Coty Anderson, LCSW, and Mercedes Moore, LCSW, present together on suicide statics in youth, including the warning signs, risk, and protective factors in suicidal youth.
Thank you for that Beautiful introduction Michelle. So again, like Michelle stated, our presentation is on the roadmap for help mental health symptoms and positive screenings. What now mm in case you are not aware, May is mental health awareness month. So we want to extend a heartfelt thank you to our viewers and our presenters who worked so diligently in providing mental health and wellness to our community. Okay, from this presentation we hope to enhance your knowledge on the following topics. Um suicide risk assessment measures we use at sea HKD as well as what prevention will look like. Yeah. On this slide you'll see several statistics um regarding suicide. This is a rising concern nationwide. What I would like to focus on our highlight is the lesbian, gay and bisexual youth are four times more likely to attempt suicide than straight you. In addition to that transgender people are 12 times more likely to attempt suicide than the general population. In addition, mental health is more common than cancer, diabetes and heart disease. And only one in five kids will receive the help that they actually need. This next slide showcases a day in the E. D. Here at C. H. K. D. And the reality is this is a nationwide concern based on the statistics that you just review. We see kids that come in for an overdose um intentional overdose as a suicide attempt self injurious behaviors. We also see kids with behavioral disturbances who are brought in by the police. I want you to take the time to review the terminology on this screen that you'll hear throughout the presentation. This passive S. I. So when we hear an individual coming in for passive S. I. Typically they have thoughts or feelings that they aren't worth living. Um that their family would be better off if they were dead. Mm. When we hear active assad, we understand that the patient has the intent to end their lives. Yeah. There are problems that may trigger a suicide attempt, stress caused by physical changes here at the hospital. We have kids that are diagnosed daily with pronto chronic, excuse me, medical conditions. Um The adjustment to that. Some external factors will include with the pandemic transitioning to virtual schooling being bullied at school in their community home environments are also external factors that may trigger a suicide attempt. Additional risk factors can include family history of suicide attempts and also trauma history. Whenever a patient comes to our E. D. Primarily for behavioral or emotional disruption, they will receive a risk assessment screening. Suicide screening measures has their pros and has their cons um like I said again at C. H. K. D. And our health system that includes our emergency department pediatric offices, urgent cares and specialty clinics. All will all of those facilities will give a suicide screening assessment. The pros to that is that early detection to provide the appropriate level of care to the patient. However, a con to these risk assessments are their standardized measures, which often does not capture an individual an individual circumstances. So we use a couple of assessments here at C. H. A. D. I stated before one that I would like to go over is the P. H. Q nine, which is also known as the patient health questionnaire and the non stands for the nine questions. Um It is used to assess depressive symptoms as well as the acuity or the level of severity of these depressive symptoms. We give our bringing assessments At the age of 10 or higher, so between well 10 plus excuse me years old. Um if the score is low then the providers, so at the urgent care at the pediatrician office um Medical social workers, they are often able to provide resources if the score is 15 or above. Um that will require additional assessment. So a more thorough mental health evaluation. And here you see an example of a PhD nine, I'll give you a moment just to review again as you see the nine questions feeling down or depressed, irritable or hopeless for appetite, weight loss, overeating and then they asked us more in depth questions at the bottom. Another screening tool used here at C. HKD is the S. S. Q. And that is a suicide screening question. Um it has five questions. Again this is given to Children at the age of 10 plus and this is typically administered when kids come in through the emergency department during triage. And here is an example of the questions that are asked on the S. S. Q. And as I stated before these questions are given during triage. So there's a high probability that there will be other yes the questionnaire will be given while their parent is there. These are questions that Children sometimes don't feel comfortable with asking especially asking truthfully. So sometimes they may pop positive for one or they'll answer yes to one of the questions that will automatically trigger a brief assessment from one of the providers mental health providers. So when we Cody and I will go into the room we sometimes find out that the score is actually much higher especially when we asked for the parents to step out. Yeah. And when the scores are higher or when we realize that patient may be guarded or the request from a medical provider or the request from a parent, we will go in and do a more in depth mental health assessment. So this is a mental health evaluation. These are 14 sections um that we will address and when a kid comes in primarily for suicidal ideation to homicide variations. We hone in on the suicidal assessment, homicidal assessment portion. And here's an example of that section. Now I know you see here is yes or no questions. However, we do ask more in depth questions to determine the frequency of the suicidal behavior. Um, recent attempts