Bipolar Disorder: Childhood’s Most Under-recognized Disorder

Abstract

Bipolar Disorder is one of the most under-recognized and misdiagnosed disorders in children and adolescents. One goal of this paper is to attempt explain why Bipolar Disorder is difficult to diagnose in children and how it is often misdiagnosed or missed in them completely. The second goal of this paper is to look at some of the promising research being done to make Bipolar Disorder easier to diagnose and separate from other childhood disorders that might occur with this disorder or share similar symptoms with it. In addition, we will look at a psychosocial treatment with pharmacotherapy that may help attain a remission of Bipolar Disorder in children.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Childhood’s Most Underrecognized Disorder

Why Bipolar Disorder in young children and adolescents is underrecognized and often misdiagnosed? The short answer here would simply be that the research on Bipolar Disorder in young children and teenagers is still being done and many questions have not yet been fully answered. One reason for this is because most of the research you will find on Bipolar Disorder in children and adolescents has been done only within the last twenty years, so in a sense research on Bipolar Disorder in children is still in its infancy. The slow start here may be because for a longtime psychiatrists, psychologists, and others in related fields were under the assumption that young children and teenagers could not either get Bipolar Disorder or that the worst or most obvious symptoms of this disorder would not appear until adulthood. Why intelligent people might have been in this mindset could stem from the fact that they know people can carry genes of medical disorders, like Huntington’s Disease, but never show symptoms of it until adulthood, so why could this not be true for some mental disorders too.

Why is bipolar disorder in children misdiagnosed or goes unrecognized?

Even with the great research that has already been done Bipolar Disorder in children and teenagers it is very difficult diagnose because children who have it will often have anxiety, depressive, and many other disorders cooccurring with it (American Psychiatric Association, 2013). Attention Deficit Hyperactivity Disorder is often misdiagnosed as Bipolar Disorder in children because symptoms overlap (American Psychiatric Association, 2013).  Rapid speech, racing thoughts, distractibility, and less need for sleep at night are symptoms seen in children with ADHD as well as children with Bipolar Disorder going through a manic period. Certain personality disorders are also shared by both these disorders (American Psychiatric Association, 2013). Unlike the adult version, Bipolar Disorder in children is more continuous. Children have

long-periods of rapid cycling and can shift from mania and depression several times a day. These shifts can be quite subtle in children. A child with Bipolar Disorder having a depressive episode may simply appear irritable and moody and a child having a manic episode may appear overly happy, silly, or goofy to the extreme (American Psychiatric Association, 2013).  Diagnosing a child with Bipolar Disorder would require you to talk to the child, interview family, teachers, and anyone else that deals with them on a regular basis, observe the child in different settings, look at medical records to see if a drug or condition is not causing the symptoms and even after doing all that and possibly more the child may not meet all the criteria for a Bipolar I or II diagnosis according to the DSM-V, but with enough symptoms a diagnosis of “Unspecified Bipolar and Related Disorder” might be possible (American Psychiatric Association, 2013).  In a sense, Bipolar Disorder in a young child or teenager is like a fiendish little gremlin that can look like other disorders, that has an evil kinship with Attention Deficit Hyperactive Disorder, that can present itself in different ways in different children, and one that can wreak as much havoc in a child’s mind as it can in an adult mind if not more, not to mention the stress it can put on families and relationships in general.

Statistics, general facts, and genetic connection

Sadly, there is nothing humorous about the facts we do know about Bipolar Disorder in general. Bipolar Disorder is a chronic debilitating condition that affects one percent of the world’s population and is the greatest cause for medical disability worldwide (American Psychiatric Association, 2013). People with Bipolar Disorder have high mortality rates with about one third attempting suicide once in their lifetime and one fourth completing their suicide (American Psychiatric Association, 2013). Bipolar Disorder also has a very strong genetic link because there is a ten-fold chance of it being passed on from one generation to the next, so the

closer the kinship to someone with it the more likely the disorder will be passed on. We also know that thirty percent of adults with the disorder show severe impairment in work role functioning. Cognitive tests done on both adults and children with Bipolar Disorder show that they do poorly on them (American Psychiatric Association, 2013). Unquestionably, the need for more study on Bipolar Disorder is clear and the fact that much less research has been done on childhood onset Bipolar Disorder than on adult onset strongly suggests an even greater need to learn more about this complex dreadful disorder in children.

Promising research in childhood Bipolar Disorder goes in many directions

The goal of many researchers investigating Bipolar Disorder in children is to increase their knowledge in general and to gain a better understanding of the cognitive changes in children, so they can find ways to more easily distinguish it from other symptomatically closely related childhood disorders, like ADHD because just like any other disorder or condition earlier diagnosis improves outcomes. Other research relating how stress plays a role in childhood Bipolar Disorder and of course other research utilizes what has been learned thus far to look at innovative treatments that go beyond pharmacotherapy.

Research toward earlier diagnosis

In one study they looked at individual subcomponents related to executive cognition to advance knowledge on this disorder and they found that adults and children do show similar deficits in cognition in executive functions (Bearden et al., 2007). The researchers admitted that more longitudinal studies need to be done, but the promise of the research in this area is that it may someday be able to develop a test to better distinguish Bipolar Disorder from other childhood disorders, like ADHD, which would allow childhood Bipolar Disorder to be diagnosed earlier (Bearden et al., 2007).  In another study seeking a greater understanding of the cognitive functions in childhood Bipolar Disorder with a focus on being able to design a specific treatment to improve impairment and academic performance they hypothesized that children with Bipolar Disorder I and II with full on mania or hypomania would have certain deficits, including those in learning (Dickstein et al., 2016). Their thought was that these cognitive differences might be used to develop some type of markers both biologically and behaviorally which might result in better and earlier diagnosis of Bipolar Disorder as well as some treatment approaches in children and adolescents with Bipolar Disorder (Dickstein et al., 2016). One example of a treatment or aid is computer assisted cognitive remediation (Dickstein et al., 2016).

Study centered on a treatment idea

A study centered on a treatment idea was done to acquire some preliminary information on the feasibility and possible efficacy of a manualized cognitive behavioral treatment for teens or adolescents with Bipolar Disorder (Feeny, Danielson, Schwartz, Youngstrom, & Findling, 2006). The study was successful to some extent in that they did find that it was feasible to use individually delivered cognitive -behavioral therapy with pharmacological treatment (Feeny, Danielson, Schwartz, Youngstrom, & Findling, 2006). The treatment showed promise because improvement in teens with Bipolar Disorder was clearly shown. In addition, teens in both manic and depressive periods shown improvement, so treatments in this direction have the potential to be quite effective (Feeny, Danielson, Schwartz, Youngstrom, & Findling, 2006). Researchers did suggest that more randomized studies on this are needed to be done, but they were successful enough to illustrate the potential of cognitive behavioral treatments for children with Bipolar Disorder (Feeny, Danielson, Schwartz, Youngstrom, & Findling, 2006).

