How Vision Problems Impact Child Behavior

Episode Transcript

Dr. Nicole Beurkens:

Hi everyone, welcome to the show, I’m Dr. Nicole and today I have the pleasure of having Dr. Dan Fortenbacher as my guest. Dr. Fortenbacher is an optometrist specializing in developmental vision, which goes way beyond what we normally think of with vision and glasses and those types of things for kids. I’ve learned a lot from Dr. Fortenbacher over the years about the eye-brain connection, how much that impacts child development and functioning.

We refer patients to his practice often from my clinic. We happen to be in the same state and not too far from each other, which is great. So I’m really excited to have him here to share his knowledge and experience around the role of vision — not only in improving things like reading and learning, but also things like attention and behavior. I think this is an often overlooked issue for kids, and one that makes a really big difference when those issues get properly diagnosed and treated.

So let me tell you a little bit about him: Dr. Fortenbacher received his Doctorate of Optometry from the Michigan College of Optometry at Ferris State University and his interest in developmental vision and rehabilitative vision therapy began early in his career, working with and helping children who struggle with binocular vision problems. He’s a board-certified fellow of the College of Optometrists and Vision Development and lectures extensively on developmental vision, Neuro-Optometry and vision therapy. Dr. Fortenbacher is a past examiner for the International Examination and Certification Board of the COVD and has served in several leadership positions at the state and national level. He has developed models of innovation in the delivery of developmental binocular and Neuro-Optometric vision rehabilitative care. Whoa, that’s a mouthful!

And in addition to his amazing private practice, Dr. Fortenbacher is also a clinical professor at the Michigan College of Optometry at Ferris State and an adjunct faculty at Southern College of Optometry, where he is the program supervisor for the W.O.W Vision Therapy developmental vision and rehabilitation private practice residency, so lots of exciting things that he has going on. And Dr. Fortenbacher, welcome to the show, thank you for being here!

Dr. Fortenbacher:

Thank you, Nicole, it’s wonderful to be with you.

Dr. Nicole Beurkens:

So I want to get right into this because there’s so much to talk about with this topic that many parents and even a lot of professionals who work with kids with challenges don’t even have on their radar as something that they need to be aware of or thinking about. So I want you to start out by just talking about how is it that a kid who is having problems with reading, attention, behavior — those kinds of issues, how is it that they can have an undetected vision problem even when they’ve had their vision screenings, maybe at their pediatrician, or they’ve even gone to the eye doctor and they’ve been told they have 20/20 eyesight. So parents are thinking, oh — we’ve passed that, my kids got great eyesight, no problem! Talk about how it is that vision can be connected to these things.

Dr. Fortenbacher:

This is a really important question because so often when I sit down with parents and talking about their children’s vision problems, one of the first things we address is the eyesight, eye health and glasses question. Because when you go to the eye doctor, this is fundamental in every eye exam. It’s important that when you have your child’s performance as a concern that you do have a comprehensive eye health and vision evaluation. But vision goes beyond being able to see clearly. That’s the paradox to this. You might assume, well I got 20/20 vision, fine. But what? We also have two eyes, right? And they have to work together. And if you’re eyes aren’t teaming together, especially when you look at near, that can result in difficulty with sustained attention, it can result in the words coming apart, overlapping when the child is reading, and it can also interact with the clarity at near that’s not measured when you’re testing at far.

So you can actually have some blurry, overlapping images when a child is trying to read at near. So this affects their performance, it affects their attention, it affects their reading fluency — and a lot of times, if parents don’t simply ask the question to their doctor: Is it possible that my child has a problem with their vision that’s affecting their reading, they may not have the testing done to actually probe these areas.

Dr. Nicole Beurkens:

Yeah, I agree that that’s true, I think that at my clinic, we see parents frequently who have done their job of making sure that their child who is having reading problems or other kinds of academic issues has had a vision exam. But when you don’t know the questions to ask or how to go beyond that, it can be hard and parents go okay, we were told that everything was okay. And what you’re saying is that there are things that need to get looked at beyond just the physical health of the eyes and beyond whether the acuity is okay, whether they need glasses or not. There are other things that need to be looked there, right?

