Teenage Self-Embedding – PediaCast 187
Today on PediaCast Dr Mike explores the recently discovered issue of teenage self-embedding with Dr John Campo and Dr William Shiels.
- Teenage Self-Embedding
- Dr John Campo
Chief of Child and Adolescent Psychiatry
Nationwide Children’s Hospital
- Dr. William Shiels
Chief of Radiology
- Behavioral Health Services at Nationwide Children’s Hospital
- Imaging and Self-Injury (Radiology Today)
- Self-Embedding Behavior: Radiologic Management of Self-Inserted Soft-Tissue Foreign Bodies (Radiology)
- Self-Embedding Behavior: A New Primary Care Challenge (Pediatrics)
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children’s, here is your host Dr. Mike.
Dr. Mike Patrick: Hello everyone and welcome to PediaCast, a pediatric podcast for moms and dads. It is episode 187 for Wednesday, November 2, 2011. I’d like to welcome everyone to the show. I’m calling this one “Self Embedding” and you’re probably asking yourself what in the world is that.
Well, you’re going to have to stay tuned for the details but I’ll give you a little hint by letting you know who we have in the PediaCast studio today—actually, we have two “who’s”. Dr. William Shiels is the Chief of Radiology here at Nationwide Children’s Hospital; and Dr. John Campo is the Chief of Child and Adolescence Psychiatry.
But before we get to them, I want to remind you that it’s easy to get a hold of us here at PediaCast. If you have a question or a topic idea, just head over to PediaCast.org and click on the contact link. You can also email PediaCast@gmail.com or call the voice line at 347-404-KIDS. That’s 347-404-KIDS.
I don’t want to preface the show too. To let you know, I’ve got a little bit of a cold and so if there’s a little bit of coughing or an awkward pause because I have to take a drink, I just want to let you know because I got little bit kiddie card stuff that you pick up in the urgent cares, in the emergency department here. But it just goes with the territory.
All right, two men sparked a worldwide discussion in 2009 when an article in the magazine “Radiology Today” brought attention to an extreme form of teenage self-injury which these guys coined “self-embedding”. The discussion continued in 2010 with an article in the journal “Radiology” and again this year when the journal “Pediatrics” published findings from this pair. So, who are they? We are fortunate to have both men in the PediaCast studio today so let me introduce them.
Dr. William Shiels is the Chief of Radiology at Nationwide Children’s Hospital and a professor of Radiology and Pediatrics at the Ohio State University College of Medicine. His primary interests include ultrasound and interventional radiology, which is, it turns out, a good interest to have because they led to discovery of the teenage trend that we’re talking about today. So, welcome to PediaCast, Dr. Shiels.
Dr. William Shiels: Thank you.
Dr. Mike Patrick: And Dr. John Campo is here as well. He is the Medical Directory of Behavioral Health Services at Nationwide Children’s and chief of our division of Child and Adolescence Psychiatry. His many interests include studying the relationships between medically unexplained physical symptoms and emotional disorders, as well as the delivery of evidence-based behavioral health in primary care settings. Welcome to PediaCast Dr. Campo.
Dr. John Campo: Thank you Dr. Mike. I did want to add that actually, the credit for self-embedding all goes to Dr. Shiels. I was not involved with those studies other than to chat with him about it…
Dr. Mike Patrick: Just to lend your expertise on the psychiatric front.
Dr. John Campo: Yes.
Dr. Mike Patrick: Seriously folks, I got to say, these guys here are the pediatric equivalent of rock stars in their given fields and we’re fortunate to have both of them here at Nationwide Children’s and here in the PediaCast studio. They won’t tell you that though, but it’s true. Dr. Campo, why don’t we start with you? What is self-embedding? If we have to define that term, what exactly is it?
Dr. John Campo: It’s essentially when in this instance, a young person takes an object, it could be a metal object like a paper clip or part of a pencil or piece of wood, and embeds it under their skin as incredible as that sounds.
Dr. Mike Patrick: Yes, is this a new phenomenon or is this something that teens have been doing for a long time?
Dr. John Campo: It’s an unusual phenomenon, number one. Number two, it does appear that this has happened in the past. I think that Dr. Shiels and his colleagues have really brought this to light in a very clear way that hasn’t been described previously.
