Doc Discussions with Dr. Jason Edwards
THIS is the podcast you have been looking for! "Doc Discussions" are just what the title says they are: physicians from a wide range of specialties, talking about relevant, up-to-date medical topics, not to mention tips on habits to help you live your best life. Your host, Jason Edwards, MD, is a board-certified radiation oncologist with a PhD in cellular and integrative physiology at St. Luke's Hospital in St. Louis, Missouri. Dr. Edwards explores not only diseases but also suggests techniques to optimize mental and physical health for a long and good life. Real people. Real advice. Real good. This is Doc Discussions, with Dr. Jason Edwards!
Doc Discussions with Dr. Jason Edwards
The Complex Truth Behind Rising ADHD Rates in American Youth
Are we experiencing an ADHD epidemic or simply recognizing what was always there? With diagnoses skyrocketing to affect 15% of American adolescents—and a staggering 23% of boys—the time has come for a frank conversation about what's really happening with our children.
Join Dr. Jason Edwards and pediatrician Dr. Lisa Ryan as they dive deep into the complex world of ADHD diagnosis and treatment. Their candid discussion sheds light on the subjective nature of ADHD assessment, where objective tests don't exist and practitioners must rely on observation and questionnaires to make life-altering decisions.
The conversation takes surprising turns as they explore counterintuitive treatment approaches—why do stimulants calm hyperactive children?—and examine research suggesting long-term medication benefits may not be as clear-cut as once believed. Dr. Ryan brings valuable frontline perspective from her practice, describing the delicate balance between recognizing legitimate neurological differences and avoiding overdiagnosis of normal developmental behaviors.
Perhaps most compelling is their examination of environmental factors, particularly how modern school structures may be setting some children up for failure. With dwindling recess time and increasing academic demands, are we medicating children to fit our educational system rather than adapting environments to serve diverse neurological needs?
Whether you're a parent navigating diagnosis concerns, an educator working with diverse learning styles, or simply someone interested in the intersection of neurology, child development, and education policy, this episode offers thought-provoking perspectives that challenge conventional wisdom while respecting the real struggles of children with attention differences.
Listen now and join the conversation about finding the right balance between medication, behavioral interventions, environmental adaptations, and accepting the beautiful diversity of how human brains operate.
Welcome to Doc Discussions. This is Jason Edwards and I'm here again with my good friend, lisa Ryan, a pediatrician. Lisa, how are you doing today?
Speaker 2:Pretty good. Thanks for having me.
Speaker 1:Good. Yeah, there was a really interesting article that came out in a lot of things with ADHD and some of the key concepts of the article was that there was a record high diagnosis of ADHD up to 15% in American adolescents, 23% in boys and it really, I think, kind of raises some interesting questions and I was just wanting to kind of get your take on it.
Speaker 2:Yeah, there are a lot of interesting points in it and you know, just to start at the beginning, like what you said about how we're seeing the diagnoses increase and it's hard to know where that's coming from. And I agree, I am certainly seeing far more people who are wanting to be evaluated for ADHD and I'm certainly making far more diagnoses than I did earlier in my career. And again, it kind of brings up the point is it because it's something we're recognizing more or is it truly more of an issue?
Speaker 1:Yeah.
Speaker 2:And the article. I mean, I don't know that it really came up with a good reason for that, but just kind of pointed out that we are seeing some of those changes.
Speaker 1:Yeah, and I think we're kind of in this era of this high information era where you can, you know there's never a lack of information, it's just trying to figure out what's right information, and I think this article has generated a lot of discussion and I think that's you know, and within discussion you're going to have people who give accurate data and you're going to have people get inaccurate things and people going to tell anecdotal stories which are, you know, have some value but are not super useful.
Speaker 1:But I think the more discussion we have, the better it is, because over time we can kind of kind of find the truth better or closer to the truth. To find the truth better or closer to the truth, and so I was happy to see a lot of discourse on something like this. One of the things that stuck out to me they mentioned this MTA study. It's called the Multimodal Treatment and Attention Deficit Hyperactivity Disorder Study, and what they found was that the short-term effects of the Ritalin and Adderall were definitely apparent up to like 14 months, but at 36 months it appeared that the children who were on this were performing no better than children on other behavioral interventions or no intervention at all. And so I was just going to get your thoughts on that.