Dr. Fortenbacher:

Exactly, and I often times refer to it — instead of getting technical, and this is one of the things I learned early on in my career when you use the doctor lingo, it confuses people. And basically, if you look at your visual system, you’ve got two eyes that have to team. They also have to track and you have to focus. So those are the eye coordination abilities to take in visual information. Team, track and focus. Beyond that, well — then you’ve got to make sense of what you see so that visual processing part of the puzzle is also a very much integral piece to being able to perform and reading, and in the classroom — and inattention. To get the visual perceptual areas and then after that you’ve got the integration. So you’ve got to integrate those visual functions with motor skills, with balance, with listening and ultimately, thinking.

So you got the teaming, tracking, focusing, visual processing and then integration. And those are developmental processes. Those are things that… we don’t come into the world knowing how to do this. It’s something that develops normally, naturally on its own. But a lot of the children that we see, the majority of them haven’t gotten it on their own. They’ve got a delay in that development, and our role is to help accelerate that development, get it up to speed so they can imply themselves more effectively.

Dr. Nicole Beurkens:

Yeah, I think that one of the things that strikes me about this whole area is just how much we take our vision and our ability to process what we’re seeing for granted, right? Aside from needing to wear my glasses, I don’t really think about my vision, I don’t think about all the processes that are going on in my brain to be able to take those images in, to understand what I’m seeing — I just take it for granted, and I think it’s really… you breaking it down like that: Here is all the different things that the brain needs to do with the information coming in from the eyes, suddenly, it makes us realize, oh my gosh! It’s kind of amazing that that works for anybody, right?

There are so many pieces to it. And I think that when we don’t struggle with these things, it’s easy to dismiss it and yet — when we work with kids, or even adults who are having these challenges, you step into their shoes and suddenly you realize, oh my goodness, there are so many working parts to this and so many things that need to be working together properly for the brain to be able to make sense of this, especially in a busy classroom environment, in a fast-paced environment and to me, I see that’s where a lot of the behavioral challenges can come in with kids who are having these types of visual processing or developmental vision types of issues, because they’re trying really hard to keep up, they’re trying to do what they’re supposed to do and they’re just getting overwhelmed and they are getting frustrated and they’re shutting down and then it looks like they’re just a behavior problem, right? Like Johnny wouldn’t want to do his work or whatever, when really the underlying issue is that they’re struggling with these vision problems.

Dr. Fortenbacher:

Yeah, exactly. And what you’ve described are the emotional consequences of a visual condition when a child is trying to apply themselves and they can’t do it as a level that should match with their overall capabilities in other areas, they’re frustrated and they start to feel down on themselves. And they say to themselves, “Well, I tried that but it didn’t work, so now — I can’t.” And they get this attitude of, I’m not even going to try. And so that’s where these visual conditions that I’m describing which are medical diagnosis, they aren’t just observational — we’re talking about the one that is the most common, the medical term is called ‘Convergence Insufficiency’. Inability to converse the eyes. And one of the things, when I sit down with a child initially in examination, I’ll say, “Do you like to read?”

And just watch the response to that. And 9 times out of 10 and the reason they are here seeing me is because that’s one of the concerns that parents have, and they’ll say, “No.” And they’ll frown. I’ll say, “Well, when you look at words on the page,” And then I’ll hold my hands up and this is where the audience has to visualize this: Put your two hands together, one on top of the other and just slide them across one another. And I’ll do that, I’ll hold that gesture in front of that child and say — do you ever see words slide on top of one another like that? And a lot of times, the kids that I see that have this condition called convergence insufficiency — they will acknowledge, yeah, they see that.

This is the first time the parents ever heard that. And if I ask the child, do you ever see double and they have double vision, they’ll typically say “No.” We don’t know what that means, but when we show the gesture, they get it. So to your point about they don’t understand what they’re missing, to them that’s their world. And this condition occurs in 8-12% of the pediatric population, so it’s not rare. This condition of convergence insufficiency is significant. And it’s by far the #1 visual, binocular vision eye teaming conditions that’s then tested and researched. 3 multi-center clinical trials have been done, NAH funded over the course of 25 years, there have been many, many research projects determine that this is impacting performance and yes it can be treated effectively with vision therapy.

