Developmental behavioral pediatrician Mark Bertin, M.D. discusses mindful parenting of children with ADHD.
(34 minutes) Dr. Mark Bertin, a board certified developmental behavioral pediatrician, studied at Cornell University and the UCLA School of Medicine before completing general pediatric training at Oakland Children’s Hospital in California. Dr. Bertin is an Assistant Professor of Pediatrics at New York Medical College, is on the faculty of the Windward Teacher Training Institute, and from 2003 to 2010 was Director of Developmental Behavioral Pediatrics at the Westchester Institute for Human Development, working in their foster care program. He is on the advisory board for Reach Out and Read, a national organization promoting child development and literacy, and also for Common Sense Media. He is a frequent lecturer for parents, teachers and professionals on topics related to child development including autistic spectrum disorders, ADHD, parenting and mindfulness. Dr. Bertin also leads mindfulness classes, having attended trainings at Jon Kabat Zinn’s Center for Mindfulness among many others, and he incorporates mindfulness into sessions on an individual basis for interested families. Dr. Bertin’s has written the books The Family ADHD Solution, Mindful Parenting for ADHD, and How Children Thrive.
For more about Dr. Bertin: developmentaldoctor.com
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Meeting Dr. Mark Bertin
HACKIE REITMAN, M.D. [HR]: Hi I’m Dr. Hackie Reitman. Welcome to another episode of exploring Different Brains. Today we have Dr. Mark Bertin. The developmental pediatrician is going to share all of his knowledge with us about ADHD, the Autism Spectrum, and all of our different brains, especially during these coronavirus times. Mark, thanks for being with us.
MARK BERTIN, M.D. [MB]: I appreciate the opportunity. Nice to meet you in person.
HR: How did you get into this?
MB: Um, I actually pretty much grew up around the field of special education, so it’s always been an important part of my life. So, I guess that’s the short of it. My family is all in special education and then a very profound part of my early childhood was we had a neighbor who ran the local Special Olympics and I started volunteering there and working there very young, so it’s just always been an important part of my life.
Parenting ADHD During the Pandemic
HR: You wrote a great article in the New York Times.
MB: Thank you.
HR: I really really appreciate it. you know, you mentioned quote, things are up in the air right now by the time this comes out things may look completely different.
HR: One of the ways I look at it is, coronavirus put everything on steroids as of where all of the neurodiversity characteristics got put on steroids, so we have had to develop more powerful tools and one of the reasons I wrote the Aspertools book about Asperger’s and Autism, is because were into here at Different Brains, giving positive tools you can really use, and so we had to develop some new tools for ADHD and Spectrum individuals and these things. Could you go over some of your favorite tools that your advising your families at this time?
MB: An important starting point in even beginning the discussion is just recognizing that we can’t do anything cookie-cutter right now and on two different levels. At least you’d have made maybe even more than two different levels but certainly I was just going to start with saying — I mean, from the child’s point of view, obviously everyone is so different that their needs are profoundly different, you know so you have children who are you know, whose social needs aren’t being met and that on some level is the biggest issue going on and then you have people who you have pretty profoundly intense neurological and neurodevelopmental concerns, where home learning just utterly undermines all of their interventions. So, it’s hard to be cookie-cutter because certainly the field is so diverse and families are so diverse, it isn’t about a single answer I think as much as being kind of I mean what I try to do with my own thinking is just to stay organized and methodical about what’s possible and then try to you know manage that and then the other side of it I think that’s important to look at is that families are all over the place right now.
You know if you have the ability for one parent to be home and you know helping out, that’s really fortunate and that’s the piece of things if you have the financial resources or the medical coverage right now there’s all sorts of things here there that’s so variable then you have other families where you have two working parents and a child who has intense needs you know and then they can’t go to school and you know and that’s a whole other discussion. So, the way I typically as opposed to giving, I think the first step before giving specific advice is just organizing like what is possible nowadays. How can I organize our thinking at least in terms of planning. I think it’s a valuable first step. I mean we have to look at it what’s the situation in our household individually and what’s possible and I think you can look at it I’m in my mind I sort of loosely break it into four parts in essence and I think that it’s a framework that you can come back to periodically to reorganize or readjust. So, one piece of things is looking at what’s possible in terms of my school supports.