or previous attempts, as well as access to means to carry out the attempt or the ideation. And here's some suicide warning times that I'm sure most of you have seen or her. Um they include given items away, substance abuse, used, making suicidal threats. Suicidal injurious behaviors like cutting and a quote that Cody and I always remember from our graduate school days is hopelessness. Plus helplessness equals suicide thoughts. That's something that we like to keep in mind when engaging with our vulnerable population. Mm Right. And I'm gonna pass it over to my colleague Cody. Uh huh. Yeah. Thank you so much. Mercedes for that information regarding um risk factors as well as screening measures we do here at th K. D. I know I may sound like I have a frog in my throat. I promise you I do not. It is allergy season. So please bear with me. Um If I clear my throat throughout this this presentation again I am Cody Anderson, another mental health therapist here um at sea. HKD primarily working in our emergency emergency department with um individuals with emotional and behavioral challenges. And so part of uh the assessment process, a major part of the assessment process. It's kind of the clinical decision making. Um And what we do typically is we comprise all the factors. And so we um we collect data from the child, the caregiver staff as well as medical records to develop an ultimate recommendation um for level of care for patients. And so when assessing the parents or guardians um we we assess their concerns about their child safety. First and foremost we also inquire about the parents ability and willingness to implement safety precautions in order to keep their child safe in the home based on the patient responses, as well as the clinical formulation, we develop a recommendation or disposition um And we asked ourselves what is the least restrictive environment um that we can recommend for the patient and ensure safety. Um And so typically there are two recommendations that are given one or two. So we will either recommend a patient go directly to an acute psychiatric facility from R. E. D. Or we recommend them go home with a safety plan and outpatient follow up. And this list of resources you see here um encompasses what the outpatient follow up could look like. So case management services. Sometimes patients may need longer term options which they will find in a residential treatment center um intensive in home therapy services. Out patient is a big big one we recommend as well as medication management and psychiatric consultation when um necessary if safety cannot be maintained in the home. Um Then likely the recommendation will be for the patient to go to a cute to ensure their immediate safety from the E. D. Here. You will see an example case of a patient we recently saw here at R. E. D. I want you to take a moment to read it. Um and then we'll kind of come back and see your brain a little bit. So you will notice that Sarah is uh an adolescent female who came in with some passive S. I. And some self interest behaviors such as cutting. Um And she's been overall feeling like sad and hopeless but she's not helpless. Um And so I want you to to to put in your question answer box. You know some of the risk factors that that Sarah has as well as some of her protective factors um that you think also what you think Mom may be interested in or Mom may need. Um And ultimately I kind of want to know what you all. I think we did with Sarah. So based off of what I previously said with the patient either being referred to acute um for further stabilization or home with a safety plan. And we'll talk about that later. So everyone can go ahead and type into the Q. And A box. And I am able to see that and read your responses to Mercedes and Cody. So I'm seeing here that some of the risk factor would be the fact that she's been cutting already. Um And the uh let's see what else we have here That two things going. Um Okay. Also somebody is saying that she's actually saying she's a burden. That would be a risk factor. Um That fantasy thinking she wishes she were dead and then she's hesitant to begin outpatient therapy. The thoughts have been pretty persistent over the past two weeks. Some of the unknown, somebody said an unknown as has she ever attempted suicide in the past. And then some was saying um as far as a protective factor or something that's on would be helpful is that she does have her mom there with her even though mama's anxious about taking her home that she is bringing her in for cancel. Thank you all so much for the participation and and you're right. The fact that she's already cutting is a big risk factor. We do not know um sure we knew during the assessment but you all do not know whether or not she has a history of previous suicide attempts which is also a big big big red flag and a huge risk factor. Um And so her protective factor of having um a support figure there who is actively seeking some kind of assistance um is a big one. And so what we did with the sarah in addition to some other things, we ended up safety planning her home with mom and part of our safety plan of process um is that when we safety plan a patient, we make sure we tailor it to to that individual. Um and include like specific safety precautions um as well as follow up recommendations. And so for Sarah the pictures that you see here, she should not have access to any means to harm herself. And so she's already been cutting. So you see a couple of different kinds of razors there. Um In addition to those razors, any knives, um scissors, any sharp objects. Um We we recommend it to be removed from the home or locked up. Well, she did not have access to that. Um Our recommendations are given based off of potential high risk behaviors. And so we know that Sarah is a cutter. Um And so potentially that's a high risk behavior for her. Um And