Bipolar no more?

The new DSM 5, the bible for psychiatric disorders, intends to do away with a bipolar diagnosis for many children and teens.  A new diagnostic category, temper dysregulation disorder (TDD) is being proposed and would include symptoms of bipolar disorder.  The new diagnosis of TDD (does this really denote a serious medical condition?) will surprise and dismay many parents.  Families usually struggle for years with their child’s unpredictable behavior, intense moods and volcanic temper tantrums while strangers, friends and family assume that what is wrong is inadequate parenting.   A bipolar diagnosis has helped many parents get treatment, school services and a recognition that what they are dealing with at home is serious stuff indeed.

The DSM is many things to many people.  Mental health clinicians rely on it to help form an accurate diagnosis.  Insurers use it to authorize payment for medically necessary treatment.  Schools often cite diagnoses in the student’s education plan.  Even juvenile courts use it to better understand the behaviors that might bring a youth into court. 

The DSM 5 Child and Adolescent Disorders Workgroup has listed several reasons for the recommended change.  The rise in prescribing psychotropic medications for children is one.  The group also cites a study that “found a 40-fold increase between 1994 and 2003 in the number of outpatient pediatric psychiatry visits associated with the diagnosis of BD [bipolar disorder].”   Yet, a 2007 study found that youth released from the hospital with a primary diagnosis of bipolar amounted to less than one in a thousand.

But in 1994, practically no children were diagnosed with bipolar disorder, so any increase from “almost nothing” would be startling.  In the early 90s, I was running support groups where parents would share stories with each other about their child’s moods (from rage to extreme silliness to wanting to die), the nightmares that came almost every night, the rigid food preferences and risky behaviors.  Most parents worked, had little support and felt overwhelmed by the impact on their family.  Parents were told their children had ADHD, anti-social personalities, were oppositional or had conduct disorder.  Somehow these diagnoses didn’t capture the gravity or complexity of the situation.

The DSM is not a coding system set up for the convenience of the insurance industry or to create a shorthand for schools. Yet, a child must often be labeled “something” in order to get services.  We all give lip service to measuring the “functioning” of a child but that still doesn’t open doors or get services paid for.  The reality is that parents often have to fight for services.  We may decry the need for labels and powerful diagnoses, but at this point in time it’s what we have.  Those diagnoses have to increase access for children as well as describe their symptoms.

Most of the children and youth who now have a bipolar disorder diagnosis require medication, therapy, special education strategies and a loving, dedicated parent who is willing to do battle to obtain the needed treatments and services in order to improve things.  It’s a diagnosis that does not imply that “bad” parenting is the cause, which allows parents to be partners in creating and carrying out a treatment plan, just as they would if this were any other medical illness.   It also does not imply the child is to blame, which is often equally important.

Any new diagnosis proposed by the DSM 5 needs to send a clear signal to insurers, schools and the general public that bipolar in children is very real and very serious.  Parents already know this.  There is still time for comments at  www.dsm5.org until April 20, 2010. 

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Yes, there’s been a gap between the last post and this one.  I got a house ready to be sold, sold it and am getting ready to move.  It certainly devoured a lot of my time.  But I have been thinking about children’s mental health a great deal and the posts will keep on coming!

Calling for mobile crisis

One of the new services for families in Massachusetts is the mobile crisis initiative or MCI.  Mobile crisis — sounds like something that will come to you when you have a crisis and stay there till the worst has passed, doesn’t it?  Except it doesn’t always work like that.

This service has incredible potential.  And in some parts of the state, it helps families whose children have a behavioral health crisis enormously. The intake worker “gets it” and sends out the team, the team goes where the child or youth is and figures out what to do, and the family has follow-up for 72 hours if that’s what they need.  The team includes a family partner whose role is to ensure that a family’s perspective and choices are heard loudly and clearly and included in the solution.  Until these new services began, the only “mobility” anyone ever saw was the crisis team going from their office to the hospital emergency department and then traveling back to their office.

The tricky thing about mental health care is that how well it works relies heavily on relationships, even very short term ones.  Clinical skills count as does experience and expertise.  But the expectation that each person has a job to do and is doing it as best they can is what builds the bond that can make things work. 