 

 

Why Bipolar Disorder in children looks a lot like ADHD

Continuing the search for a marker to identify Bipolar Disorder in children earlier, a study that centered on impaired verbal declarative memory in children was done (Glahn et al., 2005). Since this is considered a marker for Bipolar Disorder in adults, researchers were trying to find out if children suffered from exactly the same type impairments here (Glahn et al., 2005). Their results did show that these impairments are common to both adults and children with this disorder and that comparable brain systems are compromised (Glahn et al., 2005). This study takes early steps in examining memory and learning processes more specifically in children with Bipolar Disorder I and appears to be in line with or according to the diagnosis in the DSM-5 (Glahn et al., 2005). Again, research in any direction like this could bring about earlier diagnosis of Bipolar Disorder in children and may help distinguish it more clearly from other disorders. One disorder that Bipolar Disorder shows a clear comorbidity with is ADHD, so with a focus on that researchers in another study tried to find out if a unique pattern of neuropsychological deficits is characterized in children with Bipolar Disorder (Henin et al., 2007). They did this by examining whether children with Bipolar Disorder and those with ADHD displayed neuropsychological deficits and whether those deficits were more severe in one disorder than the other (Henin et al., 2007). Their results showed that the neuropsychological performance in children with Bipolar Disorder is very similar to children with ADHD alone (Henin et al., 2007). This research clearly illustrates why Bipolar Disorder in children is difficult to diagnose early and easy to misdiagnose. The work done here directly relates to the evaluation and treatment of Bipolar Disorder in children (Henin et al.,2007). Unfortunately, you cannot treat a disorder until you can clearly distinguish it from another and this study showed some clear parallels between Bipolar Disorder in Children and in children with Attention Deficit/Hyperactive Disorder.

Education plan for children with Bipolar Disorder that takes their cognitive difficulties and deficits into account    

Another study that was simply an in-depth review of the current literature on the neurocognitive impairments in children, under eighteen, with Bipolar Disorder found that children with Bipolar Disorder show deficits in a wide range of cognitive areas (Horn, Roessner, & Holtmann, 2011). Their results revealed a consistent pattern in impairments in verbal memory and in working memory (Horn, Roessner, & Holtmann, 2011). The researchers thought here was that these deficits needed to be incorporated into an individual treatment program, so the underlying goal of this review was toward identifying neurocognitive tests for evaluating these impairments in juvenile Bipolar Disorder in clinical practice (Horn, Roessner, & Holtmann, 2011). In concert with other studies they did find that there were no differences found between the deficits or impairments found in adults and children with the disorder (Horn, Roessner, & Holtmann, 2011). However, the researchers felt these deficits in children with Bipolar Disorder did need to be incorporated into an individual and school’s educational plans because they thought children might benefit from a treatment approach that takes their cognitive difficulties or deficits into account with some focus on teaching them skills to deal with the mood and neuropsychological issues (Horn, Roessner, & Holtmann, 2011). In addition to trying to garner a better understanding of the cognitive impairments in children with Bipolar Disorder studies down these avenues gives us practical insights and applications at clinical levels (Horn, Roessner, & Holtmann, 2011).

Negative effects of life events on children with Bipolar Disorder

A study that took an entirely different approach by focusing on how life events might influence child and adolescent Bipolar Disorder did find that children with Bipolar Disorder experience significantly high rates of life stress compared to children with other mental disorders (Johnson & McMurrich, 2006). Teenagers with psychopathology are more than likely to report two types of stressors failure and being misunderstood (Johnson & McMurrich, 2006). Their findings did show that negative life events are tied or associated with the course of teen or adolescent bipolar disorder and that the effects of life events are entangled or wrapped up with emergent symptoms of the disorder and family difficulties (Johnson & McMurrich, 2006). A question other studies in this area will need to work on is how these life events might make symptoms of childhood bipolar disorder worse. This study indicates an even greater need for early diagnosis of Bipolar Disorder in children, so clinicians can get in front of any external issues that might make the symptoms their patients present with worse.

Do parents with Bipolar Disorder pass learning issues down to their healthy children?         

      This research study was an investigation into the intellectual functions and academic performance or achievement abilities in healthy children of parents with Bipolar Disorder to see if these children exhibited any nonverbal learning disabilities (NLD) (McDonough-Ryan et al., 2002). The results of this study did show that children with parents who have Bipolar Disorder do demonstrate cognitive abnormalities and academic weaknesses relative to those children with healthy parents. However, the actual pattern of deficits is not consistent with NLD (McDonough-Ryan et al., 2002). This study was done to see if there was any cognitive link to parents with Bipolar Disorder in healthy children (McDonough-Ryan et al., 2002). This look at healthy children of parents with Bipolar Disorder is a different approach toward finding a way to diagnose Bipolar Disorder in children earlier. If you look at those children who have not inherited the disorder from their parents, you might be able to figure out a marker in those children who might inherit the disorder or in those who might inherit the disorder in the future.

A look at executive functioning in children with Bipolar Disorder through parental reports.

     The study looks at executive functioning in teens or adolescents with Bipolar Disorder who are in a manic or mixed mood state by garnering or collecting data from their caregivers (Shear, DelBello, Rosenberg, & Strakowski, 2002). From the information they gathered they studied their performance on those tasks related to or mediated by executive functions by utilizing a behavior rating inventory of executive function (Shear, DelBello, Rosenberg, & Strakowski, 2002). When compared to the results of healthy teens, they showed significant elevation through all measured functional domains, even among those children who had Bipolar Disorder, but not ADHD (Shear, DelBello, Rosenberg, & Strakowski, 2002). The thought behind this study was to study well-defined adolescent cases with Bipolar Disorder to perform everyday activities that are believed to be related to or dependent on executive functions (Shear, DelBello, Rosenberg, & Strakowski, 2002). These results taken together suggest that the functional deficits measured by the brief behavior rating inventory of executive functions in the sample of teens with Bipolar Disorder might potentially affect not only their current psychosocial functions, but long-term outcomes (Shear, DelBello, Rosenberg, & Strakowski, 2002). Researchers in this study, like many, were hunting for a way to diagnose Bipolar Disorder in children earlier and a way to distinguish it more clearly from other disorders. The difference is researchers in this study focused on the manic and mixed moods of this disorder alone.

