Sexual Assault and Sexual Misconduct found that 11.7% of students at 27 universities reported experiencing nonconsensual sexual contact by physical force, threats of physical force, or incapacitation since enrolling at their college.

NYU’s “The Reality Show.” The Mary Christie Foundation will be looking at all of these approaches in an effort to expand best practices and identify areas where more work is needed.

the stronger for it. And they are humble and realistic. Not for them is the misplaced overconfidence of the boomer generation that ended up falling far short of its audacious expectations.

While today’s college students may not be “alright,” they are a remarkable and inspiring group that deserves attention and support. They are ap-

I look forward to engaging in the important work of the Mary Christie Foundation with its founder, Fred Chicos; its chairman, John Sexton; its impressive collection of board members, expert advisors and staff; and you, dear readers – our audience of thought leaders and difference makers.

Drugs and alcohol were involved in a significant percentage of the nonconsensual sexual conduct. Colleges are struggling mightily to reduce sexual misconduct and to deal with its consequences.

For college administrators, addressing the behavioral and emotional health of students has become a priority at the highest level and involves a myriad of issues from liability and confidentiality to capacity and cost to student safety and campus culture.

Responses to these issues have ranged from trigger warnings on sensitive course materials to mental health kiosks to suicide prevention efforts like 13

proaching a more complex and challenging future than did my boomer generation, and they are doings so with an impressive set of strengths.

They are well educated and technologically savvy. They are open and sharing and willing to explore the issues that confront and challenge them with the promise that they, their nation and their world will be

Robert Meenan, MD, MPH, MBA, is the President of the Mary Christie Foundation, and serves on the Board of Directors. He was a faculty member at Boston University Schools of Medicine and Public Health for many years, and he served as Dean and Professor of Health Policy and Management at BUSPH for 22 years. He is a former President of the American College of Rheumatology.

Dr. Paula Johnson to head Wellesley College Mary Christie Council of Experts member named president of preeminant liberals arts college for women.

By Marjorie Malpiede college students.

Photo by Richard Howard

Incoming president Dr. Paula Johnson with Wellesley students on the search committee.

In February, Wellesley College announced the appointment of Paula Johnson, MD, MPH as its 14th President.

Johnson, an internationally renowned women’s health expert, cardiologist and professor, considers the health and wellbeing of young women a priority.

“How do we ensure that we create the healthiest environment possible so that when our students leave us and enter an ever-increasingly

complex world, they are not only educated in the most traditional sense, but they are also leaving with a healthy body and a healthy mind,” Johnson said. “This is what launches our next generation in the most powerful way.”

As a member of the Mary Christie Foundation’s Council of Experts, Johnson helps advise foundation leadership on health and higher education issues, particularly the health and wellness of American

“Wellesley College will now benefit from the extraordinary leadership and experience of Paula Johnson, one of the world’s leading advocates for women’s health and advancement,” said John Sexton, Chair of the Mary Christie Foundation Board. “We, at the Mary Christie Foundation, support and applaud Dr. Johnson as she leads Wellesley’s effort to develop our next generation of global leaders.”

Johnson is currently the Executive Director of the Connors Center for Women’s Health and Gender Biology; the chief of the Division of Women’s Health at Harvard Medical School and Brigham and Women’s Hospital; and is a professor at Harvard Medical School and the Harvard T.H. Chan School of Public Health. Dr. Johnson is a member of the National Academy of Medicine, one of the highest honors in the fields of health and medicine. She begins her duties at Wellesley in July.

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Opinion: Race Issues on Campus Rooted in Opportunity Gaps Early On Boston-based study is instructive for urban school districts and those hoping to increase the percentage of students of color on campus.

By Drs. Warren Simmons and Rosann Tung

Photos provided by Brown University

Many of the students protesting racism on college campuses have had their outrage acknowledged in the form of resignations of university staff and recently created diversity officer positions. But as satisfying as these symbolic actions may be, they don’t get at the root of a major problem. One of the strongest themes within the race narrative on campuses from the University of Missouri to Yale has been inclusion.

