ADHD is often accompanied by depression for both the child with ADHD and the parents. Learn more.

As most of you know, I began my site on Attention Deficit Disorder in 1995. Over the last several years, I have realized that ADD/ADHD is often accompanied by other issues, and the one I hear most frequently, is Depression.

Often times, with the self-esteem issues and hardships that come with ADHD, Depression appears if it isn't already there and if the ADHD child or adult isn't dealing with depression directly, the stress and chaos in the ADHD household can cause depression to be an issue among other family members.

I also have my own personal battles with depression that stem from a father who felt that verbal abuse and humilation would cure my weight problems, even at 40 years old, an 8 year relationship wrought with domestic violence, verbal and mental abuse as well as the challenges of having an ADHD child.

What Depression Is:

By Deborah Deren - from Wings of Madness Depression website

• Depression is an illness, in the same way that diabetes or heart disease are illnesses.
• Depression is an illness that affects the entire body, not just the mind.
• Depression is an illness that one in five people will suffer during their lifetime.
• Depression is the leading cause of alcoholism, drug abuse and other addictions.
• Depression is an illness that can be successfully treated in more than eighty percent of the people who have it.
• Depression is an equal-opportunity illness - it affects all ages, all races, all economic groups and both genders. Women, however, suffer from depression twice as much as men do.
• At least half of the people suffering from depression do not get proper treatment.
• Untreated depression is the number one cause of suicide.
• Depression is second only to heart disease in causing lost work days in America.

What Depression Is Not:

• Depression is not something to be ashamed of.
• Depression is not the same thing as feeling "blue" or "down."
• Depression is not a character flaw or the sign of a weak personality.
• Depression is not a "mood" someone can "snap out of." (Would you ask someone to "snap out of" diabetes?)
• Depression is not fully recognized as an illness by most health care insurance providers. Most will only pay 50% of treatment costs for out-patient care, as well as limiting the number of visits.

Extensive information on childhood and adult depression at the HealthyPlace.com Depression Community.

next: ADHD Child and School Cooperation
~ adhd library articles
~ all add/adhd articles

Even doctors have trouble differentiating bipolar disorder in children from ADHD and ODD. Here are specific bipolar symptoms to look for.

One of the biggest challenges has been to differentiate children with mania from those with attention deficit hyperactivity disorder (ADHD). Both groups of children present with irritability, hyperactivity and distractibility. So these symptoms are not useful for the diagnosis of mania because they also occur in ADHD. But, elated mood, grandiose behaviors, flight of ideas, decreased need for sleep and hypersexuality occur primarily in mania and are uncommon in ADHD. Below is a brief description of how to recognize these mania-specific symptoms in children.

• Elated children may laugh hysterically and act infectiously happy without any reason at home, school or in church. If someone who did not know them saw their behaviors, they would think the child was on his/her way to Disneyland. Parents and teachers often see this as "Jim Carey-like" behaviors.
• Grandiose behaviors are when children act as if the rules do not pertain to them. For example, they believe they are so smart that they can tell the teacher what to teach, tell other students what to learn and call the school principal to complain about teachers they do not like. Some children are convinced that they can do superhuman deeds (e.g., that they are Superman) without getting seriously hurt, e.g. "flying" out of windows.
• Flight of ideas is when children jump from topic to topic in rapid succession when they talk and not just when a special event has happened.
• Decreased need for sleep is manifested by children who sleep only 4-6 hours and are not tired the next day. These children may stay up playing on the computer and ordering things or rearranging furniture.
• Hypersexuality can occur in children with mania without any evidence of physical or sexual abuse. These children act flirtatious beyond their years, may try to touch the private areas of adults (including teachers), and use explicit sexual language.

In addition, it is most common for children with mania to have multiple cycles during the day from giddy, silly highs to morose, gloomy suicidal depressions. It is very important to recognize these depressed cycles because of the danger of suicide.

From Dr. Demitri Papolos, M.D. and his wife Janice Papolos, authors of the book "The Bipolar Child"

We have interviewed many parents who report that their children seemed different from birth, or that they noticed that something was wrong as early as 18 months. Their babies were often extremely difficult to settle, rarely slept, experienced separation anxiety, and seemed overly responsive to sensory stimulation.

In early childhood, the youngster may appear hyperactive, inattentive, fidgety, easily frustrated and prone to terrible temper tantrums (especially if the word "no" appears in the parental vocabulary). These explosions can go on for prolonged periods of time and the child can become quite aggressive or even violent. (Rarely does the child show this side to the outside world).

A child with bipolar disorder may be bossy, overbearing, extremely oppositional, and have difficulty making transitions. His or her mood can veer from morbid and hopeless to silly, giddy and goofy within very short periods of time. Some children experience social phobia, while others are extremely charismatic and and risk-taking.

If the child is fidgety and inattentive and hyperactive, isn't the correct diagnosis attention-deficit disorder with hyperactivity (ADHD)? Or, if the child is oppositional, wouldn't oppositional-defiant disorder (ODD) be the correct diagnosis?

Several studies have reported that over 80 percent of children who have early-onset bipolar disorder will meet full criteria for ADHD. It is possible that the disorders are co-morbid--appearing together--or that ADHD-like symptoms are a part of the bipolar picture. Also, the ADHD symptoms may simply appear first on the continuum of a developing disorder.

Children with bipolar disorder exhibit much more irritability, labile mood, grandiose behavior, and sleep disturbances-- often accompanied by night terrors (nightmares filled with gore and life-threatening content)--than do children with ADHD.

Because stimulant medications may exacerbate a bipolar disorder and induce an episode or negatively influence the cycling pattern of a bipolar disorder, bipolar disorder should be ruled out first, before a stimulant is prescribed.

Almost all the children in our study of 120 boys and girls diagnosed with bipolar disorder met criteria for oppositional defiant disorder (ODD). Again, the child should be evaluated for a possible bipolar disorder.

So how would a doctor diagnose early-onset bipolar disorder?

The family history is an important clue in the diagnostic process. If the family history reveals mood disorders or alcoholism coming down one or both sides of the family tree, red flags should appear in the mind of the diagnostician. The illness has a strong genetic component, although it can skip a generation.

Many parents are told that the diagnosis cannot be made until the child grows into the upper edges of adolescence--between 16 and 19 years old. The Diagnostic and Statistical Manual of Psychiatry--the DSM-IV--uses the same criteria to diagnose bipolar disorder in children as it does to diagnose the condition in adults, and requires that the manic and depressive episodes last a certain number of days or weeks. But as we already mentioned, the majority of bipolar children experience a much more chronic, irritable course, with many shifts of mood in a day, and often they will not meet the duration criteria of the DSM-IV.

