Promoting Participation and Mental Health in Children and Youth: Every Moment Counts and ESSA (Every Student Succeeds Act) Podcast

Editor's note: This text-based course is a transcript of the Promoting Participation and Mental Health in Children and Youth: Every Moment Counts and ESSA (Every Student Succeeds Act) Podcast, presented by Susan Bazyk, PhD, OTR/L, FAOTA, and Dennis Cleary, MS, OTD, OTR/L.

**Please use the handout to complete the exam.

Learning Outcomes

• After this course, participants will be able to:
  • Examine what a tiered, public health approach to mental health means and how it guides Every Moment Counts' initiatives, and how OT practitioners can promote participation in occupations to promote health (mental and physical) throughout the school day (classroom, lunch, recess, and extra-curricular leisure) reflecting OT's full scope of practice.
  • Evaluate opportunities that the Every Student Succeeds Act (ESSA) provides OT practitioners for addressing health at the universal and targeted levels.
  • Analyze how OT practitioners can build capacity of OTPs and school personnel to address the mental health needs of children and youth in schools.

Podcast Discussion

Dennis: Thank you, everyone, for joining us today. My name is Dennis Cleary, and I am a senior researcher at Cincinnati Children's Hospital. I am excited to be joined today by Dr. Sue Bazyk. Sue, could you tell us a little about your background and how you became interested in addressing the mental health needs of children and adolescents?

Sue: Great to be here chatting with you, Dennis. I have been an occupational therapist for over 40 years. My clinical experience has been in the home, school, and community settings. I am a professor emerita, meaning I am retired from teaching at Cleveland State University, where I taught for 34 years. In terms of mental health, I believe in the use of occupation to promote health, both physical and mental.

Throughout my clinical career, I was always tuned into the mental health needs of the children I served. For example, I hated children with food refusal issues being referred to as "behavior kids" or having "behavior feeding." They were children struggling with their mental well-being related to their relationship with their mouth, the feeder, and food. I have always been very interested in mental health as a part of OT identity. I am not too fond of these two areas being separated.

In 2000, I was invited to an AOTA think tank meeting. Barbara Hampt and Leslie Jackson, leaders at AOTA, brought together 20 OTs for this two-day think tank meeting to discuss our role in children's mental health. The impetus was the Surgeon General's report in 1999 on mental health. He called for reducing stigma and increasing attention to mental health promotion and prevention. We realized after two days of thinking about our publications that we did not have anything in our publications on promoting positive mental health and prevention. It was all intervention for kids with challenges. Promoting positive mental health is what lights my fire.

Dennis: This led you to create Every Moment Counts. Could you just talk a little bit about this program that has been most of your life work in occupational therapy?

Sue: We just had our 10th anniversary from when this initiative was launched. After this meeting, I published more about children's mental health. In 2005, my dissertation focused on social-emotional learning and occupation-based services for low-income urban youth. During this time, I started reading about the public health approach to mental health (Georgetown had one of its first monographs around 2008). I had an opportunity to write a book for AOTA, and I spent a long time reading about the tiered public health framework and mental health promotion. There are whole books on mental health promotion, mental health literacy, and positive psychology. I mulled over all of this reading and research. It helped shape the 2011 book "Mental Health Promotion, Prevention, and Intervention with Child and Youth: A Guiding Framework for Occupational Therapy." I had several other authors as a part of that book, and we all agreed that the book would focus on intervention for those with challenges and for every group of children. We had chapters on ADHD, learning disabilities, and autism, but we wanted to focus on how to help them be mentally healthy.

Many publications are not applied in practice. As I wanted people to use this research, I started learning about knowledge translation, implementation, and developing a building capacity process. At first, I did not get funding, but I brought together 14 OTs to be a part of a community of practice after they read the whole book. They were so excited about promoting positive mental health. Within this six-month process, I heard about funding from the Ohio Department of Education relating to mental health.

The guiding question in our first meetings was, what should we see in school practice? During those three hours, we talked about many things. The essential idea is that we should not practice positive mental health for only one hour a day. It has to be embedded throughout the day and led to Every Moment Counts. We received $720,000 in funding for three years. These OT change leaders and I developed, implemented, and evaluated this program over three years, and it has been a fantastic journey.