So yes, in psychiatry, we’ve seen patients who do this sort of thing. It’s unusual, it’s troubling. It hasn’t been widely reported and I think that’s been the achievement here in describing it.
Dr. Mike Patrick: It’s kind of a tough one because in reporting it, you want parents and you want caregivers to be aware that this is out there, but at the same time, you don’t necessarily want to broadcast it to teenagers as an idea of something that they could do.
Dr. John Campo: Exactly and I think this one of the things that Dr. Shiels and I talked a lot about and I know that he was very concerned. You want medical professionals to be aware and you want to do everything you can to prevent this. What you certainly don’t want to do is encourage any of this behavior in someone else who’s troubled and might be vulnerable.
Dr. Mike Patrick: Fortunately, our audience here at PediaCast is primarily parents and although we do have a lot of pediatricians, nurses and pediatric residents who listen as well, so hopefully this will be good information for them.
Dr. Shiels, let’s go back before we talk about self-embedding, because the field of radiology that is involved with this is called “interventional radiology”. Radiologists do a lot more than just sitting in darkrooms reading x-rays, right?
Dr. William Shiels: Absolutely.
Dr. Mike Patrick: So, what is interventional radiology?
Dr. William Shiels: Well, interventional radiology, if you break down the two words, the concept is the radiologists have at their disposal x-rays, CAT scan, ultrasound, MRI.
And in this situation with ultrasound where we can see inside the body, it gives us the ability to guide precisely instruments that are going through very small openings in the body and perform work actually in the body with direct vision using ultrasound, which for the parents is strictly speaking, it’s sonar and that’s how submarines navigate under water.
Dr. Mike Patrick: Sure.
Dr. William Shiels: Well, we navigate in the body with ultrasound guidance using instruments that can be used to guide needles into position, take biopsies but in this case, when children have embedded objects either under the skin or into muscle, et cetera, we can actually go in and remove those with precision guidance. Not only to take the objects out, but also to avoid vital structures that we don’t want to injure in the process.
Dr. Mike Patrick: When you’re talking ultrasound, the important thing with that is that it’s not really x-rays, so kinds aren’t being exposed to radiation when you have an ultrasound procedure.
Dr. William Shiels: Exactly.
Dr. Mike Patrick: Describe the procedure by which the foreign body is removed with interventional radiology.
Dr. William Shiels: Well, the short version of the foreign bodies, if you step on a wood floor with bare feet and you step on a piece of wood and it gets embedded in your foot accidentally, you can’t see that with an x-ray.
Dr. Mike Patrick: Right.
Dr. William Shiels: You may not see that with an MRI or even a CAT scan. But it will show up very well with ultrasound, so we will then make a small incision in the skin first after we’ve identified exactly where it is under the skin and the body, and then guide the instrument into that opening through that incision, reach in, spread the tissues apart and grab the little piece of wood in this case in your foot and take that out very carefully.
Dr. Mike Patrick: How does this differ from traditional surgical techniques in terms of the advantage to the patient?
Dr. William Shiels: Well, traditional surgical techniques would be utilized if you can either see the tip of the foreign body, the piece of wood or a piece of sewing needle, is just sticking inside and you can see where it’s coming through the skin, reaching and grab that, or maybe open that skin and reaching and trying to feel it.
But if it’s deeper, then there’s a high likelihood that probing in a blind fashion, if you will, is going to fail and we can make as big of an incision as you would, but you still may never be able to find literally the needle not in the haystack in this case, but a needle in the muscle.
Dr. Mike Patrick: The muscle.
Dr. William Shiels: Right
Dr. Mike Patrick: How big of an incision do you make when you do it with the ultrasound?
Dr. William Shiels: With the ultrasound guidance, the incision is on average five millimeters, and five millimeters in our measurement terms is a fifth of an inch.
Dr. Mike Patrick: OK, so about the size of a freckle?
Dr. William Shiels: Exactly.
Dr. Mike Patrick: I see. And so, there’s going to a lot less scaring with this kind of technique as well.
Dr. William Shiels: That’s exactly right, and we actually tell the families that the only scar that we’ll leave is literally the size of a freckle.
Dr. Mike Patrick: Now, how did you become interested in foreign body removal being a radiologist? How did that come about because it’s not the first thing that comes to people’s minds?
