Category: teenagers

ADHD kids become troubled adults

ADHD kids become troubled adults

I confess I used to think attention deficit disorders were not as serious as other disorders.

I have been so wrong about ADHD.  Sure, teens with attention deficits had big problems, but they didn’t seem to compare with the disabling, even dangerous, symptoms of disorders like bipolar or schizophrenia.  ADHD kids just seemed more ‘functional’ to me, and the treatments seemed to work better.  While other families with mentally ill children talked about psychotic breaks, suicide, and uncontrollable rages, I heard parents of ADHD kids talk about frustration and daily calls from school.  Heck, ADHD kids could attend school!

When I attended a children’s mental health conference, the ‘youth-talk-back’ workshop was all led by young people with ADHD.  They were articulate about their experiences and needs, answered questions, and interacted appropriately with audiences.  So many strengths!  Youth with other disorders are challenged by all of these tasks.  I learned a lot.

I confess, I also found ADHD funny…

…but my perception changed radically when I found recently published research on children with ADHD who were followed from childhood to juvenile delinquency to adulthood crime.  These studies revealed deeply unsettling news—the long-term effects of ADHD can be serious.

Adults with ADHD have a higher risk of developing other psychiatric problems, being victimized and incarcerated, and facing lifetime struggles with education and employment.  Summaries from 10 research studies on the long-term prognosis of ADHD are found at the end of this post.

“Genius by birth, slacker by choice”

Children and teens with ADHD deserve the chance to reach adulthood with skills that keep them from sliding inexorably downhill, which studies show is common.

Treatment is imperative, not optional!  ADHD hits hardest in adulthood, but starts in childhood when parents have an opportunity to change it’s course.  Parents and caregivers should aggressively and persistently seek an appropriate treatment for their ADHD child that improves functioning:  behavior at school and home, school attendance and educational attainment, self-esteem, and self-actualization.  In addition to medical/medication treatment as recommended, the child must learn self-management and self-calming skills so they can control impulses when they reach adulthood.

Little things start adding up – Without skills (and/or medication), a person with ADHD slips up on life’s daily little challenges–losing, forgetting, neglecting, overreacting, disappointing others, and undermining themselves in a thousand different ways.

Needing others and resenting it – I’ve noticed that those with ADHD seem to find or attract others they can depend on.  They seek and get support to be functional, but the effort can weigh heavily on their “caretakers” (spouse, friends, co-workers) and family.  They lose opportunities to practice self-reliance when this happens, and they resent their dependence on others.  Who wants to be stuck within other’s limits, and on the receiving end of their frustration and impatience?
 
Unfinished business – Those with ADHD drag unfinished projects with them indefinitely, keeping them in an actual or metaphorical garage full of costly but unfinished projects.  Little repairs become big expensive repairs through lack of maintenance.  Bills don’t get paid, licenses don’t get renewed, debtors get away with never paying them back.
 
Guide your child to his or her gifts – From personal experience with ADHD children and adults, I know they can love, be affectionate, funny, generous, highly creative, and show empathy for others.  They strive to be better.
Think of careers your child or teen might pursue that require creativity, energy, and enthusiasm.  Introduce them to experiences that challenge them, and ignore the myth that they can’t focus or that they mess things up, not true.  ADHD kids readily focus on projects they enjoy, demonstrate mental nimbleness with complexities, multitask with accuracy, and shine in emergencies, whether debugging software, making music, or even doing surgery.
Q:  “How many kids with ADHD does it take to change a lightbulb?”
A:  “What was the question again? I saw some thing shiny.”

 

Writer’s rant on parent resistance to medications.  I’ve read articles that question the existence of ADHD, or vilify the families that treat with medications. Prejudice against this disorder and parents who treat with drugs is common. there are too many uninformed people who think they understand ADHD, and spread personal opinions about the use of medications or consequences for ADHD behaviors. This is unhelpful. Public controversy over ADHD negatively influences parents’ decisions regarding diagnosis and their choice of a child’s treatment.

At one extreme: some think medications turn children into zombies, and that ADHD is a fake diagnosis or treatable with natural substances or meditation, etc. Non-drug options help somewhat, but what if the results are too mild, marginal, and short-lived? What if a parent stubbornly sticks with a pseudo-treatment that fits a personal goal and refuses to notice that it’s not working? If a non-drug remedy is effective, there will be hard proof: the child will keep up with school, maintain grade level, exhibit behaviors appropriate for their age, and show signs of self-control. These are more important to a child’s future than a parent’s loyalty to a belief.