Dennis: When you go to your website, which is everymomentcounts.org, there are incredibly user-friendly resources that give us language that we can use to talk to administrators and build capacity. I was fortunate to be in Ohio for many years and saw this program in action. How many OTs did you end up training in Ohio? I am sure you are still recruiting more.

Sue: We replicated that building capacity process throughout Ohio as a part of the grant. We reached over 200 OTs, and our work was published. We saw learning over time and success stories and challenges. Therapists reported statistically significant improvements in their knowledge of this framework and their belief that they should be a part of mental health initiatives in school.

As OTs, we say we are holistic, but often, we cannot describe what we are doing. The initiative to explain what we are doing is now within an online course, and I have shared the information sheet with our listeners. We have implemented this across the country, with even capstone students using this in different states. We also made it interdisciplinary.

Strategically, we knew that one or two OTs could not do this work. Instead, we needed all adults serving youth to tune into mental health and be mental health promoters. Not everybody is a mental health provider, but everybody needs to be a mental health promoter within this tiered framework. Teachers and other school personnel love this information.

Dennis: I know several of the OTs that were involved in this project. I appreciated that they felt stronger and more confident about their actions, including approaching administrators and the Department of Education to determine the size of caseloads and what was realistic. I do not know if that came entirely from Every Moment Counts, but I know Ohio has some caps regarding the number of kids on a caseload. I am in a state now where there is no cap. I talked to an OT who was trying to see 200 kids not too long ago. This caseload is not possible.

Sue: There are many issues related to enormous caseloads. The bottom line is that IDEA, the law that brought us full force into schools, states that our services should be in the least restrictive environment (LRE) to the maximum extent possible, meaning in a gen ed environment. We try to get therapists to provide services in a natural context versus an outdated clinic-based model. There are different tiers: universal is all kids at a classroom level, tier two is a small group, and tier one is more of a caseload model.

When we integrate services in the natural context, we can maximize the impact, and all children can benefit from the services we provide. In one of our studies, a principal said, "I want to get the biggest bang for my buck, so I want you to integrate into a natural context." Too many OT supervisors do not have up-to-date information, are misinformed, or are stuck in a pullout clinic-based model, which is not best practice. I think we have to work smarter, not harder.

Dennis: That is an excellent illustration of the different tiers of a public health model. How did you get interested in it? Was it the way for you to address the highest number of kids possible? 

Sue: It goes back to a tiered public health approach to mental health. Tiered services have been a part of education for at least 20 years. Response to intervention (RTI) and Positive Behavioral Interventions and Supports (PBIS) are tiered models, as is Every Moment Counts (EMC). However, I want to make a huge distinction. In the other models, tier one may only include 80% of kids who do not have challenges. EMC's tier one comprises all children and youth. We want to promote positive mental health in children with and without disabilities or mental health challenges. Our pyramid looks different as we move toward mental health promotion and prevention. However, I do find that a lot of resources gloss over promotion and go right to the prevention of problems.

Tier one is mental health promotion using evidence-based strategies that help children be mentally healthy. It includes many concepts from positive psychology. OTs believe that what we do impacts how we feel and function. We are not doing talk therapy but instead helping children participate in occupations and interactions throughout the day to help them be mentally healthy.

Tier two is a little more specific, tuning into all those at risk. Tier two includes students with disabilities or those with higher comorbid risks of mental health challenges. We see increased mental health challenges with poorer, bullied, and obese students. OTs may run small groups with these tier two kids at risk during lunch or recess, including peer buddies. We can serve many during these groups during nonacademic times.

Tier three is the go-to person services for those with identified mental illness. We need to help school personnel reduce stress and create sensory-friendly environments that help children with mental disorders succeed.

Dennis: How would you say that differs from a Multi-tiered System of Support (MTSS)?

Sue: MTSS is a buzzword now. I have seen it with four levels, but I think it is very similar to a tiered public health framework. The whole gist is working with all students to promote health and prevent health challenges. I see the models as very similar.

Dennis: When I teach public health models to students, I try to have them see the big picture, but many expect one-on-one intervention. It takes a little bit of nudging. The support you provide on the website and the other training can help OTs understand how this can look.

Sue: Right.

Dennis: Can you talk about how looking at this tiered approach can influence OTs in how they evaluate and intervene in schools?

Sue: The various tiers are not dissected very clearly. If an OT provides services or co-teaching in the classroom, they will look for struggling children. Even though they are doing a tier one service, they are layering in support for children who may be struggling. Thus, the tiers may blend, but a skilled therapist can adapt.