So, in terms of individualizing some of the supports your talking about, we can look at either introducing or adapting like a 504 plan or an IEP, and while it isn’t, I imagine no one’s had the time to push what the legal bounds are here, certainly the right thing to do is to recognize is that those supports is supposed to support someone’s education quite broadly. If you’re in a situation where you should add more online learning indefinitely then the schools have to adapt to the needs of diverse children with special education requirements. So, most learn for example on one on ones. Might want to push for the 504 plan, IEP, to add more Facetime online time because it’s going to go better than any group situation. Might be more, more of an increase in the therapies a little bit because they’re one on one and certainly in terms of some of the bullet points that you were asking about one of the single most practical things we can ask schools to do or do ourselves if our school won’t is, it might seem trivial but it’s a big deal, is to just organize each school day into a single list because I think a lot of parents and kids are getting swamped by, you know there’s a school day but it’s being posted in like six or seven different places and we haven’t really started to talk about the specifics, but it’s really important to look at ADHD for example kind of as an organizational disorder. It’s not an intention disorder really.
So, if you have a disorder of self-management skills or organization like anything you can do facilitate organization and staying on task can be epic. So just one step you know like here’s the one to keep track of for the day and it can link out to any other websites. It can be a huge deal. So, it’s one piece of things and I’ll pause in a minute so we can talk about some of the details.
HR: Oh, no don’t let me interrupt you’re on a great role here. Keep going. I’m learning so much.
MB: Okay, however you want to do it. So the educational pieces, usually it means thinking outside the box because you know we have you know educational plans can be confusing enough during difficult times but now we have to think about how can we ask the school to do things in a way that meets our child’s needs at home. That’s one piece and then the second piece, which is where it’s such an uneven playing field, I mean it’s just not fair the way our country set up in terms of resources right now or what can I do as a family you know that will help support our children are home, so the second piece of survive outside of school what can we do, and that can be again if you’re looking at ADHD in particular you we’re so it’s like what are we capable of his parents and helping kids set up a school day that’s really structured instead of keeping it open-ended, and that’s some major thing for ADHD in particular. It could be adding extra supports like tutoring, which is you know this is already being written about and discussed a lot I mean you know this is another way our country is getting more skewed because certainly if you have the resources while education is being so profoundly disrupted, small group or one-on-one tutoring is you know is way more effective for a lot of kids and just keep him up while we’re waiting for things to get back to normal.
I guess I’m not completely thinking about it in the same way you are particularly because at some point I’m assuming that we’re getting back to some new normal, but we’ll see. I suppose he was right but the thing is a home, and then the third part of that which we haven’t gotten to is, trying to meet our needs as parents because it is completely overwhelming and it’s miserable sometimes to look in and feel like you want to be doing more and you can’t right now, and you know there’s just that the bottom line message sometimes of when we take care of ourselves even a little bit as parents you know that helps our kids so you’re trying to figure out how to deal with her own you know it’s like obviously our kids come first. It’s not like when we were young and single, and we could just go away for the weekend just because we felt like that was the right thing to do. We have a lot of responsibilities, Within that it’s useful I mean one of the best piece of advice which I probably over quote that I ever got was going into medical school which, I mean there’s nothing special about medical school in our lives that are stressful and demanding was when you get there find one thing that helps keep you sane and grounded and no matter how crazy it gets don’t let go that one thing. I think that’s useful advice for any of us in any situation. I mean this is a complete mess and we all have to stay strong so as a parent like what can you prioritize for yourself that will help you stay resilient because when we more grounded, that helps our kids. Of course, that’s what lead me to start that type of thinking that concern would lead me into a certain type of mindfulness of pediatrics in the first place.
Tips For Avoiding Parenting Overwhelm
HR: You know people when I listen to so many people in the first place when they talk about the family and they talk about the parents during these tough times, it reminds me once when I got booed [Laughs] at a regional Boys & Girls Club meeting, because you know here in Fort Lauderdale, we have 12 clubs and I’m a past chair the corporate board here. We served 12,000 at-risk youths at the Boys & Girls Clubs of Broward County here in Fort Lauderdale and I was speaking at a regional thing on the speaker before me. It was so good and so well-intentioned. It was about the parents need to do this and the parents need to do that and everything I got up and said if you go to the Hackie Reitman Boys and Girls Club on Broward Boulevard behind I-95 and you ask the kids to raise their hands if they got two parents at home nobody raises their hands. So, you’re talking about foster kids, talking about grandparents, talking about individuals, and now if you add schooling on top of that, we were only the meals they were getting. We would’ve been able to still serve the kids food if the parents could come by and pick it up. Could you care to address that a little bit?