Most crises, as any parent can tell you, happen at home and after business hours.  Sure, there are times when a child or youth becomes suicidal or out of control at school or somewhere else.  But a huge percentage of mental health crises occur at home. The parent sees what sets things off, usually knows what isn’t going to work ahead of time and can judge what’s outside of their own ability to handle things.  So, they call in reinforcements. 

Sometimes problems start with the phone call.  The intake worker decides that the parent should be able to “manage” things at home.  Or advises the parent that the MCI team can’t come out and they should try the emergency department instead.  Sometimes new problems come with the team themselves.  In one instance, the mobile crisis worker remarked, “This child is running the house.  What are you going to do about that, Mom?”  In these cases, the service may have changed but the attitude hasn’t.

Massachusetts Behavioral Health Partnership, who oversees the new mobile crisis services, has been working hard to improve them by offering training, consulting and other assistance. For some provider agencies with MCI teams, this is just what they need.  Others, however, don’t seem to have the committment to adopt this new model and, instead, continue to do business as usual. 

One father wrote in an email recently of his experience with the MCI team in his area.  He called and outlined the escalation in his son’s delusions and behaviors and asked for the team to come out.  Instead he was told to go the emergency department.  After several hours, poor service and little help, a supervisor apologized for making his son and he go through it all.  “I told them that the ER visit wasn’t needed, and now all we got was an apology for having to go through it, he wrote.   “Parents need to be listened to from the beginning, not apologized to at the end. “

Who’s the expert here?

So what makes an expert, well, an expert?  It’s certainly a step up from just knowing a lot or being acquainted with the facts.  According to the dictionary, an expert has skills or knowledge that’s gained from training or experience.   Usually, those skills are in one area or that knowledge is focused on one particular subject.

Let me say it straight out:  parents are experts about their children and about their families.  And that expertise should be recognized and respected.  Far too often, it is not.

We all seek out experts when we encounter a problem that takes special skills to solve.  If your car makes a strange noise or the check engine light lights up, you might go see a mechanic.  If you encounter a legal problem, you might seek out an attorney.  If that mechanic or lawyer finds out you own a bicycle shop, he could very well ask your opinion about selecting a new touring bicycle.

From the very first moment, a parent learns everything she can about her child.  She observes her child closely and is often fascinated by what makes him laugh, what jump starts his curiosity and what works for him each step of the way.  She notices how he carves a place for himself and how his ups and downs affect the entire family.  She slowly builds a body of knowledge.  In short, she becomes an expert about her child.

When parents encounter a problem that worries them, they seek out knowledge and advice.  They might turn to a doctor, a teacher, a therapist or a relative.  They bring their observations but also a hard won understanding of their child.  However, their often expertise isn’t acknowledged.

A number of years ago, a colleague of mine told me how she took her son to a first therapy appointment.  The therapist explained his ground rules around confidentiality and how often (or not) he consulted with parents.  He ended by saying that if her son divulged he’d experienced abuse or neglect during the therapy appointment, he would have to file a report.  My colleague, without missing a beat, replied, “Likewise, doctor, if on the way home my son divulges that any abuse occurred during his appointment I, too, would have to report it.”

The therapist was startled and somewhat taken aback.  In setting up the “ground rules,” he was not thinking of my colleague as an expert partner he should treat with respect; instead he was telling her the way things would be.  While she agreed he should act if her child’s safety was threatened, she also knew that her son would benefit more if her understanding of him was included.

In our state and in the country, we are shifting away from traditional services to home and community based services.  In order for those services to be successful, they must be family driven and youth guided.  When family driven care is at its best, families are considered expert partners when planning treatment and making decisions.  It requires a shift in attitude and for some, a leap of faith.

To be successful, we have to ask:  So, who is the expert? What do you think?

Linking to effective care?

Most of the conversations I have with other parents include a description of the services that didn’t work.  Families often wait for a treatment only to find that it just doesn’t match their child’s needs.  It might be the wrong kind of therapy or the wrong school plan.  It might be bad advice (it’s just a phase) or or a poor evaluation.  But whatever it is, it is a waste of time and money.

Most parents start by giving it a try.  You go to the appointment (especially if you’ve waited for weeks) with first hope, then determination. You might wonder why someone thought this was a good match for your child or your family.  You begin to think that even online dating services offer a better profile of what you are getting into.  But you stick with it, usually long after you know that it isn’t what your child needs.