The DSM needs to be updated to reflect what the illness looks like in childhood.

If a child hears voices or sees things, does that mean he or she is schizophrenic?

Absolutely not. Psychotic symptoms such as delusions (fixed, irrational beliefs) and hallucinations (seeing or hearing things not seen or heard by others) can occur during both phases of bipolar disorder. In fact, they are not uncommon. Sometimes the voices and visions are compelling; often they are threatening. Quite a few children report seeing bugs or snakes or say that they see and hear satanic figures.

next: Medication and Therapy for Treating Bipolar Disorder in Children
~ bipolar disorder library
~ all bipolar disorder articles

Introduction from the book Self-Help Stuff That Works

by Adam Khan:

IF I WERE SITTING DOWN to read this book for the first time, my question would be: "What will I gain by reading this book?"

The answer is: You will gain a large number of ideas you can apply practical ideas that will help you make your circumstances better. And you will get those ideas separately: Each chapter is independent from the others and can be read in any order. And the ideas are served up in bite-size, easily digestible chunks.

This book covers a broad spectrum of feelings and situations, so at any given time and for any given circumstance, you could profitably look in here and find something useful some principle you could apply that would improve your situation or your attitude toward it.

The main thing you'll get from this book is a collection of methods you can use to direct your actions more effectively. For example, if you try to vent when you're angry so you don't "hold it inside," you'll find out on page 250 that venting doesn't work and why. And you'll find out what does work. The ideas in this book will help you direct your actions so that the things you want to happen will be more likely to happen.

Self-Help Stuff That Works is a collection of articles I wrote, mostly for my column Adam Khan on Positive Living in the newsletter At Your Best, published by Rodale Press. When I decided to compile them into a book, they naturally arranged themselves into three categories: attitude, work, and relationships. There were some odd exceptions a few articles on how to make changes in general and I added one or two to each section to help you translate the ideas into real improvement in the quality of your life.

Are you ready? Okay, but we have one more thing to cover: How to get the most out of this book the subject of the next chapter.

Online Bookstores
You can order Self-Help Stuff That Works from any of 12 online bookstores, including Amazon.com.

You can go on to the next chapter from here:
How to Use This Book

If worry is a problem for you, or even if you would like to simply worry less even though you don't worry that much, you might like to read this:
The Ocelot Blues

Learn how to prevent yourself from falling into the common traps we are all prone to because of the structure of the human brain:
Thoughtical Illusions

next: How to Use This Book

Chapter 104 of the book Self-Help Stuff That Works

by Adam Khan

IN THE MOVIE Made in America, a daughter raids the files at the sperm bank her mother used, and despite her shock in finding out her dad is an infamously slick car salesman, she loves him because he's her dad. Everything is beautiful until they discover it was a mistake. He really wasn't her dad after all.

She loved him because she thought he was her dad. Most of us are like that. We have an automatic acceptance of people in our family - even a distant cousin we meet for the first time.

What if we treated all people as relatives? If they are older, we can imagine them to be uncles or aunts or great uncles or great aunts. If close to our own age, they could be long lost siblings or cousins. Youngsters could be our nieces and nephews. Love comes naturally when we haven't labeled someone as "other."

It's really not much of a stretch. In truth, we all are related in one way or another, probably more closely related than you'd think. According to the experts on genetics, you wouldn't have to go very far back in time to find where your family tree intersects with your friend's or spouse's family tree, or anyone's tree you know. And as you keep going back, the trees cross again and again. We are all, at the very least, distant cousins of one another many times over.

Keep this in mind when you interact with people and the world will feel like a friendlier place.

This doesn't mean you have to become an easy target for con artists. You don't have to turn off your good judgement. But you interact with people every day: the bus driver, the clerk at the store, a neighbor, the people you work with. Think of them as family and you'll feel differently toward them, and that'll make you act differently toward them, which will make them act differently toward you, and voilà ! The world is a friendlier, happier place for real.

Practice it on the next three people you talk to, and you'll see what it's like. In your mind, imagine the person is a relative. You don't have to do anything differently. Simply entertain the idea that the person may be related. We all know intellectually we're all members of the same human family, but it's nice to feel it too.

When you talk to people, think of them as relatives.

How to be here now.
This is mindfulness from the East applied to reality in the West.
E-Squared

Expressing anger has a good reputation. Too bad. Anger is one of the most destructive emotions we experience, and its expression is dangerous to our relationships.
Danger

Comparisons are natural. Indeed, you can't really help it. But you can direct it in a way that enhances your relationships, even making you feel better about people you haven't even met yet.
How You Measure Up

It is unnecessarily limiting to label yourself shy, outgoing, Aries, Taurus, strong, weak, or any other label. Be your true, flexible self and you'll be better off.
Personality Myth

There may be evidence that prayer may actually have medical benefits, even if the prayed-for doesn't know it's happening.
Send a Blessing

Why is it important to make a good impression? Because human brains aren't perfect and are biased by our earliest conclusions.
Very Impressive

next: Mastery

Chapter 67 of the book Self-Help Stuff That Works

by Adam Khan:

RESEARCHERS PUT SOME RATS in plain cages, each one alone. Then they put some rats in bigger cages with other rats and toys to play with. The ones in the "enriched environment" grew smarter (they learned mazes faster). And when the researchers cut open their brains, they found that the rats in the enriched environment had bigger and heavier brains because they had more dendrites (connections between brain cells).

Mental ability for rats as well as people doesn't depend on the number of brain cells, but on the number of connections between those brain cells. And the stimulation of play increases the number of connections.

To refine their understanding, researchers then put some rats in an enriched environment and some other rats in a position so they could watch the rats in the enriched environment. What they found is revealing: The ones who watched didn't get any smarter and their brains grew no bigger.

Preliminary studies on people are finding the same thing: Something about playing games increases brain power. But watching people play games doesn't do it.

And playing games usually gets you face to face with people, talking to them. We are social creatures, and we are healthier and happier when we have enough enjoyable social contact. Passive entertainment like television doesn't encourage much interaction. The television programmers and the people who design the commercials don't want you to turn away from your TV and talk to your spouse. You might miss a commercial. So they try to keep it as lively and appealing as possible. The end result is people can "be together" for hours on end without talking to each other. This doesn't satisfy our need for sociability.

So...playing games can increase the connections between brains cells and between people.

But we all know games are a waste of time. The problem is, we do waste our time. We watch TV and movies. We waste hours. Apparently we have a need to waste time, or at least to spend time doing something other than working, even when our work is enjoyable.

Since passive entertainment like watching TV doesn't seem to enrich our minds and playing games does, here's the bottom line: Games are a better waste of time than TV or movies.