so the family's willingness and ability to carry out and implement safety plans but ultimately save her life. Um And it also promotes the continuity of care for our patients when they follow up with those recommendations. Here is a sample safety plan. We would do with the family who comes into our E. D. Um and we deem appropriate to discharge home with this follow up. And so we usually recommend families to follow up with their outpatients um providers if they already have one established. If not we make sure we give them lots of resources while they're here as well as um information about potential providers um As well as following up with the child's pediatrician. Because what we know is that our Children's pediatricians, they typically develop a relationship with them over the years and so they have some helpful insights and they may feel comfortable was potentially managing a Medford anxiety or depression or something like that. Um And so we always recommend our families to follow up with their positions um towards the bottom of the safety plan, you'll see where we provided families resources. And so the resources look like crisis services. Um As well as um the psychiatrist and the community for medication management and psychotherapy services mm All families. Well parents and caregivers have to be willing to follow through with the safety plan. Um If they are not again we we recommend a higher level of care to ensure safety. And so the ultimate goal is to prevent S. I. And S. I. B. And and and suicide attempts. And so we want to start thinking about what prevention looks like. Um And it looks like less talking about suicide and the fear and the taboo surrounding the topic and more talking about how to help these kids learn to recognize and cope with difficult emotions and situations as well as how to ultimately become resilient um to the ability to bounce back from from difficult situations because the reality is we will face difficult situations. Um the goal is to learn how to overcome. Yeah, we um want to teach kids how to identify protective factors because we all have them one way or another, whether they're internal external protective factors. And so some of the protective factors um could be a feeling of connection to community through school or through some kind of social organization, a spiritual belief, um and the ability to adapt and adaptability is a huge one um that all of us have, we just have to learn how to hone that skill, our role as providers is to communicate, um have healthy communication with our patients and our clients and in a way to do that and to ensure that um it's received is simply reflecting, reflecting that I hear you, I hear what you're saying. Um It's simply just saying back exactly what you heard someone say and that communicates to them that you understand and you're actively listening to what they have to say. Um it's amazing how a simple, reflective statement with a suicidal patient could put them at ease and when they are in our offices also validating um validation is huge and what validation is, it's just communicating and understanding of another person's um emotional experience. It's not necessarily agreeing with that person's behavior or emotions. Um and sometimes for patients or clients who are unable to speak our validation maybe gear just towards the patients experience, which is huge. Um and the quote here on this screen do not judge my story by the chapter you walked in on is big. Um because our ultimate goal is to validate a person in a nonjudgmental way. And I know that's difficult for a lot of us. Um because humans by nature, we judge, we judge appearance, we judge all kinds of things. And so just being mindful of interactions with, with, with your patients and clients and even your colleagues and loved ones. We all deal with some pretty difficult stuff day in and day out and the work specifically that Mercedes and myself, we've gotten into seeing suicidal patients and and and patients who deal with difficult things. And so we hear some pretty horrendous stories and, and and that affects us. It affects our emotions. And so in addition to, to dealing with and and paring some pretty hard things that even kids have to deal with. There's a broader context, especially from last year with the pandemic and all that that entailed as well as, you know, the things that we see on the news day in and day out is like on this loop with, you know, the political arena and like um you know social and emotional um discrimination, all kinds of things. And so we have to be mindful of how that affects us because what we're talking about here essentially is vicarious trauma and and vicarious trauma is, you know, the indirect disclosure of, excuse me, the indirect exposure have a traumatic event. And and so that's either through like recounting the events or experiencing that event firsthand. Um we all see tough stories and we hear tough stories every single day um and and and that can affect a provider and and it could um enhance provider burnout. And so we want to be mindful of that um and we want to be mindful of the way we respond to that trauma because sometimes um it affects us and we become ambivalent or um no, um if you will to to certain situations and if we're not mindful we can allow that trauma um to affect our day to day with working with the individuals we serve in the community and in fact do more damage than good. And so um here are a few like trauma indicators. Um I know a big one is, you know, fear and anxiety as well as um you know, just worrying about what could potentially happen based off of the history and what we've known to happen in the past. And so we have to be proactive in caring for our own mental health as providers. Um and the way we do that is through self care because we know that you cannot pour from an empty cup. And if we're working