MB: Oh, totally. I mean, there is a basic reality of what were capable as parents too, and you have to put that in the mix. It’s not, there’s a lot of discussion sometimes that it cuts both ways a little. On the one hand, you just have to start from what’s actually possible, and there’s are a lot of interventions you can do that do rely heavily on parents and if you don’t sort of explore what is apparent capable of literally, logistically, you’re not going to get anywhere, and there’s a lot of kids who you know both parents work, one parent’s home and there’s four kids, you know somebody has really intense neurodevelopmental needs that require you know more constant attention almost. There are all sorts of things that undermine what are parents are capable of and we have to talk about that, and we have to talk about parents’ emotional health too. There was a paper years ago looking at ADHD alone that had something just called decision making angst, which is just the overwhelm of having to constantly make these hard choices. So, all when I sit upon the table if were really going to address the needs with these parents and families. The flip side, which is nuances, but worth examining every once in a while, is that kids really do require adult support sometimes, and a lot of the times, the analogy is use is kind of like pushing a boulder over a hill, so it’s like choosing your battles and if there are times where even though you don’t have much to give as a parent, like if you can rally for you know three to six weeks of somebody plan things get so much easier afterwards. You know, there is that exploration sometimes.
You know, when it comes to when it starts feeling like Sisyphus, I mean that actually to me is when it’s time to come back to this sort of overall model of re-examining our whole plan that I talked about. I mean that would be the short of it, which I think is an important part of life anyway. We try something and then we have to sort of check in once in a while to see if it’s working. So, the analogy of pushing a boulder over a hill is not a warm and fuzzy one, but at the same time, it’s true sometimes that you know if like for example if a child’s acting out a lot of home, you know it’s really hard to be really serious about a behavioral plan but often if you can just you know hold that to even though you’re overwhelmed if you can pull that together you know for a short stretch of time then their behavior gets better then you know that a month from now you know you’re going to be putting in less effort to grab a little more time and space and that’s real. If it does start feeling like Sisyphus that’s why I use this overall model. I think that the important thing to do then is to step back and reexamine what’s possible. What can I change? Some things are working now. So when you start feeling there, you need to step back and say okay you know and then that’s why I start thinking and halfway through, but these areas of life are working you know if it’s not working do I need to change the school plan, do I need a different resource at home? You know its totally understandable that it’s not always possible, but you want to examine and see if its possible. Is there something that I’m doing at home that needs to change, or someone I need to call, or something you know if it starts feeling like Sisyphus, you got to step back.
HR: Change the status quo, it’s not your fault.
MB: Yeah, something in the plan isn’t working. What can I what am I capable of shifting right now? Before I get into mindfulness, I’ll just mention the last two things really quickly and then get you more detail, but the rest of the way that I look at things that there’s a third piece of things that has to do with health. That’s a big thing. We’ll talk about resilience, talk about learning, and then talk about neurodiverse people, children who often you know have issues with sleep or aren’t exercising much you know there’s this whole health piece.
MB: Yeah Diet. So, health is a whole thing, like you can sort of check in once in awhile. And then the last one and then I’ll come back to mindfulness like you asked, but in terms of the four pieces of reexamining is the medical piece. It’s just looking at is there something medical or around medication that needs to be looked.
HR: So, let’s review for our audience at this time. The list of the four things.
MB: So, its school-based supports, family-based supports, health, and medical. Medication or medical. So, when it starts feeling like Sisyphus, which it certainly is reasonable in retrospect, it may in the middle of everything going on at times. You know, that’s what you can control. I think that it covers almost everything, and you can just look at not necessarily all things at once. Like okay on one side something’s not going right you know that school is incredible stress every day, you know what what’s the next change we can make or what’s possible. Or do we have to reconfigure something about our school or at home, and even the medication piece which is something I tend to be very methodical about, I sort of work my way there in most situations, In the middle of a pandemic it might not be the time to watch and wait quite as long because it’s like call in order for trying to get a handle on a real crisis and you know they can be helpful for some kids and it might be worth discussing also.