In 2006, Judge Michael Ponser issued a decision in federal court in the Rosie D case.  He had heard weeks of testimony about what was not working for children and families.  A pivotal part of that decision was about assessing children so that they would get services that matched their needs.  He said, “Without a clinically appropriate, detailed assessment of a child, proper treatment is obviously impossible.”

Out of this decision came a plan and that plan included using an assessment tool called the Child Adolescent Needs and Strengths or CANS for short.  The CANS is intended to be filled out with the child’s parents and help inform a process to choose the best course of action for a child and his or her family.  It is crucial to involve families in the assessment process.  After all, they are the experts on their children and their families.  Parents know what works and what has been a dismal failure.

At this point, thousands of clinicians in Massachusetts have been trained to give the CANS assessment.  We know that numerous children and youth have received this assessment (sometimes over and over again) and some clinicians have embraced it while others find it cumbersome.  But what we don’t know is whether it is leading to more services that match the child’s and family’s needs.

And that’s the bottom line.  Parents make sacrifices for their children every day.  They invest their time, money, energy and emotions so that their children will get the care they need.  But they want that care to be effective.  One father I know says that he just can’t believe how ineffective the mental health system is for childen.  He notes that in the business world, some of the programs would go out of business because of poor performance or lack of customer satisfaction.

What we don’t know yet is whether the CANS is leading to more effective services for children with mental health needs and their families.  That’s the real goal.  As we hear of the number of clinicians trained, assessments given and other milestones, let’s not lose sight of it. In the end it’s the only number that matters.

Yolanda and her law

If Yolanda were alive today she would be wowing us all.  She was articulate, engaging, moving, smart and courageous.  And she, like many other young people, battled an illness that can bring formidable challenges. There are many other young people who are coping, just as she was, with a terrible struggle within them.  And alongside each one of them are the people who know and love them. 

Yolanda died 2 years ago today.  In an impulse no one still quite understands, she committed suicide one January night.  Her battle with bipolar illness was over.  If she were still here, she would now be 18, once an age of increased privileges.  Today, many of those privileges come earlier or later, but it is still a milestone year. 

Yolanda left a legacy.  In May 2007, she went before the Massachusetts legislature and spoke about her struggles with bipolar disorder, the system that often didn’t meet her needs and her own desire to make a difference.  She knew that the system that provided mental health services to children and teens needed some changes and she made sure she was part of seeing those changes begin.

Now, it’s pretty scary to go before legislative committees and talk to them. And this was a large hearing in a huge auditorium.  Yolanda had to sit and speak to a committee sitting raised above her with 300 people listening behind her.  It took courage, poise and determination.  It’s unusual for legislative committees to hear from teens.  They hear from heads of companies and advocates like me and they certainly hear from lobbyists.  So they paid attention to every word she spoke that day.  I later talked to members of that committee and they remembered her verve and poise.

 On that day, and probably many other days, Yolanda was an advocate.  I looked up the definition of advocate and the dictionary definition is, “to speak or write in favor of; support or urge by argument; or to recommend publicly.”  Because of her amazing qualities, the bill she testified for became known as Yolanda’s Law and was passed by the legislature in one session, a remarkable feat. 

Even though Yolanda’s influence lives on through “her” law,  her presence is felt strongly in other ways.  Her mother, Maryann Tufts, says that Yolanda “speaks to me often in amazing ways. Through every kid I see who is struggling to get through their day, to make friends, to feel better, to fit in.  We miss her so much, but know that she is still so present in every way.” 

Yolanda touched many lives. She was a remarkable young woman.  She was loved by her family, her friends and touched so many lives.   If love alone could have kept Yolanda here,  she would have lived to be a hundred years old.

Diagnosing very young children

Last week Rebecca Riley’s mother went on trial, accused of deliberately overdosing her 4 year old daughter.  Although most of the media coverage has so far been focused on the facts, I keep waiting for the other shoe to drop.  What might also end up on trial is the practice of diagnosing and treating young children.  

As little as 10 to 15 years ago the public found it difficult to believe that elementary and middle school children could experience depression or be diagnosed with mental health disorders.  Childhood is supposed to be a time of happiness, right?  The combination of increased media coverage, targeted studies and consequent data have helped increase public acceptance that children can and do experience depression, anxiety and mood disorders as well as ADHD.  However, the public doesn’t really accept that young children can have mental health problems and has no idea what that looks like if they do.