Dr. William Shiels: Well, the procedure was actually developed when I was in the army and the first patient I ever had a foreign body remove was a sailor at Pearl Harbor. It was a Friday night and he had a sewing needle stuck in his heel and the surgical resident wasn’t able to take it out. The question of continuing with live x-ray to take it out with the exposure and the difficulty with a two-dimensional perspective came up and the surgical resident asked if we could take it out.
And it was one of those situations wherein necessity is the mother of invention and next thing you know, we were comfortable with ultrasound and we knew we could see the sewing needle with ultrasound, so I proceeded to remove the sewing needle from his foot with him wide awake, and he could walk immediately afterwards. And then, that just escalated into removing things you couldn’t see on x-ray. And then, over the past 20 years, it just exploded at Nationwide Children’s Hospital.
Dr. Mike Patrick: In 1995 or so when you came and brought that here?
Dr. William Shiels: Correct.
Dr. Mike Patrick: Yes. Now, has that caught on with other pediatric institutions? Is that something that we train folks from other places on how to do?
Dr. William Shiels: We do the majority of the training worldwide for the removal of foreign bodies and there are some centers that pick it up, other centers don’t feel that they have the fine motor skills, but those centers that have the will and the skill, then they develop that. But yes, we train people around the world to do this.
Dr. Mike Patrick: And we’re certainly willing partners for anyone who wants to learn, right?
Dr. William Shiels: Absolutely. We have great simulators just like flight training simulators. We have simulators that train doctors how to remove these in live tissue.
Dr. Mike Patrick: Now, how did the self-embedding trend come to light? As a radiologist, it’s interesting. How did we figure this out?
Dr. William Shiels: Well, we were studying our experience over 15 years with foreign bodies.
And actually, I have to make one small correction to Dr. Campo. The true credit for this discovery was not Dr. Shiels but indeed, a young medical student, Dr. Adam Young who’s at the Ohio State University College of Medicine. He was working with me on a research project. We were combing through literally 500 patients’ experience with foreign body removal in our department over those 15 years. Adam came forward and said, “Do you realize that we have a cluster of patients that did not accidentally have these foreign bodies in their body. They induced this injury themselves or embedded these foreign bodies into themselves.”
As we looked at these and looked at the case histories and the issues, we noticed that there was a consistent pattern of behavioral abnormalities. And it was a cluster of abnormalities instead of traditional cutting where children will have either depression or anxiety disorder et cetera. These children had much more severe behavioral health abnormalities but I will let Dr. Campo discuss. But they had multiple abnormalities in one patient.
So, we looked at the collection, we saw the consistent trends. It’s pretty much like profiling other situations in the forensic world where you see consistent patterns of abnormalities. And so, the behavioral health issues and the embedding behavior, we had 11 patients. Now, we’re up to 13 teenagers that have gone beyond cutting and they embed these foreign objects into their arms, legs, feet, neck, different areas of the body.
Dr. Mike Patrick: What sort of objects have you removed?
Dr. William Shiels: Well, the more common objects are metal objects, things like staples or paper clips that are unfolded. One of the favorites is the large paper clip that we all like to bundle six or eight pieces together. If you unfold that, that’s a 16-centimeter long piece of metal and that can induce a significant amount of pain as you drill that into your body.
But another interesting object is pencil lead as Dr. Campo mentioned. Number two pencil lead. Getting number two pencil lead out of the pencil is a chore in itself, but to take out a piece of that intact that’s two inches long and then insert that into your arm is whole other determination issue that is fascinating. So, wood, pencil, glass, plastic, even the tines on a comb, they break those off and they bury those through that cut they make in the skin.
Dr. Mike Patrick: Is this typically so deep that you can’t see it through the skin? I mean, they’re just doing this to put something deep into their skin or are they trying to create a look or is it so that it’s just right under the skin, or both?
Dr. William Shiels: No, you cannot see these under the skin.
Dr. Mike Patrick: So these are deep?
Dr. William Shiels: The majority of the presentation is infection when they put multiple of these objects in and then that area gets infected, then they are forced to come forward and declare that they’ve got a problem. But the deepest one that we’ve had is a girl who embedded one of those long 16-centimeter long paper clips unfolded, one into each of her biceps muscles. So, it was actually very deep into the body.
Dr. Mike Patrick: I know that you have a passion as a radiologist for helping kids and with these self-embedders, they really then need a referral to behavioral health and psychiatry. What’s the role of the radiologist in referring self-embedders?