Ironically, the choice of drugs for those of us with children with severe disorders may be easier than for parents of ADHD kids. Drugs keep psychotic and severely depressed kids safe and alive. Worrying about side effects is a luxury.

At the other extreme: some parents want a “quick fix” with pills only, but chemical control also makes it easier for these parents to avoid hard parenting work like teaching their child to check impulses and set boundaries. And if parents are happy with the drug, might they overlook their child’s discomfort with side effects and ignore this child’s need for an adjustment? Might they also overlook how their home environment promotes distraction and chaos? A pill will compensate for bad parenting and a crazy-making lifestyle until the child reaches adulthood, having never been taught to make choices that promote their gift of creativity and reduce their risk of addiction, or having never been taught self-discipline.

–Margaret


High School Students With ADHD: The Group Most Likely to…Fizzle

 Breslau J, Miller E, Joanie Chung WJ, Schweitzer JB.Childhood and adolescent onset psychiatric disorders, substance use, and failure to graduate high school on time. Journal of Psychiatric Research.  Jul 15 2010

 Adolescents with attention deficit/hyperactivity disorder (ADHD), conduct disorder, or who smoke cigarettes are least likely to finish high school (HS) on time or most likely to drop out altogether, researchers at the University of California, Davis, School of Medicine (UC Davis) have found.

Lead investigator Joshua Breslau, PhD, ScD, medical anthropologist and psychiatric epidemiologist reported that of a total of 29,662 respondents, about one-third (32.3%) of students with combined-type ADHD were more likely to drop out of high school than students with other psychiatric disorders. This figure was twice that of teens with no reported mental health problems (15%) who did not graduate. Students with conduct disorder were the second at-risk group (31%) to drop out or not finish on time. Cigarette smokers were third in line, with a staggering 29% who did not finish high school in a timely manner.

Educational achievement squelched in children with ADHD
Newsletter – NYU Child Study Center, New York, NY, February 2009
Attention Deficit/Hyperactivity Disorder (ADHD) is one of the most common disorders in childhood and adolescence, with prevalence estimates ranging from five to ten percent.  Children with untreated ADHD drop out of high school 10 times more often than other children.

Adult psychiatric outcomes of girls with attention deficit hyperactivity disorder
American Journal of Psychiatry, January 2010
Researchers studied age 6 to 18-year-old girls with diagnosed ADHD and followed up after 11 years.  Conclusions:  By young adulthood, girls with ADHD were at high risk for antisocial, addictive, mood, anxiety, and eating disorders. However, ADHD medications appear to reduce the prevalence of multiple disorders at least in the short-term.  These findings, also documented in boys with ADHD, provide further evidence for negative long-term impacts ADHD across the life cycle.

Brain abnormality found in boys with attention deficit hyperactivity disorder
Journal of Abnormal Psychology, March 2009
Researchers trying to uncover the mechanisms that cause ADHD and conduct disorder found an abnormality in the brains of adolescent boys suffering from the conditions. The research focused on two brain areas, the “mid brain” striatal, and cerebral cortex.  The mid brain motivates people to engage in pleasurable or rewarding behavior.  The cortex notices if an expected reward stops and considers options. However, this doesn’t occur as quickly in boys with ADHD or conduct disorders.  Instead, the mid brain region keeps trying for rewards, which is a quality of addictive behavior.

Kids with ADHD more likely to bully, and those pushed around tend to exhibit attention problems
Developmental Medicine & Child Neurology, February 2008
Children with attention deficit hyperactivity disorder are almost four times as likely as others to be bullies. And, in an intriguing corollary, the children with ADHD symptoms were almost 10 times as likely as others to have been regular targets of bullies prior to the onset of those symptoms.  Bullies were the kids in class who couldn’t sit still and listen, didn’t do their homework and were almost constantly in motion.  Children with ADHD symptoms make life miserable for their fellow students, and they too can develop attention problems related to the stress of being bullied.