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Campus culture makes many Black students feel isolated, marginalized, feared and questioned. This exclusion occurs because of negative stereotypes, the low percentage of students of color within the student population, and the dominant culture’s default to a “colorblind” approach to education.

One way to address racism against students of color on American colleges is to in-

crease the pipeline of college-bound students of color in American elementary and secondary schools and weave discussions of diversity into the fabric of the curriculum and school culture. A recent study on the educational opportunities and attainment of Black and Latino boys in the Boston Public Schools provided information that is disturbing but instructive for any large urban school district and for those of us hoping to increase the percentages of students of color on college campuses.

The two-part study, commissioned by Boston Public Schools and conducted by the Annenberg Institute for School Reform at Brown University and the Center for Collaborative Education, determined that at every stage of education, Black and Latino males had limited access to rigorous coursework. For example, despite Black and Latino males accounting for almost four-

fifths of male enrollment, they account for just one-tenth of male enrollment in Advanced Work Classes, the primary path for Boston’s college-prep exam schools.

Invitation to Advanced Work Classes is determined in the third grade, when students are separated into two tracks based on one standardized test. Many of the eight-year-old test-takers are just learning English.

Others – disproportionately, children of color and/or low-income – did not have the benefit of pre-K programs. These children and those with special needs form a separate group – one where the course work starts and stays less challenging, the expectations are lower, and the track becomes harder to jump – with each passing year.

We have learned time and again that children are adept at understanding and adapting to the expectations that adults set for them. Given the opportunity gaps noted, it was no surprise that there are far fewer male students of color heading to college after graduating from urban high schools. We strong-

ly recommended that these schools change their tiered systems of learning to ensure that all children have access to rigorous programming, high levels of support, and an academic

We know that one quality of good schools is “knowing your kids.” The cultural diversity that now exists in large urban school systems calls for a professional response and a dif-

“One way to address racism against students of color on American colleges is to increase the pipeline of college-bound students of color in American elementary and secondary schools.”

- Warren Simmons and Rosann Tung trajectory that leads to a higher-education degree.

Our research, which intended to discover best-practice strategies for Black and Latino male achievement, found that the explicit affirmation of race and diversity in curriculum and instruction – which can lead to higher levels of academic achievement – was absent even in those schools doing comparatively better with Black and Latino males.

Cultural responsiveness was limited to the classrooms of highly motivated teachers or the occasional “feasts and festivals” celebration. Some teachers and administrators interviewed weren’t even aware of their own students’ cultural backgrounds, which is troubling, given that immigrants are the fastest-growing segment of the student population.

ferent lens. Teachers must be more versed in who is in front of them and willing to learn and practice what works with students of different cultures and histories. Black and Latino males need to see teachers and administrators who look like them and know them well enough to provide appropriate academic and social supports.

These students also need to be enrolled in high-quality learning opportunities so that their presence is a norm, rather than the exception.

Warren Simmons, Ph.D., is the former Executive Director and current Senior Fellow at the Annenberg Institute for School Reform at Brown University; Rosann Tung, Ph.D., is the AISR’s Director of Research and Policy.

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Q&A: Dr. Judy Platt Boston University’s Director of Student Health Services on creating a healthy community.

Interviewed By Marjorie Malpiede

In talking with Judy Platt about the wide-ranging health needs of college students, it is not surprising to learn her background is in primary care. As a practitioner of family medicine, Platt views health and wellness broadly and acknowledges the important link between one’s health and one’s environment. It is an approach that serves her well as the new Director of Student Health Services at Boston University, an urban school with 33,000 students from around the world.

Platt’s office is comprised of four departments, which, in addition to primary care, includes behavioral medicine, wellness and prevention services, and sexual assault response and prevention (SARP). There’s no doubt she has a big job. But if one of the objectives of campus health centers is to encourage students in need to show up at the door, she’s the right person to fill it. As inviting as she is earnest, Dr. Platt tells MCQ what life is like on the front lines of student health:

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MCQ: You have a large purview with a number of different elements. What is the philosophy behind that?