Here are two tips for replacing some of your TV time with games:

1. Mix it up. Different games require different skills. Your partners will be good at some, lousy at others. Mix it up and you won't win or lose all the time and you'll get better in areas in which you are now weak.

2. Play games you think are fun. The games that are likely to do you the most good are the ones you think are fun. If chess isn't fun for you, regardless of its stature in the gleaming world of the sophisticated set, don't start there. Be guided by one criterion: Fun.

YOU DON'T NEED to find games that stretch your mind. You don't need to make a game "do you some good."As long as you're having fun, it is doing you some good. The benefit is in the fun. If you're concentrating too hard on trying to do something good for yourself, it won't be as much fun, so it won't be as good for you.

So relax and enjoy yourself. Replace some of your TV time with game playing, and you'll be better off.

Would you like to turn your job into a spiritual discipline? Check out:
Getting Paid to Meditate

Do you feel overwhelmed with things to do? Do you constantly feel that you don't have enough time? Check out:
Having the Time

Dale Carnegie, who wrote the famous book How to Win Friends and Influence People, left a chapter out of his book. Find out what he meant to say but didn't about people you cannot win over:
The Bad Apples

An extremely important thing to keep in mind is that judging people will harm you. Learn here how to prevent yourself from making this all-too-human mistake:
Here Comes the Judge

The art of controlling the meanings you're making is an important skill to master. It will literally determine the quality of your life. Read more about it in:
Master the Art of Making Meaning

next: Taking Credit

How does bipolar disorder affects girls? Frank talk about premenstrual symptoms, self-injury, hypersexuality, addiction, weight gain, more in bipolar girls.

Girls with Bipolar Disorder: Special Concerns

What remedy is there for the teenage girl with bipolar disorder who suffers suicidal depression for several days before each menstrual period? How do bipolar illness and its treatments affect a girl's sexual feelings, fertility, and unborn children? What can parents do to keep a risk-loving daughter safe as she passes through adolescence?

As parents, we dread our daughters' descent into the maelstrom of raging hormones, bipolar mood swings, adolescent rebellion, street drugs and alcohol, and medication side-effects. Families seeking professional guidance often feel trapped in a revolving door of disjointed referrals—to pediatricians, psychiatrists, psychotherapists, substance abuse counselors, gynecologists and endocrinologists—hearing from each some version of "sorry, that's not my area of expertise." Meanwhile, a girl's energy, judgment, demeanor and appearance can vary dramatically throughout the month depending on which biochemical, hormone, or neural circuit has seized the reins. Bonds forged or projects begun in periods of wellness or mania may be abandoned in despair or derailed by impulsive self-injury and suicide attempts, which themselves bring further trauma. Periods of extended grief and shame can occur when a girl comprehends the depth of her wounds.

Cognizant of the risks our growing daughters face in the world beyond our doors, and of that fast-approaching eighteenth birthday when our role as legal guardians abruptly (and absurdly) ends, we scramble to equip them—and ourselves—with the knowledge, tools and skills needed to survive the perils that lie ahead. Too often, lacking the means to protect our beloved daughters, we grieve—then rage—as did the Greek goddess Demeter upon learning that her young, risk-loving Persephone had been abducted to the underworld.

Note: Concerns discussed in this article may be painful to discuss or recall.

Risk factors and gender

In childhood, fewer girls are diagnosed with bipolar disorder than boys. CABF's 2003 Membership Survey revealed that 65% of its members' affected children are male and 35% female. Some neuropsychiatric illnesses—such as autism—affect girls at lower rates than boys, and others—such as schizophrenia—tend to emerge later, on average, in girls. Beginning in adolescence, bipolar disorder occurs with equal frequency in males and females. Girls, who often are less disruptive in school than boys, or whose symptoms are more internalized than externalized, may be less likely to be referred for treatment. There are as yet no epidemiological data from research studies to inform us how many prepubertal girls or boys, for that matter, actually have bipolar disorder.

In adults, women appear to manifest rapid-cycling and depression more often than men, but gender differences remain largely unexplored.

Menstrual irregularities

Parents of girls with bipolar disorder often report on the CABF message boards that their daughters have difficulty with their periods. Females with bipolar disorder may have higher than usual rates of anovulation (absence of periods) and longer than normal cycles. These abnormalities are associated with an increased risk for diabetes. Heavy bleeding and severe cramps interfere with school attendance and participation in sports. A consultation with a gynecologist and/or endocrinologist may be helpful if puberty seems abnormally early or delayed or if periods are highly irregular or painful. Careful charting of symptoms and monthly cycles is essential, and should be started at the earliest possible time. Several mood charts are available on the CABF Web site (see below).

Premenstrual symptoms

Some CABF parents report that their daughters have a sharp increase in irritability, depression, impaired concentration, sleeplessness, panic attacks, self-injury or anxiety prior to their first menstrual period, and experience these symptoms before each subsequent period. Symptoms of other chronic illnesses—epilepsy, migraine, and multiple sclerosis, for example—also are known to worsen premenstrually. A sudden increase in symptoms may signal that a period is imminent, but until the bleeding actually starts, it is impossible to tell whether the symptoms are worsening due to the hormonal change.

Psychiatrists in the emerging specialty of reproductive psychiatry study the interaction between mood and hormonal changes at all stages of a woman's life. They find that premenstrual dysphoric disorder (PMDD) (a severe form of premenstrual syndrome, or PMS) may be associated with a serotonin deficiency during the luteal phase (second half) of the monthly cycle. Low serotonin is associated with depression. The current treatment for simple PMDD includes low-dose antidepressants, such as a selective serotonin reuptake inhibitor (SSRI), administered for a few days during the luteal phase. However, girls with both bipolar disorder and PMDD who take SSRIs risk increased cycling, irritability, or induction of mania. Some CABF parents report that their daughters become disinhibited on SSRIs, with increased self-injurious and suicidal behaviors.

Other treatment strategies have been reported in medical journals and by parents on the CABF Web site, but data supporting these strategies in teens and young women with bipolar disorder are limited. For patients taking lithium, doctors may order pre-and-post period lithium levels to determine whether the level is dropping premenstrually. If so, and the girl's periods are regular and predictable, dose adjustments can be made as needed. Some doctors prescribe birth control pills or the contraceptive patch. One recent study of women with bipolar disorder found that women taking oral contraceptives had much less cycling during the entire month than women not receiving oral contraceptives. Some gynecologists will prescribe "the Pill" to be taken continuously for several months at a time. The Pill reduces the risk of unplanned pregnancy but some medications—such as Trileptal® and Carbamazapine—interfere with the effectiveness of oral contraceptives. Trials of several different brands (with differing types and levels of hormones) may be necessary, and some girls report increased depression on some brands. In some studies, complementary and alternative measures, including light therapy, exercise, L-tryptophan, calcium carbonate, and cognitive behavior therapy have been shown helpful in treating PMDD. Benzodiazapines are sometimes prescribed for premenstrual anxiety and agitation, but they can be abused and create dependence.