Girls’ hyperactivity and physical aggression during childhood and adjustment problems in early adulthood:  A 15-year longitudinal study.
Archives of General Psychiatry, March 2008
Girls with hyperactive behavior such as restlessness, jumping up and down, and difficulty keeping still or fidgety, and girls exhibiting physical aggression such as fighting, bullying, kicking, biting or hitting, all signs of ADHD, were found to have a high risk of developing adjustment problems in adulthood.

Teen’s inattentive symptoms may determine how long they stay in school
Forum for Health Economic & Policy, November 2009
Poor mental health of children and teenagers has a large impact on the length of time they will stay in school, based on the fact that at conception there are differences in genetic inheritance among siblings. This study provides strong evidence that inattentive symptoms of ADHD in childhood and depression in adolescents are linked to the number of years of completed schooling.

Children with ADHD more likely to participate in crimes
Yale School of Public Health and University of Wisconsin at Madison, October 2009
Children with ADHD are more likely to participate in crimes such as burglary, theft and drug dealing as adults.  Those who had attention deficit hyperactivity disorder as children were at increased risk of developing criminal behaviors.  Researchers said one reason is that children with ADHD tend to have lower amounts of schooling.

ADHD may affect adults’ occupational and educational attainments
Journal of Clinical Psychiatry September 2008
Adults who have ADHD generally have lower occupational and educational attainments as adults than they might have reached if they didn’t have the disorder, at least compared to what attainments would have been expected given their intellect.  “Educational and occupational deficits… are a consequence of ADHD and not IQ,” lead researchers Dr. Joseph Biederman said. The finding strongly underscores the need for “diagnosing and treating ADHD to avert these serious consequences,” he said.

Attention-deficit/hyperactivity disorder (ADHD) in the course of life.
European Archives of Psychiatry and Clinical Neuroscience, September 2006.
ADHD is a pervasive disorder that extensively impairs  quality of life and that can lead to serious secondary problems.  Long-term studies have demonstrated that the disorder is not limited to childhood and adolescence. The clinical experience indicates substantial difficulties for adults whose ADHD is not diagnosed and treated, and they often create extensive costs for the welfare system. The evidence-based psychiatric treatment available is highly effective and inexpensive.

70% of crystal meth (methamphetamine) inpatients had ADHD
Journal of  Addiction Disorders. 2005, and the blog: Adult ADHD Strengths.
Methamphetamine-dependent inpatients were screened for childhood attention deficit hyperactivity disorder (ADHD), and of the participants, 70.6% screened positive for ADHD and reported significantly more frequent methamphetamine use prior to baseline.  ADHD participants exhibited significantly worse psychiatric symptomatology.  At a three-week follow-up, all who didn’t complete treatment screened positive for ADHD.

When is it OK to search a teen’s room?

When is it OK to search a teen’s room?

“My son is always in his room and gets extremely upset if I go in there. He says he has a right to privacy, but I suspect something bad is going on, and want to search his room when he’s not there. Would I be violating his rights? It is OK to search his room?
–Mother of 15-year-old boy

I’ve gotten asked this question many times. The answer is “Yes” in the following circumstances:

  • Your child’s behavior has been changing recently, or they have become more secretive, irritable, or defiant than usual
  • He or she has left old friends for new ones whom you are concerned about, or has fewer and fewer friends
  • His or her grades have fallen recently even though they were formerly a good student
  • You sense that he or she is depressed or overly anxious or paranoid
  • Your child pressures you for money, or steals it from you, or finds ways to get money
  • You’ve tried talking with your child about general things in life, school, or feelings, and were met with anger or excuses or deflection.

If there is any concern that something that can be dangerous is being hidden from you:  search your child’s room.

When a young person gets very upset about invading their privacy, they likely are hiding something from you because they know you’ll disapprove. What could it be? Drug or alcohol use? An inappropriate relationship? Porn? Cutting or self harm? Severe depression? The onset of paranoid psychosis?

You have ample legal rights as a parent, but use them wisely and cautiously.*

If something is going wrong with your child and they need your help, you must do a balancing act: 1) get the facts; 2) maintain their trust and keep open lines of communication. Some of the dangerous activities above are common for ‘normal’ difficult teenagers, who can grow out of it or be rehabilitated with treatment and ample family support. Some of these are emergent mental illnesses that need treatment immediately. Why immediately? The sooner the child gets treatment at early onset, the less likely their disorder will develop into serious symptoms as an adult. Mental illnesses are degenerative to the brain, but you can stop it from going further if you start treatment early.

