Beyond the virus there is a great risk of an increase in mental illness, especially in youth. Teens coming to the end of their school life have had huge disruptions this year. For some it has triggered episodes of depression. In this podcast we take a thorough look at the signs, treatment, parent support and the role of friends for teens suffering depression. Please share this with any teens you know in case this could help them or any of their friends.
Justin Kyngdon: In this episode of the Annie’s Centre Podcast, we’re going to be discussing your teenager, depression, and the lasting impacts of COVID-19. My name is Justin Kyngdon.
Dr. Anne Chalfant: I’m Dr. Anne Chalfant. Welcome to the Annie’s Centre Podcast.
Speaker 3: One mother, one mission. To create a world where families thrive, Dr. Anne Chalfant, internationally acclaimed clinical psychologist, family therapist, author and mother of four children, brings you powerful and practical parenting techniques from her clinical and personal experience. Ladies and gentlemen, the doctor is in the house.
Justin: Good morning and welcome to all of our listeners from near and far. Good morning, Dr. Chalfant.
Dr. Chalfant: Morning.
Justin: Why are we talking about this particular topic today?
Dr. Chalfant: Well, I think COVID-19 has shone a light on mental health, and particularly on depression. There’s been suggestions within governments here and worldwide that not only might we be up for second waves of COVID-19, the physical illness, but the risks to mental health could be even greater. Lockdowns, school shutdowns and living remotely is definitely shining a light on people who are struggling with upheaval in their lives and being distanced socially, or being forced into being distanced socially, and all of the ramifications that has for mental health and normal functioning.
Coming to the point of teens, we’re talking about that because when you think about upheaval and disruption– I’ve been really thinking a lot lately about senior high school students and the disruption to their lives, particularly because of COVID-19. For those who may have already been at risk of mental health difficulties maybe with pressure from school or family circumstances living with some stress and anxiety and low mood, this kind of situation is really a great trigger or tipping them over the edge, if you like, for many, into a major depressive episode.
I can certainly think of my own patients at the moment, and some who are senior high school students, who are experiencing great difficulties with depression at the moment. So I wanted to talk about that this morning. If you can think about some of the reasons why, the end of high school is looming already for teenagers and for many, they don’t really know what they’re going to do with their life. That uncertainty, the added pressure of exams and assignments that are finally due, possibly pressure from family, within family, to work out what their path is going to be moving forward. That’s already stressful for them, without COVID-19.
Then bring in COVID-19 into the mix and suddenly school is shutting down prematurely. Those milestones that they are possibly looking forward to as great markers, almost like a rite of initiation really or a rite of passage into adult life. Final school gatherings, final school award ceremonies, marking great achievements or even effort for many. Also, the fun social activities that they’ll be missing out and the final dinners, school formals and all those sorts of things, that they look forward to so much as a reward for hard work, and an opportunity to be with friends, again, who they’ve really spent, in many instances, the last 12 years with, for some it’s the last six or seven years.
That’s certainly a large and very important part of their life. When that is abruptly disrupted, again, that level of upheaval overlapping or overlaying what is already a stressful and difficult time really serves as a trigger for mental health difficulties. Then bringing into the mix further re-entering normal life in a different kind of way now that there’s some restrictions being eased in Australia, certainly, and across the globe. Then there’s a readjustment that they have to undergo. What does school look like now? The fact that certain schools at different times may need to be prepared to close again for a couple of days as different pockets of the virus may raise its head. I suppose the uncertainty around that, being prepared for any situation around remote learning again or learning face-to-face, not really having great clarity perhaps around what’s happening with end of year exams, all of those things are disruptive and unsettling.
When there is that unsettling, those extra factors that create further unsettlement, as I said, that overlapping whatever is already a difficult, stressful and anxiety-provoking time in the final years of school, really is a recipe for poor mental health. Particularly for low mood, for feeling possibly a sense of frustration or maybe even hopelessness about the current situation, certainly, and maybe even into the future. All of those are the sorts of thoughts that go along with depression.
Justin: I also imagine, because we are going to be looking at the lasting impacts here, is also the job market at the moment is very gray in terms of if you’re looking as a teen, post-learning to go get a job and there’s high unemployment at the moment.