Self Injury

Self injurious behavior is the deliberate, repetitive, impulsive, non-lethal harming of one's body. With onset at puberty, girls may cut themselves with razors or household knives, or use any number of means to scratch, pierce, or otherwise injure the skin in a behavior that has become endemic in America, according to Wendy Lader, Ph.D., clinical director of the S.A.F.E. Alternatives Program at Linden Oaks Hospital near Chicago and coauthor of Bodily Harm: The Breakthrough Healing Program for Self-Injurers (Hyperion, 1998).

Signs that a girl may be cutting include telltale bandage wrappers or bloodied tissues in the bathroom wastebasket, broken-off razor heads from disposable razors on a bedside table or in a dresser drawer, or red lines and scabs on her belly, thighs, or the insides of her wrists. Sometimes girls wear sports wristbands to cover the scars. Girls may find it a self-soothing, but addictive behavior, often learned from movies, or other girls in schools and hospitals.

If a girl is found to be self-injuring, this does not necessarily mean she is attempting suicide, although girls who self-injure can also be suicidal. Self-injury is best treated by therapists using cognitive-behavioral therapy working with the girl's psychiatrist who prescribes medications. In severe cases, residential treatment or hospitalization may be needed.

Hypersexuality and rape

The overtly sexualized and impairing behavior of many children and adults with mania is called hypersexuality. This behavior is little understood by the public or professionals who work with children. Clinicians, social workers, and teachers may jump to a false conclusion that the child is being sexually abused, and horrified parents may find themselves the prime suspects. In a study led by Barbara Geller, M.D., among a group of young subjects in which the rate of sexual abuse was less than 1%, hypersexuality was displayed by 43% of the prepubertal children with bipolar disorder.

Girls who dress and act provocatively and lack mature judgment are likely to draw the attention of sexual predators. Rape is a very real threat for these girls, whose behavior (even when driven by a brain disorder) may be viewed by authorities as consent. A Florida court recently held that the rape of a 14-year-old girl with bipolar disorder by four older males did not violate its statutory rape law when the girl had sneaked out of her home for a rendezvous with her boyfriend. One mother showed me a picture of her lovely daughter, age 13, who accepted rides and food from "friends" (pimps) who drove her to Chicago and Detroit to engage in prostitution (the girl had symptoms of bipolar illness from an early age but had not yet been evaluated by a psychiatrist). The newsletter Preventable Tragedies, a publication of the Treatment Advocacy Center, recently reported the story of a 16-year-old girl with bipolar disorder who ran away from a youth center in New Jersey in July, 2004, and was found one month later on a street corner in the Bronx, covered with bruises and apparently forced into prostitution. An article on the web site of the Treatment Advocacy Center summarizes research documenting the increased risk of sexual assault to females with bipolar disorder and schizophrenia.

The Internet is also a potential source of harm. Girls may find accounts of their sexual histories posted online by former friends turned bullies. Some caregivers report finding nude photos of their daughters attached to sexually explicit e-mails between the girls and "boys" met online, along with plans to meet in person. Parents must stress the potential dangers of such behavior, and educate our daughters about the symptoms of hypomania or mania and the importance of making safe choices-not an easy task, given the late development of the frontal lobes of the brain (thought to be the seat of judgment). Early training in self defense, strong parental controls on Internet use (or removal of access altogether), and sex education are a must. Some parents send their vulnerable daughters to boarding schools or residential treatment centers hoping to prevent the consequences of impulsive sexual behavior such as rape, STDs, unplanned pregnancies, and stigma.

Treatment itself can affect sexual behavior. This topic is entirely unstudied in young patients with bipolar disorder. Antidepressants can fuel manic behavior, including hypersexuality; or, alternatively, dampen sexual desire. The use of Wellbutrin®, an antidepressant, to restore libido in adults with antidepressant-related sexual dysfunction, raises the question whether it might stimulate hypersexuality in girls with bipolar disorder. There is no research to guide us on this question. Prolactin is often found to be elevated in girls and boys taking atypical antipsychotics—elevated prolactin levels are associated with breast enlargement and lactation in both sexes (see below). There may be other understudied hormonal side effects of long-term treatment, such as "cellular memory," where a medication taken in childhood changes a patient's response to hormones years later. Longitudinal studies that follow children taking these drugs throughout development and into adulthood (alone and, as is more common, in combination with other medications) are desperately needed to answer these questions, but federally-funded and pharmaceutical industry-funded research rarely extends beyond the first few weeks or months.

Pregnancy

Hypersexuality and impulsivity often lead to early sexual behavior and pregnancies in teens with bipolar disorder. Girls need to know the facts about sex and understand the importance and means of preventing unplanned pregnancy. A young woman with bipolar disorder who finds herself pregnant while taking medication and who wishes to continue the pregnancy needs prompt medical attention to develop a treatment plan that provides stability while minimizing risks to the baby, before, during, and after delivery. Childbirth often triggers episodes in women with bipolar disorder, who are at high risk for post-partum psychosis and depression. Husseni Manji, M.D., chief of the Mood and Anxiety Disorders Section of the National Institute of Mental Health, says that postpartum psychosis is almost exclusive to females with bipolar disorder (and often undiagnosed until then). "It looks like it's not the magnitude of hormonal changes, but the impact of the "normal" hormonal changes that interacts with a specific neurobiological vulnerability," says Manji.

Babies exposed to psychiatric medications in the womb can suffer birth defects. A young woman who wishes to become pregnant needs to discuss this intent with her psychiatrist prior to conception, as medications may need to be changed or removed during certain months of the pregnancy to minimize risk to the child.

Substance abuse and addiction

The effects of substance abuse are magnified in females; a woman with bipolar disorder is approximately 7 times more likely to have a substance use diagnosis than is a woman without bipolar disorder (the comparable increased risk in men with bipolar disorder is three-fold). Early cigarette smoking appears to prime the brain to be more responsive to other drugs like cocaine, and females addicted to nicotine have a harder time quitting than do males. Teenagers become addicted faster than adults. Street drugs (such as marijuana, cocaine, and ecstasy) as well as nicotine can cause psychiatric symptoms. Smoking pot can cause psychosis and hostility, destroy a girl's motivation for learning and achievement, and render her incapable of concentrating or comprehending what she reads (these are also symptoms of schizophrenia, which typically emerges in the late teens and early twenties). An increase in these symptoms during the teenage years, or any level of known substance abuse, should be a red flag to parents, who may then choose to require mandatory random urine testing and outpatient drug treatment as a condition for living at home. Residential treatment centers with strong recovery programs may offer the best chance to treat the often considerable effects of street drugs on the bipolar adolescent, and research shows that earlier interventions make recovery more likely.