A comparison of the dysfunction between type 1 Bipolar Disorder and II in children

     The goal of this study was to determine phenotypic cognitive profiles of patients with Bipolar Disorder. In other words, a composite of characteristics in patients with Bipolar Disorder (Schenkel, West, Jacobs, Sweeney, & Pavuluri, 2012). To do this they studied both type I and II Bipolar Disorder and compared them both with healthy people (Schenkel, West, Jacobs, Sweeney, & Pavuluri, 2012). They found that patients with type I Bipolar Disorder performed more poorly compared to healthy people on all domains they looked at, but they also found the type I Bipolar Disorder patients to be far worse off than those with type II Bipolar Disorder (Schenkel, West, Jacobs, Sweeney, & Pavuluri, 2012). Findings like these could move us closer to creating or developing effective cognitive interventions tailored to the distinct types or sub types of Bipolar Disorder in children (Schenkel, West, Jacobs, Sweeney, & Pavuluri, 2012). The researchers proved their hypothesis in finding that children with type I Bipolar Disorder showed more severe and wide spread cognitive dysfunction and the results indicated that the most notable deficits in all groups were in verbal learning and memory (Schenkel, West, Jacobs, Sweeney, & Pavuluri, 2012). Researchers here felt that any treatment should target these areas (Schenkel, West, Jacobs, Sweeney, & Pavuluri, 2012). This kind of research is an attempt to try to define Bipolar Disorder by looking at the characteristics of it and trying to create a profile from the information.

A child and family based or focused Cognitive Behavior Therapy

     This study was a report of a group adaption of child and family based or focused Cognitive Behavior Therapy (CFFT-CBT), nicknamed Rainbow (West et al., 2009). The object of the study was to find out if this therapy was feasible and acceptable to families and if the treatment resulted in any significant improvement (West et al., 2009). The treatment resulted in significant improvement in manic symptoms, but not in depressive symptoms and in the psychosocial function post treatments (West et al., 2009). One great outcome, but not necessary for the success of the study was that parents reported being able to cope with their child’s illness much better (West et al., 2009). This is important because any kind of mental illness puts an unusual amount of stress on families. This group psychosocial treatment with pharmacotherapy might help bring about or attain remission of symptoms (West et al., 2009). This is just the beginning, but this is a crucial area for research because the need for psychosocial treatments for bipolar disorder to be used in conjunction with pharmacotherapy may help to combat the chronic and devastating course of this disorder (West et al., 2009). Any integrated treatment that has the potential to not only improve the quality of the lives of patients but reduce the public health burden must be considered (West et al., 2009). Discovery of more treatments for this disorder are critical, so more studies in this direction are just as important as those that search for a way to diagnose it earlier or distinguish it better from other disorders.

Conclusion

     The research on pediatric Bipolar Disorder discussed in this paper of what has been done and is being done to understand, diagnose earlier, and to treat this devastating disorder in children represents just a few grains of sand in a beach of information yet to be discovered and learned from research on childhood Bipolar Disorder. The research on Bipolar Disorder in children thus far is inspiring and dynamic in nature for it goes in many directions and that must never stop because the need to unmask this gremlin of a disorder in children and make it easier to identify and distinguish from the other childhood disorders it hides among or shares clear comorbidity with like ADHD is critical to recognizing it sooner and avoiding misdiagnosis. If this can be achieved, Bipolar Disorder in children could be treated sooner and sooner is always better than later as far as outcomes are concerned.

To illustrate the issue of not being able to identify Bipolar Disorder in children easer or more clearly consider how devastating it might be for a mother to have been told by one psychologist or psychiatrist that her child has ADHD only to find out from another a few years later that her child has Bipolar Disorder or vice a versa. If you were the mother or even a father in this scenario, would you not be wondering how a psychiatrist or psychologist could make such a huge error in diagnosis. Unfortunately, what they would not know and would not ever understand no matter how clearly it was explained is how a mistake like this could be made. The sad truth is according to just the information discussed here this mistake could be made very easily by a psychiatrist or psychologist. One might argue that it was a rush to judgement or to a diagnosis, but that may or may not be the case. A psychiatrist or psychologist could have interviewed parents, teachers, and others that deal with the child on a regular basis, obtained medical records on the child, looked at school records, observed the child at multiple times in multiple locations, interviewed the child, considered some potential environmental factors and from all accounts did the homework necessary to make a diagnosis and still make a mistake. Yes, everything does have to fit the criteria in the DSM-V to make a diagnosis of Bipolar Disorder but finding that the symptoms in the child you studied also somewhat matches ADHD with another disorder can still leave you without a clear diagnosis of either or leave with just enough symptoms to contemplate a diagnosis of Unspecified Bipolar and Related Disorder. People always like to use the phrase “the devils in the details,” but when it comes to diagnosing Bipolar Disorder in children the devil is in a huge complex forest of details that can make it look like other disorders, be hidden among other disorders, function in concert with other disorders, and that has a close kinship, as far as symptoms are concerned, with ADHD which is a disorder that is diagnosed in children with such great regularity that it would make even the wisest psychologist or psychiatrist pause to consider it. Hopefully someday research on Bipolar Disorder in children will clear this forest a little for psychiatrists and psychologists, but until then Bipolar Disorder in children will remain either under-recognized or occasionally misdiagnosed in children.

 

References

Glahn, D. C., Bearden, C. E., Caetano, S., Fonseca, M., Najt, P., Hunter, K., & … Soares, J. C. (2005). Declarative memory impairment in pediatric bipolar disorder. Bipolar Disorders, 7(6), 546-554. doi:10.1111/j.1399-5618.2005.00267.x

 

Bearden, C. E., Glahn, D. C., Caetano, S., Olvera, R. L., Fonseca, M., Najt, P., & … Soares, J. C. (2007). Evidence for disruption in prefrontal cortical functions in juvenile bipolar disorder. Bipolar Disorders, 9(Suppl1), 145-159. doi:10.1111/j.1399-5618.2007.00453.x

 

Johnson, S. L., & McMurrich, S. (2006). Life events and juvenile bipolar disorder: Conceptual issues and early findings. Development And Psychopathology, 18(4), 1169-1179. doi:10.1017/S0954579406060561

 

Schenkel, L. S., West, A. E., Jacobs, R., Sweeney, J. A., & Pavuluri, M. N. (2012). Cognitive dysfunction is worse among pediatric patients with bipolar disorder type I than type II. Journal Of Child Psychology And Psychiatry, 53(7), 775-781. doi:10.1111/j.1469-7610.2011.02519.x

McDonough-Ryan, P., DelBello, M., Shear, P. K., Ris, M. D., Soutullo, C., & Strakowski, S. M. (2002). Academic and cognitive abilities in children of parents with bipolar disorder: A test of the nonverbal learning disability model. Journal Of Clinical And Experimental Neuropsychology, 24(3), 280-285. doi:10.1076/jcen.24.3.280.980

 

Dickstein, D. P., Axelson, D., Weissman, A. B., Yen, S., Hunt, J. I., Goldstein, B. I., & … Keller, M. B. (2016). Cognitive flexibility and performance in children and adolescents with threshold and sub-threshold bipolar disorder. European Child & Adolescent Psychiatry, 25(6), 625-638. doi:10.1007/s00787-015-0769-2

 

West, A. E., Jacobs, R. H., Westerholm, R., Lee, A., Carbray, J., Heidenreich, J., & Pavuluri, M. N. (2009). Child and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: Pilot study of group treatment format. Journal Of The Canadian Academy Of Child And Adolescent Psychiatry / Journal De L’académie Canadienne De Psychiatrie De L’enfant Et De L’adolescent, 18(3), 239-246.

