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Chris De Villeneuve
Worked at Central Washington Comprehensive Mental Health
Attended George Fox University
Lives in Yakima, WA
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Oxytocin 'Normalizes' Social Deficits in Kids With Autism

Author: Caroline Cassels

Date: December 10, 2013


A single dose of the hormone oxytocin administered via nasal spray enhances brain activity in key regions, temporarily improving social information processing in children with autism spectrum disorder (ASD), new research suggests.

The double-blind, placebo-controlled imaging study of 17 children and adolescents with ASD showed that those who received intranasal oxytocin had increased activity in brain regions associated with reward, social perception, and emotional awareness compared with their counterparts in the placebo group.

"We found that brain centers associated with reward and emotion recognition responded more during social tasks when children received oxytocin instead of the placebo. Oxytocin temporarily normalized brain regions responsible for the social deficits seen in children with autism," lead author Ilanit Gordon, PhD, Yale Child Study Center, Yale University, in New Haven, Connecticut, said in a release.

Dr. Gordon added that the study is the first to evaluate the effect of oxytocin on brain function in children with ASD.
The findings were published online December 2 in the Proceedings of the National Academy of Sciences.

Mixed Results

In typically developing adults, intranasal oxytocin has been shown to enhance processing of social stimuli and heighten activity in neuroanatomic brain structures involved in processing socially meaningful stimuli.
In addition, behavioral studies in children and adults suggest that a single dose of intranasal oxytocin improves social interaction and comprehension of affective speech. It has also been shown to reduce repetitive behaviors, improve social cognition, and increase understanding of others' mental states.
However, the authors note that results from clinical trials examining the effect of daily administration of oxytocin on behavior in children and adults have been "mixed at best."
To examine the neural basis of oxytocin's effects, the researchers conducted a randomized, double-blind, crossover functional magnetic resonance imaging (fMRI) study.
They investigated the effects of a single intranasal administration of oxytocin on brain activity in 17 high-functioning children and adolescents aged 8 to 16.5 years with ASD. They note that previous reports have not included individuals younger than 12 years.
The Social Brain
The researchers hypothesized that "during a task involving social judgments, OT [oxytocin] vs Placebo would heighten brain activity in the neural circuitry that supports reward (dorsal and ventral striatum and nucleus accumbens [NAcc], as well as social attention and social cognition (eg, posterior superior temporal cortex, cingulate, precuneus), that is, the 'social brain.' "
Participants were randomly assigned to receive either oxytocin or placebo nasal spray on 2 consecutive visits. Forty-five minutes after administration, brain function was assessed using the Reading the Mind in the Eyes Test (RMET), a validated fMRI emotion judgment task.
The results showed "oxytocin increased activity in the striatum, the middle frontal gyrus, the medial prefrontal cortex, the right orbitofrontal cortex, and the left superior temporal sulcus."
The researchers also reported that oxytocin increased activity during social judgments and decreased activity during nonsocial judgments in the striatum, nucleus accumbens, left posterior superior temporal sulcus, and left premotor cortex.
The researchers also tested oxytocin concentrations in saliva at baseline and 30 minutes after administration and found they were positively associated with enhanced brain function.
Potential Clinical Utility
These discoveries, the researchers write, are "particularly important given the urgent need for treatments that target the core social dysfunction in ASD."
"The functional neural attunement we demonstrated might facilitate social learning, thus potentially bringing about long-term change in neural systems and subsequent behavioral improvements," the authors conclude.
The researchers predict that clinically, oxytocin may be most useful when administered just prior to proven behavioral treatments that "provide opportunities for feedback and learning in supportive social contexts."
The authors report no relevant financial relationships.
Proc Natl Acad Sci. Published online December 2, 2013. Abstract
 
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Cite this article: Oxytocin 'Normalizes' Social Deficits in Kids With Autism. Medscape. Dec 10, 2013.
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There is a lot of research posting on Oxytocin. It's showing some interesting positive results. 
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This article posted this morning in "Cont Edu Anaesth Crit Care & Pain Anaesthesia" regarding, "Children With Special Needs Including Autistic Spectrum Disorder." 