with these patients who are already struggling emotionally, our, you know, our ethical role is to do no harm. Um, and so the way we do that is to prioritize and and recognize that we have to care for our own mental health. And so what you see here is some examples of some self care. Um, my favorite on this slide is rest. I'm lacking that lately. Um, here are some additional examples of self care and I'm curious to know what the audience um, is doing for self care or what they would like to do for self care, um, because that's going to be important if we're going to continue to do the hard work that we do. So if anybody would like to type into the Q and A box, some of the things that you do for self care, I think this is a really important point that Cody is making here. Somebody says that they do debriefings as a team after something challenging has happened. Absolutely. Uh does yoga. I like this one, talk to myself. Uh that depends on what you're actually saying to yourself. Yeah, cooking, enjoying sunshine. So all of those are key. I kind of want to focus on the first one which is debriefing and working here at th K. D. We walk we work on a multidisciplinary team, so we there's doctors and nurses um and and therapists and social workers and all kinds of people who work together on a team in order to provide the best patient care and and part of what we've implemented um is debriefing and the briefing is really helpful because it allows us to kind of talk about how the experience just affected us in either a negative way or even a positive way. Um And feeling heard again, one of the protective factors is feeling connected as if you are a part of a community. And so here we've developed this sense of community um that has been helpful with with dealing with the hard things that we've been doing. So that's a really good one. I challenge you all to prioritize self care for yourself. Part of self care is deacon therapy, you know there's therapist for the therapist um and there's therapist for the caregivers and the parents and the patients and Children. Um And so the screen here just just list a few of those resources that's available. I encourage you you screenshot, take a picture whatever you have to do so that you can have access to this. Um Also if you like um we will email you this information um and our contact is coming at the end of the slide. Mhm. Also for all of the providers with an M. P. I. Number, this slide is for you and I strongly encourage you to um to utilize this resource. It's the emotional PP. Program um which offers free therapy services completely free um to providers with an M. P. I. Number. So all licensed providers if we've been dealing with some really really tough stuff um throughout our career, but especially over this last year with the pandemic and how it's um affected everyone's emote. Like it's just been really taxing on all of us. And so I encourage you to tap into the resources that's available um through this program. Mhm. Thank you. So we, you know as mental health providers and providers in the community, it's all of our responsibility to ensure mental wellness for ourselves as well as the people we serve and so we want to take the time to just thank you for allowing us to shine the light on such a prevalent issue throughout the community and nationwide um Here is our contact information feel free to reach out um for questions if you want any of the resources we have. Um we're here to help support you in supporting our community. Um Thank you so much for giving us the time to speak and we hope that you've taken at least one thing from the presentation today. Thank you. Thank you so much. Um Miss Anderson and um this more so um I'm reminding you to put your questions into the Q. And a community track. Um The the function is on the left hand side of your screen. You can just type in your questions there and then I will read them out loud and they can respond to them. So um so one of them here is actually without disclosing any confidential information. But each of you think of a time when you felt like in your clinical practice that um you really made a difference. So a highlight maybe of your clinical practice without sharing any confidential information. I feel like thank you for the question. I feel like um we make a difference every day, every assessment I will say. Um when we send patients home we spend some extra time with that family to provide them with the level of education and support um to feel confident in their ability to keep their child safe. And so um particularly we we have patients who come in um the younger kids, they're difficult to get placed um at an acute psychiatric hospital due to their age and so recently um I believe the patient was 34 who came in who was having some emotional outbursts and some behavioral outbursts in the home. And so just spending that additional time with mom to hear her out and to make her feel supported and to make her feel as though um she's not a bad parent because she's not, I think letting people know that they're not alone. This is something that is happening throughout um our community and nation wide and and just just hearing them out and being there to support them I think makes a huge difference with every assessment. Yeah. Thank you. But I agree just provide that that level of education psycho education to our parents and building them up and their confidence that you know, these are the challenges you're going to face. However there are resources, there are people there to get out your concerns to validate you and we're actually here for you. So that's the that's the part of the job that I enjoy. Some people are seen and heard and they feel understood. Absolutely. Okay, let's see what else we have here. Um So you mentioned referring back to a primary care physician, um can you talk a little bit about what sorts