 

Horn, K., Roessner, V., & Holtmann, M. (2011). Neurocognitive performance in children and adolescents with bipolar disorder: A review. European Child & Adolescent Psychiatry, 20(9), 433-450. doi:10.1007/s00787-011-0209-x

 

Feeny, N. C., Danielson, C. K., Schwartz, L., Youngstrom, E. A., & Findling, R. L. (2006). Cognitive-behavioral therapy for bipolar disorders in adolescents: A pilot study. Bipolar Disorders, 8(5 pt 1), 508-515. doi:10.1111/j.1399-5618.2006.00358.x

 

Shear, P. K., DelBello, M. P., Rosenberg, H. L., & Strakowski, S. M. (2002). Parental reports of executive dysfunction in adolescents with bipolar disorder. Child Neuropsychology, 8(4), 285-295. doi:10.1076/chin.8.4.285.13511

Henin, A., Mick, E., Biederman, J., Fried, R., Wozniak, J., Faraone, S. V., & … Doyle, A. E. (2007). Can bipolar disorder-specific neuropsychological impairments in children be identified?. Journal Of Consulting And Clinical Psychology, 75(2), 210-220. doi:10.1037/0022-006X.75.2.210

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).  Arlington, VA: American Psychiatric Publishing.

 

 

 

 

 

Where Did Our Beloved America Go?

A Democracy forged in the fire of human discontent

and molded into an enduring symbol of freedom.

A Republic founded on the highest of human ideals

to aggressively defend against tyranny and oppression

that may come from within our borders and far beyond.

A country of immigrants from every corner of the world

who always held true to the promise for others that came.

A land of hope cradled between two shinning seas

where anything no matter how improvable was possible,

where dreams that seemed impossible could be realized.

A nation full of people who are stronger and better

only when they elect to embrace their great diversity,

and not only celebrate their differences, but relish in them.

The home of a grand lady with a torch standing in a busy harbor,

a bold monument to the virtues and principles of freedom itself,

a profound testament to what our great country proudly stands for,

a welcoming sight for those desperately seeking a flicker of hope,

for those yearning to be free from persecution and oppression,

for those seeking a new beginning in a more accepting place.

 

Please! Please! tell me where did our beloved America go?

How did we go from tearing down walls in other nations

to erecting these unwelcoming monuments in our own backyard?

How did we go from being the leader of the free world

to putting people from neighboring countries in metal cages?

How did we go from being the world’s defender of democracy

to separating small children from their families at our borders?

How did we lose our civility and our national sense of purpose

to become repugnant provocateurs of ignorance and intolerance?

Today one small child cries for their mother on our border.

Tomorrow we mourn in silence for a great nation,

that once was the focal point of democracy in the world,

that once set the example for other nations to follow,

that once stood as the standard-bearer for freedom everywhere.

Please! Please! tell me will our beloved America ever return?

For The Students Standing Up Against Gun Violence In Their Schools

To all the students that are walking out to take a stand on and seek action on gun violence, I would like to say that every American in this country should be proud of you. Your voices are those that should and must be heard on this issue. You are the ones that must attend our schools and you have an absolute right to be safe in them, no matter what must to be done to achieve it. Do not allow anyone to deny your voice, do not allow anyone to dissuade you from lending your voice to not just the cause of your lifetime, but the greatest good of your lives. Your voices, your tears, and your anger over the senseless death and human carnage these school shootings have caused across this country must be heard, so do not be afraid to shout from every city, town, and village in this country “this must stop now.” Your voices hold the promise that students coming behind you will not have to hide in terror while gun shots ring out in their school, watch as the bodies of friends and teachers are carried from their school with tears of abject terror and sorrow running down their cheeks. Your voices hold the promise that not one more parent will have to stand over the coffin of a child contemplating the life that could have been had it not been for a gunman with too few screws, too many bullets, and the means to turn a school into a war zone. Your voices hold the promise to give voice to all the young people that have been silenced by gun violence in our schools. Your voices hold the promise of a tomorrow when the halls of our nation’s schools will once again hold only memories of the hopes and dreams of those who pass through them, not the memories of bodies, blood, and tears that fell on them or the screams of terror and rapid gunfire that echoed through them one day shattering the lives of many in an instant and forever engraving a horrific memory in the minds of those who survived. You hold the promise of a better tomorrow, so young people be loud, be proud, and make your voices heard every damn chance you get.

Written by Kim Morrison

A Prescription for the Death of Generations

A Prescription for The Death of Generations

By Kim E. Morrison

Saint Leo University

PSY-499

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Despite our wars on drugs and the numerous slogans we have used to try and keep people, especially our youth, off illegal drugs, drugs have always been a pervasive part of the American culture. As a matter of fact, one could argue that illegal drugs and those who used and sold them were a culture within culture because in the past not every nook and cranny of America were touched by them in the same way. Yes, you would here about the occasional drug overdose death or here about some dealer or group of people being busted for selling and distributing drugs, but many people in suburban and small-town America could say I am glad we do not have a drug problem here or say my kids would never get addicted to drugs here, so drug abuse and addiction was not something talked about around the dinner table of rural or suburban America. The average American dismissed drugs as being a problem of larger cities. Drugs were something that were sold on seedy street corners by emaciated drug dealers trying to support their own addiction, by gangs in ethnic neighborhoods trying to make a buck by first poisoning people within their own ethnic group and then reaching into other groups to increase their profit and power, by pimps trying to make more money on their prostitutes or as means to increase their production, or the pure for profit drug dealer who is always around to capitalize on the misery of others. A “Sugarman” as they were once called in song, that could be found in the shadows just waiting to take advantage of those desperately needing a fix to fend off the unrelenting agony of withdrawal, those trying to escape personal demons that haunt their every waking hour, and those who live lives of quiet desperation seeking a temporary freedom from the chains of their situation and dilution of the thoughts associated with it.

Unfortunately, the demon of drug abuse and addiction that we once believed would remain in the dark corners of American life has stepped out of the shadows into a new seemingly respectable form that is leaving no age, ethnic demographic, or socioeconomic group untouched by its consuming grip.  America is in the throngs of what many are now calling an opioid epidemic that shows no signs of abating. An epidemic not fueled by illegal drugs, but by legal prescriptions drugs and the dealers are not on dingy street corners, but in fine offices wearing white coats and stethoscopes armed with nothing, but prescription pads and the best of intentions for patients in pain. As a result, prescription drug abuse, addiction, and dependence has become a repugnant addition to the drug problem in America that not only could be eliminated, but must be before we witness the death of more generations.