Speaker 2:Yeah, that's probably the point in the article where I was kind of like, oh wait, what really? Yeah, because that's not what I see in the office.
Speaker 1:Yeah.
Speaker 2:So that was kind of the first point in the article where I was like oh, wait a minute, this isn't what I was expecting, because you know I so I mean I do treat ADHD and we do have people on stimulants and we do see them, you know, back for many years needing them more and just finding use from them. So I've never seen someone have a stimulant work and then just kind of not work but also have them not needed.
Speaker 1:Yeah.
Speaker 2:Like we do run into points, obviously, where the stimulant isn't doing the same job anymore and then we have to make some changes. But I've never seen someone just kind of need it and then not need it in such a short period of time.
Speaker 1:Yeah of time. Yeah, so when I kind of delved into this um the you know I didn't do like the deepest dive, but what I found was is that you had a lot of people online kind of giving anecdotal stories like it worked for me or like my neighbor tried it and didn't have a good experience with it, and things like that. And I I don't like discount that kind of stuff. Like there's some value in those kinds of things. Um, experts weighed in and we're kind of saying like hey, like that was a weak study.
Speaker 1:And so I think, when, when you're seeking truth, you know you want to try to find like well, what's the best evidence? And I I think we did this in one of our other podcasts I so I typed in like like, what's like the like, what's the strongest evidence? And there was actually a meta-analysis, that which is a culmination of randomized controlled trials, kind of typically regarded as one of the strongest forms of evidence, and they found something similar. Now, I didn't, you know, you've read scientific articles. I've read scientific articles and there's always strengths and weaknesses of each and I didn't go into that. But are there any other strategies in treating patients who have ADHD aside from like these stimulants?
Speaker 2:So I mean I think we should even take a step backwards and make and talk just a little bit about the diagnosis of ADHD, that's.
Speaker 1:that's a good idea.
Speaker 2:Sure. So, um, it's a. It's a tough diagnosis to make you know, and I always tell my patients I wish I had a blood test, like I wish.
Speaker 2:I had, you know, or or something I can observe on you that makes sure that we know this is ADHD. But we just don't have any of that. And the article talked a little bit about biomarker studies that, you know, never panned out. So what we have instead is really just observations and subjective data. So we give questionnaires they're called Vanderbilt scales to parents, we give them to teachers. I always tell everyone to get as many back as you can and then they send them back and we score them and we look through them and there's kind of there's. They ask you like nine questions about inattention, they ask you nine questions about hyperactivity and if you answer yes more often than not to six of those on either of those categories, then that's considered positive and it's considered a diagnosis. There's a couple of other things, but those are kind of the big ones. So what I've decided over the years to do in my practice is I go by those. You know, if it's not diagnostic, on those I'm like, no, I don't, I'm not going to treat you Sure.
Speaker 2:Because the other thing we've seen is it's actually somewhat easy to get this diagnosis. Like you can walk into there's certain places who will say they will test you for ADHD and report back. And I'm seeing strange reports come back that are almost always positive on patients who I've seen as negative. So it's really hard to kind of make the diagnosis from that standpoint already. And then you have other things that also cause inattention. You know, is this an anxious kid? Is this a depressed kid? Is this someone who's being bullied? Is this someone with a learning disorder? So it's really important also to kind of like wade through all of those things first, before you even come back to the ADHD as the cause and really make sure that if you do find there's a learning disorder or you think there might be, that you fully evaluated that first.
Speaker 2:So by the time you've gotten back to ADHD and you've decided to treat, most of the time a stimulant is going to be involved. In my experience, you know, depending on the age of the kid and sort of the degree of symptoms and how impairing it is, we'll send kids for counseling and they can work on, you know, coming up with coping strategies.
Speaker 1:Developing techniques to kind of get through these.
Speaker 2:Exactly, and there's an OT clinic down at WashU who really focuses only on like executive functioning skills and really kind of teaching these kids how to get through their day, how to keep things organized and all that. So I think there's a huge component to that and that might help a kid for a while. But typically over the course of the years you kind of hit a point where it's just too much. School's getting harder, there's too much going on. I need more help, and that's often where the stimulant comes in. Okay, there's some non-stimulant medicines and I kind of use those in conjunction with stimulants. I've also never been able to have a kid be fully successful on a non-stimulant med either. So that's kind of where the diagnosis and then the treatment comes in.