Dr. William Shiels: It’s a fascinating role. Let’s imagine it’s a Friday night and you have your own duty. You’re the only radiologist there, the Emergency Room has a patient with an infection in her elbow. You look at the x-ray and you see 20 pieces of material—18 pieces of pencil lead, a screw from an eyeglass and then a paper clip. You immediately know that this is self-inflicted injury.
And so the role of the radiologist is very critically to identify that this is self-inflicted. Let the emergency physician know immediately and then, help to stimulate the team to mobilize the behavioral health specialists, the psychologists and the psychiatrists to engage in the immediate care and to interrupt this cycle of self-harm.
Dr. Mike Patrick: Right. Dr. Campo, why do teens do this?
Dr. John Campo: “Why” is a great question and I think, obviously, it’s really tough to delve into the motivation of folks. Certainly what many of them will tell you — I think that it’s important to recognize that self-embedding is a subtype of self-injurious behavior, what we’ll call “non-suicidal self-injurious behavior,” which interestingly is becoming increasingly common in young people. Twenty, 25, 30 years ago, to see someone who was a self-cutter, typically those patients were quite troubled, quite disturbed, had a lot of the same really deeper character problems that a lot of these self-embedders have.
Over the years, that group of patients with self-injurious behavior has become much more diverse, so there are some very disturbed patients and they’re also patients that have more “run of the mill” problems with depression and anxiety.
Why do they do it? I think many of them tell you that they do it because they think it helps them to feel better. That it becomes a way of them managing uncomfortable feelings of pain, emotional distress, and that there is something about the self-embedding behavior that helps them feel less agitated. Some patients will talk about not knowing that they’re real unless they’re actually hurting themselves in some ways.
Folks have speculated that sometimes the self-injurious behavior itself might actually encourage the release of some internal opium-like chemicals…
Dr. Mike Patrick: Like endorphins in the body.
Dr. John Campo: But again, a lot of this is speculation.
Dr. Mike Patrick: Sure.
Dr. John Campo: What we do know is that in addition to what folks say about the behavior is that it can be sometimes a very powerful communication. Self-injurious behavior, what it says in a lot of ways, is it can be a self-communication of the need for care. It can be seen as a careless behavior. Now as Dr. Shiels have said, many of these patients do the self-embedding in a very private way and are walking around with these objects, so it’s not as simple as that. Yes, multi-determined.
Most often though, the kids with the self-embedding behavior are young people who have oftentimes had a history of really inconsistent attachments. They’ve been mistreated oftentimes in a variety of ways and they suffer from a whole variety of psychiatric symptoms and overlapping disorders so, this is often more than a circumscribed psychiatric disorder. Oftentimes in a young person who has really experienced a whole variety of deprivations and insults, psychosocial.
Dr. Mike Patrick: The kids that we have seen here Dr. Shiels, have there been some consistencies—like are they mostly males, mostly females; and then just their socioeconomic situation or their psychiatric situation? Are we seeing trends?
Dr. William Shiels: Well, the trends interestingly are consistent of the 13 patients that we have now. Eleven of them are female, obviously two are male. The average age is 16 years of age and again, the more consistent patterns that we’re seeing are about 90% have suicidal association. Again, that’s in the expertise of Dr. Campo to discuss that.
Seventy percent repeat their injuries. The most we’ve ever seen is one girl who repeated it four times over the period of one to two years. The behavioral abnormalities, again, as Dr. Campo mentioned, the deprivation things, the abuse patterns, post-traumatic stress disorder. The behavioral abnormalities such as personality disorders, and depression anxiety, obsessive-compulsive disorder, again post-traumatic stress disorder and it gets rather complex.
Dr. Mike Patrick: Yes. I think in the study that I read that you published, 70% of the kids did it more than once and 70% also had an escalating pattern where each time they came back, it was a larger, more painful object.
Dr. William Shiels: Exactly right.
Dr. Mike Patrick: The fact that they’ve done it once is definitely a risk factor for them to do it again.
Dr. William Shiels: When we discuss this, and again we’re not therapists, but as we do the ultrasounds, as we engage in the removal discussions with the patient before they are asleep, they’ll tell us that it’s easier to deal with physical pain than it is to deal with emotional pain.