Hyperprolactinemia

Antipsychotic medications may increase the secretion of prolactin by the pituitary gland. Prolactin stimulates the production of breast milk (called galactorrhea when it occurs in non-nursing women and men), and hyperprolactinemia (high levels of prolactin) and may lead to estrogen deficiency and, in turn, bone loss, amenorrhea (absence of periods), and infertility. Prolactin also may elevate testosterone levels in females, leading to acne and/or excess body hair growth. Few of these questions have been studied in children or teenagers receiving these drugs, and it remains unknown what long-term implications there may be in teens who show elevated prolactin without any clinical signs. It is not yet known whether medications taken in childhood will affect future response to female hormones during puberty and adulthood.

Weight gain and acne

Bipolar disorder is associated with obesity, diabetes, and heart disease. Sadly, the side effect profiles of medications currently used to manage bipolar disorder also include significant weight gain and diabetes. Weight gain is likely to leave a girl unwilling to take the prescribed medication. Parents informed in advance of these possibilities can help prevent obesity and promote treatment compliance by providing their daughter with a program of frequent, vigorous exercise, and placing the whole family on a healthy diet free of junk foods and high-calorie sodas (fruit-flavored, no-calorie spritzers are available if your daughter wants something to drink from a can). Consultations with fitness trainers and nutritional experts can be helpful in getting started (and may be covered by insurance). Exercise helps depression by delivering more oxygen to the brain and raising serotonin, a brain chemical found to be abnormally low in people with depression, and is associated with numerous improvements in various measures of mood, cognition, and physical health. No research studies have yet been done to measure the effects of diet and exercise on weight control or cognition in adolescents with bipolar disorder. For some, the appetite is so stimulated by a medication that dieting is impossible.

Acne, a potential (but not inevitable) side effect of lithium, is also distressing to adolescents. Acne in a girl may be a sign of hormonal imbalance. If lithium is working to stabilize mood, dermatologists can usually treat acne with prescription skin care regimens. As with all medications, if side effects become unmanageable, a change of medication may be needed.

Polycystic Ovarian Syndrome

Parents of girls taking valproate (an anticonvulsant sold in the U.S. as Depakote) need to know that it may precipitate hormonal abnormalities and lead to excessive hair growth, ovarian cysts, decreased menstruation, elevated testosterone levels, and central (abdominal) obesity. These symptoms can lead to polycystic ovarian syndrome (PCOS), which in turn increases a woman's risk for infertility, diabetes, and cardiovascular disease. This concern surfaced in a 1993 study from Iceland, in which 20% of women on valproate over the age of 20 with epilepsy had PCOS, as did 60% of women in the study who began taking it in adolescence. "These data are compelling and warrant that families of children and adolescents be fully informed of these findings before valproate is begun, and that menses in girlsand testosterone levels in girls as well as boys are monitored during treatment," says Barbara Geller, M.D., who chairs CABF's Professional Advisory Council. "As PCOS can be associated with infertility, it is important that this potential side effect be discussed with families. Future studies can address the frequency of early PCOS symptoms in children with bipolar disorder who receive valproate." The causes of PCOS are probably many (including weight gain and epilepsy), and some girls may be genetically predisposed to the condition.

Studies of adolescent girls with bipolar disorder on valproate have not yet been conducted; however, a recent review by Dr. Hadine Joffe of Harvard found that adult women with bipolar disorder taking valproate had substantially more treatment-emergent symptoms of PCOS than women taking other medications (10.5% compared to 1.4% for non-users) and the difference in symptoms appeared within the first year of valproate use. "Based on our findings, it is important for doctors prescribing valproate to monitor women taking the drug for signs of PCOS," says Dr. Joffe.

Oral contraceptives with low-androgenic progestins and glucophage, an anti-diabetes medication sometimes used to control insulin resistance and weight gain, may have beneficial effects in girls with PCOS, but data are lacking in this age group.

Residential treatment

Some parents reluctantly conclude that residential treatment is necessary for their vulnerable daughters with bipolar disorder. Residential treatment centers with good clinical care allow girls with bipolar disorder to be educated in a safe, structured, recovery environment that provides therapy, psychiatric care, teaching of coping strategies for impulse control and management of overwhelming feelings, along with round-the-clock staff supervision. If substance use and unsafe sexual behavior is discovered, intervention by placement in a wilderness program for girls or a residential treatment center (typical stays are six to eighteen months) that offers a good substance abuse program may divert a girl from becoming trapped in a lifelong cycle of addiction, hospitalization, and relapse. Intervention is most likely to succeed when done in the early stages of substance abuse and addiction, although no research has been done on the prevention of substance abuse and addiction in children with bipolar disorder as they pass through the age of highest risk. Placement in a residential treatment center is often not covered by health insurance, quality of care varies tremendously, and fees range from $3,500-$7,000 per month (better facilities typically have higher fees). Educational consultants can help with finding a suitable placement, and school districts will sometimes cover the academic costs.

Conclusion

Girls with bipolar disorder face enormous risks. We, as parents and helping professionals and researchers, must educate ourselves about the risks associated with bipolar disorder in girls, including the consequences of lack of treatment and treatment side effects. We must seek or create environments-sometimes, of necessity, away from the home and community-where our girls can be educated, receive medical care and taught self-awareness and management of their symptoms and cycles, in order to help them seize the reins and navigate the territory ahead. We must insist upon vastly increased federal funding of research on all aspects of diagnosis, treatment, and prevention of pediatric bipolar disorder. We must teach our girls, those who survive their sojourn in the underworld, how to use the insight and wisdom they gained there to heal and illuminate the way for others. Like Demeter, we must raise our voices in grief and outrage at the prospect of losing our daughters forever.

About the author: Martha Hellander, J.D. is Child and Adolescent Bipolar Foundation Research Policy Director

next: Mood Swings and Drugs
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When I was four years old, I woke up in the middle of a severe thunderstorm, crawled out of bed and knocked on my parents' door. My mother got up, took me to the living room, and she sat in an old, overstuffed gray armchair. I buried myself in her lap - I remember the geometric pattern of her flannel pajamas--and covered my eyes and ears, while she looked at the brilliant flashes through the bay window, not flinching when thunder shook the house. Somehow, in the morning I found myself in bed again, the thunderstorm having passed, and life continuing as usual.

This is one of the warmest and fondest memories I have of childhood, a childhood in which I asked for very little in the way of comfort because, in part, little seemed available. Perhaps because of my early experience and my natural curiosity, I often found myself wondering (and still do): what if things really weren't o.k.? What if no one or no answers could provide comfort?