We need to shift. We used to provide one-on-one intervention, but then consultation became big. I think consultation has its place, but teachers are stressed and overwhelmed. If we ask teachers to do more, I think it can be problematic. They may struggle with therapists telling them what to do in their classroom. Instead, we can co-teach, which was part of Jane Case-Smith's Right Start program. Co-teaching is "doing" with the teacher or doing a unit of something related to what they are teaching.

Coaching strategies are also gaining a lot more attention. Our cafeteria and recess programs involve coaching. We develop relationships with the supervisors and model what we would like them to do. Modeling is very powerful.

In applying a tiered approach, we take our students at Cleveland State University into Cleveland schools to implement the cafeteria and recess programs. And by doing that, they learn how to implement a tier one service where evaluation differs. Evaluation is more like an environmental scan, which we have on our website. It analyzes the context and the sensory, physical, and social-emotional factors and caters to the specific needs of the cafeteria context. It is a different skill set than one-on-one intervention.

Our students need experiences, and therapists may need to develop new skills. Even practicing therapists may scratch their heads and think, "How could I do that?" We have "Maverick OTs" who are confident and jump in and do it as they know it is right.

Dennis: Absolutely! One of my former students had a son with Down syndrome that was in speech therapy in a public school. She attended an IEP meeting with the speech therapist and asked how she incorporated therapy throughout the day. The SLP said, "I'm responsible for 30 minutes in this room." She and the SLP problem-solved how this could look to create the best scenario for this child.

I have been working with many Canadian OTs recently. They are not at the level we are but are now starting to get a little more involved in the schools. Some of them shake their heads about our school-based practices, particularly transitions. They want to know why we are working on anything that will not help these kids when they are out of school. They want to know how we get the best bang for our buck or give them the skills they need to be successful for a lifetime. Positive mental health skills are a huge part of that.

As an aside, I recently saw the same young man mentioned above in the 4th of July parade with the high school marching band. The communication skills he has developed have moved beyond the 30 minutes a day/week.

Can you talk more about Every Moment Counts and what you are doing to focus on participation and promoting positive mental health throughout the day?

Sue: You mentioned doing work that helps children do more than a 30-minute session. The programs we envision are embedded throughout the day in the classroom, like in the lunchroom and during recess. Meal times are a part of the OT scope of practice, as are play and social participation. Why are we not fostering health during lunch and recess?

We also need to make leisure matter. Much literature on the importance of structure and leisure, including Reed Larson's work on youth development, is available. Leisure is a forgotten occupation for many OTs, even though students with disabilities may need support and services to help them participate in leisure. So, I will start with this area. Making leisure matter is based on occupational justice, that all children should have a right to participate in meaningful out-of-school leisure. We started with individual leisure coaching for children and youth with disabilities or mental health challenges that had no leisure. We developed OT leisure coaching steps to help them participate.

Then, we branched off into more of a tiered approach to leisure promotion. What could we do at a tier two level with those at risk? The Cleveland Clinic Children's Rehab has developed some small leisure groups that work on fostering hobbies and interests. We also do some tier-one interventions, including doing an environmental scan of leisure in the community and sharing that with parents. 

The cafeteria and recess programs are six-week, one-day-a-week programs that focus on promoting participation and enjoyment for all students and building the capacity of supervisors to be effective in their job. Most of the time, supervisors are not given any information. Principals love these programs. We focus heavily on soft skills kids can develop during these unstructured times. You can also work with children one-on-one in a little room, but learning occurs best in the natural context, doing real things with peers, and focusing heavily on friendship promotion. We can work with kids on how to be good friends or have mealtime conversations. These are life skills. We also want kids to respect differences, include others, eat healthily, and participate in active play during recess.

I describe the pandemic as an occupational disruption that decreased participation opportunities. As a result, we see decreased occupational endurance in kids. Occupational endurance is needed to concentrate and socialize throughout the day. I am hearing many more reports of bullying, depression, and anxiety. Many Every Moment Counts programs are in huge demand right now, as is mental health across the globe. I am getting invitations to speak in Pakistan, Ireland, and the UK.

The last area is building the capacity of school personnel to promote mental health.