Dr. Chalfant: Well, certainly, many teens will look to things like casual employment to subsidize what their university studies, for example, they need funding. Many are considering longer-term prospects in terms of career paths. Many will be in families just considering the job market, not just for themselves, but in families at the moment where parents have actually lost jobs or lost employment.
That adds further stress to their lives as well because they watch that loss of their parents and they feel perhaps, obviously, very sorry for them, very worried about what their future will look like, for the parents and for themselves and for the family unit. They may feel guilty unnecessarily so. There’s all sorts of emotions that are stirred up, negative emotions. Yes, definitely, that’s one aspect as well worth considering.
Justin: Let’s look at the definition of depression and then some statistics there youths face today when it comes to that.
Dr. Chalfant: Well, in terms of statistics, these are two quite troubling statistics. One statistic is when we look at youth, so I’m thinking about individuals that are anywhere from 4 to 17 years of age. One statistic is that one in 35 will experience or suffer with depression. I think that’s a pretty astounding statistic when we consider that we’re talking about people who are 17 years and younger.
Then another astounding statistic is that 15% of 16 and above year olds will experience some form of depression in their adult life. Whether that’s a major depressive episode or whether that’s just longer periods of low mood, which we call dystonia. I think again, that’s a troubling statistics. Definitely, depression is no small issue and certainly is something that needs attention and support.
Then, what is depression? The definition around it. It’s really a sense of feeling– We all identify with feeling sad and low or losing a sense of hope at different points in our life, maybe through specific events. Depression is feeling like that more intensely for typically longer or more sustained periods of time. Feeling extremely intensely low for weeks, months, or in some instances, it can be years in time. Feeling hopeless, feeling worthless, feeling guilty. For teenagers, if we think about comments that they may make, “I’m a failure,” that things are their fault when they may not be so really personalizing experiences in a negative way and imagining that that’s a reflection of them when it may not be.
Accompanying depression is typically quite unhealthy negative thinking or unhelpful negative thinking. Often unrealistic and sometimes irrational negative thinking around guilt, around problems being because of them solely. Seeing difficulties as permanent and quite pervasive that, for example, if they’ve–
Justin: Right now, they might look at the pervasive difficulty of COVID-19, the isolation, that they’re not maybe doing as well as they thought they’d be doing in responses back from teachers with their work. This could be quite a self-fulfilling cycle.
Dr. Chalfant: It could be. Also, even within themselves, making situations more personal than they need to be. For example, teenagers, obviously with socializing, if there was some sort of issue with a friend or a disagreement maybe, a teenager who is inclined. towards depression would personalize that, would believe that that difficulty or disagreement was entirely their fault. Therefore, they may always have difficulties with friends into the future and that all their relationships may be impacted by their poor handling of social situations or conversations. They over personalize and they see things as more pervasive and more permanent than they really need to be. That unhealthy, unhelpful thinking is characteristic of the negative thinking that is part of depression.
Then, it affects obviously, because of that low mood, there’s a real lethargy, so there’s a loss of energy and a loss of interest in daily activities. For teenagers, that might be in socializing, it might be in completing everyday tasks, it might be attending school all together, a sense of withdrawal from those things.
Certainly, the physical impacts of depression are important to discuss as well or be aware of. The impact to sleep, to diet, often is either under-eating or overeating because of low mood and lack of energy leads to lack of interest in activity like exercise which we know has very important benefits for us. They are some of the characteristics or hallmarks of depression.
Justin: There seems to be three groups that parents should be really taking notice of at this time, which, there are things that the child says, and you mentioned some of the key phrases and then what they do or don’t do in terms of their not wanting to go to school, not wanting to complete tasks fully or to their best ability and then noticing those and then seeing them actually withdraw potentially. Would there be anything else that you’d suggest for parents to hear for or look for to pick up if their teenager is depressed?
Dr. Chalfant: Sometimes teenagers just will have unexplained angry outbursts, we can all do that when we’re stressed and frustrated, can’t we? But that may be another indicator, unexplained angry outburst. Teenagers who withdraw and hold things in for long periods of time. The teenager that once might have been more open and communicative with you is suddenly more shut down and hard to communicate with and then, all of a sudden, may burst or have a meltdown or an angry outburst that you feel is unexplained or unaccounted for. They may be other indications that something is really not quite right.
As I mentioned, the social withdrawal, the lack of interest in completing schoolwork or even attending school are big indicators for teenagers.