JP: We are an integrated health center which means that care of students may be managed by primary care and behavioral medicine providers who will communicate to determine the best treatment for our students. This allows us to provide a holistic approach to the care of our students. We focus on everything from infections and injuries to non-clinical interventions like the prevention of risky behaviors and general wellness. The collaboration between all the departments to educate our students about how they can positively impact their health unifies us and provides opportunities to focus our outreach efforts.

Traditionally, when people think of their student health centers, they think of being told they don’t have mono or they aren’t pregnant. But what we do in student health is actually very unique in terms of

health care provision. Where else do you find health centers doing prevention work around stress management and advocacy work around sexual assault? We are specifically and strategically tailored to meet the comprehensive health needs of students that might otherwise prevent them from succeeding academically.

MCQ: What do you think of affirmative wellness and the role that plays on campus?

JP: I like the definition of wellness as “the active process by which you make choices to maximize your physical, social and mental wellbeing.”

This is where we feel we are contributing to the academic mission of the university because we are recognizing that health and wellness is an educational process. We are going to help you make choices that will maximize your physical, social and mental wellbeing and your academic pursuits will go further. We may have a student who is academically brilliant but if they are struggling with mental health needs

Counseling Association reported that 95% of college counseling centers saw an increase in the number of students coming in with severe psychological problems. This is a phenomenon that is not just impacting student health departments.

It affects the whole university, to the level of professors who worry about students’ reactions to grades; to students themselves who cannot remain in school if they are not Photo by John Gillooly emotionally well.

Dr. Judy Platt in her Boston University office.

Your health and wellness impacts then they may not reach their everything. The student health academic goals. center may be where you turn when you have an urgent MCQ: What are some of problem but student health your biggest challenges? and wellness is something that JP: One of the common themes needs to be university-wide. for universities nationally is the rise in the incidence and acuity of mental health issues.

When I look across our four departments and ask, “What is it that drives people to us?” there are a variety of health issues we are seeing but stress is often coupled to many concerns.

Teaching adaptive strategies to deal with stress, or providing education around self-care is something that unifies much of the work we do.

In 2013, the American College

MCQ: That can’t be easy to do. What are some of your strategies?

JP: One of the things we are committed to is having really good, open lines of communication with other key stakeholders like the Dean of Students office, Residence Life, and other groups on campus that are dealing primarily with students. We are always looking to provide the community with information about what we do at Student Health.

Last year, we increased the number of health care providers in our behavioral medicine department. We also opened a satellite mental health center on our medical campus. But the big thing for us is really to think creatively, partner with other groups on campus to figure out the best way to get the message out about the importance of balance and the need to make healthy choices. We repeatedly ask “how can we reach more students in a way that is meaningful to them and at a point when they want to hear it?” Prevention means addressing something before it becomes an issue, but this is a challenge. We want to make sure people are devoting time and practice to health and wellbeing but that doesn’t always happen until there’s a problem.

One new initiative we’ve begun is the Terriers Connect program – it is a training program for staff, students and faculty in recognizing and assisting a student in distress. At its core, it is a suicide prevention program. It gives you basic tips on how to talk to someone who is struggling and where to send them for help. It gives us beacons all over the community, and it has the dual benefit of destigmatizing mental health issues. Even though we see an increase in the number of mental health visits, there is still a stigma so we know we’re not seeing all the people who might be suffering.

Our Wellness and Prevention and SARP departments have student peer educators and student health ambassadors.

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Fortunately, we have a lot of students who are interested in topics around mental health, sexual assault, health and wellness. We have over 40 students who are working to educate their peers on issues from healthy sleep to how to deal with anxiety before an exam.

The less stigma, the less barriers, the better access to care.

MCQ: What about alcohol?

Dangerous drinking is one the of the greatest public health problems on college campuses. Each year, millions of students experience a variety of negative consequences ranging from academic problems to personal injuries to sexual violence and increased suicide risk.