Eight years ago PAL and Health Care for All issued a report, Speak Out for Access.  We surveyed families whose children had identified mental health needs about their experiences.  We were surprised to find that almost half (48%) of the parents who responded said that their child showed signs of mental health problems by age 4.  Let me say that again:  almost half the parents said their child with mental health needs showed signs or symptoms by age 4.  When they brought their worries to their child’s doctor, many felt their observations were dismissed.  Some felt that earlier treatment would have reduced many of the problems they faced later.

This is a topic that is near and dear to me.  When my own son was three, he had a bedtime ritual that lasted 20 to 25 minutes.  It involved an empty spray bottle and a series of spots we had to spray to banish monsters.  If we missed a spot or were interrupted, the ritual had to begin again from the beginning.  He cried and was terrified if we skipped the ritual and then couldn’t fall asleep — often for hours.  His pediatrician assured me he would grow out of it.  He did, but other fears and rituals immediately took its place.

Last Friday, a journal article authored by Mark Olfson of Columbia University, reported that the number of children aged 2 to 5 who have been diagnosed with bipolar disorder and treated with psychiatric medications has doubled over the past decade.  The study also noted that fewer than half the preschoolers had received a mental health assessment or a therapy visit, which is worrisome but unsurprising.  After all, where do you go to find help for a 3 year old?

There is a difference between prevalence (how often something is diagnosed) and incidence (how often something actually occurs), although we confuse the two.  According to the journal report, young children are being diagnosed more frequently.  According to parents in our report, a large percentage of children, later diagnosed with mental health disorders, show symptoms quite early. 

Parents want to help their children, especially when they see them hurting.  They spot the intensity or unusual length (like my son’s ritual) of a behavior.  A diagnosis often feels like a double edged sword;  it can open doors to treatment and services but brings the stigma of a label.

We don’t call them “wait lists”

Every parent knows what it’s like to wait for that call back from the doctor when your child’s fever has jumped into the stratosphere.  Or the call that tells you what the strep culture showed or if the x-ray revealed a broken bone.  If that call doesn’t come right away, you experience a lot of nail-biting anxiety and a sense of frustration watching your child feel just miserable.

Now imagine that the call you are waiting for is because your child’s violent moods are holding the whole family hostage.  Or your son is doing risky things and just doesn’t care about his physical safety.  Or your daughter talks about death and dying in a way that sometimes makes you think she’s trying to shock you and other times gives you a frightening glimpse of her inner pain.  These things are urgent symptoms just as  much as a fever is.  It hurts as much — if not more — to wait for that call while watching your child’s emotional pain.

Famillies of children with mental health needs have been waiting in this state  for decades.  For more than ten years, my organization has been documenting how long parents have waited for an appointment with a psychiatrist (months), a therapist (often weeks), a hospital bed (hours or even days) or a therapeutic school placement (weeks or months again).  However awful the waits, there have been ways to approach them.  Parents are told there is an opening for their child on a certain day or that there are 3 children ahead of theirs on the wait list.  After all, this is good customer service. If you know how long it’s going to be, you can draw upon that last bit of fortitude and hang in there for a week or month or however long it is.

In 2006 federal judge Michael Ponsor ordered changes in the way Medicaid services for children and youth are delivered in Massachusetts.  At the heart of that order is a requirement of “reasonable promptness” when services are medically necessary.  More than 2000 children and their families are enrolled in the new coordinated community-based services offered through the Children’s Behavioral Health Initiative (CBHI).  Some families experience a fast response to their phone calls and requests for services.  Others, however, are having a much worse experience.

Some families are calling to apply for services and never get their calls returned.  Others go through the initial intake process and then hear nothing for weeks.  Still others are told that there are no openings near their home; instead they must go to another area and see if there are openings there.  When one parent asked where her child was on the waiting list, she was told that “We don’t call them wait lists.”

Waits are nothing new for families whose children have mental health needs in Massachusetts.  While it’s disappointing to see that the new CBHI services have lengthy waits in some parts of the state, it’s a puzzling strategy to eliminate the use of wait lists.  Most of us use wait lists as a way to check in; to see if there is a system for triaging should our child become worse and as a mechanism to ensure fairness (first come, first served). 

Living with a child who has mental health needs includes a lot of uncertainty.  Many parents wake up each day and worry, Will it be a good day or a terrible one?  A system where there is no way to gauge just how much longer you have to hold on adds to the burden for parents. Waiting is hard enough all by itself.