Hospitalization, doctors appointments and medical procedures can be traumatic but with planning can be less overwhelming.  

Here are a couple of highlights from the article that I thought were interesting.

Sample preoperative checklist for children with ASD.

Patients may be taking regular medication to modify behaviour, which should be taken into consideration on an individual basis. Such drugs may include stimulants, anti-psychotics, and nocturnal melatonin.
•Patient care: some general strategies for managing a child with ASD are suggested in . The anaesthetic room should be a calm environment facilitated by the presence of a parent/carer, low-level lighting (compatible with safe working practices), minimal extraneous noise, and the fewest healthcare personnel possible. If the child is very uncooperative despite preparation, premedication, or both, re-sedation or postponement of surgery may be necessary.

Table 2.  Autism dos and do nots

◦Dos

■Minimize waiting times
■Warn before making physical contact
■Get information from parents and carers
■Speak quietly and gently
■Recognize that the patient may not wish to communicate
■Offer preferred foods when possible
■Give clear explanations
■Minimize disruption to normal daily routine
■Provide a clear plan for the day ahead

 ◦Do nots

■Allow prolonged waits in noisy environments
■Initiate physical contact without the patient's assent
■Make assumptions about a child's understanding or cooperation
■Raise your voice
■Assume that a lack of communication indicates a lack of understanding
■Spring surprises—routine is very important
■Use complex language such as metaphor or imagery
 
•Restraint: physical restraint should be avoided if at all possible, although it is important to acknowledge that a degree of restraint may be a usual element of the daily lives of some children with special needs to promote their safety; if parents or carers are skilled in holding their child, it may be considered acceptable for therapeutic holding to occur to facilitate induction. If physical restraint is considered unavoidable as a last resort, adequate members of trained staff should be available to control the situation as quickly and effectively as possible. Parents should be forewarned about what to expect. It is good practice to record how the child acts during induction and after the operation to aid future anaesthetic management.

Peroperative Care

While sedative premedication may have been necessary to allow induction of anaesthesia, there are advantages to keeping the anaesthetic plan as simple, straightforward, and flexible as possible. Good analgesia is essential, with liberal use of local anaesthetic techniques, paracetamol, and non-steroidal anti-inflammatory drugs. There should also be a low threshold for administration of an antiemetic agent and an isotonic crystalloid fluid bolus to minimize postoperative nausea and vomiting. These measures are particularly important in children with special needs, as it may be very difficult to assess and distinguish between the potential causes of postoperative distress—pain, nausea, numbness due to local anaesthetic, emergence delirium, unfamiliar nurses, residual disorientation from preoperative sedation, etc.

Postoperative Care

A rapid smooth recovery and early discharge should be the aim for physically well special needs patients who have had straightforward day surgery. I.V. cannulae often cause distress and should be removed as soon as possible once it is clear that the patient has full control of their airway and there is no obvious need for further i.v. medication. To minimize disruption to the patient's' daily routine, and after discussion with carers, they may be discharged once they have regained their usual baseline in terms of orientation and mobility, without necessarily meeting the usual discharge criteria (e.g. to have eaten, drunk, or passed urine). Advice and instructions should be offered to carers regarding regular appropriate analgesia at home. Vigilance should be advised in helping a child to protect an area which has been infiltrated with local anaesthetic (e.g. avoiding lip biting after dental surgery).

Pain management in non-verbal children may be challenging and the use of behavioural pain rating scales and the assistance of the parents and carers may be required. As many children with special needs are unable to manage patient-controlled analgesia systems after major surgery, they may benefit from nurse-controlled protocols allowing for background infusion of opioid with the facility for bolus administration in response to pain scoring. Any i.v. cannulae, nasogastric tubes, or other clinical or monitoring apparatus may need to be well secured and bandaged to prevent their dislodgement.