Speaker 1:Yeah, so it's not an objective diagnosis where it's like you do some tests and you get a yes or no. It's subjective meaning a person has to look at all these things and make the decision yes or no, and these tests help.
Speaker 2:Right.
Speaker 1:And then some people will criticize the tests, sure, and then some people will, and you know, I think it's always okay to revisit some of these things. One thing you know I think about a lot are biases. You know I have biases, everybody has biases. Based off of their, your own life experiences can help you make decisions, but they can also kind of work against you too. Right and it and I'm not saying so first of all, everybody has biases. If you're listening, you have biases.
Speaker 1:If you're a school teacher and who most of them are salt of the earth, god bless them. But if you have a kid who's a little bit on the rambunctious side and he's impeding your objective of teaching the class side and he's he's impeding your objective of teaching the class, like taking a stimulant like this will make you sit in the chair better and help you focus better. So there there is some incentive for the teacher and the parent who's dealing with a kind of a wild kid or a hyperactive kid to. I mean, it makes their life easier if they're on it, for sure, and I sometimes I wonder like that has to play into it. Some they're not. Parents aren't bad people for having their kids on this. Teachers aren't bad for recommending it, but sometimes I wonder if that moves the needle some as well.
Speaker 2:A lot of the times that is sort of how the kid gets into my office and I guess I should preface so I'm married to a middle school teacher.
Speaker 2:So he teaches eighth grade and so we have lots of discussions about ADHD over our dinner table and he will tell you. I can tell who needs to be on meds and I can tell when they did not take them. But there's actually a law that school professionals are not allowed to diagnose per se. So they're allowed to talk to a parent and be like, hey, your kid's having some problems. He can't sit in his seat, he's doing these things. They can kind of allude to, hey, maybe you should go see your doctor. But they're not supposed to be able to say, hey, your kid has ADHD, go get a diagnosis.
Speaker 1:I did not know that.
Speaker 2:Yeah, that's how it's supposed to be. I mean, I get variants of that in my office, but so they're allowed to, you know, sort of walk around it. But yeah, sure, you can see. I mean, I had a kid we did an evaluation on recently and their parents were like we're here because the school said we had to be and his teacher thinks he has problems and needs meds now. And we don't think so. And you could tell when the scores came back the teachers was, you know, off the charts, everything was positive and the parents were not. So. But with that particular kid too, we also delve a little bit deeper and he seemed to have an anxiety diagnosis. So we're actually focusing on anxiety and we've started some treatments there and we're already seeing some improvements. So if we can, like you know, get the right diagnosis and the right treatment, sometimes you'll see those school problems kind of come around as well.
Speaker 1:Statistically, I think that we call it a kappa analysis. When you analyze, like when you would compare the difference between the concordance between the parent's score and the teacher's score or somebody else's Right, are they typically concordant or are they typically different?
Speaker 2:They're usually pretty close.
Speaker 1:Okay.
Speaker 2:I mean, this was kind of a more unusual point where the schools were really Like nothing's perfect, right, right, right.
Speaker 2:But you can usually, from talking to the parent and seeing what the teacher's right and what the parent's right, kind of figure that out too. But to your other point about just kind of wanting your kid to sit in a chair, I, you know they. The other part of the ADHD diagnosis is you have to have this impairment both at home and at school. It can't just be in one place.
Speaker 2:Okay, and you know parents will often talk to me about. You know, yeah, he, he, he does all of these things but it doesn't bother me so much and it's like well, but is that, you know, because you're willing to put up with it and someone else isn't? And you know we'll talk sometimes too about will that cause problems with friend relationships? You know, are you not going to get picked up for the pickup basketball game because I throw you the ball and you're always looking in the other direction? So I think even this ability to kind of have a kid sort of be in a calmer place is a benefit for him moving forward. And I always tell the kids I'm like you know, this isn't a do well in school medicine, this is really a do well in life medicine.
Speaker 2:We want you to be the best you in all of these situations.
Speaker 1:Yeah. So it does seem kind of odd that you know a child's revved up and having a tough time paying attention and then they're treating it with a stimulant. What are your thoughts on that?