In addition to our education and outreach programming, we are working with our School of Public Health on “social norms” to provide evidence and a voice about what’s really going on in terms of alcohol use. There is this perception when you come in freshman year that everyone is drinking; everyone is using prescription study aids. That is not necessarily the case for the majority of students and it is valuable to give them this perspective in terms of real data.

MCQ: Sexual assault on campus is a huge concern.

How are you dealing with this at BU? Sexual assault on college campuses is a national concern.

Our SARP counselors see stu019

dents who have experienced interpersonal violence of any sort and they also provide advocacy. If a student comes in who has been assaulted, our counselors work with them through a number of intersections, from examinations and counseling to reporting and legal procedures. We have a dedicated prevention specialist who oversees our SARP peer educators and ambassadors, teaches courses to incoming

that represent actual incidents that have occurred on campus. Our Wellness and Prevention Services department provides an entire month of creative programming in the month of February related to sexual health and the definition and importance of consent. There is also our highly attended program “Sex in the Dark,” where you can ask any question about sex to an expert panel, and we constantly

“In college, we have this captive audience that’s jut starting to define what their health will be.”

- Dr. Judy Platt

freshmen, and is actively involved with Step Up Step In BU (SUSIBU), which is our University’s primary sexual violence prevention program. SUSIBU is where students, faculty, and staff learn to be an “active bystander” and discuss how they can safely intervene in situations that may lead to a harmful outcome, such as sexual assault. As a community, we want to empower you to say something.

MCQ: How are you guys dealing with consent issues?

The subject of consent comes up all the time and we address it in many different ways. We discuss it in a variety of venues at our incoming student orientation and our SARP ambassador students perform skits

weave the importance of consent into our responses.

MCQ: What is it about your job that most excites you?

I think it goes back to the amazing scope of what we do and the opportunity we have to instill healthy habits for a lifetime at a very important and impressionable time in someone’s life. In college, we have this captive audience that’s just starting to define what their health will be. Prior to that, someone took you to your physical, someone made the food you ate for dinner. But for the first time, you are making your own health choices and establishing your own health trajectory. That’s really exciting.

Exercise & Eating Disorders on Campus Until recently, exercise has been seen as a symptom of eating disorders. Can it be a part of recovery as well?

By Ashira Morris “Really rampant.”

That’s how Claire Mysko, CEO of the National Eating Disorders Association (NEDA), describes the state of eating disorders on college campuses.

Data from one college that participated in the organization’s Collegiate Survey Project showed that between 1995 and 2008, total eating disorders increased from 23 to 32 percent among females and 7.9 to 25 percent among males.

College campuses create, in many cases, the ideal conditions for disordered eating. Adjusting to new lifestyles and responsibilities can be stressful, particularly in a highly competitive environment. Many students are living away from home for the first time, away from their family support system. Starting a new social circle means that friends don’t know one another’s baselines, making it difficult to know when a fellow student’s “usual” self is slipping away.

The combination of increased

pressure and a new environment can lead to feeling a loss of control. And even good habits, such as diligent exercise, can go too far in the quest for regaining it.

Eating disorders often arise as a way to feel control in stressful situations. For students who have already experimented with dieting, college is often when those behaviors progress to a dangerous and unhealthy level. Negative body talk and dieting are generally accepted in American culture, but are es-

pecially pervasive among college students. On campus, it’s socially acceptable to complain about thunder thighs or casually compete for who has gone the longest without carbs, allowing eating disorder pathologies to continue without social

repercussions.

Nationally, an estimated thirty million people struggle with an eating disorder, according to NEDA. And yet many do so invisibly, because they don’t fit the stock photo image of a severely underweight woman.

“That picture of a young white woman dying to be thin is reinforced in the media,” Mysko said. “With that, unfortunately, comes a lot of judgment and misunderstanding.”

Obese people struggle with eating disorders. Athletes struggle with eating disorders. And men struggle with eating disorders, as evidenced by the rapidly growing statistics.