Communication

One of the most important aspects of high quality healthcare is good communication. Many strategies are available for communicating with unimpaired children, to provide explanations, or influence behaviour, including descriptions, stories, training in coping strategies, distraction, metaphor, imagery, and modelling. Some of these options may be appropriate for children with lower IQ, but alternative methods may be more suitable for children with language and communication disorders, for whom conventional communication is difficult or impossible.

Patients with limited speech may benefit from the use of sign language, such as Makaton (www.makaton.org), symbol charts, or the Picture Exchange Communication System (www.pecs.org.uk). Patients with ASD and limited social understanding may benefit from practical coping strategies, concentrating on how to manage a new situation. Examples would be symbol timelines, social stories, and behavioural management programmes. Some familiarity with the communication aids used by patients at school and home can help in providing information and encouraging discussion in hospital.
When speaking to a patient with special needs, it is helpful to use simple words and language, to speak clearly and directly, to make eye contact if possible, and to avoid complex forms of language such as jargon, abbreviations, acronyms, sarcasm, or metaphor. For patients with little receptive or expressive language, various alternative forms of communication exist (AAC).
Augmentative and Alternative Communication
AAC includes methods which supplement the usual use of speech/writing and which help expression as well as understanding. They may be:

•Unaided

◦methods which use only the body to enhance communication;
◦body language, facial expressions, gestures, signing.

•Aided

◦methods which require the use of equipment or resources;
◦low tech: writing, drawing, picture boards, symbols, objects;
◦high tech: require a power source: message devices, computers, electronic aids.

Symbol timelines may be particularly useful to break down the process of admission to hospital and subsequent treatment into discrete manageable steps. This can reduce anxiety by allowing activities (such as being weighed and having a name band put on) to be rehearsed in advance and then prompted individually when required during the hospital stay. If the steps are illustrated in a way which is familiar (e.g. Widgit symbols used in special needs education), children may be empowered by recognizing a system they understand and by exercising some choice in terms of the order in which some of the steps are tackled. It is important to emphasize a clear benefit to completing the sequence, such as eating, drinking, and going home. Examples of anaesthesia-related symbols are shown in Figure 2; a day-case admission timeline is available for free download from the RCoA patient information website children's pages (http://rcoa.ac.uk/childrensinfo), along with other anaesthesia information resources for children and young people.

 
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Chris De Villeneuve

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Makes you feel sick thinking how much money is siphoned off for personal gain.  Do your research before donating.
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Yep that is so true.
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This is your chance to win a free Google Glass! All you have to do is:

+1 and SHARE this post, then join the giveaway here: http://muo.fm/1hy6duU
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It does seem like doctors do not communicate with one another as much as they should. It seems like, with all the technology and digitizing of information, medicine could potentially work a lot faster. I know there are issues with integrating technology with medicine, however, and that may be a major concern.
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Stop the Pop: Soda Linked to Aggression, Inattention in Kids

Author: Deborah Brauser

Release Date: Aug 22, 2013
Consumption of even 1 soft drink per day may be associated with increased negative behavior in young children, new research suggests.
A cohort study of almost 3000 5-year-olds showed that those who drank 1 to 4 servings of soda per day had significantly higher aggressive measurement scores than their peers who drank no soda.
In addition, those who consumed 2 or more servings had higher withdrawn behavior scores, and those who consumed 4 or more servings had higher attention problem scores.
"We were seeing a dose-response effect. So with every increase in soda consumption, the association and the scores basically increased," lead author Shakira Suglia, ScD, assistant professor of epidemiology at the Mailman School of Public Health at Columbia University in New York City, told Medscape Medical News.
"This held up even after we adjusted for candy or fruit juice consumption and for a variety of social factors, especially for aggression with the highest level of soda consumption," she added.
Although the investigators suggest that "future studies should explore potential mechanisms" that might explain these association, Dr. Suglia noted that past research has shown that even 1 soda per day is too many for young children.
"Certainly water or milk is more nutritious and a better alternative. Our advice is consistent with what is already out there: for the very young kids, any soda is not a healthy option. And even for adolescents, I think parents should really limit the amount of soda their kids are drinking."
The study was published online August 15 in the Journal of Pediatrics.
World's Biggest Soda Consumers
According to the researchers, more soda per capita is sold in the United States than in any other country.
Although past research has suggested an association between soft drink consumption and aggression, depression, and suicidal thoughts in adolescents, the current investigators sought to examine possible links between sodas and negative behaviors in young children.
 