Dennis: Gotcha. As you said, mental health is at the root of our profession and makes us different from some of our other rehab colleagues. Even in the adult rehab world, there is more emphasis now on leisure. Do you want to talk a little about the service delivery models that are important for occupational therapy practitioners as we are looking to provide these kinds of initiatives?

Sue: As I mentioned, we are shifting from a pullout clinic-based one-on-one model to an integrated one. One of the myths is that services need to be in the classroom to be educationally relevant, but we need to focus on both academic and nonacademic settings. When I talk to therapists about our cafeteria and lunch programs, I often see a "deer in the headlights" look. In one state, someone raised their hand and said, "I never thought about being in the cafeteria before." We have not taken our full scope of practice seriously.

The other thing is shifting from a bottom-up to a top-down model. A bottom-up focus is looking at component function. In Ohio, for example, there was an OT referral form with "fine motor" or "other" listed with checkboxes. Some OTs were saying they could only address fine motor deficits. We need to assert ourselves and bust these myths. The law states that we can focus on participation, function, and prevention, but it does not say what areas we address as OTs. We can define our scope of practice and correct misinformation. I think this is an issue we are trying to tackle in Ohio.

We used to have Kathy Cheney in Ohio, representing related service providers. It is imperative to have a connection at the state level to influence how our services are defined. Non-OTs supervise too many OTs. However, in districts like Cleveland and Columbus, where there is an OT director, it is easier as they can articulate our role and supervise therapists in that area.

Dennis: Related to that, we fought long and hard to get Medicaid reimbursement in the schools. In terms of that one-on-one service delivery, how do you negotiate that? I was a paid consultant at the Ohio State School for the Blind, where I helped an OT there was overwhelmed by a large caseload. The superintendent was excellent and said, "Whatever a kid needs, a kid gets." I certainly did not know who was on Medicaid in terms of billing and reimbursement. I have talked to some OTs who feel pressure to maintain that one-on-one billable service. How do you address that?

Sue: It is very complicated where some schools do not even bill. There are many differences. OTs who the school hires tend to become a more significant part of the school's culture. If they feel something is needed, they do it within our scope of practice, and they run things like small lunch bunch groups or more universal-type programming. They can make a case that they are serving kids on their caseload, but it does throw a wrench in an individual needing a plan of care. I keep returning to the idea that even 15% of funds are allotted for students not on our caseload as part of RTI. When you have a leader at the top saying, I want you to work within a workload model and provide tier one and tier two services, I think that nudges therapists out of the direct one-on-one model, as we know, is not best practice. We can demonstrate our value the more therapists that do this overarching model. We can also apply some of these other strategies, like coaching.

I think small groups and environment-focused interventions are very powerful. When we change the environment, we can impact the person's participation. We have always done that as OTs, but now we have a term for it.

Dennis: Other personnel, like reading specialists, provide interventions in many different ways. They are not just doing one-on-one interventions with kids and pulling them out. My wife is a teacher educator, and we have some these discussions over dinner about how we interact. Do you have an example of a school district that had done an excellent job of moving beyond the one-on-one clinic-based model?

Sue: When we started our work in 2011, Carol Conway, a therapist in Hudson City Schools, a wealthy district, felt she was stuck in a pullout and one-on-one therapy model. She knew this was not best practice, but parents viewed school as a place their children could be educated and receive therapy. The bottom line is that children receive school therapy to help them participate. Carol always said, "We cannot do Every Moment Counts if we only use a one-on-one pullout model." We did an in-service with related service providers and the director of special ed to get everybody on the same page about why integrated services are best practices. It is the law and theories of motor control and learning support this. After we got the therapist-related service providers on board, instead of announcing it, we developed a community of practice, as we were concerned about pushback from parents. The community of practice included representatives from paraeducators, parents, speech-language pathologists, special and regular ed teachers, and administrators. We did some short inservices and led some discussion groups. As we started integrating this program, we did a lot of awareness raising and sharing success stories. Within about nine to 12 months, things shifted. The therapist did a time study of service provision where integrated services went from 40 to 80%. It took strategic thinking to get everybody on board, but it was very successful.

Dennis: Good. During COVID, I helped remotely supervise level one students at a residential school. All the kids at the school learned to ride a bike from the OT in this high-end residential school in a "bike riding class" they all had. They are not billing Medicaid, and the OT and administration looked at the important things for these young people. Bike riding is within our scope of practice, but all the kids raved about their great OT experience because of focusing on an important skill they would have for a lifetime.