of services that primary care physician might be able to offer to the patient? Absolutely. So we see lots of patients here um who potentially um has some behavioral emotional disturbances that may require a certain medication. And and there are wait lists throughout the community for psychiatric consultation and medication management. And so sometimes Pc PS, especially when they know the patient and they've been working with the patient for years. Sometimes they feel comfortable with offering or prescribing medication to the family. Additionally, um some providers, some some pediatricians they feel comfortable with having the families talk to them about certain depressive symptoms and if they feel like there's like um additional assessment or resources that's needed. They call into our office and and speak directly to myself, Mercedes or one of the other clinicians here to ask for guidance. Um I think the PCP is a huge valuable um asset to have for the families because we go to our pediatrician's office far more than we come into the E. D. For any type of behavioral crisis. And so just having that relationship with your pediatrician I think could help prevent a lot of um you know I. S. I. S. I. B. Um and even suicide attempts. Great answer. Okay so in your introduction, you mentioned for both of you that you enjoy working with disenfranchised populations and then marginalized populations. So can you talk a little bit about some of the mental health needs of those populations? Absolutely. Mercedes what you like? I'm sorry. Um So marginalized populations are those who are reluctant to receive mental health care. So those are the ones where we again provide that psycho education. We normalize um suicidal ideations. We normalize behavioral events and we just try to, especially with our parents um are african american population who are reluctant to seek out these resources or to minimize their child's behaviors until it's not to the point because it's never too late. But to it's to a point where they're burnt out and they're at their wits end. So, those populations we enjoy working with because a little disclosure, we come from those populations, we come from those backgrounds, so to be able to provide the education to individuals who look like us and we understand what neighborhoods they come from, that another part of the job that we enjoy. Also, just just to um to piggyback off of Mercedes and and and to add an additional population and they are those individuals who live in the rural areas, there aren't many resources out there for them. And so it's not necessarily that they do not want to receive the help is that they do not have access um to receive the help. And so we enjoy working with those populations to help get them access to the care because just as well as any privilege, um individual who has unlimited means and access, we would like to see those individuals who do not have the access to at least get the information. Um so that they can know where to go in their time of need. Um lots of psycho education because sometimes what we see is um an angry outburst. And, and underneath that angry outburst, there are all kinds of things that, you know, whether it's embarrassment or, you know, abandonment or some type of traumatic event that they've experienced. And so just taking the time with the families to hear them out and provide them with information. Um, I think it's helpful that they otherwise would not have access to. Definitely information is, uh, well, knowledge is power. Knowledge is power. Let's see. So you had talked about, you're saying about hopelessness and helplessness. Uh, somebody's just mentioning that and um, how do you offer hope to the families that you work with? That's a great question. Um, and part of part of offering hope is to to hear them to make them feel heard and validated and hear them at every encounter because we have our frequent flyers, but every time they come in, this is a new crisis. Yes. And so, um meeting the families where they are in that crisis. And so I think it says a lot when, when someone feel heard and validated. And so I know I'm one of the slides I presented, there was a quote. Do not judge my story based off the chapter you walked into. Um, it's powerful because by nature we want to judge, we want to judge people. Oh Lord! Such as such as back such and such has um been having these emotional, she's doing it for attention on blah blah blah. Um, and so every single time we encounter patients, we treat them with dignity and respect and we validate them and we make them feel heard. And every time we do that we're instilling a little hope in that patient. Um, in addition providing them with resources and and actually taking it a step further, A lot of patients um they struggle with maybe transportation and so they can't get to certain appointments. And so we may give them information about transportation that's out there and available through a Medicaid cab or you know some type of program um nonprofit organization who who sponsors transportation. And so I think being present with the families um and still hope. Mhm. For the answer anything you want to add to that Mercedes? No, you guys are good. Do you ever get to work together or are you on separate shifts? Uh They gave us a nickname of razzle and dazzle and so we I asked him a lot. Yes. Right, so we do have a request here. Um So aim sleep. Oh, it's from me. Okay, could you please show the slide again with the online suggestions for 2020? Can you backtrack to that slide? Uh huh. Therapy tools? There we go. Yeah. And again, if you email last week and send you direct links um, as well. And I'm seeing here also some additional self care. Somebody mentioned pets. That's a huge one that we actually have pets here that we use as our therapy. Yeah. Yeah. Tell us a little bit about that program. The pet therapy