ADHD and Executive Functioning
HR: Do you consider as one of the world’s authorities on ADHD, which I consider it, would you say it’s more of a focus or more of an executive function?
MB: Oh, I think the only way to look at ADHD and really get a handle on it is to see it as a concrete delay and executive function skills. So executive function, in a way to define it, is more or less like the brain manager. There’s a part of the brain, a skill set, that’s responsible for organization, planning, prioritization, the way I shorthand it with parents or ask parents as shorthand it is if you have to put the word management to it is probably has to do with executive function. You have to manage your attention. So, when kids have attention issues, they don’t have a short attention span alone. They have hard shifting attention, they can’t get hyper focused, they can’t attend my gets demanding, so you know you have to manage your attention, manage papers, manage social situations, manage your emotions, so anything you can put the word management to is executive function based, and if you put ADHD in the attention box you’re going to way out manage yourself because this is way more than that, and so when it comes to ADHD, again it’s always good to have a general approach to something and then the details. I mean a really vital, general, approach to people with ADHD is that some people kind of thumbnail it as a third layer of self-management skills. You know, I have a brilliant 9-year-old who academically you can do eleven or twelve-year-old work, but their self-management skills are like a six-year-old. You know, so in the short run, the interventions are what’s going to catch him up but in the short run, that’s what his skills are like. You know how would I approach the school day recognizing that he is really demanding academic work to do but his self-management skills like time management, organization, staying on task, are more like a six-year old, and by the way this is where it directly become stressful to parents of course you can’t say that without realizing that ADHD inherently puts more demand on adults. There’s no you can’t that’s why you always have to work with families to me. I mean you can’t separate the two things cause immediately all of the interactions rely on adults.
HR: Can you tell us about your books?
MB: I can, that comes back to my questions getting answered by the way, because it all ties together mindfulness.
HR: Lets talk about mindfulness first.
MB: The answers overlap, really in some ways. So, I’ll start with mindfulness because it all ties together. Mindfulness is a word that gets used many different ways now and it’s almost cliched it’s been in the pop culture, its almost becoming a headline, but its been around for centuries and you know the core premise of it is really not what people often think. It’s not about being calm all the time or like you’re perfect in some way. It’s really the opposite. I mean the core premise or premise practice is that life is inherently changing all the time and if we can start a train ourselves to live without with Morty’s you know it makes our lives better so it’s not it’s like a gym program, just like the boxing analogy. It’s just like training. We have all this metal how to read results over lifetime turns out the brain and there’s this concept of neuroplasticity, which is you know at least to a degree you made me can retrain our brains and create different habits that help us manage things, so the definition of mindfulness in its simplest edition is usually in essence giving moment-to-moment unbiased attention to what’s going on basically and each of those pieces is I hope practical. It’s meant to be mindfulness is supposed to be something anybody can do it’s been studying like cross-culturally, Intercity, you know it’s all over the place, because you know what it really means is that we tend to spend our lives caught up in reactivity, future, past, you never doing one thing that our minds is 11 years in the future or somebody annoys us and were of on our little this is what I do when I get annoyed spin and while that’s going on, were kind of on auto-pilot. We’re not thinking clearly. We’re not re-examining our assumptions. We’re just not at our best and its intuitive to most people. You know, you just have these moments where you just on vacation or just having a good day and you just you just see things clearly you just see things in a reality-based way. So, the practice of mindfulness is just about trying to reach that kind of resilience more consistently. It’s also not meant to be passive. You know there’s also a fear that we’re supposed to be okay with everything. It’s actually quite the opposite. The goal is you left so that you can see clearly you know if there’s something to be done. Which you know, so in a moment of crisis, you know even navigating that is going to be more straightforward if we can think clearly. So, the real premise is that you know without putting some effort into it, we tend to be caught up in reactivity, which makes more reactivity. You know, if you want to look at it from the point of view of stress it’s like when we’re stressed, we think differently. You know when we’re thinking stressful thoughts, that makes our body and our emotional state, which changes how we think again, and it just sort of escalates constantly. So, it might cause us to try to practice something that helps us, so that it said the core practice doesn’t have to leave it off and is a practice of meditation, but it’s very specific kind. You’re not trying to make anything magical happen. It’s just that you just get yourself more often when you’re caught up in your thinking and caught up somewhere else and come back to you know giving full attention. You know for example, a friend of mine who practices mindfulness is a surgeon and he says he’s been trying to teach it to the interns because he finds they get too much and autopilot distracted when they’re finishing up a surgery because they’re sowing it and they’ve sown it a million times before ,so they’re not really paying attention and he’s just trying to teach them you know each stitch you throw you have to pause long enough to know exactly where that sutures going. You have to give full attention to that moment because maybe it’s different this time. Make sure you’re doing it correctly. So, mindfulness is about seeing with precision in that way and with our kids they pick up on it right away. It’s that moment where we catch ourselves because you know we’re hanging out playing but 80% of our brain is dealing with a work problem and they know the difference of mindfulness. First day of mindfulness might just be catching ourselves at that moment and for the next few minutes, the most important thing is to try to get full attention to you know this game right now and ill deal with work later and it just comes a habit and an imperfect one, it’s not that a habit of getting caught up in the future is going to go away completely.