Again, the behavioral health experts can help us understand why you would escalate this one time after another. If it’s not suicidal, there’s something driving them to want, to get something resolved with this repeated behavior. So the conflicts that are inside, somehow manifests, that it concretizes that.
Dr. Mike Patrick: Especially when we see that they aren’t necessarily seeking attention by doing this because a lot of times, it doesn’t come to light until there is an infection or a problem.
Dr. John Campo: That’s a complicated issue, right? The whole attention seeking aspect and I think, perhaps an overly simplistic way to think about it, but I think a useful way to think about this is oftentimes, these are individuals who seem to, for all intents and purposes, feel very, very empty inside.
This behavior is an attempt to maybe fill the hole, if not with the embedding itself, with the care and the attention that goes with it. It’s a really unfortunate sort of bargain though because what these individuals pay a high price for feeling cared for, right?
Dr. Mike Patrick: Right.
Dr. John Campo: A lot of these kids live in foster homes or group homes and don’t have a parent figure in their life, so some of that love and acceptance gets confused. I can’t emphasize enough that I think based on what we know now is that the vast majority of these folks who have engaged in self-embedding behavior have suffered a variety of insults, often times at very vulnerable periods of their lives.
These are folks who need more than your standard behavioral health treatment. They almost need a whole society wrapped around them, and the bottom line is sometimes, when these things happen in critical periods, you’re always playing catch up.
Dr. Mike Patrick: We talked about 90% of them demonstrated suicidal ideation. What are some other co-morbidities that exist in this population?
Dr. John Campo: I think the suicidal ideation is really important to emphasize because a lot of folks get the idea that if these folks engage in non-suicidal self-injury, they don’t want to kill themselves right? Well, actually that’s not exactly the case. I think that individuals who engage in self-injurious behavior are at significantly greater risk of actually attempting or completing suicide than individuals who don’t engage in self-injurious behavior.
All we can say that not all self-injurious behavior is suicidal, but it you engage in self-injurious behavior, you’re at greater risk for suicide.
OK. These patients have a whole variety of symptoms. I think one of the core things is these are folks who have difficulty regulating their moods. They’re prone to irritability. They’re often times remarkably sensitive to rejection. And in social situations, they are prone to negative moods to dysphoric moods. They often times feel chronically bad, chronically low, chronically empty. Many of them will meet criteria for other sorts of cyclical type mood disorders where they have periods of really marked irritability and sometimes, perhaps, meet criteria for bipolar disorder.
It wouldn’t be uncommon that many of them suffer from anxiety disorders and added to that, a whole rash of other sorts of behavioral disorders; problems with conduct, problems with interpersonal relationships, problems managing in school. Many of them would be vulnerable to things like learning disorders and that sort of thing. This is a pile of morphously troubled population.
Dr. Mike Patrick: How do you go about managing this then? Obviously, if they have these other issues, if they have depression, ADHD, obsessive-compulsive disorder, other disorders along with it. Obviously, you want to manage those. If you can get those under control, then might the self-embedding follow?
Dr. John Campo: Right. I think that you’re right. I think that treatment has to be multimodal.
That said though, one of the threads that run all through these is a whole thread of trauma, right. So, how do you (a) address the history of trauma in these kids, and (b) help work with them to find a way to deal with a very difficult internal life. I mean, these folks suffer internally. But how do you help work with them so they can work each day to make their life a little bit better?
Interventions like the dialectical behavioral therapy that’s been popularized by Marsha Linehan and her crew, can be extremely important in these sorts of patients. Now, I don’t think anyone has ever done an intervention study of patients who are self-embedders. But certainly for patients with this sort of unstable personality, this sense of behavioral dysregulation, emotional dysregulation, dialectal behavioral therapy often times, there are maybe some medication that can be specifically targeted towards symptoms.
I think that treatment is symptomatic but I think that this idea of what’s nice about dialectical behavioral therapy is a way of really helping people to learn how to live better.
Dr. Mike Patrick: Yes, what exactly is that?
Dr. John Campo: What they do in that treatment is help people focus on the here and now, to be mindful, to be aware of how they got to this certain point in life, and then how to begin to adapt and to manage and regulate their emotions better.
I’m clearly not the person you want to talk in any detail about dialectical behavioral therapy, but it is certainly…
Dr. Mike Patrick: Sounds practical.