Justin: Right, excellent. Now, so what are the main treatment options?
Dr. Chalfant: In mainstream treatments, if we think just about that, typically, treatment involves either some psychological therapy, or medication, or a combination of both. They’re the three main pathways, one or the other, or both. In terms of the psychological therapies, there’s probably the most evidence, or scientific basis, or support for a treatment called cognitive behavior therapy, or CBT. I think most people are pretty aware of that these days.
Essentially, what it involves is looking at the unhelpful thoughts that we were just talking about and trying to address those in therapy, helping to highlight to the depressed teenager the degree to which those thoughts may be unhealthy and possibly unrealistic or irrational even and helping them to think differently about their situation to try and think more realistically, more rationally, and possibly more positively to focus on their strengths as well.
Then the behavior part of cognitive behavior therapy is about trying to get the individual to increase their activity levels essentially. We call it behavior activation. Really what it involves is two things. One, trying to schedule in more pleasant events for that teenager so that there are things through their week that are deliberately planned, that they can look forward to. By being pleasant, they then lift the mood and scheduling in other activities, so trying to increase just their general activity level through things like exercise, getting back into maybe some routine around completing tasks for school or other things at home. Anything really that lifts their activity levels so that they can derive some satisfaction from completing a task or seeing something through. Activities that lift their mood because they’re pleasant plus other activities that just generally give them some sense of satisfaction and accomplishment over something. That’s the behavioral part.
There are other types of psychological therapies that are becoming more well-known and well-regarded. Things like acceptance and commitment therapy is another one because there’s an emphasis within that on mindfulness and meditation, and trying to accept one’s challenges, but look to focus more on the present moment rather than get very caught up in ruminations and worries that are either future-focused or regretting past actions, because clearly those are unhelpful thoughts to any individual.
Then, as I said, the medication is the other mainstream approach. Clearly, if you have a teenager that is depressed and you’re seeking a path of either psychological interventions or medication or both, you should be tapping into very experienced and qualified health professionals to assist with that. For medication, the first port of call is a GP to hopefully give you a referral to a child psychiatrist or adolescent psychiatrist, and for the psychological interventions, then you’re best place to see a good clinical psychologist who’s experienced in treating depression.
Justin: Excellent. Can you tell me a little bit more about how these treatments work and what a teenager would expect going through that treatment process?
Dr. Chalfant: Well, you’re talking about psychological interventions?
Justin: Yes, the psychological interventions.
Dr. Chalfant: Okay. In the area of medication, obviously that’s not my expertise, I’m not a medical doctor, but that’s a matter of working with a medical professional, as I said, a child or an adolescent psychiatrist, and having them manage and support that process. It’s not ideal for people to be self-medicating or really going to their GP, being put onto some medication, and then checking in every now and then from there. There really needs quite specific support.
In terms of the psychological interventions and what that looks like for a teenager, in my practice, maybe if I use that as a proposed good standard, what it looks like is, first of all, the parents, actually, without the teenager, going along to see the clinician or the professional and speak to them at length about what their concerns are, what they’ve noticed in their son or daughter and how life is going at home and getting assistance as to anything they can do to better support their son or daughter. Then subsequent to that, or after that, it would be about the adolescent or the teenager going along for some regular sessions. If someone’s very depressed or has major depression, then at least weekly, sometimes multiple times a week, they might need to be seeing a clinician.
Really, those therapies are about talking with that person. The first step is really getting to know the client well. The first couple of sessions might simply be a matter of really understanding the teenager’s perspective and trying to build a relationship and establish rapport with them. I’m sure many people would understand that if you don’t have a good working relationship with someone, then all of the advice and suggestions in the world don’t mean much to a teenager if they don’t find you a credible person to work with. Building rapport with a teenager is really critical because they have their gut up typically when they come along for therapy or for treatment.
Then, as I said, it really is about breaking down the elements of addressing thoughts and the way thoughts interfere in depression, the negative thoughts and the ruminations, and the cycling through unhelpful thinking that can happen, and trying to find an inroad with that. Then, working with them in a step by step way to increase their activity levels gradually and get them back into life, whatever that might look like for them, and certainly to try and also give them support socially because typically they have withdrawn socially and trying to build up and renew, I suppose, social interaction and social skills as well
Justin: In the era of telehealth, which we find ourselves in, how are these treatments playing out today?