The eating disorders themselves take different forms and are not always well understood. Anorexia is characterized by an obsession with thinness that leads to a rigid routine of self-starvation. Bulimia and binge eating both involve eating large quantities of food to reduce stress; bulimics then take a compensatory purging action, such as self-induced vomiting or taking laxa020

tives. “Other Specified Feeding or Eating Disorder” includes any other unhealthy eating that causes stress or impairment but doesn’t fit into the checklists the Diagnostic Statistical Manual uses to define the other three categories.

Usually, exercise is categorized as a symptom of an eating disorder or an indicator that one could develop, but new research suggests that it could also be a powerful tool for treatment.

Physical activity leads to a wide range of benefits, from reducing the risk of heart attacks to improving mental health.

Regular exercise can reduce chronic pain, substance abuse, insomnia, and obesity, all established risk factors for eating disorders.

But exercise is often absent from prevention programs and treatment plans because of its association with the development or maintenance of an eating disorder.

In 2003, then-President of Tufts University, Lawrence Bacow, was frustrated with pre-

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vious tactics to curb students’ risky behaviors.

“Instead,” he said, “I challenged the student body to do something aggressively healthy.”

That “something” was running the Boston Marathon. Bacow secured bibs for Tufts runners for 12 years through a deal with John Hancock Financial Services, the Marathon’s main sponsor.

Student Tara Vance wanted to claim one of the Tufts Marathon Team bibs. But in order to participate, all students needed clearance from the school’s health services. Vance had struggled with an eating disorder in high school, and health services was concerned that the training would cause the disorder to resurface. Before granting approval, they required her to sit down with Don Megerle, the marathon team coach.

After a long and tearful conversation, she was approved to run. Her training and racing went successfully without any sign of her previous disorder, and when she ran again two years later, she was one of the

top 100 female finishers.

“I feel as if I dug some place that I didn’t even know existed within me, and I know you helped me find it,” she emailed Megerle after the race.

Every year, Megerle watches the process of training for the marathon improve the students’ self-esteem and shoot their confidence through the roof. “They become different people,” he said.

The science backs him up.

Exercise releases chemicals in the brain similar to dopamine, which improves mood while reducing the immune system chemicals that can cause depression.

But the Tufts Health Services was also right to be cautious: for students coping with or at risk for developing an eating disorder, exercise has the potential take on an addictive quality.

For bulimics, exercise can be a compensatory action, seen as a way to get rid of the calories.

Most people hospitalized for anorexia exercised obsessive-

ly and excessively somewhere along the trajectory of their disorder. Even before hospitalization, students with an eating disorder can develop an addictive relationship to exercise.

However, Heather Hausenblas, a kinesiology professor at Jacksonville University, argues that most previous studies have

or promoted (when either low or nonexistent) under appropriate conditions,” she wrote in her paper “Can Exercise Treat Eating Disorders?”

Her research has highlighted the physical, psychological, and social benefits of exercise in relation to eating disorders. She also developed the Exercise De-

“It’s like any addiction. The question is: Is abstinence the best model? Or do you learn to incorporate it in ways that are moderate and positive?” - Nancy Zucker started with the assumption that the relationship between eating disorders and exercise is negative, leading to a body of research detailing the various ways that exercise exacerbates an eating disorder and limited knowledge of how it could serve as a remedy.

“The byproduct of the dominant view of exercise as negative in the context of eating disorders is a lack of understanding of how exercise can be moderated (when excessive)

pendence Scale, based on the criteria for substance dependence, to determine when exercise becomes a compulsion.

“It’s like any addiction,” said Nancy Zucker, director of the Duke Center for Eating Disorders. “The question is: Is abstinence the best model? Or do you learn to incorporate it in ways that are moderate and positive?”

Zucker is currently collaborating with Duke’s Recreation and

Physical Education department to determine if strength training programs can help students with eating disorders. The study will track participating students’ eating disorder symptoms and their motivation to exercise.

By examining the relationship between exercise and mental health, they hope to determine when a fitness regimen is beneficial and when it is harmful.