In less than a decade studies trying to ascertain the extent and depth of this problem as well as find viable solutions to this problem have yielded some mindboggling heart wrenching statistics and clearly explains why everyone is calling this an epidemic. Just from late 1999 to 2011 opioid overdose deaths in the United States quadrupled (Cheatle, 2015). In 2012 drug overdoses was the leading cause of deaths, surpassing automobile accidents (Barry et al., 2015).  By 2016 nearly two people per day were dying of opioid overdoses (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017). In just one month in 2008 they found that 4.7 million adolescents and adults in this country were misusing prescription opioids which represents about 2% of the entire U.S. Population (Cleland, Rosenblum, Fong, & Maxwell, 2011). The number for those seeking treatment for addiction in the period from 1999-to 2008 skyrocketed. The increase for heroin addiction was 69%, but the increase in those seeking treatment for prescription opioids jumped up twenty-fold to 1, 896% (Cleland, Rosenblum, Fong, & Maxwell, 2011). The number of prescribed opioids from 1999-2012 increased to 400% which is enough to supply every adult in the United States with a one-month twenty-four-hour supply of narcotics (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017). In 2012 opioid pain relievers were directly involved in 470,000 hospital emergency department visits and the economic costs associated with opioids which included medical, productivity, and crime came to 50 billion dollars (Barry et al., 2015). One of the most heartbreaking of these statistics was that there has been a 400% increase in Neonatal Abstinence Syndrome just between 2000-2012. What this means in simple terms is that a baby is born addicted to drugs approximately every twenty to thirty minutes in the United States and some figures put it at every fifteen to twenty minutes (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017).

In 2006 the Prescription Opioid Addiction Treatment Study, POATS, was launched in response to the epidemic level trends of prescription opioid abuse and addiction in this country, and the burgeoning number of people seeking treatment to drug programs for addiction (Weiss et al., 2010). These continuing studies have proved informative on many aspects of the opioid problem. They found that people who can no longer acquire prescription drugs will try to obtain and use heroin in place of it. As a result, along with the prescription opioid epidemic, there has been an uptick in heroin use in this country as well (Weiss et al., 2010). POATS has studied treatments for opioid drug addiction and dependence and found that there may be different outcomes for pure heroin addicts versus those who are addicted to prescription opioids and the fact that many people have used more than one drug complicates everything, including studying the problem because it makes it harder to define study groups. As a result, the statistics and figures obtained on the opioid epidemic may be conservative, so this epidemic may be even worse than the data shows. Researchers considering these factors and others have suggested that treatment programs should be tailored toward the individual and their specific drug use pattern to be more effective (Weiss et al., 2010).  Another issue related to the opioid epidemic that researchers have discovered is that some portions of rural America, even when adjusting for density, have the highest rates of opioid poisoning and death. Kentucky, Oklahoma, West Virginia, and Alaska have been hit the hardest by the opioid epidemic with all having rates of poisoning and death from opioids not only greater than more populous areas, but far above the national average (Keyes, Cerdá, Brady, Havens, & Galea, 2014). The trouble is there is very little empirical data to explain why this is occurring in these areas. However, some researchers have suggested that these high rates are related to the extreme poverty levels in these states and the tight kinship between people there because statistics have shown that 70% of those who report non-medical use of prescription opioids state that they received them from friends and relatives (Keyes, Cerdá, Brady, Havens, & Galea, 2014).

Oklahoma, one the rural states hit the hardest by this epidemic, was among the first to begin initiating statewide policies to combat the epidemic at the pharmacy benefit or payer level. This was prompted by the fact that the costs associated with abuse and dependence diagnosis among Medicaid patients was much higher than for other patients. The policies which included quantity limits on certain drugs, pharmacy lock in programs on patients thought likely to misuse due to their medical utilization history, prior authorizations for specific drugs, step therapy program which basically requires that a physician use designated products for the first step before you go on to other steps, and other restrictions were perceived as prevention methods with the goal of reducing potential abuse and costs (Keast, Nesser, & Farmer, 2014).  In the short term the strategies created by Oklahoma Medicaid, MOK, seemed to achieve some results. The CDC, Centers for Disease Control and, the NIH-NIDA, The National Institutes of Health- National Institute on Drug Abuse are now funding research to determine not just the impact of these policies, but any policies like them and the consequences from them (Keast, Nesser, & Farmer, 2014). There are a few problems with dealing with this issue on the costs side of it alone. One, it doesn’t address the problem of those already addicted to prescription opioids and two, it seems logical that just doing these cost related measures alone is sure to cause an uptick in illegal drug use, particularly heroin, so the idea of the groups above studying these measures make sense on a lot of levels.

In 2009, to find some balance between the potential effects of prescription opioids without reducing legitimate access to opioids for pain relief the FDA proposed a Risk Evaluation and Mitigation Strategy, REMS, to look at the risks and benefits of opioid medications and describe requirements and procedures to reduce the misuse and abuse of these types of medications (LING, MOONEY, & HILLHOUSE, 2011). The idea here is to put some type of restriction or create or make some arrangements controlling prescribing practices in ways that might reduce or lessen opportunities to misuse opioids (LING, MOONEY, & HILLHOUSE, 2011). Patient education on these medications would be a part of REMS as well and that is necessary because research shows that 80% of the people fail to understand just how easy it is to become addicted to prescription opioid pain relievers (Barry et al., 2015). There are some great ideas here as well because 78% of the people surveyed on this issue say doctors are responsible for a solution to this problem (Barry et al., 2015). However, once again these solutions do not address the problem of those already addicted or the 70% of the people who report non-medical use of prescription opioids that state that they got them from friends and family (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017).

Every idea some states and the federal government have come up with so far to do something about the opioid epidemic in America deserves merit, but what has been done so far to address this problem is tantamount to a group of men urinating on a forest fire with the hope of keeping it from spreading.  What is needed to effectively solve this problem is a full-throated approach toward every angle of the opioid epidemic and to do this you would need to get everybody that is directly involved in, connected to, or touched by this massively growing social problem to generate ideas and workable solutions to the problem. This would include bringing people together from the medical community, the police, drug enforcement, emergency medical personnel, policy makers from the state and federal level, clinicians, doctors and pain management specialists, drug rehab and treatment center specialists and counselors, people from state Medicaid agencies, health insurance providers and other payors, pharmacists, drug manufacturers and distributors, psychiatrists, psychologists from every discipline, family members of addicts, and former drug addicts themselves because no one understands the problem of drug addiction better than those who have been intimate with this demon. To some great extent the Clinton Foundation and the Johns Hopkins Bloomberg School of Public Health have done exactly this very thing and have come up with recommendations that would greatly reduce this problem if not eliminate it entirely. First, mandate prescriber registration and optimize Prescription Drug Monitoring Programs, PDMP’S, in all states. These programs if optimized would be highly effective in reducing drug abuse and diversion. Their purpose is to monitor, collect, and analyze electronic data collected from and submitted by dispensing pharmacies and prescribing physicians. This data can also be used for research for public education, and abuse prevention (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative).  Second, the Centers for Disease Control has had guidelines on prescribing opioids to people with chronic pain for some time, so the next obvious step is to work with medical boards to pass policies that reflect these guidelines (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017). Third, expand drug take back programs and provide clear guidelines on safe disposal and storage of prescription opioids (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017). Forth, work with drug manufactures to look at innovative packaging and in creating prescription opioids that are more difficult to abuse (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017). The have already shown that they can reformulate oxycodone, so it can used without being abused. The savings in costs and in lives alone with be worth researching this more and doing it to other opioid medications (Kirson et al., 2014). Fifth, work to obtain funding to build more drug addiction treatment centers in those rural areas or any other areas where addictions rates are high (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017). Sixth, work with developers to reformulate Naloxone, Narcan, the drugs that can reverse opioid or opiate drug overdose, so they can be used by non-medical professionals to prevent drug overdose deaths and work to get them distributed to schools, clinics, all first responders, and any where else they might be needed (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017). Naxolone, Narcan, should be easy to utilize and as easily available as epi pens because it could prevent a death and give someone another chance at life. Seventh, work to create more public awareness on the opioid epidemic issue and work to avoid and end stigmatizing language with relation to drug users, treatment, and everything else associated with it (Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative, 2017).