Dr. Nicole Beurkens:

First of all, I didn’t realize those statistics. That’s a pretty significant number of kids, 8-12%, you said. And the other thing, I think that’s so important there is, you’re saying there is good clinical research to show that these are real issues and the problems that they present. And I think that’s so important because a lot of times it’s easy to dismiss things that we haven’t heard about or we don’t really understand, right? Or that’s some idea or opinion that somebody has, but what you’re saying is there has actually been quite a lot of really good research into establishing what these conditions are, how they impact kids and then what is needed to treat them.

Dr. Fortenbacher:

Exactly. And one of the most recent publications from the journal of American medical association, in the ophthalmology division was to study — yes, these conditions exist, we know, convergence insufficiency, the tracking is another area that’s called oculomotor dysfunction, and accommodative dysfunction is the focusing condition. We know it exists, but the research that was done and published by the JAMA publication was to determine — what’s the frequency of these conditions with children that have reading problems, and they coined it ‘Developmental Dyslexia’. And what they found was a significant amount of children with developmental dyslexia have binocular, accommodative and oculomotor dysfunction. So we are seeing research that shows that these conditions are present compared to a normal reader and then the next question is, what are you going to do about it? Are you going to do something to treat these children or are we just going to work around it with compensatory strategies. So there is treatment for this to help these children.

Dr. Nicole Beurkens:

And I want to get into that because I think that’s such an exciting part of what you do in your work and at your clinic, is innovative ways to treat these things. I want to spell out for people, so parents who are listening who might be thinking, oh my gosh! This maybe sounds a little bit like my kid, or no one’s ever looked at this for my child, I wonder if this is an issue. What are some things that parents should be looking for, or what are some signs that would indicate that maybe this is going on for a child, or that this is something that parents should be delving into further?

Dr. Fortenbacher:

I think anytime that you have your child struggling in reading and learning, it should be one of the things that you check off the list. It should be, let’s rule this out first. And so, first of all you have to consider, when your child is struggling — let’s have their vision evaluated. Not just in eye health and eyesight glasses. That is important, yet you have to go beyond that. So we have to evaluate these areas of binocular vision, tracking, focusing, visual processing to truly determine if there’s an issue with that.

The other areas again would be falling into attention and concentration. Another area that falls into the common theme that I see are children that just resist doing their homework. Homework is a battle. And we’ll see that it’s the visual motors. The visual eyes and hands working there to copy from book to paper or they’re just burned out at the end of the day, they’re just so visually stressed, they can’t concentrate to do their homework. So it’s the avoidance of reading, dislike for reading, the attention, the difficulty of homework. Reversals is another common theme, the children that we see that have frequent reversals beyond a certain age. Usually, by age 7, those should be worked out developmentally, but if it’s persisting, then that’s a concern. And otherwise, I would say the other performance concerns could be with general coordination too. So that would be another category to look at.

Dr. Nicole Beurkens:

Yeah, I was going to say, beyond the things that you mentioned, some the things that I just scream for clinically are things like kids who are having very immature gross motor skills or coordination problems well past the age when they should be able to throw and catch a ball or do balance activities or things like that and they’re really struggling with that, I’ve seen that it’s another indication too. So I think that all those things are really helpful for parents to think about — okay, if these are some of the things going on with my child, then this is stuff that I should look into further. So let’s talk about the assessment and then the treatment process because I think, first of all, a lot of these problems go undiagnosed or under-diagnosed in kids. Nobody realizes that this is what’s going on. So can you talk a bit about what an evaluation for this looks like, what kinds of things are you doing with the child, and then I want to get into how we treat these.

 Dr. Fortenbacher:

Exactly. And then the initial evaluation does look — and I want to emphasize that it is important that we look at the ocular health, the visual acuity and also proper lens application because lenses are a critical piece to getting the eyes in balance. So if lenses are needed, that’s an important aspect of the assessment. And then after that, we are looking at binocular vision, eye teaming which begins with the ability to converge the eyes. So we have testing that is very basic and even a parent can do this at home and on your own child. You can just use a pencil or a pen or an object.

Just put it in front of the bridge of their nose and move it towards the bridge of their nose and have them report when they see double. Now there are more sophisticated ways we look at this but the research shows that that should be about 2-3 inches. They should be able to converge their eyes on a pencil or a pen at 2-3 inches. And if they can’t do that, if they start to report they go double beyond that, that’s a big red flag. We then look at tracking. A tracking test, there are standardized methods we do, and there is also a chair-side method that also can be done at home, and a lot of times teachers will do this. They’ll use a pencil or a pen and have them just follow the object as they move it up and down, around in a circle and see if the child can keep their eyes on that target.