Speaker 2:Yeah, I don't know that anyone truly understands how the stimulant works to help, sort of. The best way I've seen it explained is that a child who has ADHD is basically telling his brain, hey, focus on the teacher, focus on the teacher, focus on the teacher. And their brain is like being no, no, look over here, look over here, look over here. And when they take the stimulant they feel that that look over here. Part of the brain kind of calms down so that they're able to focus on what they want to focus on.
Speaker 1:Okay.
Speaker 2:So that's the best way I've heard a kid, you know, kind of explain what the medicine does when they're on it. But you know, I think one of these other things with the article, when it was talking about how this isn't necessarily a disease process, might stem from that in part, that we don't truly understand how these medicines work. No-transcript, that that would be a big deal.
Speaker 1:You know, lisa, I really appreciate you putting it like that, because a lot of things in medicine we don't fully understand fully. Most things we don't fully understand, but there's um, you know, our egos make us hesitate to say that.
Speaker 1:You know, we don't fully understand that and it takes some humility to say that, but I I do appreciate when people you know accurately say accurately, say hey, there's a lot that's unknown here. We know that this appears to help people. It's an evolving process. I do think the discussion is positive, so we can continue to optimize this. And whether they revisit the diagnosis criteria or focus on fine tuning some of the medications or adding adjuvants to it, such as exercise, diet, neurofeedback, other things, I think that's the way forward is to have good, honest and open conversation, and so I appreciate your candor, One of the things that you know.
Speaker 1:As I was going into it, I thought well, what are the potential long-term adverse effects? I don't think anybody argues that if you take the medication, that it helps initially and to say, well, you know, if it seems like maybe you know it's questionable, but maybe there's like long term it's not as good or maybe it is, you could argue that. But like, what are the downsides? I I actually found that kind of two things the downside, long-term downsides and upsides. The two things I found were that there was a uh, an increase in psychosis of about four percent. So pretty small but not great. But the substance abuse went down about 50%, and so I think like you don't want either, obviously, but in the real world you know, the 50% is huge for substance abuse. Substance abuse will derail your life and they thought it was because of impulse control, and so I thought that there's a negative and a positive there. Sure.
Speaker 2:And I also wonder if that's partly self-medicating.
Speaker 1:That's exactly what I thought.
Speaker 2:What can I do to kind of get myself in a better?
Speaker 1:place. Yeah, I mean, if you were kind of pretty revved up by nature and maybe, you know, smoking a joint or having a beer kind of took the edge off. I mean, a lot of substance abuse is that. And then I read a post that kind of actually resonated with me. It said I would go. I noticed this was an issue for me and ever since I was a kid I would go run every morning and then go to school and I don't work out in the morning anymore, but I used to and it definitely relaxes you through the day. I mean, it definitely settles you down. And I thought and I actually didn't look to see if there's any clinical trials, but I wouldn't be shocked if exercise was helpful with this. You know, shocker exercise is good, right.
Speaker 2:Right there, good for everything. Well, you know and that's the part of the article we haven't talked about yet we're saying that you know it gets into eventually saying that ADHD is really environmental and it depends on what environment you're in. And you know, oftentimes when I'm talking with parents about whether we should start medication or not, they always ask is he going to be on this forever? And you know my answer is usually that probably not. I mean, we never know. But you know there's a good amount of kids who can. Well, they learn to control it to some extent. But, more importantly, you reach a point in time where you are able to control your day, where you know a kid with ADHD is probably not going to be drawn towards a job where he sits in a cubicle all day. You know he'll be a forest ranger, you know he'll be out, he'll be able to do something that you know works towards his interests and towards his needs.
Speaker 2:And maybe while doing that he won't have to take the medicine quite as much.
Speaker 1:Yeah, they make a great point on touching on that, as people kind of find their lane and usually that's how they kind of come off of it, whether it's exercising or finding a vocation or a way they spend their life. That helps with that Right. And then you know it goes a lot into like what you talked about. Is it something that's inside you? Is it something as an external factor? I think a lot of life it's. It's. It's always more complex than you think. A lot of disease and um, and you know people will say like the genetics like cock the hammer and the environment pulls the trigger. It's a little bit of both, you know, without sounding like a politician, but it's a little bit of both. And um, and I think you know you can't change the genes that you have, but you can certainly always optimize your environment.
Speaker 2:Sure.
Speaker 1:Now, truth be told, I'm sure, when you're, when you're talking to um, when I'm talking to patients about things, sometimes you you meet new people every day, so you get a good sense of people and what they can do and what their capacities are.