*”Your rights as the parent of a teen with a mental disorder.”

You can search through all their items for things that are or may lead to unsafe behavior. Things you might look for are razor blades, illicit drugs or drug paraphernalia, over-the-counter drugs or drugs that can’t be purchased under the age of 21 (e.g. Benadryl), pseudo-drugs like bags of incense powder, weapons (knives, guns), porn, sexual items, blood on clothes from cutting, etc. You can read your child’s email and texts to search for dangerous activities, plans, or people who may be negatively influencing your teen. You can remove any dangerous or inappropriate item and not return it–it is not stealing. No officer, no judge, no social worker would ever find you guilty. You would be praised instead.

“He was so mad at me when I found a bong in his room and took it.”

He said,”you’re stealing from me!”

“It’s my house and it’s not supposed to be here.”

“But it’s mine! I paid for it! It was really expensive! I’m reporting you for stealing!”

Also search other potential hiding places in your house or any other storage areas. If you find nothing unusual or dangerous on a search, great! You’ve at least satisfied your rightful need to know. Now, when you speak with your child about problems, you can set some fears aside and listen to him or her without bias.

Trust with a teenager is everything.

If your child finds out you’ve searched their room, yes, you will lose their trust, and he or she may go to greater lengths to keep secrets. So don’t tell them. And don’t bring up anything else you discovered if it’s not directly related to safety! What if you find stacks of incomplete homework? Forget it. Did you find food scraps in the bed? Forget it. A moldy sandwich in the closet? Don’t say anything that reveals you searched their room. As a responsible parent, safety and mental health trump lazy, messy behavior. Find other ways to address these.

In dire circumstances, a parent may need put some values aside.

What if you find something dangerous? Act on it immediately. Your child will feel violated and you’ll lose his or her trust, but it’s temporary. Do not defend your decision or try to rationalize it. It’s better to have uncovered a secret and opened the way for getting help. Now the tables have been turned on your child. Under serious circumstances, their trust of you is less important than your trust of them.

 

Good luck.

My son has the problem, yet the therapist focuses on me, huh?

My son has the problem, yet the therapist focuses on me, huh?

Question:   My son’s therapist keeps telling me what to do, or that I’m not doing the right things at home.  But my son is the one with the problem, why all this focus on me?

Answer:
   You could be the problem or the therapist could be the problem.  You are working hard to manage a difficult situation, and you clearly care about your son because you are bringing him to therapy, but your own stress and exhaustion may look like you’re the one with the behavior problem.  My guess is that the therapist is trying to tell you how to change your parenting or communication style to reduce your son’s stress and better manage his issues.  This is a hard message to take when you know you’re doing everything you can, and you’ve been put through a lot by a difficult child.

Someone who doesn’t know me is telling me I’m not good enough?  What?

How can you tell it’s the therapist with the problem?

  • One problem I’ve seen with therapists is that they often don’t know how to talk to parents about parenting issues without sounding like they are making presumptions and blaming the parent for the child’s problems.  Everyone loves to blame the parents.
  • Some therapists put themselves in the child’s shoes.  That’s why they got into child therapy in the first place, they love children!  Yet pro-child therapists put their emotional biases in the mix to protect your child from you.  This ridiculous attitude is changing, thankfully. The mental health profession has begun to realize how critical the family is for the child’s treatment.
  • The worst situation is when a therapist embarrasses you or blames you in front of your child.  That’s grounds for firing them!  You may indeed need parenting guidance, but you should never have someone undermine your authority.
  • Another problem is when a therapist doesn’t have children, or doesn’t have troubled children.  They feel too confident in their abilities and don’t know what it’s like living with a troubled child 24/7, so they make assumptions and you constantly feel you need to defend yourself.

A good therapist or doctor will show compassion for a stressed parent, listen to their side of the story, and help the parent feel understood and believed.  Then they will take the time to explain exactly what the parent might do differently at home and why.

You should leave every meeting feeling better about yourself and child.

Try giving this therapist a chance first, and ask him or her if you can meet them without your son, and request that they fully explain their advice.  Let them know that this has been hard for you and you’ve felt blamed, and that you need their support.  Then listen carefully.  If you’re still not convinced of their point, ask them if there’s a book or a website or support group for you (it’s easier to accept advice from other parents who’ve learned from their mistakes).  If you feel that you can’t work with this therapist, consider finding someone who takes a better approach to you and your situation.