The unexpected parent

“You have to be the parent your child needs you to be,” she told me,  “not the one you expected to be.”

This piece of advice was offered to me by a veteran parent at the beginning of my odyssey through the children’s mental health system.  I was at a parent support meeting hoping to learn something that I could grab on to.  Most of the professionals in our lives were quick to tell me the things they thought were wrong with my child and the ways they could or couldn’t help him.  But no one told me what I could do that might actually work.  So I turned to other parents to find out what it was they did.

This advice intrigued me.  I could change myself.  (I sure wasn’t having much luck changing my son). I was definately being transformed already by my frequent failures and less frequent successes with a very challenging mental health care system.  I had already discovered that I had to throw out all of society’s ideas of what a “good” parent or a “bad” parent is.  The rules had all changed.  Looked like I would have to change too.  I had become a member of a very elite group of parents and wanted to learn from the other members.

Parenting a child with mental health needs can be difficult and exhausting.  Typical parenting strategies from time outs to rewarding good behavior might get you a different result every time.  Like many families whose children have mental health needs, I tried a system of rewards and consequences only to find that no matter how consistent I was, my son’s reactions were not.   I knew how to parent my other son but often wondered, “How do I parent this child?’

Most of us learn from our own parents and the parents of our friends while growing up and form an idea about what a “good” parent is.  Sooner or later we discover that we need to shift our focus from being a “good” parent to being an “effective” parent and it’s pretty tough to figure out just what that is.  Some weeks it seems that Thomas Edison’s observations about the process of inventing should also apply to parenting.  He remarked,  “I have not failed. I’ve just found 10,000 ways that won’t work. ”

In many parent support groups or other groups of parents whose children have mental health needs, I have often observed that two parents with very different parenting styles can face almost identical challenges.  An authoritarian parent and a more laissez-faire parent each find that their middle school child with a mood disorder has intense rages or irritability, for instance.  Although their child’s behavior is not a result of their parenting style, the authoritarian parent is advised to be less rigid, while the lenient parent is told to have a firmer hand.  And other parents might murmur (often in front of them), “I would never let a child of mine behave like that.”  They, too, are looking for ways to become the parent their child needs.

When parents tell me of their experiences and the many calls they have made, strategies they have tried, hours they have spent and love they have lavished, I often say, “How lucky your child is to have you as his parent.”  And I can’t say it often enough.  Therapists, teachers and treatments may all come and go.  Some solutions might work for a while but then you have to find a new one.  Most parents become advocates, walking encyclopedias and could write a critical review of children’s services for Consumer Reports.  They are the parent who hangs in there, is resourceful and has a sense of humor is.  Maybe that’s the parent we should expect to be.

Morphing diagnosis

By the time parents find us at the Boston or Worcester PAL office, their child usually has a lengthy list of mental health diagnoses.  Part of what might prompt that first call is the sense of panic or desperation a parent feels just reading and trying to absorb what this list means.  The more diagnoses, they reason, the worse off my child must be.  When we get to the part of the call where the list is recited, the diagnoses often are overlapping, repetitive or seem to have evolved something like this:  first there was ADD, then depression was added and later someone diagnosed (and added) bipolar disorder.  Anxiety or a sleep disorder was thrown into the mix along the way. On top of all that, no diagnoses whatsoever have been eliminated.

This experience is what I call the “morphing” diagnosis.  Remember those 90s videos or TV ads where one face was blended into the next and the next?  Wikipedia calls morphing “a special effect that changes one image into another through a seamless transition.”  Thus, the ADD child is changed into the depressed child and then into the bipolar child while the parent tries to understand what is taking place.

This is a very common experience.  And it happens to a lot of families.  According to the U.S. Surgeon General, mental health disorders occur in about 20% of children in any given year and about 5 million children and teens have a serious or significant mental health need that interferes with their daily life at home, at school or in the community.  Their families are usually trying to figure out what is going on, hoping that a clear diagnosis will open the doors to services that their child needs.  They find out that there isn’t a diagnostic tool like a blood test or an x ray and identifying what’s going on can be tricky.  Piecing the picture together usually relies on the observations of teachers, family members, doctors and others and their observation skills can vary greatly.