The program hopes to retrain the students’ motivation for exercise by emphasizing what the body is capable of, rather than the calories burned. Removing body image from the equation is a necessary first step if exercise is going to be a part of the treatment.

Both eating disorders and exercise exist on physical and mental planes. The physical is the action, the what. The mental is the motivation, the why.

Although actions such as restricting food intake or purging after binge eating are the symptoms of an eating disorder, anorexia, bulimia, and binge eating are all rooted in psychological motivations.

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Students with an eating disorder may be driven to exercise because they want to burn a certain number of calories or clock a certain amount of time on the treadmill. The motivation is weight control and how the body looks, and it creates a rigid structure that can lead to exercising to the point of exhaustion or illness.

Researchers hope that by shifting the motivation to exercise away from body image and toward capability, exercise can become a way for students to gain body confidence and, ultimately, maintain a more healthy relationship with food.

If exercise is driven by how the body feels and the health benefits it provides, the action becomes more positive.

“The relationship can be very different, person to person,” Zucker said, “but rather than taking a punitive action like restricting gym access, we should make the message about working as a team with your body.”

“It has to be a highly individualized process to determine what would be appropriate,” Mysko said. “It depends on 023

where they are in their recovery and what their relationship to exercise is. The same behavior can be helpful for one individual and not helpful for another, given circumstances and context.”

The key, experts say, is knowing what to look for and when to intervene. Colleges and universities may be target zones for eating disorders, but as communities, they are uniquely able to reach students where they eat, sleep and work out.

They have the potential to provide systemic support for their students coping with an eating disorder, and the campus fit-

ness center is a critical part of that support structure.

“I really believe that fitness professionals—coaches, trainers—are part of that category

that I’d call the ‘front line,’” Mysko said. “They are the ones who can recognize problematic behavior and direct people to help.”

But despite their front-line status, only a small percentage of college athletic and fitness professionals are trained to detect and respond to a person with an eating disorder. Nearly all students surveyed by NEDA (91 percent) thought that training opportunities for fitness instructors and dieticians was important in supporting students with eating disorders, yet fewer than one quarter of schools (22 percent) said that their campuses provided this training for their employees.

There are still gaps between the resources universities offer and what students need. But an eating disorder is not a lifelong illness; students can and do recover from them. By investing in support systems, college campuses could become a place for students to establish a positive relationship between food and exercise.

Young Voices: We Need Help Asking for Help Taking the first step toward treatment can be a challenge in and of itself.

By Blair Ballard one suffering from an eating disorder. I reasoned if I could manage my life so well on the outside, I’d eventually be able to solve my internal turmoil.

Photo provided by the author

Asking for help never crossed my mind. My internal voice reasoned I couldn’t be suffering from a mental illness; I was doing well in my classes, and I wasn’t falling into the typical college freshman peer pressure traps. I certainly didn’t feel like the stereotype our society portrays of some-

By the end of the semester, it became readily apparent to my family that I’d hit a breaking point — their daughter, sister and friend had been swallowed by an eating disorder. My rationales, excuses and half-hearted efforts to admit anything was wrong and accept any sort of help were no longer holding up, given my noticeably deteriorated mental and physical health. It was time to take the control out of my hands. One week later I went into treatment, still convinced I was doing just fine.

It has been five years since then, and now with the gift of hindsight and distance, I have a better understanding of why I had, and so many others have, trouble asking for and receiving the mental health support they need in college.

Of course we all have unique external and internal barriers

that prevent us from seeking help, but it is particularly difficult for a college student suffering from a mental illness.

First, asking for help requires self-awareness; you must understand yourself and your emotions in order to know when things aren’t right. Going to college can be an emotional rollercoaster. It is exciting, stressful, and disorienting, often all in the same day. It’s often a person’s first big life transition, filled with new opportunities, pressures, and responsibilities. There are so many new challenges and emotions that it’s hard to know whether what you’re experiencing is “normal.”

Asking for help also requires confidence and the belief that needing support is not a sign of weakness. This can be hard for several reasons, but chief among them is the tendency for college environments to reinforce the perception that everyone else “has it together.”