Speaker 1:And there are a lot of probably non-medical things you could do, but people only have so much capacity and some people have more than others and a child or something like that, or to completely change your diet or to watch less TV. Those things take effort and energy and it's tough to do for sure.
Speaker 2:Well, and you know, you do sometimes see the people who are coming in for kind of the quick fix per se. You know, I do get a couple of, you know, high school juniors being like he tried to take the ACT and it was super hard.
Speaker 2:We think he has ADHD and you need to evaluate, and so I've kind of put an age limit in my practice as to, you know, once you reach a certain age and you think you have ADHD, you should be evaluated by a psychiatrist or somebody else to kind of like weed some of that out but you do see some of that sometimes or the kids who haven't needed it for a long time and then suddenly want it because college is a little bit harder and it's sort of tough to know what to do about those kinds of things.
Speaker 2:Like we diagnosed you in the past, you took it for a couple of years and then you did really well. And now, in this new environment, you need it again and I usually advocate for sort of a new evaluation, which you know, I guess, reasonably so.
Speaker 1:Sometimes the parents balk at a little bit. Yeah Well, I mean to be totally honest. Like you know, the first time I really maybe it was I was aware of it for the first time or not but the first time I really saw you know a lot of people on Ritalin and Adderall was medical school.
Speaker 2:Sure.
Speaker 1:And did you have a similar experience?
Speaker 2:A little bit, you know, and there was actually a New York Times article about that several years ago. And it was talking about how the presence of Adderall is kind of raising the bar, because you do have these group of ADHD kids who need it, and they need it to get everything done. But a kid who didn't have ADHD, or a college kid who doesn't have ADHD and takes it, is now going to be able to stay awake longer, is now going to be able to study longer.
Speaker 2:And in some ways, you're now raising the bar for everybody.
Speaker 1:It's no doubt about it. It's a performance enhancer. There's no doubt about it. I think I wouldn't recommend it.
Speaker 2:Never tried it.
Speaker 1:But I think it's not good for your health. It's probably, you know, if you don't need it. But that's where I kind of saw some widespread use. And but that's where I kind of saw some widespread use and I'm sure in undergrad it was there too.
Speaker 2:Yeah, I mean we monitor our prescriptions really carefully. I mean like to the point where I think it's annoying for others. But I mean that's what you've got to do, and I have had a few maybe like two, three patients over the years who it's been like wait a minute, I don't think you're taking this, I think you're doing something else with it.
Speaker 1:Yeah, yeah, People you know take it like like they drink coffee, you know, before they study, or something like that, or sell it to a friend or something like that. And um, but you know the to me the just the the. The last time I looked before this article it was about 13% in boys, and to see that it was bumped up to 23% by the time you're 17, that you've used it once, boy, does that seem high to you?
Speaker 2:I mean, yeah, it does Um, and I think I mean there's just kind of so much that goes into it you know, like, like, making, like. Are these kids who were just kind of getting it somewhere? Are these people, are these providers who are making these diagnoses that aren't being careful and are, you know, handing out these meds easily?
Speaker 2:Are they not being followed long term. I mean, you know there's certainly something that happens to middle school boys. You know they, they're my, my own middle school boy. You know, we, we, we hear what happens in his classroom sometime and some of the things he's doing all of a sudden that were like you never did this before.
Speaker 1:Like you know, can we double click on that? Not with your son.
Speaker 2:No, but like there's, there's just a lot of so well, I guess I like silliness just, silliness just not.
Speaker 2:You know, these kids who, who used to be able to sit still in a classroom, suddenly are not. You know, like I've had some conversations with our middle school principals just because of my kid. But you know, and I'm like telling them, I'm like, I'm really embarrassed, I'm so sorry he's doing this. I don't know where this came from and the response I get is this is what happens in middle school. They're pushing boundaries, they're trying to find who they are, they're showing off for their friends, they want to be the popular kid, and that's kind of where some of these personality changes happen. And could this be viewed as sort of ADHD or behavior problems? And that's why it comes up? Maybe that's part of it.
Speaker 1:Yeah. So as somebody who's a complete amateur, like what do I know about Pete? It's nothing. So as somebody who's a complete amateur, like what do I know about Pete's nothing?