That simple test can tell you a lot of information about that child’s visual readiness for reading and paying attention in the classroom. The third area is the focusing category and that’s a harder one for you to measure at home, but in the office, we are using lenses to measure their amplitude or strength of focus, their ability to relax focus and their ability to jump focus from near  to far, which is what you have to do when you are in the classroom copying from board to paper. So we are looking at those areas. That takes about an hour. In our evaluation process, that’s about an hour — a long procedure.

After that, when there is a reason for concern that there are visual processing issues, we’ll have them return for a more comprehensive evaluation of their visual perceptual abilities and that takes about an hour as well and there’s a long list of things that we do to address that, whether it be from form perception to visual memory to visual directionality, which measures letter reversals, we look at eye-hand coordination, we’ll do reading tests to see where they are. This is an important point: Is it a reading disability or is it a reading fluency problem because they’re not the same. Your child is in 4th grade but doesn’t know their words at a first-grade level, that’s more of a reading disability, that’s another type of issue vs. a child who is in 4th grade but reads very inefficiently, losing their place and having to reread to get the information. They know their words but they’re just having fluency issues. So those are 2 different areas we want to evaluate.

And then after that, we are looking at visually directed gross motor skills, vision imbalance and some of the visually directed fine motor skills. That’s kind of the big picture. Once we have a diagnosis, then we sit down and talk about how we treat this. And the therapeutic part of this is like thinking of vision therapy as other rehabilitation, whether it be occupational therapy or speech-language therapy — and to some extent physical therapy.

But we’re really working on helping a child, and we do work with adults too — I think that’s important to emphasize, but for this talk, we’re working with a child on activities that are visual challenges woven into something that’s interesting and fun but has ways for them to develop awareness, feedback and do this with distraction. So each activity is kind of like a sports drill. So they’re doing activities that have visual challenges guided by the therapist, one on one in the office, typically once or twice a week with some home reinforcement.

And in the course of time, we are reevaluating the progress periodically and we’re measuring feedback from the parents and we’re also getting feedback from the therapists and the doctor working with the patients. So that’s is how we measure the progress. In general, it takes us about 3 to 4 months to completely remediate these areas we’re talking about. The more complex patients have more complex issues, it could be with autism or another developmental place, certainly that takes longer and kids that have strabismus or a crossed eye or amblyopia, lazy eye — that’s more complex and can take longer but the thing to understand is that it doesn’t have to be a lifelong problem. This can be addressed in a relatively short period of time.

Dr. Nicole Beurkens:

That’s great to layout how you go through that process, what parents can expect from a good therapy protocol like this and the kinds of things that are worked on. And I know because I’ve been in your office. When you talk about visually engaging tasks or just tasks that are motivating engagement, kids are really engaged and they’re working hard and they’re certainly working their brain and their vision hard, but it’s an enjoyable process.

The way that you go about this is to have the kids doing tasks that are meaningful, that are interesting to them. Because I know that some parents may be listening that are going, “Ugh, the thought of trying to get my kid to do vision exercises again.” Because a lot of us who are parents think of maybe vision exercises that we were given when we were young or something that the eye-doctor handed them, you know — have your child do this kind of drill over and over, it’s like pulling teeth to get kids to do that. But what you are talking about is really incorporating the practicing of these skills into meaningful and engaging activities, which I think makes a big difference.

Dr. Fortenbacher:

That’s huge. That’s so important. Without having that awareness and feedback and engagement, it’s monotonous. And what you’ve just described is an example of where giving somebody an “exercise” over a period of time becomes monotonous and your brain turns off. You really aren’t developing anything from that. So it’s so critical to have a large repertoire of variety and that’s what we draw from. Whether it be low technology or high technology, we are now on the cutting edge of vision therapy applications.

I just wrote a text, a chapter in the textbook in the latest advancements in optometry and ophthalmology on vision therapy applications in virtual reality. And so this is what we are working on now, is we are working on virtual — we’re actually able to use vision therapy in virtual reality examples. Not just virtual reality games, but therapy and applications that have been designed in a virtual reality. So that has its place in certain types of cases. Not everybody applies to that, but we use other examples of technology that makes it engaging, makes it fun and interesting. And bottom line is, we get fast results. Because when the patient is engaged and we’re stimulating these areas, the brain catches on faster and we get better results.