When you think about our practice in schools, and you have used the word "distinct value," what do you think is essential that we share with administrators, families, and other personnel in the school? Are we practicing in a way that we believe will help the most kids and have the best outcomes?

Sue: I think the key is participation. Not everybody understands the term occupation, but I like to consider the interactions that foster health within our scope of practice. There are nine areas of occupation that are listed in our practice framework. With the special ed legislation in 1975, occupational therapy came into schools, and the floodgates opened. We are the third largest practice area. Legislation is critical.

Secondly, in 2015, the Every Student Succeeds Act (ESSA) replaced No Child Left Behind. It focuses more on mental and physical health within MTSS (Multi-Tiered System of Supports), and we are listed as SISPs or Specialized Instructional Support Personnel. States are responsible for implementing ESSA and developing their guidelines. One of the problems is that while we are a related service provider and listed as a SISP, we are not at the table yet. No Child Left Behind focused on testing and academic success, but ESSA focuses more on health. When children are physically and mentally healthy, they do better in school and life.

The whole child framework (whole community) is being adopted throughout the country and in most states. For example, the Ohio Department of Education has adopted it, and there is the Whole Child Advisory Group. I have sat in on some of their virtual meetings during COVID, but we do not have related service providers represented in that advisory group or ESSA. ESSA, in most states, has to have an advisory group, and related service providers are not represented. One of the challenges I now see is that we are pigeonholed into special ed and need to be educationally relevant for the rest of the school population. School personnel do not always recognize us as healthcare providers in schools.

In one of the Whole Child Advisory Group meetings, an OT from Nationwide Children's Hospital in Columbus asked why they had to have hospital-based OTs advise schools instead of the OTs and PTs already practicing there. I see significant tension across the country because we are not at the table related to health initiatives. More and more money is going into school health centers. For example, PTs could be addressing obesity prevention and physical fitness, and we could be addressing mental and social-emotional health. I see this as a problem, and we need to advocate and be a part of those state advisory committees.

Dennis: Do you have advice for OTs out there that are interested in getting to the table? What would a first step be?

Sue: At a district level, many have wellness committees. In the Cleveland district, Karen Thompson is the OT director. She and some of her OTs and PTs attend their monthly wellness committee meetings. I presented on the "comfortable cafeteria" at one of them. We must look at the districts and schools to see what committees are available. I know many OTs in other states on their school's mental health, Positive Behavioral Interventions and Supports (PBIS), or Social and Emotional Learning (SEL) committees. We must ensure we are at the table, even at a school level.

At the state level, I mentioned the Whole Child Advisory Group. I contacted them but missed the deadline. They do not advertise those things very well, but I think we need to look into those advisory committees and even where money is going for school health to see how we can access that. I have never seen any state where an OT is involved.

Nationally, I stay connected with Abe Saffer, our lobbyist overseeing school-related legislation. About three years ago, he started bugging me, asking, "Why do OTs not know about ESSA and are not doing anything about it?" He contacted me every couple of months. I decided we should do something about it with Amy Coopersmith, an OT working for the New York Department of Education and New York schools. Additionally, Pam Stevenson from Virginia has been involved in AOTA. Collectively, we decided to start the grassroots OT-ESSA Advocacy Network. We chose not to do it under AOTA because we knew we could do things more quickly and include non-members. Again, it is grassroots, and we have about three virtual meetings a year. There are already over 250 OTs, all recruited by word of mouth. Our goal is to educate OT practitioners and students about ESSA and how we can be at the table and address health at tier one and tier two levels. We also share success stories.

It has been exciting to see the OTs already doing tier one and two services that address health, social, emotional, and physical health. We also developed two information sheets that will be shared with this podcast. The short one is for school administrators to educate them about our roles under IDEA and ESSA and our scope of practice. The longer one is a little denser and is for OT practitioners. I think this is a start, but...

Dennis: I am involved in many things that involve the Workforce Innovation and Opportunities Act, specifically for employment for transition-age students with intellectual and developmental disabilities and other disabilities. Every three years, the state has to submit a report to the Federal Government to give them an update. Every state should have a plan for addressing some of these federal initiatives and receive a report card. People making the decisions are not occupational therapists, so they do not know what we can do.