Speaker 1:But to me, I think you know you have like this bell curve, the concept of a bell curve, and you know the like the 50th percentiles in the middle and you know the. I think there's this normal kind of distribution of behavior. And then on the fringes you have like some disease and I think some of the normal folks are kind of getting diagnosed with ADHD. What I would consider kind of a normal ornery boy, because boys are, you know, they're knuckleheads, they're rowdy. There's plenty of literature on this. School is not really made for boys. I mean, they're not great at sitting in a chair and listening to things, not nearly as good as girls, and there's all sorts of research on that and that's a whole other topic. But I mean, this seems to affect boys a lot more than girls. Girls and and and sometimes I wonder you know if to me, exercise seems like a good option to try to take the wind out of their sails. Now, maybe they don't pay attention as good or not, but something to take the edge off so they're not so amped up.
Speaker 2:And that's part of the idea behind recess, right, like we give elementary kids several recesses a day and there's a lot about you know why are we punishing kids by taking recess away when we should actually be getting them out there more? And in middle school, you know you don't really have recess. You've got your lunchtime and if you finish your lunch fast enough, you, if you inhale it in five minutes yeah, then you might be able to go outside and play a little bit of basketball, for you know like 20 or something.
Speaker 1:And maybe have gym class, maybe not, yeah.
Speaker 2:So there's certainly you know and I think that teachers know this and you know there's you'll find a lot more sort of alternative seating. You know, like some of them will have, like the bouncy balls that you can sit on, or a futon you can sit on, or a place that's not in front of a desk.
Speaker 1:Yeah.
Speaker 2:But you know, yeah, there's just a lot of changes at that time. And do we? I mean, are there people who are misdiagnosed? I'm sure there definitely are. But you know, I think that's part of just kind of being careful about making the diagnosis, and really really closely following is just really important.
Speaker 1:What's your husband think about the boys as a school teacher? What's he think? What's a school teacher think about this? Well, I mean, he's the one who you know like when my child gets the phone call from the teacher and all of that.
Speaker 2:This is new to us. Our other ones didn't do this, but, um, you know he'll be like, yeah, this is, this is what they do or they have this crazy language. They all talk, which I don't understand.
Speaker 1:And this is just exactly.
Speaker 2:And this is just kind of what they do. So you know he'll say, he'll tell you that there's a big change between, like seventh and eighth grade.
Speaker 1:Yeah.
Speaker 2:And a lot of it. You know, like the is just just sort of finding, finding your place. But you know, like this morning, as he was heading off to school, he's like I'm going to deal with the monsters.
Speaker 1:Yeah. So yeah, I I don't know if this is good or bad, I don't. If I see a young boy who's a little bit rowdy, I don't hate it. I don't hate it, it's I. I like to see a kid with a little bit of pizzazz. You know, maybe that's framing it too nicely, but, but I don't hate somebody who's testing the boundaries a little bit. Sure, but if it just it can get you know to be too much, or they don't know when, like they've kind of crossed the line and they need to reign it in.
Speaker 2:Right, and I think that's what you're seeing in the classroom and I'll see some of my high school kids will come back and be like I'm not taking my meds, I don't want to take them anymore, and I'll be like, well, why not? And they'll say they say it in different ways, but essentially what they're saying is I used to be the class clown and now I'm not and I like being that person that everyone looks to and everyone laughs at and everyone thinks is really funny.
Speaker 2:And you've taken that away from me, and that's a hard thing. I always tell them we're not going to take away your you-ness. You're still going to be you, but we just need to tone it down so that you can be a part of the society, whether it be in your classroom or wherever else. And just trying to, you know, explain to them sort of these grades of behavior and what we can accept and what we can't is sometimes really difficult for them to understand.
Speaker 1:Lisa, this is a super complex matter. My instinct is a lot of people you know read these articles and don't have, you know, much like me, you don't have a lot of experience with it and you form strong opinions. And then you kind of hear from people who are in the trenches, um, which I would say is the pediatricians and the school teachers, and it's nice to have that nuanced perspective to kind of, you know, see the whole issue in totality. And so I really appreciate for you, appreciate you coming in and adding that context.
Speaker 2:Sure my pleasure.
Speaker 1:Yeah.
Speaker 2:Good to see you again.
Speaker 1:Thanks so much.
Speaker 2:All right.