Since peers tend to put up a composed and idealized facade

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to others, it can be difficult to express any sense of struggle without seeming inadequate, or feeling inferior.

Beyond confidence, asking for help also requires a willingness to give up control. Since college is often the first taste of significant independence, it can be difficult to voluntarily relinquish this newfound autonomy and admit you need support.

For someone with an eating disorder, this is especially hard, as a desire for control is exactly what leads many people to develop the illness.

For people with anorexia and/ or bulimia, regulating eating behaviors provides a sense of solace, offering a space in life where you can have complete control, and even feel powerful. Asking for help requires a willingness to sacrifice this control and put it in the hands of someone else.

One of the most potent lessons I learned after suffering from an eating disorder is how unbelievably powerful the mind can be. Despite the fact it was readily apparent I was suffering from an eating disorder, I shut out the reality of my illness and was blind to the overwhelmingly harmful effects it had on my life for over a year.

I was distancing myself from the people I love, I couldn’t

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form relationships with my peers, and I was constantly living inside my own head, torturing myself with endless thoughts of what I “should” be doing at every single moment of the day.

On paper, I was one of the “lucky” ones: I had an attentive family well-versed in mental health challenges, I had some of the best eating disorder specialists in the country on my campus, and I had counselors checking on me.

Training staff to identify problems, educating students in coping techniques, providing access to peer support, and offering easy, effortless outreach to those who self-identify the need for help are all critical factors in building an effective college mental health network.

Most importantly, these critical support systems must be an integral part of the day-to-day student experience, taking into account that those who are

“Asking for help requires a willingness to sacrifice this control and put it in the hands of someone else.” - Blair Ballard

Despite all of these factors, I was able to exist in private with my eating disorder until it got to a very dangerous point. Situations like mine are evidence that these problems exist in alarming degrees on campuses throughout the country, even when mental health services are readily available. It compels us to examine whether colleges and universities are not only providing strong mental health systems, but using the most effective methods of escorting students into them.

most at risk may also be the least likely to reach out.

Until there is this much needed systemic change, this epidemic will continue.

Blair Ballard, a graduate of Duke University, works in Boston. She is the first award winner of the MCF Young Voices Award given to young people who articulate an interesting perspective on a topic related to the health and wellness of their peers.

Science Summary A recap of research worth noting.

By Dana Baarsvik

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A recently released report by the Center for Collegiate Mental Health at Penn State provided a dire view of mental health on college and university campuses. Student demand is straining college health and counseling centers: the number of students seeking mental health services has grown at more than five times the rate of institutional enrollment over the past six years, and the number of counseling center appointments has grown at a rate of more than seven times that of institutional enrollment. At the same time, indicators of “threat to self” have been increasing at an alarming rate: lifetime prevalence of serious suicidal ideation has increased from 23.8% to 32.9%; among students with a history of serious suicidal ideation, the frequency of ideation within the past month has increased 7.2 to 8.3 over the past two years.

Number of College Students Seeking Mental Health Services Rising at Faster Rate than Counseling Capacity

The frequency that students in treatment express seriously having considered suicide has increased by 38% over five years. Positively, the percentage of students seeking counseling services for substance abuse, eating concerns, and academic distress, and sexual assault/harassment has remained stable or decreased slightly over the past five years. And the number of students seeking treatment for depression and anxiety has increased at a slow but consistent rate.

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An editorial by MCF Expert Dr. Paula Integrated Interventions Johnson on the subject of violence as Required to Fight Sexual Assault a women’s health issue appeared in Science Magazine following the release and Violence on Campus of the disturbing results of the Association of American Universities’ Campus Climate Survey, which showed that almost a quarter of female graduates from 27 colleges and universities reported having experienced sexual assault during their undergraduate career. Dr. Johnson called for investment in gender-specific research, and interventions that span science, public health, and healthcare systems, in order to address the widespread prevalence of sexual assault and exposure to violence, its immediate harm, and long term health consequences. Effective interventions will integrate public health’s surveillance and community-based research with screening and treatments of individuals in the context of the healthcare system.