Sue: Right, we are underutilized. I presented recently at Arkansas' Department of Education for related service providers. The OT representative said, "We're so underutilized." We are pigeonholed into just working with kids with disabilities, and our knowledge about health is not being utilized. We have so much to offer all students to help them be physically, socially, and emotionally healthy. What makes us very different in the mental health realm is that our therapy is doing, not talking. We help children participate in things we know will help them be mentally healthy. We need to be a squeaky wheel like Abe was with me. Many OT practitioners across the country are interested in ESSA, like capstone students. I think this is a good sign. Having a platform that does not require money or is time intensive is also essential. I think too many groups have monthly meetings, and it is too much. A few sessions a year can do some nice things. We record our meetings and share information via our Google Drive folder to keep things simple.

Dennis: Yeah, that is great. When we shared resources before this, I loved your occupation wheel (in the resources). Is that your creation to help explain our scope of practice? 

Sue: I do love that. A social work scale used a similar circle, but I developed this one. My daughter is a graphic designer, and she helped me design it. I looked at AOTA's and other websites but could not find any graphic depicting the nine areas of occupation we address. We need something like this because many evaluation forms tend to be still bottom-up, looking at fine motor, handwriting, visual perception, and sensory processing. I want to say, "Where's the occupation?" A group from the ESSA network gave input on what things we would look at in children and youth during the school day in these nine areas.

I am also developing an occupational therapy wellness screening tool that would look at wellness in these areas of occupation. I consulted with Sendero Therapies in presenting this, and they are piloting the screening. We looked at how it shifted their practice. Over three or four months, they devised action plans addressing health management, mental health literacy health, sleep and rest, leisure and play, and social participation. These were areas that they had not discussed typically. I think it could help therapists, and the sheets could be shared with other school personnel.

One school OT shared it with the school psychologist who oversaw OT referrals and had only "fine motor" or "other" on the referral sheets. She said, "I did not know you addressed all of these areas. We need to change this form to depict more of what OTs would address." That is education. We cannot just hand people the form, though. We have to hand it to them, talk about it, and give examples of how we would address these areas of occupation. For instance, I know OTs address sleep and rest in school, but the therapist could embed this in a handwriting lesson. There are a lot of great resources on sleep and rest.

Dennis: When you talk to parents, what do they want you working on with their child? Do they care about handwriting, or are they focused on more significant issues? It reminds me a little bit of a transition service menu I came across for our scope of practice for that age group. It is looking at a bigger picture in terms of what we do or can do when we have motivated therapists who can see the big picture and a child's long-term outlook.

Sue: Right. We must have it as a part of our lens. I asked one of the OTAs in the region to tune into recess and lunch. She had a couple of autistic children on her caseload. They could not go outside for lunch because of safety issues. She thought this was unacceptable, so she made a point of taking two with her at a time to work on safety and play skills. That is an example of advocacy and demonstrating our value. Therapists said that kids were eating in their classrooms and watching videos this past year. We should look at that with a health lens and think this is not a healthy practice. How can we change that scenario? Can we put a conversation starter on the whiteboard and encourage conversations during lunch or whatever. With nudges, we can have therapists think about what they are doing.

Dennis: Sometimes, we have to question what we are being asked to do. What will be in the best interest of the kids we are trying to support? How would people get more information about the advocacy network?

Sue: The Every Moment Counts website has a lot of information and needs to be approached like a book. Everything is free and downloadable since it was grant-funded. You can also sign up to stay connected. We had live webinars this past summer with many of our OT change leaders. We will be selling them on-demand in the fall, but there is a free online course that I developed with Dr. Sarah Nielsen from the University of North Dakota. It was SAMHSA-funded, and I am sharing an information sheet on that. People who do not have funds could use these resources. There are also five one-hour webinars with facilitation guides to guide a team.

People can also email me if they want more information on Every Moment Counts and ESSA. The OT-ESSA advocacy network has a Facebook page. It is an excellent way to share information related to ESSA school health tier one and tier two services. 

Dennis: Wonderful. Sue, thank you so much for your time. I know that our listeners learned a lot. I certainly learned a lot. Thank you also for what you do for the profession, and I think you have transformed the way I think about school-based OT. I know you have done that for thousands of others to benefit the kids we serve. Thanks for all you do.

Sue: Thank you, Dennis. It was a pleasure. And I always say, "Stay the course," as there is a lot to do.

References

Available in the handout.