Dr. Chalfant: Look, I think telehealth has been such a welcome addition in COVID-19 for treating depression or treating any mental health difficulty, and certainly for teenagers. If we just think about people in region and remote areas, to begin with, of course, for them, that has been a major benefit because they can access support more readily and more regularly without all of the practical difficulties that they may have once experienced so that’s fantastic.
I think for those living in central business districts or metropolitan areas, telehealth, again, has been I think for the large part very positive. Certainly, from my own clients, they seem to be finding it beneficial. From the psychological bodies and professional bodies that I’m a member of, the feedback from clinicians is that it definitely that it has been of benefit. It’s not as clunky or as awkward as we were concerned it might be, not sitting face to face with a client or a patient. There seems to still be the ability to have good rapport and a good working relationship with a client across the screen.
I think the fact that at this time there is this extra risk of mental health difficulty and things like depression for teenagers, it’s critical that we have a way for them to access support when they can’t access a face to face session. Many clinicians now are going back to their rooms and with new social distancing measures and protective and hygiene measures in place, opening up the face to face sessions. But for some teenagers, they may want to simply stay using telehealth. They might not be comfortable enough to get out of the house, get on a train and get to a clinician or get the bus somewhere or be driven somewhere. They may want to remain from home and access therapy at home.
I think telehealth will really address that part of the population who are not yet able to get themselves to an appointment for various reasons either practically or because psychologically they’re not ready yet but still give them support that they need.
Justin: Fantastic. What other strategies would you suggest?
Dr. Chalfant: I think beyond the sorts of things that are covered in the mainstream treatment, there’s a number of things specific to teens, for families, I suppose, listening to this who have teenagers that I wanted to raise. Some of these are pretty common sense but I think they can never really be overstated because they are quite critical.
One thing is just introducing mindfulness for teenagers. As I said it is an area of research that we’ve now seen quite a lot of good support from in the last 10 to 15 years. Allowing teenagers to have a 10-minute time a day perhaps where they focus on some sort of mindfulness activity, meditation, or trying to be just present to the present moment and focused on that only rather than caught up in worries. So, creating some distance from worries and anxieties and thoughts that get you down. Trying to focus on the present moment, the here and now, in a mindful way is really important. There are some really good apps that can assist with that. Two apps that I really like that I recommend to my own patients are either Smiling Mind or Buddhify, so Smiling Mind or Buddhify. They’re apps that have very easy to use mindfulness activities. Just 10 minutes a day really is all that’s required. If you’re incorporating that into a routine daily that would make a big difference.
I think you can never overstate some of the practical common sense aspects of health and well being like sleep, like good diet, like exercise. For someone who is depressed, these things really tend to be the first that go out the window. They are typically poor sleepers. Teenagers generally are the ones that are going for high sugar bursts snack foods because of study, wanting a quick burst of energy et cetera to get them through the afternoon and evening. Let alone when they are depressed and can’t be bothered either making a meal or participating in a meal that’s made for them. They just don’t have the energy to do that.
Diet and helping them with diet as parents or as a family is really important and exercise for sure because we know that there are actually chemical changes that occur in the brain in terms of increased levels of serotonin and endorphins when we exercise. Doing that more regularly to help lift mood. They are natural ways that the brain lifts mood through those chemical changes. Trying to rebalance, if you like, the chemistry of the brain through regular exercise is important and that can be as simple–
At the moment we can’t get to gyms and I know in terms of mental health– I was listening actually to someone speaking about this the other day and I’ve certainly seen this with my own patients, for those who like to go to the gym as a structure in their life where they feel that they are accomplishing something and it does lift their mood. With gyms closed, there is some risk to mental health around that. I know my own clients who enjoy the gym have commented on feeling lost without it. Things as simple as going for a regular walk, maybe walking with a parent so that there’s extra support. There are certainly lots of YouTube clips and great exercise professionals who are now putting their work online so that people can access those routines and plans at home. There’s no reason not to be able to exercise in whatever way that works for you.
Keeping connected with people is another thing that’s really important. Teenagers may be socially withdrawn when they’re depressed, so finding opportunities to keep them connected even when they’re isolated. So, using things like Zoom, WhatsApp chats. Encouraging that as parents I think is critical.