Dear Mr. and Mrs. not my children, not in my neighborhood please be advised that the opioid epidemic in America is a lot closer than you think if it isn’t already at your door. The time for national complacency on this issue has long past. We can no longer afford to declare another meaningless war on this problem and try to incarcerate it away or simply just say no to the problem with our eyes closed wishing and hoping that drug abuse and addiction goes away. What we must do is call this opioid epidemic what it is and that is a national health crisis. A crisis that is shattering and destroying families and communities in every corner of our country, costing our country billions upon billions of dollars, and taking human lives at a staggering rate of one every twelve hours of every day. We can no longer afford to say not my clowns, not my circus because we are all in this clown car of hell and it is headed for a cliff. We can no longer just nibble at the edges of this massive social problem. There are no quick fixes for what we are facing, no single approach that will even begin to put a dent in it. What is needed are real solutions to solve this issue and we will not get them if all the voices, even those remotely connected to this issue, are not heard and our approach to it is not a multifaceted effort with every idea considered and utilized if good and every possible consequence of the actions taken thought through. The opioid epidemic has already cost us a couple of generations and it is poised to insure the death and destruction of more generations if concrete action is not taken now.

Our mission will not be considered complete if teenagers who were prescribed pain medications for injuries are getting addicted to them and when they cannot get them are searching for illegal alternatives before the sickness and agony of withdrawal begins to kick in.  Our job will not be done if mothers and fathers or grandfathers and grandmothers in chronic pain from injuries or illness are getting addicted to prescribed pain medications and requiring rehab to free them from addiction. We will not have done enough if young people of any age are able to buy prescription drugs like oxycontin from neighborhood drug dealers under street names like hillbilly heroin, kickers, and killers. Our task will not be over if people addicted to prescription opioids are replacing them with heroin or a lethal cocktail of opiates and benzodiazepines and dropping dead from overdoses in homes and streets across our country. We will not have done all we could if one person dies of an opioid overdose just because there was no access to Naloxone, Narcan, to reverse it. This will not be over if distraught parents with tearsoaked eyes and a hole in their heart are still picking out little pink and blue coffins for children who could not be helped before the relentless grip of drug addiction drained the light of life from their eyes. If one infant somewhere in our country lays in a neonatal intensive care unit (NICU) inconsolable, screaming an agonizing shrill, twitching, seizing or shaking like a tuning fork involuntarily as he or she awaits a nurse to administer a baby sized dose of methadone or morphine to fend off the painful agonizing sickening effects of narcotics withdrawal our job is not done, our mission will not be complete.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reference

 

 

Ford, J. A., & Lacerenza, C. (2010). The Relationship Between Source of Diversion and Prescription Drug Misuse, Abuse, and Dependence. Substance Use & Misuse, 46(6), 819-827. doi:10.3109/10826084.2010.538461

 

Cheatle, M. D. (2015). Prescription Opioid Misuse, Abuse, Morbidity, and Mortality: Balancing Effective Pain Management and Safety. Pain Medicine, 16(suppl 1), S3-S8. doi:10.1111/pme.12904

 

Cleland, C. M., Rosenblum, A., Fong, C., & Maxwell, C. (2011). Age differences in heroin and prescription opioid abuse among enrolees into opioid treatment programs. Substance Abuse Treatment, Prevention, and Policy, 6(1), 11. doi:10.1186/1747-597x-6-11

 

LING, W., MOONEY, L., & HILLHOUSE, M. (2011). Prescription opioid abuse, pain and addiction: Clinical issues and implications. Drug and Alcohol Review, 30(3), 300-305. doi:10.1111/j.1465-3362.2010.00271.x

 

 

 

 

Weiss, R. D., Potter, J. S., Copersino, M. L., Prather, K., Jacobs, P., Provost, S., … Ling, W. (2010). Conducting Clinical Research with Prescription Opioid Dependence: Defining the Population. The American Journal on Addictions, 19(2), 141-146. doi:10.1111/j.1521-0391.2009.00017.x

 

Barry, C. L., Kennedy-Hendricks, A., Gollust, S. E., Niederdeppe, J., Bachhuber, M. A., Webster, D. W., & McGinty, E. E. (2015). Understanding Americans’ views on opioid pain reliever abuse. Addiction, 111(1), 85-93. doi:10.1111/add.13077

 

Keast, S. L., Nesser, N., & Farmer, K. (2014). Strategies aimed at controlling misuse and abuse of opioid prescription medications in a state Medicaid program: a policymaker’s perspective. The American Journal of Drug and Alcohol Abuse, 41(1), 1-6. doi:10.3109/00952990.2014.988339

 

Keyes, K. M., Cerdá, M., Brady, J. E., Havens, J. R., & Galea, S. (2014). Understanding the Rural–Urban Differences in Nonmedical Prescription Opioid Use and Abuse in the United States. American Journal of Public Health, 104(2), e52-e59. doi:10.2105/ajph.2013.301709

 

 

 

 

 

Kirson, N. Y., Shei, A., White, A. G., Birnbaum, H. G., Ben-Joseph, R., Rossiter, L. F., & Michna, E. (2014). Societal Economic Benefits Associated with an Extended-Release Opioid with Abuse-Deterrent Technology in the United States. Pain Medicine, 15(9), 1450-1454. doi:10.1111/pme.12489

 

 

Jeffery, D. D., May, L., Luckey, B., Balison, B. M., & Klette, K. L. (2014). Use and Abuse of Prescribed Opioids, Central Nervous System Depressants, and Stimulants Among U.S. Active Duty Military Personnel in FY 2010. Military Medicine, 179(10), 1141-1148. doi:10.7205/milmed-d-14-00002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Secondary References

 

Johns Hopkins Bloomberg School of Public Health, and the Clinton Foundation, Clinton Health Matters Initiative. (2017). THE OPIOID EPIDEMIC from Evidence to Impact. Retrieved from https://www.jhsph.edu/events/2017/americas-opioid-epidemic/report/2017-JohnsHopkins-Opioid-digital.pdf

 

A special thanks to all those recovering from drug addiction that I transported to Operation Par Inc and other drug addiction treatment centers over the course of several years in my position as a Non-Emergency Medical Transport driver because without the many casual conversations I had with you over that time the parts of this paper where I did not point directly to a peer reviewed or secondary reference would not have been possible. I truly hope you are all living large and free from the chains of drug addiction.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Someone Up There has Got To Love Us

I wrote this piece for a thought provoking college class I am currently taking on Faith and Salvation online at Saint Leo University. I do not know yet what grade I will get on it, but I figured it was worth sharing with my readers up here.