Of course, many people feel inherently safer than I do. Some experienced a greater level of security in their childhoods, never questioning its very foundation, and somehow this carries over to their adult life. Others have an unflappable belief in a compassionate God, and have faith that all things, even horrific things, happen for good reason, however un-understandable. Still others, perhaps most, feel safe because, psychologically speaking, they are so well defended. In large part, I suspect the very nature of our individual brains, our genetic makeup, in conjunction with life experience, determines how safe we feel in the world.

But as we learned two weeks ago, even the strongest, or most defended of us sometimes feel unsafe - events happen for which there is no immediate comfort. Last Tuesday, many of us missed our mother's laps, the calm and soothing words and an omnipresent heartbeat. Still, before we resurrect our adult defenses and somehow create a less painful home in our psyche for this tragedy - (a process that is inherently human, and essential for us to go on), let us take a minute to experience more fully---and even value our very feelings of vulnerability.

What could possibly be the benefits of acknowledging and sharing our vulnerability? By pretending the opposite--to be invulnerable-- we put up walls to intimacy, empathy, and compassion. Look at the news this past week: along with pictures of unbearable loss and suffering, we see the greatest outpouring of generosity and empathy this country has seen in a long, long time, perhaps since World War II. The donations of money, blood, time, food, supplies, hard work, are beyond people's wildest expectations. These acts of kindness and generosity have their roots, at least in part, in a shared sense of vulnerability. As a country, if you will forgive the new age parlance, we have gotten in touch with our vulnerable self, long forgotten and neglected, and responded magnificently. Our landscape may be marred, but the ugly American is ugly no more. I feel a sense of relief about this. Ironically, the terrorists were able to humanize our country in a way that the "kinder, gentler" folks were never able to do.

Sadly, this makes the events of last week no less tragic. Grief is the worst that life has to offer, for which there is no remedy save time and an ear. Even then, the cure is never complete - nor would we want it to be, for if we simply forgot those whom we loved, life would lose meaning. The grief that many people are suffering at this very moment is simply unbearable.

But the vulnerability this tragedy has engendered in the rest of us is nothing to be ashamed of. It has given us the opportunity to be closer to one another - to not pretend, to be humble, to be generous, empathic, and compassionate. We have rediscovered one of the real strengths of our country. Look at the people around you. We are all vulnerable, we are all scared, and if we share our feelings we can all take great comfort in this - because vulnerability is an important and precious part of being human.

About the author: Dr. Grossman is a clinical psychologist and author of the Voicelessness and Emotional Survival web site.

next: Curriculum Vitae

Alcoholics and addicts are turning to alternative and complementary treatments as an adjunct to traditional addiction treatment programs.

Bill Beilhartz had run out of options. In fact, he was close to death.

At age 44, the Denver father-of-two had just spent two weeks in the hospital for alcohol-induced ulcers in his esophagus and stomach. He'd registered a nearly lethal blood alcohol level of .675. He'd been through two failed marriages, and his tall, once-handsome frame was withered from years of drinking a half-gallon of vodka a day. Yet, his first stop after leaving the hospital? Incredibly, the liquor store.

Three days later, after being rushed to the hospital again—this time for internal bleeding—he began desperately flipping through the Yellow Pages looking for something beyond what his three previous treatment centers had offered—something that might actually work.

"They all had the same approach," says Beilhartz, an international casino consultant who had checked himself in each time before, paying as much as $10,000 per stay. "They tell you, 'Don't drink,' and that is pretty much the education they give you."

An ad for InnerBalance Health Center, a Colorado treatment program that takes a comprehensive holistic approach to addiction, jumped out at him. The clinic prescribed such treatments as nutritional counseling, intravenous vitamin therapy, yoga, and exercise programs. "It was different than anything I'd ever heard of. And it all just made sense to me," says Beilhartz, who checked in to the 35-day program in January 2006.

Months later, he's healthy, hopeful, and boasting more days of sobriety than in all the past 15 years combined. "Within a week of arriving, my mind was completely clear, and I felt energized and motivated to get on with life. I hadn't felt like that since my early 20s," he says.

Battling brain chemistry

Beilhartz is among a growing number of addicts and alcoholics turning toward complementary and alternative therapies to address the physiological underpinnings of addiction. The programs are rooted in the theory that addiction is largely the result of skewed levels of certain chemical messengers in the brain.

With too much of some messengers and not enough of others, researchers believe, addicts are caught—often from childhood—in a state of chronic imbalance and turn to drugs and alcohol to self-medicate in an attempt to feel "normal."

Most addiction experts agree that talk therapy and 12-step programs—considered the gold standard for addiction treatment for decades—are a necessary component of a successful recovery. But in and of themselves, such methods have not proven terribly effective. Between 70 and 85 percent of addicts completing such programs will relapse within six to 12 months, studies show. Meanwhile, some alternative clinics that incorporate both physiological and psychological approaches boast six-month sobriety rates as high as 85 percent.

"If you have a broken leg and your bone is sticking out, you aren't going to want to sit around and talk about it. You are going to want to go to the emergency room, fix the physical problem, and stop the pain first," explains Joe Eisele, clinical director of InnerBalance and a recovering alcoholic. "Then you can sit down and talk."

Reward deficiency syndrome

The notion that addiction is a biochemical disease dates back to the late 1980s when Texas brain researcher Kenneth Blum coined the phrase "reward deficiency syndrome." Blum theorized that for most people, the stimulus of everyday things like good food, sex, or a funny movie set off a cascade of feel-good neurotransmitters in the brain. But some people are born with either an inability to produce enough of these chemicals or a kink in the line that delivers them. For such individuals, the cascade of reward is hindered and pleasure muted, if it comes at all.

"Addicts are always looking for a way to feel better, and when they discover certain mood-altering substances—those things that fit into the same receptors in the brain that the deficient 'feel-good' chemicals do—they feel like they are getting what they have been looking for but have never been able to find," says Merlene Miller, an addictions specialist and coauthor of the book Staying Clean and Sober: Complementary and Natural Strategies for Healing the Addicted Brain (Woodland, 2005).

Today, experts readily accept the notion that faulty brain chemistry plays a role in setting people up for addiction, but for the most part, addiction researchers have focused on correcting that brain chemistry with pharmaceuticals, rather than addressing it more holistically. Meanwhile, more and more clinics around the country use that same information to take a different, more holistic approach.

Vitamins through a tube

Step into InnerBalance Health Center on any given Wednesday and you'll find a room full of resident patients, from grandmothers trying to quit binge drinking to musicians who want to kick cocaine. They're watching videos and chatting as orange liquid drips into their veins through intravenous tubes.