Dr. Nicole Beurkens:

Two things I wanted to circle back and touch on because I think these are really important. One is: you’ve talked about treating adults as well and I do think that’s really important to mention. We’re talking a lot about kids, but kids of all ages, right? Little tiny kids, all the way through to our older kids, our teens and our young adults. But also adults maybe who never had these issues treated, or maybe who have had a traumatic brain injury or something that has happened later on in life that has impacted their visual processing. So I think that that is an important thing to mention because there are maybe some parents listening who are applying this to themselves and then going — wait! I have this issue! Or, you know, these are things that I had when I was a kid. Is the process pretty similar for adults as it is to kids?

Dr. Fortenbacher:

It is. Actually, our adult patients are our best patients because they are motivated to be there for one thing. And while the kids, we have the toys section and they do well and we reward them, they can select from the toys. The adults, I don’t have to give them toys for them to participate in these activities, they are there because they want to be there. And age is not a barrier, that is another myth that is percolating so long out there that somehow this only works for children. I have had patients in their eighties working with us in vision therapy.

So there’s plasticity in our brain, no matter what age — as long as we can interact and engage in the process. So I would say about 30-35% of our patients are adults. All the way from older teenagers to college-aged kids and older adults. A lot of the adults are with us because either, like you say, they’ve had the condition their entire life or it could be that they’ve acquired a concussion or a traumatic brain injury. So a lot of our — again, the segment of our patients, about 25% have had some kind of a neurological event that has also resulted in them having these visual issues and we work through the process with them the same.

Dr. Nicole Beurkens:

Yeah, and this makes me think another issue that we didn’t touch on in sort of the list of symptoms or the challenges to watch out for, but I am thinking about a particular adult patient who had a very successful course of treatment with your clinic. I sent her there just because of a lifelong history of severe dizziness issues. And you were able to identify some of the underlying brain-eye pieces there and she went through treatment and did really well with that. So I think that might be another thing for people to be aware of, that maybe that’s a symptom that your child has as well, but nobody has ever been able to get a handle on it, could be that some of these things would be helpful for that too.

Dr. Fortenbacher:

Yeah, the one condition that is common is motion sickness with the children we see. Very sensitive to taking trips with family and anywhere in the car, easily, they are having motion sickness. And for a lot of parents, that was like, oh he’s got motion sickness, but they didn’t really associate that with what we’re doing. That’s one of the things that resolves pretty quickly, actually. And the reason for this is because vision ties with a part of the brain that’s to do with balance, it’s called a vestibular system. So you get this visual-vestibular integration and if there’s a disruption in that for whatever reason — again, it could be developmental or it could be some kind of neurological event. That can be rewired if you will, through vision therapy. So a common theme of the patients we see is that, we call it SEE Sick protocol. See – S E E Sick protocol and a very effective way to resolve this. Usually, we can take care of that particular aspect in maybe as little as 8 weeks.

Dr. Nicole Beurkens:

That’s great. That could be life-changing for so many families, especially if this is a chronic issue. Kids who can’t ride on the bus comfortably, can’t go on car trips, plane rides, those kinds of things, so that’s great. I wanted to circle back too because you mentioned more specific issues like strabismus, amblyopia — conditions that very often, parents are told, “There’s not really anything that we can do about this, so we’ll do some patching or we’ll do some surgery to correct your child’s crossed eyes.” And I see kids who have had those kinds of traditional procedures or treatments done and they are still really struggling with using their vision with being able to interpret what their eyes are seeing. And I know I’ve learned a lot from you about that over there. Can you just touch on that briefly for parents who are dealing with that with their kids?

Dr. Fortenbacher:

Right, so the strabismus, that’s the medical term for eye teaming failure, that’s where the eye crosses in or turns out or up or down or other varieties of that. But basically, what we are describing there is a dysfunction in binocular vision that is more severe than the ones I was describing earlier. They do take a more advanced approach to the treatment. Patching in itself doesn’t treat the strabismus.

Patching is designed to stimulate the sight that was lost due to the crossed eye, that’s called the amblyopia lazy eye. And what we have now are techniques — evidence-based methods that allow us to treat amblyopia without having to use patching as our go-to approach. It’s in a binocular approach to treatment, so patching is no longer needed as the go-to method. And that’s so hard on parents and for the patient to do patching anyway.