Dr. Shakira Suglia
The ongoing Fragile Families and Child Wellbeing Study was created to assess 4849 pregnant women from 20 cities in the United States at delivery. Follow-up interviews were conducted starting when their children were approximately 2 years of age.
For this analysis, the investigators evaluated data on 2929 of these children (52% boys; 51% black, 28% Hispanic/other, 21% white).
When the children were 5 years of age, their mothers filled out the Child Behavior Checklist (CBCL) and reported approximate servings of daily soda consumed, up to "4 or more."
The mothers were also asked about the consumption of candy/sweets and fruit juice, television viewing habits, social risk factors (including maternal depression and intimate partner violence), and sociodemographic factors.
Results showed that 43% of the children drank at least 1 serving of soda per day, with 4% of the participants drinking 4 or more servings per day.
Unadjusted analysis showed that higher levels of soda consumption were associated with significantly higher overall aggression scores, as well as higher scores on the withdrawal and attention subscales of the CBCL (all, P < .05).
After adjusting for sociodemographic factors, results showed that the participants who drank at least 1 soda per day had a 0.74-point higher mean aggressive behavior score (95% confidence interval [CI], 0.1 - 1.4) than those who drank no soda (P < .05).
Consuming 2, 3, or 4 or more servings was associated with even higher mean aggression scores of 1.8, 2.0, and 4.7, respectively (all, P < .05).
Those who drank 4 or more daily servings also had higher mean scores on the attention problems (1.7; 95% CI, 1.0 - 2.4) and withdrawn behavior (2.0; 95% CI, 0.8 - 3.1) subscales (both, P < .05).
Adjusting for consumption of candy/sweets or fruit juice, television viewing, probable maternal depression, intimate partner violence, paternal incarceration, and obesity in separate analysis of 1868 of the participants still showed an association between high levels of soda consumption and negative behaviors.
Those who consumed 4 or more daily servings of soft drinks had fully adjusted mean scores of 2.62, 1.75, and 0.88 on the aggression, attention problems, and withdrawal subscales compared with those who consumed no soda.
Are All Sodas Equal?
Further analyses showed that the children who consumed the highest levels of soda were more than twice as likely to destroy others' belongings (odds ratio [OR], 2.54), physically attack people (OR, 2.28), or get into fights (OR, 2.12).
"In this large sample of 5-year-old urban US children, we found strong and consistent relationships between soda consumption and a range of problem behaviors, consistent with the findings of previous studies in adolescents," write the investigators.
However, future studies "in other populations of children and of a longitudinal nature may provide further insight into the relationship between soda consumption and child behavior," they add.
When asked, Dr. Suglia reported that the study did not ask about the specific types of soda consumed, such as whether they included diet or noncaffeinated drinks.
"So it would be interesting in the future to try to parse out whether the findings are specific to a certain ingredient that we should be focusing on, such as caffeine or sugar, or is it just overall diet or lack of something they should be consuming? More specific data could be helpful," she said.
In response to the study, the American Beverage Association issued the following statement: "It is a leap to suggest that drinking soda causes these or any other behavioral issue. The science does not support that conclusion. The authors themselves note that their study 'is not able to identify the nature of the association between soft drinks and problem behaviors.' "
"Importantly, our member companies do not promote or market the consumption of soft drinks to children in the age group examined in this study," they add.
The original study was funded by the National Institute of Child Health and Human Development. The study authors have disclosed no relevant financial relationships.
J Pediatr. Published online August 15, 2013. Full article
 