Alcoholism and drug abuse can ravage the gastrointestinal system, limiting its ability to absorb nutrients, so pumping vitamin C, calcium, magnesium, zinc, and B vitamins directly into the blood has a more immediate effect than administering them orally, says Eisele. And because underlying nutritional problems, such as hypoglycemia or B-vitamin deficiencies, often prompt cravings, IV therapy can often quell the withdrawal that leads addicts to relapse early on.

At Bridging the Gaps Inc. in Winchester, Virginia, patients begin treatment with a series of blood and urine tests to assess their liver and kidney function and nutritional status. They also fill out a psychological survey to determine if they might be lacking in certain brain chemicals. They then receive a customized cocktail of nutrients and amino acids—the building blocks for neurotransmitters—through an IV tube for six to 10 days.

The amino acid given depends on which neurotransmitter appears to be lacking. For example, clinic staff members presume that addicts who prefer sedatives or alcohol lack the calming neurotransmitter GABA, so they give them its amino acid precursor. Someone who gravitates toward drugs like cocaine, on the other hand, would get amino acids that stimulate excitatory activity in the brain.

James Braly, MD, medical director and attending physician at Bridging the Gaps, says the medical journals have published few studies about the benefits of IV and oral nutrient therapy specifically, largely because most research dollars support pharmaceutical approaches to treating addiction. But Braly's clinic has produced some promising data. One study surveyed newly sober patients about the severity of 15 "abstinence symptoms" (such as cravings, anxiety, depression, insomnia, fuzzy thinking, and restlessness) both before and after six days of IV and oral nutrition therapy. It found that all 15 symptoms were radically reduced, making it easier for the patient to stick with the psychosocial counseling part of the program.

Once the body is better able to absorb nutrients and the brain chemistry is rebalanced, patients are placed on a daily regimen of oral vitamins, amino acids, essential fatty acids, and probiotics. At the same time, they receive nutritional counseling aimed at steering them toward lots of fresh fruits and vegetables; quality proteins such as fish, poultry, and eggs; and nutritional oils such as extra virgin olive oil and omega-3 fish oils. They are strongly urged to stay away from junk food and refined carbohydrates, which can cause blood sugar to fluctuate wildly, aggravating cravings.

Such nutritional approaches stem largely from the work of Joan Matthews Larsen, whose groundbreaking book Seven Weeks to Sobriety: The Proven Program to Fight Alcoholism With Nutrition (Ballantine, 1997) sparked many people to open clinics based on her Health Recovery Center in Minneapolis. One published study conducted there found that 85 percent of clients had remained sober six months after treatment. After three and a half years, 74 percent were still sober.

Another success story, Ty Curan, 29, a recovering heroin addict, experienced dramatic results by changing his diet and adding a supplement regime. A drug user since the age of 15, he had completed nine residential in-patient treatment programs before checking in to Bridging the Gaps in December 2005. "I would go to treatment for a month, stay clean for a month, and fall back apart," he recalls. The difference this time, he says, is after his stay at Bridging the Gaps, he's been able to stay sober: "It truly is the best I've felt in a long, long time."

Needling the ear

Another key component at Bridging the Gaps is ear acupuncture—now being used in more than 800 federally recognized addiction programs across the country.

Chinese medicine practitioners discovered more than 2,500 years ago that when they manipulated certain points in the ear, they could relieve the discomfort of people going through opium withdrawal. In the 1970s, a neurosurgeon in Hong Kong revived the practice after noting that when he delivered electrical stimulation to a certain acupuncture point in the ear for post-surgical pain relief, he also alleviated his patient's opiate withdrawal symptoms.

When word of the treatment made it to the US, the practice took off here, ultimately evolving into a protocol that calls for five needles placed in ear points said to regulate the nervous system, cerebral cortex, respiratory system, liver, and kidneys. Today, the nonprofit National Acupuncture Detoxification Association teaches the method worldwide, and the federal government has granted millions of dollars to study its efficacy.

Research has produced mixed results, but some studies have shown this method of ear acupuncture can not only quell withdrawal symptoms in notoriously hard-to-treat heroin and cocaine addicts, but it has the added benefit of helping people stick with a treatment program.

For the past 30 years, Michael Smith, MD, director of the Recovery Center at Lincoln Hospital in the Bronx, New York, has offered ear acupuncture to addicts awaiting methadone therapy for heroin and cocaine addiction at the clinic.

He began to see results immediately. "This one woman took the treatment, and after about five minutes, her nose stopped running, and she looked more comfortable. About a half hour later she said, 'I'm hungry. I want to eat something,'" recalls Smith. "No heroin addict in the middle of withdrawal has ever said, 'I want to eat something.' She ate a double helping." Even more remarkable, she also left without the methadone and returned the next day for another acupuncture treatment instead. Five years later, the clinic stopped offering methadone therapy altogether. Now, it treats as many as 50 patients at a time with ear acupuncture, upping the chances that they will return for counseling. "You start it as soon as they arrive because it helps people when they are in crisis," says Smith.

While ear acupuncture is by far the most researched form of needling for addiction treatment, traditional Chinese acupuncture, which uses points all over the body, can also play an important role—particularly for pain relief.

Studies show acupuncture relieves pain effectively, which makes it ideal for people trying to wean themselves off prescription pain killers, and it can also help people deal with chronic health problems resulting from years of drug and alcohol abuse.

At Bridging the Gaps Inc. in Winchester, Virginia, patients begin treatment with a series of blood and urine tests to assess their liver and kidney function and nutritional status. They also fill out a psychological survey to determine if they might be lacking in certain brain chemicals. They then receive a customized cocktail of nutrients and amino acids—the building blocks for neurotransmitters—through an IV tube for six to 10 days.

Don't stress out

Once the body has begun to heal, keeping stress at bay becomes a critical factor in continued progress. Many clinics across the country offer classes in meditation and yoga and also mandate a regular exercise program. But some have also begun to look toward a more novel approach to stress reduction called brain wave, or EEG, biofeedback, a computer-assisted relaxation technique that helps patients learn to manipulate their own brain waves. Research has shown that prolonged drug use can actually alter brain wave activity, prompting mental sluggishness or agitation depending on the substance used.

"It's almost like the brain is misfiring because [recovering addicts] have been using these drugs, and biofeedback helps them learn how to make it fire properly," says Don Theodore, a certified addictions specialist who runs the brain wave biofeedback program at Cri-Help Inc. in Hollywood, California.

For 45 minutes twice a day, clients lie in a comfortable chair with brain wave-charting sensors attached to their heads. As they make their way through visualization and relaxation exercises, a tone in their ear "rewards them" when they reach alpha and theta brain wave states, which are associated with calm and openness. So far, the research is promising. In one 2005 study, addicts who underwent 40 to 50 biofeedback sessions, along with counseling, were far less likely to drop out of treatment; after 12 months, 77 percent were still clean.