HR: That’s interesting. There’s a lot of physiology to that too.
MB: Yeah, there’s a science to that now, which is actually how I got here. What does a lot you know why I did this why I think it’s valuable really my books too, you know what happened for me is that I was fortunate enough that somebody introduced me to it as a medical resident. You know I was obviously we all that same message. That was what was stressful to me at that time and all have our stresses and I found it very helpful, but I kept it to myself for quite a long time. This was before it became popular in essence and then what happened was, I went to a medical conference about the science of mindfulness, stress management, and neuroplasticity. You know, a lot of famous researchers and speakers there, and really on weekend and I realized to myself, this is crazy. I’m working in this field where everyone is overwhelmed, you’re really having a hard time managing stuff, and this is practical and real and its like you know since that point, which was about the early 1990s, the research has totally taken off. There is now plenty of research showing that helps with stress, anxiety, physically changes the brain in different ways, some of it in short amounts of time. There’s a Harvard study showing a growth in the area of the brain related to emotional self-management after about eight weeks of practice and so the point is that
HR: I’m sorry to interrupt the concept.
MB: No please, go ahead.
HR: I had was just something that I recently got into. The concept I had was that you had to spend hours in there with bells and candles and 10 minutes in. The way I approach it is the same way when I reboot my computer. You know just take a couple of minutes and then and now let me get back to non-interrupting. I’m sorry, I just wanted to say that to our audience.
MB: That’s a great thing to say and it’s about reality and you know if you’re a parent are not going to do hours and hours with bells and whistles it’s just like you catch yourself when you can. You know you do five minutes, then ten minutes. There was a study done a few years ago where they just taught people how to wash their hands mindfully, which is again it can sound like mumbo-jumbo, but it’s very practical. It’s like you can wash the dishes. You can do a wash your hands nowadays. You can get caught up in washing the dishes and how much you resent it and because at school at work and I wish my partner would do the dishes once in a while and you spend the whole time the core of the practice is simply that you can there’s ways to just bring your awareness back like you can be all caught up and all that anxiety and resentment or you can just focus on physically what it feels like to be washing dishes because not forcing anything to happen but just cause it’s something to pay attention to innocence after a week of that practice people’s anxiety level was starting to come down because it’s just a reboot for a few minutes and you break that stress cycle and if people get in a habit of breaking that more often, it helps you stay more subtle more often. So, from that point forward in my professional life, I started talking about my phone directly, integrating into my clinical practice, speaking about it.
HR: It’s a real tool. It’s a real tool.
MB: It’s a really valuable tool and should never be packaged or sold as a fix, but it’s a very valuable support for lots of other things. So, in ADHD care for example, ADHD is overwhelming stress producing disorder. It really is because it’s a life management disorder so it’s very hard for people to have it because they get overwhelmed trying to keep up with life. You know, it’s hard for their parents for all the reasons we talked about. In any part of life when you’re trying to make a change happen, it’s really hard when you’re disrupted and feel overwhelmed. So, mindfulness can be a tool that helps you feel more resilient, feel more consistently settled, and that enables you do to some of the other things consistently because ADHD requires lots. You know, you’ve got to manage dealing with your school and you got to do these things differently home to get homework done and got tough navigate choices to make about medication you know your child doesn’t want to exercise but you want them to and it’s all stressful. So, mindfulness is a tool that helps you navigate all that and that’s true for any of us in any situation. It’s also very I mean I feel like in the middle of everything going on right now, it’s important to just acknowledge that its also very reality based. It’s not saying that you’re happy with things, its acknowledging whatever’s actually going on so, you know it isn’t always pretty like it set up to be. it’s like a totally can be recognized at the start of this is totally overwhelming and I don’t know what to do and it’s important to acknowledge that if that’s how you’re feeling because it’s part of what’s going on.