Dr. John Campo: It’s very practical and it’s allowed for success with populations of patients that have really defied success with a lot of other treatments.
Dr. Mike Patrick: I guess from a parent’s standpoint, if your child has issues with the things that we’ve talked about, if they’re chronically depressed or have anxiety issues, obsessive-compulsive tendencies, those are the kids that the parents really should kind of watch out for this.
Dr. John Campo: Certainly. If your child is engaged in any sort of self-injurious behavior and heaven knows anything like this, it’s clearly a signal that’s there is no substitute for a thoughtful evaluation by a professional.
I encourage patients and families, often times, to begin with their primary care physicians. Your primary care doctor can certainly do an initial assessment and help direct you. If you have concerns about depressed mood, anxiety, any of the things that we’re talking about that in many respects are extreme as something like self-embedding behavior. This is certainly worthy to talk about with your primary care doc.
You can always give us a call in Behavioral Health at Nationwide Children’s Hospital or at OSU, we work together. There are some other really outstanding agencies in the community where you can seek help if you have any concerns about your child or adolescent and worry about their safety. By all means, contact us. Take them to your nearest Emergency Department or to NetCare here in the city.
Dr. Mike Patrick: We have lots of listeners throughout the United States, and actually around the world too, so the take home here is that if you have a concern and you think it’s a life-threatening concern or an immediate concern, find emergency care. If it’s not that emergent, then you want to go to your medical home and start there because your primary care doctor is going to know what resources are available in your community and where to go.
Here in Columbus, or if you like a second opinion if you’re anywhere in the country, we will have a link to the Behavioral Health Services website at Nationwide Children’s Hospital on the show notes over at PediaCast.org just to make it really easy for folks to get in touch if that’s what they really need.
We also have links. I had mentioned some articles in Radiology Today, the magazine, back in January 2009 at Imaging and Self Injury. We’ll have a link to that in the show notes and also, the two studies that we talked about, one in the Journal of Radiology and the other, in the Journal of Pediatrics. We’ll have links to the abstracts for both of those, so if you want to know more about all of these from a scientific standpoint and the research that was involved in the study, you can go to PediaCast.org, click on the show notes and get that information pretty easily.
I want to thank both of you for stopping by the studio today. Really quick before you leave, one thing that we talked with all of our guests about, one of my passions is for families to do things together that don’t involve screens. We’ve been talking about board games with all of our guests. So just really quickly, Dr. Shiels, what’s your favorite board game in the past or in at the present?
Dr. William Shiels: Favorite board game, that’s a good question.
Dr. Mike Patrick: I caught you off guard.
Dr. William Shiels: You did, absolutely. Monopoly is a favorite.
Dr. Mike Patrick: Yes, that’s number one about guests. Are you a traditionalist with Monopoly or do you like the Beatles, Irishopoly. All the…
Dr. William Shiels: No, I must say I’m really more a traditionalist in that regard.
Dr. Mike Patrick: OK. You like the old fashioned one.
What about you Dr. Campo.
Dr. John Campo: Our kids do a lot of things. They called it Bananagrams where you build links of words. It’s an offshoot of Scrabble. But Scrabble is great, Bananagrams I really like too.
Dr. Mike Patrick: It comes in little banana-shape pouch.
Dr. John Campo: Yes.
Dr. Mike Patrick: Yes, I have seen that one around. We’ve not played it, but it sounds like fun.
All right, thank you both of you for stopping by. I really appreciate it.
Dr. William Shiels: Very good. Thank you.
Dr. John Campo: Thank you Dr. Mike.
Dr. Mike Patrick: Also, I want to remind everyone out there, iTunes reviews are helpful, as are mentions on your blogs, in Facebook and in your tweets and make sure to tell your doctor about PediaCast so they can spread the word to other patients, and that your family and friends, let them all know as well.
Once again, if there’s a topic that you’d like us to discuss or if you have a question, just give us a holler at PediaCast.org, you can click on the contact link. Also, PediaCast@gmail.com is the email address, or you can call 347-404-KIDS, 347-404-KIDS, and leave a message that way.
Until next time, this is Dr. Mike saying stay say, stay healthy, and stay involved with your kids. So long, everybody.
Announcer: This program is a production of Nationwide Children’s. Thanks for listening. We’ll see you next time on PediaCast.