But finally someone does arrive at a diagnosis.  Then maybe another.  And a different therapist or someone during a hospital stay adds yet another.  Parents often ask, If no one can agree on my child’s diagnosis, then how can I ever decide on what treatments or services he (or she) needs?

Treatments for children’s mental health disorders are being studied and evaluated with the goal of matching the most effective treatment to a specific mental health disorder. We are hearing more and more these days about “evidence based practices” in the children’s mental health system.  It conjures up the feeling that science and precision will be applied to matching the “right” treatment to any child with a mental health disorder.  There is already strong evidence that certain medications are effective for children with ADHD and cognitive behavioral therapy is a promising treatment for children with anxiety or depression. 

But therein lies the rub. An accurate picture of what is going on for a child with mental health needs is required in order to choose an effective treatment.  Therapists sometimes refer to the “art” of diagnosing and in the next breath outline the science of evidence based practice.  Perhaps this reflects where we are in the children’s mental health world.  Maybe it is morphing too — from a denial not too long ago that children’s had mental health disorders; to a recognition that adult treatments can be ineffective and even unsafe for children; to an interest in studying what truly works for children, youth and their families.

In the meantime, I think we’ll just keep answering those calls.

The power of parent support

It’s been 8 or 9 years since I led a parent support group, yet every story, every success and every frustration of each group member has stayed vividly with me .  The two groups I ran were for parents like me — their children and teens had mental health needs.  They came looking for much more than support.  They needed to find elusive resources, locate smart, competent therapists and figure out how to make their child’s school day better.  But they got support, too.  And it was from parents who had also been blamed for an illness no one seems to quite understand and who persevered until they found a way to improve their lives.  And even after they found needed resources, therapists or strategies, most stayed for the support.

When I stopped leading the groups it was as if I’d stopped watching a favorite soap opera.  I wanted to know how things turned out and I missed being able to hear each installment.  While I’ve heard from one former group member or another intermittently, 2009 was a banner year.  This year, I heard from 4 different parents who had attended that group and they wrote to let me know how well their children and families are doing.  I was amazed that they could track me down — and wanted to!  In these busy times, I was also touched that they took the time to send a card or email and made it a priority.  Wow, people are just amazing.

First, I got a card last January from a couple that had since moved back to the South.  He was in the military and when their then-13
year old daughter began acting out, the base chaplain suggested they apply for services and somehow they also found my group.  The children’s mental health world was very different from their military world and they did their best to learn what they needed. Their daughter had just managed to complete treatment when their military transfer came through.  And that was the last I expected to hear from them.  So when I got a card last year telling me how well the whole family was doing, I was surprised and very pleased.

Over the remaining months of 2009 I heard from three more group members.  One emailed to share some resources that she hoped I could pass on to families or use on our web site.   She took the opportunity to tell me how her sons were doing and how much the group had meant to her.  “You saved our lives,” she wrote.  Another emailed about her daughter — who she worried would end up dead, in jail or lost somewhere in the system.  But she is now a mother herself and a wonderful mother at that. As she cares for her young son, she tells her own mother that she learned how to nurture “when you thought I didn”t notice.”  This fomer group member wrote that her grandson is now in preschool and loves it! When her daughter thanked her for helping her with his IEP, she wrote, “I couldn’t help quietly thanking you for all your support through the years.” 
In November I got another unexpected email.  This mom had attended the group and always stopped the conversation when she announced that she had 6 daughters.  I think we were all imagining what the laundry must be like!  She wrote that the daughter who was “my reason for coming to the meetings” was taken off all her meds when she was 18 and was thought to have been misdiagnosed.  Her life has changed dramatically and she is now happily married with 3 children.  She ended her email by writing, “I just was thinking of you and decided to look you up and say hi.”
 
Those parents in my long ago group and hundreds of thousands of others are searching for professional supports and treatments.  And they should   But I think that we underrate how much impact a support group and an ongoing supportive relationship with peer — in this case other parents — can have.  There’s only one study that I’ve found about the value of support groups (that study concludes that parents who attend support groups seek out a greater range of services) but of course, it’s a topic that’s rarely studied.
 
So anecdotal information will have to do.  So many services are short term, intensive and focused on the child yet it’s parent support that is often a lifeline and helps the family build a bridge with new skills and needed information. It’s hard to measure how important groups can be, but for the 4 people above, they certainly have made a difference.
 
Have a great 2010!!