You and your child have to “click” with a therapist or doctor, or they can’t help you.

Support Your Child or Teen’s Recovery From a Disorder or Addiction

Support Your Child or Teen’s Recovery From a Disorder or Addiction

What recovery looks like – A person with a mental or emotional disorder who is in “recovery” lives a normal life and aren’t affected by their disorder.  They look and act normal.  At the very least, they have stable relationships, a steady job, a place to live, a regular diet, cleanliness, and regular mental health check-ins.  Recovery is maintained when the person pays attention to themselves and notices if their symptoms are starting, and then takes action to stop the symptoms.

Recovery is like the alcoholic who stops drinking–they still have an addiction, but they stop using.

What your child will need to sustain recovery as an adult:

INSIGHT  +  STABILITY  +  RESILIENCE

Insight – self awareness

Insight allows a child to recognize they have a problem, and choose to act to avoid the problem.  If insight is not possible, they need a toolbox of options that help them to respond appropriately, instead of reacting to chaotic messages in their brain. Knowing and admitting they have a problem, or knowing techniques for avoiding problems, are very powerful skills they need as adults.

Stability– fewer falls or softer falls

Your child is like a boat that’s easier to tip over than most other boats; any little wave will capsize them, and everyday life is full of waves, big and small.  Your job is to notice when the troubled child is starting to capsize and show them how to right the boat, or if that doesn’t work, how to use the lifesaver.  Eventually, your child will learn how to sense when trouble is coming on, avoid the thing that causes problems, and ask others for help.  Sense it.  Avoid it.  Ask for Help.

Resilience– bounce back when they fall

Troubled children have a much harder time bouncing back from problems.  They have extreme responses to simple disappointments like breaking a toy, or poor grades, or something as serious as the parents’ divorce.  Some even fall apart in joyous times because the emotional energy is too much!  You must be acutely aware of this–they will not get back on track by themselves.  Don’t worry that helping them will spoil them or “enable” them.  Eventually they will learn from you how you do it.

“…We are all born with an innate capacity for resilience, by which we are able to develop social competence, problem-solving skills, a critical consciousness, autonomy, and a sense of purpose.”

“Several research studies followed individuals over the course of a lifespan and consistently documented that between half and two-thirds of children growing up in families with mentally ill, alcoholic, abusive, or criminally involved parents, or in poverty-stricken or war-torn communities, do overcome the odds and turn a life trajectory of risk into one that manifests “resilience,” the term used to describe a set of qualities that foster a process of successful adaptation and transformation despite risk and adversity…”   http://www.athealth.com

Are you trying to reason with an irrational child?

Are you trying to reason with an irrational child?

I regularly speak with parents with children with a brain disorder and a history of serious behavior problems. Many are truly at the end of their rope.  The parent is so exasperated by their child’s relentless acting out, they start repeating themselves to exhaustion. and wondering why the child isn’t getting it.

They plead for answers: “Why does he keep doing this?, or, ” Why doesn’t she stop after I’ve explained things over and over.”  Then they answer their own questions:  “It’s because he always wants his way,” or, “She’s doing this to get back at me.”

The parent then lists all the ways they’ve tried reasoning with their child or disciplining with consequences.  As they tell their story, they continue to ask questions and provide answers, going around and around and around:  “He does this just to make me mad;”  “She manipulates the situation because she wants more (something) and I won’t give it to her.”  What’s interesting to me is that these children can be quite young (4 or 5), too young to expect reasoning in the first place, or they can be young adults (early 20′s) who have a long track record of doing things that don’t make sense.

Saying something a 1000 times doesn’t work. Your child tunes you out.

Parents’ stress and frustration vanish if they accept that their child is not ready to reason or control their behaviors.  It’s not their fault, and not the parents’ fault. Irrationality is the hallmark of brain-based problems, and chronically challenging behaviors are the evidence.

If you feel you have run into brick walls over and over again, and your child is not learning what you’re teaching, do both of yourselves a favor and stop trying the same things that still don’t work.  Stop assuming they will  listen, or that they even can listen.  Your child or teen does not have an evil plan to push your buttons and control your moods like a puppet.