 

Will man be saved by God? Who will be saved by God? Is one of the Catholic faith more likely to be saved by God than a Lutheran, a Presbyterian, or someone from another faith? Can a simple man who believes in God and occasionally reads the revealed word, but elects not to be connected to any church be saved by God? Would God even bother to try to save a true atheist or a non-believer in God and Heaven? Is there a way for a man to receive the grace of God and be saved and welcomed into God’s Kingdom on his own? I think any man, even those in Godly robes with full knowledge of the revealed word, that thinks he can answer these questions unequivocally to an absolute certainty is exhibiting a level of human audacity, so grand in dimension and size that even God himself is stunned by it. I have no absolute proof, just as no one else does about salvation, but I believe every time our human minds entertain questions which are purely in the hands of the divine one, God is sitting on his throne in heaven with his hand on his forehead going oy vey these wondrous creatures that I have created in my own image cannot even understand what is in their own hearts and minds, yet they presume to know what is in their creators heart and mind based only on those I spoke to or through centuries ago. However, I do believe despite it all that God loves us though and like a mother of many children, God is most protective of the creation, no matter how imperfect or screwed up, that is most like him. I do not believe “man set himself against God and sought to attain his goal apart from God,” because I do not believe there was a deliberate conscious effort on the part of humans to go against the creator. Any appearance that we set ourselves against God must be considered either a thoughtless action on our part or at the very worst an act of hubris in ourselves without regard to God. Pride or hubris is one of the seven deadly sins, but it is one of the sneakier sins because we often do not know it has a hold of us until it is too late. God knows all too well about man’s inclination toward sin because we have failed, starting with Adam, every test he has thrown in front of us, but God also has the wisdom to know that our inclination to sin is equaled with our inclination to do great good.

If we are truly all God’s children and he is our father in heaven as we have often been taught, he must forgive us of our sins for it is not within in a true father to stop loving, to stop caring, to stop being father. It is a job that never ends and with that job comes a lot of worry, pain, and sacrifice and the best any father can hope for, be he God or human, are a few fleeting moments of joy and pride in the being or beings born from the seed he planted.  I do not care whether you are Catholic, Baptist, or whatever, or you never go to church, or what nonsense you believe in, or think you know.  If he is a true father, “our father who thou art in heaven” will not forsake us because it is not in the nature or soul of a true father to do so. Our father will try to illuminate the path to heaven for us all, he will try to save us all if he can, and he will try keep us all from falling into the clutches of Satan’s grip because a true father will protect and defend his children to the end. Unfortunately, just because our father has the will and desire to try and save us all does not mean he will be able to do so. The desire and will to do something even if heaven sent does guarantee thy will be done or achieved. A baby growing in the womb of a mother is not guaranteed life in this world, so how could we expect our father in heaven, no matter how great and wonderful he is, to guarantee us ascension to heaven in the next life. We all know that natural life from start to finish holds no guarantees, so why would you think be you Catholic, Protestant, or a simple man with a deep abiding belief in God above think that a place in heaven is guaranteed to you. God, our father in heaven, does not guarantee us eternal life in his heavenly kingdom.  God merely offers us the promise of eternal life in his Kingdom if we manage to get there through his will and desire.

If it is all dependent on God’s will and desire, what role does the church or organized religion play? They are all well-worn pathways to realizing that promise, but it cannot be the only one otherwise far too many would be left out. If he were to select only Catholics, that would leave all the Protestants and Jews out. If were to select only those who attend some church, he would leave out all those who do not attend any kind of church. A loving forgiving father would not leave so many of his children out in the cold, so there must be other ways he can save them, to help them realize his promise. As our reading states, “the scriptures tell men that God wants everyone saved.” Whether it is a “supernatural salvation” God just grants to his non-Christian or non-believing children or he has some plan or some other way beyond man’s comprehension to save us, a pathway to realize his promise must exist for us all. As we have read, we are all afflicted with the burden of the “original sin,” so through no fault of our own we are all on the road to perdition from the moment we are born. If this is true, there must be more ways off that road. It cannot be all exclusive to one faith, like the Catholic Saints we have read have tried to convince us of for our father in heaven would not want one half or three quarters of his children to perish in the flames of hell just because they do not subscribe to the idea that a wise exalted old fellow in a funny hat is the only one that holds the keys to heaven gate.

I haven’t been to Sunday services in a church in decades, but sitting behind me on my book shelf right at this moment rests several different Bibles. Do I believe every word in the Bible? Absolutely not because literal interpretations of that wonderful book causes people do stupid appalling things in the heavenly father’s name.  God is wonderful, God is great, God loves us and forgives us for our trespasses, but not even divine intervention can fix certain kinds of stupid. Do I believe in God? You bet I do because one not believing in God is far to frightening to contemplate. Two, if any creature on earth ever needed a divine Sheppard to watch over them, it is man because no creature on earth is more hell bent on their own destruction than man. Three, only God could help us make sense of this beautiful chaos we call life. We can only pray that one day we will get the chance to stand in the light of our heavenly father and receive the answers to all the questions religious wars have been fought over, the answers that have always been just out of our minds reach, the answers that have at times both mystified our minds and tortured our mortal souls.

Would My Love Endure?

If I were to have to say goodbye tomorrow,

would you know how much I loved you?

If I took my last step on this earth,

would you remember the feel my love?

If I kissed your luscious lips one last time,

would they remember the taste of my love?

If I gasped one last I love you before dying,

would the breath of my love linger in the air?

If my heart were to stop beating in your arms,

would you still feel the rhythm of my love?

If the angels were forced to take me from you,

would the memory of my love for you endure?

Dixie Rose

Dixie Rose!

You are an enduring natural beauty of immeasurable quality.

The blanket of pink flowers that embrace your lovely branches

conceal an internal strength and a unique unwavering grace

for not even the torrential flood waters of life

or the relentless savagery of a soulless pair of hands

could overcome your will and stubborn resilience

to rip you out by the root and rape you of your splendor.

Despite it all you remain just as desirable as ever

full of a yearning passion that could never be denied.

 

Dixie Rose!

Fear not these tired rugged old hands for they are mere extensions

of a loving heart, full of more patience, and understanding

than you have ever known or could even begin to imagine.