But it is one of the advancements I would say, now and there’s more information on that on our website and also the amblyopia project by the VisionHelp project is another resource I’ll touch on. But the strabismus area is one that usually you might think of as eye surgery, but in reality, eye surgery is a cosmetic procedure — it doesn’t teach the brain how to use the two eyes. There is a place for it, and we do, from time to time, refer when it’s a severe form of crossed eye. But in general, it is not teaching the brain how to use the two eyes and that’s what vision therapy is for.

So for patients that we treat that do ultimately need surgery, we do the vision therapy to get both eyes aware and turned on, then surgery to get them in the ballpark to where they need to be, and then post-surgical vision therapy for those that are again, the more severe forms. But the majority of the patients we see that have the crossed eyes don’t need surgery.

And we can get the excellent results, develop the binocular vision, and also the ultimate is depth perception. Back to your point about now knowing what you’re missing — when you have 3D vision, you can see pockets of space. And I had a patient, an adult patient last night as a progress evaluation and he just was saying how he’s just so amazed at what he’s able to see now. He said, “I’m playing around with my vision.” He’s playing around with seeing pockets of space. And for those of us who know how to do that, it’s just like so what — but if you’ve never had that before, it’s kind of a cool thing.

 Dr. Nicole Beurkens:

Yeah, it’s amazing that the things that can be done and just to open people’s minds to the idea that these things can be treated, that you don’t just have to settle for, well maybe just put a bandaid on this or you know, kind of do a little bit of this or that and get it to be okay — that really, you can, using these kinds of techniques and therapy processes, kids and even adults can develop really… they can have the joy of having vision that really works for them and experience the visual world in a way that the rest of us do and I think that’s so cool.

 Dr. Fortenbacher:

Yes, and I want to make one other final point, is that when I talk about these areas that vision affects attention, vision affects reading, vision affects sports. Vision therapy by itself sets the stage for the patient to respond. So a lot of the patients we see that have reading problems, they still require educational support. It’s not like you do vision therapy and suddenly now they’re going on and they’re just a — the kids that have visual fluency problems, they can take off. But the kids that have reading disabilities, they still need educational support. Kids that have these potential issues, those are deep-seated issues. They need to work with counselors, they need to work with coaches, they need to work with psychologists to help continue. So it’s a collaborative effort here. It’s not like a panacea that fixes everything. And if you have a problem with golf and you do vision therapy, it’s not going to automatically make you a scratch golfer. You’ve got to get up and play golf, so the same principle applies in other aspects of life.

Dr. Nicole Beurkens:

Yeah, I think that’s a great point and it’s one of the things I appreciate about you in your clinic is that it is a collaborative approach, there are pieces that we offer, there are pieces that you offer. Many of these kids, especially with more severe challenges need a team approach and the way that I look at it is addressing these visual issues that you are talking about as part of the foundation and it sets the stage then for other treatments and for further development to rest on. So I appreciate you mentioning that. Unfortunately, we are at the end of our time together. That went so fast! We can talk for a lot longer, but I want to make sure that I give you a chance to let people know where they can find more information about these topics, where they can find information on your clinic, what are your websites and other resources that you have.

Dr. Fortenbacher:

Well there’s a lot of really excellent resources now and one of them I want to direct attention to is a project that was put together by the VisionHelp group, and it’s called The Vision and Learning Project. So visionandlearningproject.com, and it’s taken all these things that I’ve talked about and it has warehoused them into one site, it’s got the research, the white papers, the videos, the books — it’s a composite for parents, for allied professionals, for eye care professionals, so check that out. Also, the COVD.org website, so covd.org has also find-a-doctor if you are not in the area, or if you are in an area that you aren’t sure where you might be able to find a provider, covd.org. Also our website for sure, we have an abundance of information, wowvision.net. And so we’ve got the resources there, we’ve got examples on our Facebook page, of success stories, our YouTube channel and a variety of other material. So I encourage people to take a look.

Dr. Nicole Beurkens:

Awesome. Thank you so much for being here today and for sharing your knowledge and experience with us. I know that so many families are going to find that helpful, so thank you so much. And I hope that you find this helpful, apply this information to your kids, keep doing the best that you can for them each day and we will see you on the next episode of the show!