When you find yourself trying to reason with a troubled child or teen (or young adult), step back and calm yourself this way, and ask what your child needs in the moment.  Then change your whole approach.

  • Try different ways of communicating, such as softening your tone of voice.
  • Pay attention to whether they respond best to words or images, and use what works most naturally for them.  Try using touch to communicate, or withdrawing touch if that’s threatening to them.
  • Post (polite) signs and simple house rules in the house as reminders for things they need to do every day.
  • Show instead of tell. Your child or teen may not be able to learn through their ears.  Or they tune you out.  Demonstrate how instead of telling them how.
  • Avoid explaining how their behavior will hurt them in the future.  Children and teens often cannot track how pushing one domino leads to all the dominoes falling.

If you’re nagging and harping and chiding your child, forgive yourself.

It’s so common one might call it normal.  You are still a good parent who wants the best for your son or daughter.  Over the many years I’ve facilitated parent support groups, I’ve heard so many regret how they’ve treated their child once they begin to understand that it won’t work.  You are not alone.  Raising a child like yours is tough, but you’ll move on and figure things out.  Don’t give up.

Mental illness is more deadly than cancer for teens, young adults

Mental illness is more deadly than cancer for teens, young adults

Why isn’t everyone more upset?

A disease is killing our children and it’s more deadly than cancer and leukemia!  Did you know it was mental illness?

Out of curiosity, I did some research on child mortality rates from various causes because I wanted to know how death from mental illnesses compared with other fatal illnesses of childhood and adolescence. The results were astonishing, unexpected, and disturbing.

Look at the highest bars in this graph. They are 3-4 times the height of average cancer and diabetes rates in children. There are gaps in the available data, but this simple comparison is disturbing.

* The starting point for the mortality rates of medical illnesses was the website for the Center for Disease Control and Prevention www.cdcp.gov  in Atlanta; the starting point for the mental illnesses was the website for the National Institute for Mental Health, www.nimh.gov.

** The suicide data was from those with depression, bipolar disorder, schizophrenia, and psychotic disorders-unspecified.  (Suicide from other mental health causes, such as borderline personality disorder and co-morbid substance abuse is also prevalent, but I could not find data for children to young adult age ranges.)

On suicide:

  • It’s often normal for children and young people to think about suicide, but just in their imagination. They might consider it during some painful time in their lives, but there are no plans made or steps taken.  When the difficult times are over, they don’t think about it any more.
  • Young people with early onset mental illness can’t endure much stress; thoughts of suicide recur over time, starting as early as age 6 or 7.  These children are vulnerable to repeated intrusive suicidal thoughts because they live with a combination biological, psychological, and social/relationship causes (called “biopsychosocial”).  More about this is explained here: “Use the “S” Word: Talk with your Child about Suicide.”
  • There are ‘fast’ and ‘slow’ suicides in young people.
    • The ‘fast’ ones are 1) direct self-harm that has been planned, or 2) spur-of-the-moment suicide due to an extreme emotional reaction to a single intolerable event (examples: a boyfriend/girlfriend or best friend dies; a teen has a serious fight with a parent and (without planning) wants to ‘get back’).
    • The ‘slow’ suicides result from a persistent pattern of harmful behaviors that eventually lead to death.  Young people struggling with anorexia can die by heart failure or other causes due to their weakened body.  Others abuse substances and/or participate in extremely risky activities that expose them to multiple lethal situations:  overdose, criminal environments, disease.

The chart above screams out for a changes in attitude, policy, and investment in children’s mental health treatment and suicide prevention.  I had no idea that death rates from mental illness could be 3 to 4 times higher than most cancers and leukemia.  It is imperative that young people with mental health issues receive as aggressive and sensitive treatment as is expected and demanded of medical systems that treat cancer in children.

 

Parents: talk about this. Talk to your child; share it on social media; and talk to mental health organizations about what you can do.

The data on mortality rates for mental illnesses was difficult to find, and it required searches in many different medical journals and websites.  I chose to use the data on cancer, leukemia, and diabetes because the mortality rates from these are high and because deaths from all other causes were insignificant by comparison (motor vehicle accidents are the one exception).  In this graph, the death rates for cancer and leukemia are averages for the different forms of each, and in the medical journals they were presented together.

I welcome additions or corrections of this data from any other sources, and encourage readers to investigate this for themselves.

–Margaret