I fear not your painful sharp thorns or the blood they may draw

for I know in my heart they were put there to preserve you.

Spirit Of Santa Claus

Whether you choose to call him Santa Claus, Pere Noel, Papai Noel, Viejo Pacuero (“Old Man Christmas”), Dun Che Lao Ren (“Christmas Old Man”), Kerstman, Joulupukki, Weihnachtsmann( Christmas Man”), Kanakaloka, Mikulas ( St. Nicholas), Babbo Natale, Hoteiosho (“A God or Priest who bears gifts”), Julenissen ( “Christmas gnome”), Swiety Mikolaj (“St. Nicholas”), Ded Moroz, (“Grandfather Frost”) Jultonten (“Chritsmas brownie”), Father Christmas, Kris Kringle, or SinterKlass let us not forget the meaning behind Santa Claus. A meaning that is not just built around the religious significance of Christmas. A meaning that we should hold dearly in our hearts each day of the year. A meaning that demands that we strive toward or constantly reach for the better angels of our nature even when it seems impossible to do so. This season is representation of a spirit of goodness, kindness, compassion, and love that should exist within us all the whole year long. A spirit that demands we open our hearts to others without out any expectation from them, but as an example for them to follow. This is the season where the feet of doing the right thing hits the pavement knowing the right thing to do and the realization that the only thing you will get in return for your efforts is the good feeling you get in your heart for doing it. As I used to tell my bus students and now patients, “it is not hard doing the right thing. What is hard is knowing what the right thing is.”  The right thing is that which demands the best from you in the worst of circumstances, that summons that better person inside you, that person you never realized you were capable of being, that person who realizes that doing the right thing routinely comes without awards, gifts, and sometimes without even a simple thank you, but does so just because of how it makes them feel inside.

Merry Christmas To All

Kim Morrison

My Charlie Brown Christmas Tree

I remember a Christmas growing up in the mountains of upstate New York when things were hard, money was shorter than usual, and my father was not around much. As we approached Christmas that year, it looked like my mother and I were not even going to have a Christmas tree. I was only about twelve or thirteen that year, but the idea of not having a Christmas tree that year just didn’t set well with me, so without my mother knowing I got up early one morning and gathered up a hand saw and my father’s double-bladed axe. It had snowed the night before and it was very cold as it usually was up there that time of year. However, I was determined to have a Christmas tree one way or another, so I trudged through about four inches of snow into the woods behind my house with the saw in one hand and a double-bladed axe over my shoulder.  Even being bundled up good I was getting cold, so I knew I had to find a tree soon. The best tree I could find was a tall oddly thick pine tree. I could not use the whole tree because it was too tall, so I climbed half way up the tree carrying the handsaw and cut the top off. I tossed the saw down just before I cut through it all the way and pushed the tree top with my shoulder just enough to make it crack and tumble to the ground. When I got down, I tied the saw and axe on the tree with a piece of rope I had stuck in my pocket and dragged my Christmas tree through the snow to my house about a mile or so away. I was really freezing by the time I got back and my hands because I had to remove my gloves to use the saw felt like they were not far from frostbite, so I went in to get warm and to pull out the tree stand. I told my mother I got tree and she looked at it from the window and said, “I do not think that old pine tree is going to work because the needles are going to fall off quicker.” I said, “I guess will just have to make it last somehow.” After warming back up, I went back outside and shaved the trunk flat, brought it in the house, and stood it up in the tree stand. I looked at it and thought well at least my tree looks better than “Charlie Brown’s.” We decorated the pine tree with just about every decoration and light we had that year and it wound up being one of the best Christmas trees we have ever had and the aspirins we put in the tree water did make those needles stay on into the next year. We didn’t have much more than my “Charlie Brown Christmas tree,” but it still wound up being very special Christmas because we made our own Christmas that year.

When we think about Christmas we need to realize that it isn’t just about Santa Clause, presents, or even Jesus Christ, but about tradition. It is about doing those things your family has always done despite what is going on in your life, the passage of time, or the loss of loved ones and friends along the way. The traditions you follow may seem trivial, or unimportant to anyone else, but they are what makes your holiday season special to you. The little things people and families do every Christmas is where the spirit of this season comes from. I make a Christmas cookie from a recipe that has been in my family for a hundred years around every Christmas. I certainly do not need the cookies because I am diabetic, but it is one of the smells of Christmas I remember as child when my mother made them and others. I have Christmas bulbs on my tree now that have hung on my families Christmas tree since my birth and I am fifty-six years old. They say people are usually a little kinder and gentler this time of year. If you believe that they are, it is not just because it is Jesus’s birthday, but because of all of us following our traditions during this special season and doing the things our families have always done for years. The sights, sounds, smells and everything that is wonderful about this holiday are born out of the traditions of families.  Santa Clause is alive in the hearts of small children and the spirit of Christmas is alive and well in the hearts of many during this season because of things big and small that families throughout history have always done. We make this wonderful season what it is to us by the little things we do every year. It doesn’t take much to make a Christmas special or memorable. Sometimes all it takes is a “Charlie Brown Christmas Tree.”

 

Once we Were the Greatest of Friends

Once we were the greatest of friends

We enjoyed each other’s company

We could talk to each other for hours

We talked about anything and everything

Nothing was off limits or sacred between us

I used to love to make you laugh and smile

I never thought you did enough of either

You once said that we had a special connection

I thought nothing could ever come between us

I thought you would always be a part of my life

I thought we would be friends until the end

I cared for you to the very depths of my soul

I came to love you for unique reasons

Your difficult life made me crazy with worry

Your silence only served to make that worse

I would wonder if you were hurt or dead

I foolishly tried to be your everything

knowing full well that was impossible

but that did not keep me from trying

because you were always worth it to me

 

Once we were the greatest of friends

You once said you had a big heart

but there was no room in it for me

You must hate me to your very core

You knew nothing would hurt me more

than to leave me writhing in confusion

behind your unrelenting wall of silence

forever to wonder if you are dead or alive

silently praying that your life got less scary

because I will never stop caring about you

I refuse to give up on you like others have

You and others may think me a fool

but realize that I do not have it in me

to do to you what you are doing to me

I truly hope you are in a better place now

and nothing but good ever comes to you

I hope you find everything you seek in life

 

 

Maybe someday before I take my final journey

you will realize the kind of friend you had in me

Hopefully someday you will find a way to forgive me

for being crazy enough about you to foolishly believe

that I could fill all the voids and vacuums in your life

that others deliberately caused or callously left behind

Perhaps someday you will finally come to understand

that I did this because I believed you were far better

than the sum of all your mistakes and bad judgements.

When I looked at you I never saw just another woman

who had simply been ravaged by life and left broken

I saw what I believed was a “Masterpiece Undefined”

Alas maybe I am nothing more than a crazy blind dreamer

stumbling through life seeing only the very best in people

daring to believe that I can make them see what I see.