The need for good routines to be maintained. We talked at length about this in the podcast that we did on routines that the benefits to mental health of having a good routine or a clear pathway through the day that gives the teenager a sense of structure and then allows those opportunities for them to feel that they are actually accomplishing something as little as that may be is very important.
I think parents need to really help a teenager keep perspective in their final years of high school, to understand that although high school and the end of high school is a very important milestone and maybe does create some paths into things like further study or further education or further training programs, it’s not the be-all and end-all. These days most adults change their career, change their paths as they go on and I think the level of pressure that we place on teenagers to somehow have a clear path now at this stage in their life where developmentally that’s not typically expected or the case is really unfair to them and puts unnecessary pressure on them.
In New South Wales we have the Higher School Certificate, or the HSC, that’s our final set of exams. In other states of Australia it’s called something else. In other parts of the world they’d be other markers but whatever they are they need to be kept in perspective absolutely and family pressure, I think, only makes that worse. For parents to just be mindful of that is really important.
I think the other thing I would say as a final strategy is just the importance of persistence. Teenagers who are more withdrawn because they are depressed are not going to be inclined to come to parents with their problems. They may not even go to their friends, who they identify more with potentially, with their difficulties. Keeping up open and regular communication with your teenager, even if it’s not the first, second, third even the tenth time when you approach them and speak to them and they feel comfortable to open up to you.
Not giving up, not letting them see that you’re frustrated by that and that you do give up on them just because, “Oh, I’ve tried, I’ve tried and I’ve tried.” I know many parents say that to me. You must never give up on a teenager who is so low because it may be the fiftieth time when you speak to them that they feel that they’re comfortable then or something you’ve said, maybe it’s a word or a phrase on that fiftieth occasion that reaches them and they feel more comfortable then to act. Not letting them go and not letting them think that you’ve tried enough and you’re done with that is really important. Persistence is really critical.
Justin: That’s a really good message, never give up. What can teens do right now with the HSC or final year exams, as a broader name for that, that’s around the corner? So what can they do right now to manage their depression or low points?
Dr. Chalfant: I think, as I said, the most critical things they can be doing, with these exams around the corner, is trying to get themselves, with support from family, some sort of a structured routine around attending school, participating in activities, some element of socializing with friends, routines around study of preparing for final exams and the possible final milestones that there may be for them at school, final milestones and extracurricular activities that they may be involved in. It’s really about establishing structure and routine. That’s one really critical thing that teenagers need to do.
Someone who is depressed is not going to do that on their own. They need support to do that, the support of the clinician that’s working with them but certainly the support of parents and the professionals in the school that may work with them, their teachers as well.
Then the other aspect, just as I said, that’s really critical beyond accessing psychological support is around sleep, diet, and exercise. Having a good sleep routine, a regular bedtime, you’re not being awake till all hours of the night doing work and then, you know, online potentially with friends, that’s really unhealthy. We know that when we don’t sleep well, we don’t function well mentally, we don’t think clearly. When you’re depressed and you’re not thinking clearly because of lack of sleep, it’s even worse.
Diet and exercise, we talked about the importance of those. Having a good diet, that’s supported by family, because again the teenager is not going to be inclined to do that themselves at this point when they’re depressed and exercising regularly, getting them out to exercise. So they are some practical things that we’ve covered.
The other thing is just accessing help. If someone is depressed and they’re not yet accessing professional support, get them to a GP. The family needs to take them along to see the GP to trigger off a process where they can go and see a clinician and perhaps access some funded support. Certainly, in Australia, we have Medicare items that relate to psychological intervention, and accessing those through a GP mental health care plan is really important. Some families don’t want to do that and they can just go straight to a clinician. You can self refer to see a clinical psychologist, but seeking professional support.
Depression is not something that goes away on its own. It does need the input of a professional. All the other strategies that I was mentioning beyond that. I think that the family and the individual can do, but it has to be done alongside seeing a professional.
Interviewer: If we flip the switch here and say if you are a teenager listening to this and you notice, or maybe think your friend might be suffering from depression, as a friend, how can you support that person?
Dr. Chalfant: I think there’s two things that I would say. One is understanding what your role is in that friendship. What I mean by that is the balance between maintaining a friendship and being supportive versus going beyond that into acting as if you are a third parent to that individual and trying to fix them or rescue your depressed friend, because that’s not your role in a friendship and that can do more harm than good. It can do more harm to you as the concerned friend because it can really wear you down and you can become at risk of depression and low mood yourself. It also can do harm to the relationship that you have with the friend who may be depressed.