Pulling it all together

Back at InnerBalance in Colorado, Beilhartz credits a combination of things for his long-sought recovery. The IV vitamin therapy and supplements certainly helped him get through the initial cravings, both the nutritional counseling and the mandatory three-day-a-week exercise class helped him recover his health, and the group counseling provided much-needed peer support.

As a result, he recently left his job in the casino business and is now preparing to go back to school. His future plans: to become an addictions counselor specializing in a holistic approach.

"I spent the last 44 years thinking only of myself. I'd like to spend the next 44 years returning favors and taking care of people," he says. "These guys are amazing. This place is amazing."

Eating right to kick the habit

- Lay off the sugar. Once alcoholics quit the bottle, they gravitate toward the sugar bowl, which can be disastrous. The high they get from sugar leads to a crash, a mood slump, and a subsequent craving—for alcohol, drugs, or more sugar.

- Reach for whole grains. To break the cycle, choose raw or lightly cooked fruits and veggies, exchange white rice for brown, and eat oatmeal for breakfast.

- Snack on protein. To keep blood sugar at an even keel, eat a healthy protein snack, like hard-boiled eggs, chunks of cheese, nuts, or peanut butter and apples, every two or three hours.

Alternative Treatment Resources

InnerBalance Health Center
2362 E. Prospect Rd., Suite B
Fort Collins, CO 80525
877.900.QUIT
www.innerbalancehealthcenter.com

Bridging the Gaps Inc.
423 W. Cork St.
Winchester, VA 22601
540.535.1111
www.bridgingthegaps.com

Health Recovery Center
3255 Hennepin Ave. South
Minneapolis, MN 55408
612.827.7800
www.healthrecovery.com

Cri-Help Inc.
11027 Burbank Blvd.
North Hollywood, CA 91601
818.985.8323.
www.cri-help.org

Source: Alternative Medicine

next: Nutrition Therapy for Treating Alcoholism

Articles and essays addressing change, growth, healing, life, spirituality, and more.

• No Body is Perfect: Body Image and Shame
• The Magic of Appreciation
• Final Conversations as Expressions of Love
• The Journey Through Cancer and The Seven Levels of Healing®
• Kenosha
• How We Become Who We Are Not
• When Ordinary People Achieve Extraordinary Things
• Why Even Bother?
• A Day in the Heart of Pain
• A Lesson in Change that Changed My Life
• Radical Common Sense
• Traveling Toward Home
• A Celtic Response to An Inconvenient Truth
• Healing Our Wounds
• The Giving Gift

next: No Body is Perfect: Body Image and Shame

A short essay on the importance of passing on personal and family stories to children as they provide a sense of continuity and personal history.

"What remains of a story after it is finished? Another Story..."

Eli Wiesel

Life Letters

Yesterday while I was working, my daughter, Kristen, sat beside me and began to ask one question after another about my childhood. It wasn't a good time for me to answer, and so my responses were short, vague, and distracted. Eventually she wandered off in search of a more satisfying way to occupy her time.

Finally free from her interruptions, I began working again but soon found that I had lost my ability to concentrate because of my nagging conscience. When Kristen was younger, she hounded me with questions: "How did you and Daddy meet?" "Did you get in trouble when you were a little girl?" "What did grandma do?" Not long after I answered them, she'd return with a new series of questions. She would demand that I tell her ­— yet again —about how her father and I had met, what games my sister and I played as children, and about how my mother would punish us. Sometimes, I felt like a wind-up doll that spewed forth the same sentences and words over and over.

Remembering how important these stories were to her helped me to not feel too annoyed or frustrated by her seemingly endless and repetitive questions. Although my stories entertained her, they also provided her with a sense of continuity and personal history. From these tales, she learns that she is not only my daughter, but also someone's niece, grandchild, cousin, etc. Not only is our family's history a part of her, she too is adding her own chapter in our ongoing family saga. Also, by sharing tales about my family, I may occasionally provide answers to the deeper questions that she may not know how to ask.

I loved my mother's and my grandmother's stories when I was a little girl. Their vivid memories both enchanted and delighted me, and in some inexplicable way they became my stories too. One particular story still pulls at my heart decades after I first heard it.

When my mother was a child, my grandmother would stand her on the open door of the old cook stove in an attempt to warm her as she dressed her in the morning. The family was poor, and the house got so frigid during the winter that ice formed on the inside walls and froze the contents of any glasses that were left out overnight. On my mother's first day of school, she assumed her normal position on the stove door so that my grandmother could get her ready. Although my mother was filled with the excitement of embarking on the greatest adventure of her young life, she was also more than a little bit worried.

Anxiously, she asked, "Will I get to eat lunch?"

My grandmother reassured her that she would.

Although briefly comforted, my mother queried, "Will I always come home?"

Again, her mother responded affirmatively.

I have no idea how many other questions she asked or how my grandmother responded, but there was one more exchange that I'll never forget.

With wide, innocent eyes, she looked at my grandmother and asked, "Will I be able to dance at school?" My grandmother informed her, "No, you probably won't, you'll need to sit quietly and pay attention."

The little 5- year-old that would someday be my mother grew silent for just a moment and then cheerfully proclaimed, "Oh well, then I'd just better dance now!" And she began twirling around on the stove door with her little feet tapping and skinny arms held up towards the heavens. And she danced.

Sadly, I have no memories of my mother dancing. Her's has been a difficult life, even tragic in some respects. Her spirit has been repeatedly battered, and the beautiful singing voice that used to captivate me as a child eventually grew silent. Although she has no more songs for me now, she still has her stories. In my mind's eye, I still see that precious little girl transformed into a little ballerina, her wild and yet tender heart refusing to be daunted.

Today, it occurs to me that perhaps this is a significant piece of her legacy to me that is lovingly wrapped in a story that was first told me as a little girl by my grandmother. To this day, I can still hear that story whisper it's lesson to me: "Don't dwell on what you can't do, what you've lost, what you seek and have yet not found. Instead, you'd just better dance now, now while you can."

Setting aside my work, I eagerly searched for my daughter so that I could answer her questions, share our collective stories—mine, my mother's, my grandmothers', and my daughter's. She was engrossed in a telephone conversation with her best friend when I found her, and she had forgotten her questions. I'm hoping that she'll ask them again soon. She didn't last night, and I didn't press her. I learned long ago that when I miss an opportunity with Kristen it often doesn't come around again for a while. So before she went to bed last night, I turned on the music, held my arms out to her, and we danced.

next:Life Letters: Nurturing Your Soul During the Holidays