A recent article published in the Journal of American College Health suggests that college sexual assault interventions may benefit from programming that integrates primary prevention (preventing initial perpetration) and risk reduction approaches (aimed at teaching potential victims how to thwart an assault attempt). The study demonstrated that participation in a sexual assault prevention program combining these approaches directly lowered the odds of assault, and had a lasting change on students’ beliefs and attitudes.

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3.

College students of color have unique mental health needs, facing different obstacles than their white peers, and are less likely to seek and receive help. Researchers at Vanderbilt predict a looming mental health crisis for black college students, who they say must draw on “grit” to succeed on predominantly white college campuses. Grit, a buzzword in higher education, is used to describe the combined character traits of mental toughness and perseverance.

Black College Students Face Unique Mental Health Challenges

Researchers argue that the added burden that black students bear – to prove their worth in predominantly white academic institutions, frequently in the face of overt and covert racism – takes a toll mentally, contributing to disturbingly high rates of anxiety, stress, depression and thoughts of suicide. A recent national survey of college students, conducted by the Jed Foundation, found discrepancies in first year college experiences between white students and students of color. The survey found that, compared to students of color, white students feel more academically and emotionally prepared for college, are more likely to report that college is living up to their expectations, and are more likely to feel that their college experience is good or excellent.

Meanwhile, African American students were more likely than white students to report feeling overwhelmed and angry in their first year, and were less likely to seek help for their mental and behavioral problems. Three quarters of black students reported keeping their feelings about college difficulties to themselves, and white students were almost twice as likely to report receiving a diagnosis of anxiety, depression, or attention-deficit hyperactivity disorder.

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Mental health programming produces benefits far beyond the individual; preHealth Programming Has vention and early intervention programFinancial Societal Benefits ming can produce great societal gains.

Individually, mental health disorders are associated with worse educational outcomes in college: lower grades, delayed graduated, and higher rates of dropping out. A RAND Corporation study investigated the outcome of a statewide mental health initiative in California, the California Mental Health Services Authority (CalMHSA).

The initiative allots public funding for prevention and early intervention mental health programs to 145 public colleges, investing $8.7 million annually. According to the RAND study, this investment led to a 13.2% increase in students receiving mental health treatment, and the researchers estimate an additional 329 students will receiving a college degree for each year of investment.

Graduating from college has a direct result on lifetime earnings. RAND estimates that the benefits from the added 329 graduate’s will result in a $56 million societal benefit in the form of lifetime earnings, assuming the increase in mental health treatment is due to CalMHSAs initiative. That is a new benefit of $6 for each dollar invested in the programs, $11 for community colleges.

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5.

Research has repeatedly endorsed the

Early Intervention and Integratedimportance of early intervention, along with integrated approaches for mental Approaches to Mental Health

health issues - especially in early adulthood, when mental health disorders often emerge. MCF Expert Terry Fulmer participated in a panel discussion focused on finding solutions to combat chronic disease among young people. Mental health issues were a key topic of the panel, which produced a report on the discussion that emphasized the need for integrated approaches to behavioral health treatment. College health centers are adopting integrated behavioral health care models; one University found that underserved populations, including students of color and international students, are more likely to access behavioral healthcare in an integrated model than through traditional mental health services. The panel called for colleges and universities to put a higher priority on mental health screening, prevention and early intervention for young people.

The consequences of falling short on prevention and early intervention for young adults with mental health disorders are made apparent in a recent New England Journal of Medicine case study, co-written by MCF Expert Dr. Derri Shtasel. In the study, which features 40-year-old homeless woman with psychosis, Dr. Shtasel explains how the developmental complications of schizophrenia, commonly diagnosed in late adolescence and early adulthood, hinder educational, vocational and interpersonal development. She highlights how schizophrenia’s symptoms can create challenges for daily life. This case also underscores the need for an integrated approach to mental health care, one that incorporates both mental and physical health treatment.

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