So, understanding that your role is to be supportive as a friend and to be available. We talked about with parents maintaining open communication, it’s the same within a friendship. Friends and teenagers are usually the people that a depressed teenager may turn to first. Perhaps they have a better relationship in some instances with their friends. They do or feel more comfortable with their friends than they do with their parents.
If you notice a change in your friend for the worst, if you notice that they seem more withdrawn or down or low, mentioning that to them at a time that seems appropriate and calm in a caring way and trying to suggest to them that they access some sort of professional support is a really good thing to do. It may not always be easy to know when that time is and how to go about that conversation.
On that point, one app that I’ve discovered, that Beyond Blue, an organization in Australia, have put together, is a fantastic app called the Check-In App. What the Check-In App does is it actually creates a clear scaffold for a concerned friend to approach their possibly depressed friend with exactly how to have the conversation. The app helps you talk about what phrases or identify what phrases you’re going to use, knowing what you know about your friend and what would work best for them. What timing you might use, when will you have that conversation, in what kind of location will you have the conversation? What do you think will be the best environment to have that conversation?
It provides you with a detailed plan basically to arm yourself with to then approach your friend so that you feel more confident and more comfortable speaking to them. It gives you backup plans as well. So, if the first time round the conversation is unsuccessful, then it gives you a backup plan as to what to do next, what to say next time, how to handle that in yourself, and then to have another try. It’s a fantastic app and I think any teenager who’s concerned about a possibly depressed friend should download that. It’s free and that would give them great confidence and a great guide.
As I said, I think the main thing to remember is just your role. We don’t want other teenagers being worn down and exhausted by feeling that they are now the parents so that they have to fix or rescue their friend. You can’t rescue someone within a friendship. When another person is depressed, they need professional support. You can be available and supportive of them and enable them to seek support by giving them feedback that you notice changes in them and that you think that they need that help and that you’re available to them if they ever want to talk to you and that you will support them through whatever help they seek. That’s as far as it should go so that you are maintaining your own mental health.
Interviewer: Excellent. Just to finish, what other resources would you recommend?
Dr. Chalfant: I mentioned the Beyond Blue website [unintelligible 00:36:01]. So, beyondblue.org.au, beyondblue.org.au. That website and that organization provides a huge number of resources for people from fact sheets to little checklists that an individual can complete to even assess themselves to see whether they may be at risk or showing some signs or indications of depression. The Check-In App is what they produced, as I said as well. There’s separate information there for depression in adults versus youth. There’s great information for carers and people in the support network to look at and access. There’s a wealth of information in that organization.
A similar website in terms of great information for individuals is The Raising Children website. That website address is raisingchildren.net.au, raisingchildren.net.au. Of course, for someone where they’re not only depressed but there’s also risk of suicide or thoughts around that, we would recommend in Australia that they contact Lifeline. The number is 13 11 14, 13 11 14 for Lifeline.
Then as I said earlier, those apps for things like mindfulness, so, Smiling Mind, Buddhify, and as I mentioned for a teenager who’s concerned about a friend, the Check-In App. There’s some great resources there that people could access.
Interviewer: Fantastic. Thank you very much, Dr. Chalfant, for all of that wonderful information, we hope that it’s been useful to our listeners. Please comment on this episode when we put it up on Facebook and when we’re on- you’ll find us on Apple Podcasts, Spotify. Please go to the Facebook page, Dr. Anne Chalfant, and please communicate with us and share these episodes with friends who may have teenagers who could be struggling, or is just good advice in general. The website is www.anniescentre.com. If you go to the podcast page, you’ll see all of the podcasts that we’ve previously recorded there including the podcast on routines.
There’s also a routine download that you can access and you can see the structured routine example that was put together by Dr. Chalfant and you can use that as a starting point, or your child can use that as a starting point in organizing their day, particularly as we now seem to be returning in some way to some level of normalcy. Hopefully, we can soon see sports opening back up as well, and as you talked about children-
Dr. Chalfant: Exercising.
-yes, exercising and may have missed out on- maybe missing their football club. So, it’s fantastic that that’s starting. So getting them back into gear around that can be enormously beneficial all around for them. Again, thank you for your time.
Dr. Chalfant: Thank you.
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