program. Mm Well, Michelle, it's actually service dogs that are here. I know we have one um, sterile eat It is her name. Um, and she goes around to the different floors of the hospital. Um, kind of helps you with anxiety, um, medical procedures or that these Children face day in and day out. She is there to provide that comfort and support. And we also, um, in addition to our very own serially, we have volunteer dogs um, in the buddy brigade. And so volunteers will will bring their dogs and then they'll do like a dog parade for the patients, um, and our mental health patients. They find the dogs presence very calming and soothing. And so, um, a lot of times I think when patients come into our hospital because we're a medical facility, we forget that mental health patients also um, could benefit from a lot of the things that typically our for our meta conversation. Yes. Um, and so we've allowed, um, are mental health patients to have access to the body brigade as well? We have here. Thank you for these resources. Um, speaking of online options, I will share with our Ch Katie pediatric residents. Absolutely information to share with everyone. Yeah. Okay. If we have any more questions coming in, so please type in the Q and a box. If you have any additional questions for either of our panelists today, Let's see. I shot it down. Um I think you kind of covered this one. So if if you're doing a screening and you find out that there's some some social determinants in place that could be impacting the child's well being. Um you know such as homelessness or poverty or domestic violence, how would you respond to that? That's a Great one. Mercedes that you want again it would be just about connecting with those community providers. So um it may be taboo to hear about child protective services but we we use that as an advocate for this family so they're able to provide resources within the community um not only helping with housing, emergency housing but helping with placement, getting different funding resources um and that connection to case management services with that department of social services within the city. Um Still Michelle, can you repeat the question? I'm sorry. So it was if you did see that there's social determinants of health and they need resources or mr poverty because it is um impacting the child's wellbeing correct. And again, help obviously. Yes. And like we stated before, those are external factors that will affect a child's behavioral or emotional mindset. So therefore we know like Cody said when we're safety planning, these are the things that we put into account. So we will take that extra time to reach out to case managers to reach out to child protective services for that city um to see how we can all work together. Two reduce the idea that this child may walk back into our facility. Of course we're always here to help, but if we can keep them stable in their environment and at home and that reunification, that's our our number one goal. That's great. So stabilization for the family? Yes. All right, so I don't see any other questions coming in. Um So if we just want to do a little bit of a ramp up, if you want to give your, you know, one or two sentences just to say what you think is most important about what you information you have provided today. Um and then we'll take a little bit of an early break if I don't get any more questions. Um I think the most important is just being able to talk about Children's feelings, having those conversations with those with Children don't take it as a taboo. Um Educating yourself, educating your colleagues again at this hospital where a multidisciplinary team, we all are not big to learn something daily um and just take the stigmatism away and like normalize that these are feelings that Children have and we don't want to wait to adulthood to address these concerns. We have the ability, we have the resources if you don't have the resources, if you lack in those abilities, you have individuals who you can reach out to Cody and I are always available to vet out any questions um and to help you all feel comfortable because we don't mind asking questions and again, just just keep in mind that mental wellness is all of our responsibilities, It's our responsibility to take care of our own mental wellness in order to be able to provide the best care to the individuals we work with and for um self care. Self care is a huge one and I am going to continue to advocate for all of us to challenge ourselves because some reason, um we decided to put ourselves kind of on the back burner. And um, and especially with the current climate, we need to make sure that we're prioritizing ourselves and not uh, waiting until we're completely burned out where a crisp before we're like, okay guys, I need, yeah. Um, and so self care is a huge one. Um, and I trust that you all will, will, will prioritize your own mental wellness by practicing health care frequently. Thank you so much. Um, I do have one comment here as we're winding down. Um, Hampton Roads has a large number of programs that work with families to locate and maintain state housing. We are blessed to have resources. Um, and I know that you can Get information about those resources at 757 resources or Virginia 211. Absolutely. Thanks for that info. All right, well, thank you so much for taking time to be with us this morning and for the good work that you do every day on behalf of Children and families, um, at sea HKD and throughout the community, we are going to go on break now. We will return back at 1230. So 1230 will come back and the community track will be the power of lived experiences. Open healing. We'll continue the journey also, since you're having a little bit of a longer break here, make sure to do some good self care. Have a nice woman. Everything. Go for a walk. All right. Thank you, ladies. Thank you.