Dr. Bertin’s Books
HR: You got your different systems; your parasympathetic system and you know your breathing. Let’s talk about your books.
MB: Okay, so the books then just to continue that thought, you know my passion is sort of integrating mindfulness, which I now really think is part of evidence-based practice into supporting families. So, I have a fourth book coming out, but the two books I wrote about ADHD are integrate mindfulness as a support for all the rest of kind of evidence-based ADHD, and I always want to present things in a way that just makes it as accessible as possible to parents and families so were kind of just using plain language. Help families understand first of all why from an ADHD point of view, it’s important to really like not an academically way understand what executive functions is because from the ADHD point of view, you know the science has outstripped a lot of the older books in the a lot of sort of its understanding it as an attention disorder. So, as a parent, if you want to understand ADHD fully and support someone, it’s not about the medication or not the medication or the 504 plan or not the 504 plan, its really understanding how executive function impacts life across-the-board. You know, for example, it’s been linked to obesity. I mean it’s like it’s all over the place. So, it’s really meant to be a practical support for families and then, it’s in there if you want it’s not required if you don’t want it is this mindfulness piece and how mindfulness helps all the practice for yourself and maybe for your kids that helps you navigate this tough situation. So, those two books integrate.
HR: What are the names of the books?
MB: The first book was family ADHD solution, which was kind of a narrative approach to it all the workbook that came out called the mindful parenting for ADHD. The third one I wrote was called How Children Thrive, which is really bringing a lot of the same concepts into general parenting. I guess the short hand of that, we sort of come up with little bit, as it’s kind of done to modern science of back to the basics parenting and one of the things, its really valuable to hold onto in the middle of just the chaos. This is even before the pandemic obviously, but just of the internet-based world we’re living in, the pressures and there’s so much being sold to us at parents and kids are being pushed so hard so young to recognize that the science of childhood hasn’t really changed and what really helps children grow up strong and resilient are things that any family can do. So, that other book. It’s more of a general approach to supporting kids that integrates mindfulness again and then in the next book that’s coming out is the first book that I’m writing for teens.
HR: What I’ve learned today, okay, that crystalized for me that I had an idea about what which is really that ADHD, like some of the other entity, should be renamed because it’s a misdirection you know and I’m kind of seeing all of our brains is being on a spectrum. Not on an Autism Spectrum, but on a spectrum, and these different entities have different traits more or less and you’re seeing all of the overlap as a developmental pediatrician because nothing exists in the vacuum. You can’t have your ADHD or your Autism or you name it without some degree of anxiety without some degree of say some depression. At the other end of the spectrum, you can’t have the cognitive impairment or early Alzheimer’s without having lots of overlap and you can’t have Down syndrome without a 50% chance of developing else so it all comes together and you, you Dr. Mark Bertin. You have to save all of us.
MB: [Laughs] That’s a lot to ask but …
HR: Please do though please do. Can you please tell the audience how they can learn more about you?
MB: I have a website which is developmentaldoctor.com. It certainly has information about me, but also, practically speaking, it’s important to say that it has a lot of resource pages on it. So, if you want evidence-based information on ADHD and Autism, you know mindfulness, there’s a useful resource section to it also.
HR: What’s the biggest take today that you would tell our audience about ADHD? The biggest single thing you can tell them.
MB: I think I said it several times. The most practical things that were said under ADHD that really helps it manage it more thoroughly is that it is a delay in executive function, self- management skills, you know, and not what we typically used to think of it as an attention disorder in isolation. You’re going to start to think again what executive function means later today just as a wonky scientific word and a lot of solutions will come together for you.
HR: Well Dr. Mark Bertin, thank you so much for teaching us today about ADHD and everything associated with it. I personally learned a lot but I’m sure our whole audience did. Thank you so much for all you do.
MB: Thank you. I appreciate the opportunity to be here. Appreciate it.