Medscape Medical News © 2013  WebMD, LLC

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Cite this article: Stop the Pop: Soda Linked to Aggression, Inattention in Kids. Medscape. Aug 22, 2013.
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Low Omega-3 in Kids Linked to Behavior, Cognitive Deficits
Author: Pauline Anderson

Quick Summary and why I wanted to post this... "These findings, together with the finding that lower omega-3 fatty acid status was associated with poorer reading ability and parent-rated behavioral problems, highlight the importance of eating 2 servings of fish, particularly fatty, per week," she said. "However, in cases where increasing the fish consumption is not an option, omega-3 fatty acid supplementation can be a good alternative."   (p.s. i'm not advocating for diet controlled behavior but holistic approach).


Date: Jul 23, 2013
Blood concentrations of omega-3 fatty acids in school-aged children in the United Kingdom (UK) are well below the minimum recommended for good cardiovascular health in adults, according to a new study.
The research also found that low levels of omega-3, particularly docosahexaenoic acid (DHA), which is found in fish, seafood, and some algae, are associated with worse performance on reading tests and working memory, and more symptoms of attention-deficit/hyperactivity disorder (ADHD) in the children, even after controlling for sex and socioeconomic status.
"The blood omega status in these kids is worryingly low, given what is known about omega-3 and its benefits for brain development, and cardiovascular and immune system health," said study author Alexandra J. Richardson, DPhil, a senior research fellow at the University of Oxford, UK, and founder-director of the charity Food And Behaviour Research.
The study was published in PLoS ONE. The study was funded by Martek Biosciences Inc.
DOLAB Study
This study formed the screening stage of a previously published randomized controlled intervention study that included 362 healthy children aged 7 to 9 years from primary schools in Oxfordshire, a large county in the UK, who had low reading scores. The DOLAB study reported that supplementation with 600 mg DHA daily for 16 weeks improved reading and behavior in children with the lowest 20% of reading scores.
The DOLAB study followed a 2005 study — the Oxford Durham Study — that showed "highly meaningful" benefits for reading and spelling from long-chain omega-3 supplementation, said Dr. Richardson.
The current cross-sectional analysis, which included 493 children, aimed to determine the status of long-chain polyunsaturated fatty acids (LC-PUFAs) in these children and its relevance for cognition and behavior.
Researchers analyzed fatty acids through fingertip-prick whole-blood samples. They measured reading proficiency using the well-validated Word Reading Achievement subtest of the British Ability Scales 2nd Edition (BAS II) and working memory using the Recall of Digits Forward and Recall of Digits Backward subtests form the BAS II.
Parents and teachers rated ADHD-type symptoms, such as inattention, hyperactivity, and impulsivity, in the children using the long version of the Connors Rating Scales. These measurement tools are commonly used to assess behavior problems related to ADHD and have been successfully used in previous studies on the relationships between nutrient status and behavioral problems.
Although the children had been underperforming in reading according to national tests carried out at age 7 years, formal testing as part of this study showed that the actual distribution of reading scores in this screening sample was within normal population ranges. Only the children whose scores still placed them in the lowest third of the normal range were entered into the subsequent treatment trial, explained Dr. Richardson.
In this current analysis, the average blood omega-3 LC-PUFA concentration in the children was 2.46% and was slightly lower in girls than boys. In adults, concentrations of 8% to 12% are considered the optimal range for general health, while those below 4% are considered to signify high cardiovascular risk.
The study showed that reading scores were significantly and positively associated with the omega-3 fatty acids DHA (P < .003), docosapentaenoic acid (DPA; P < .04), eicosapentaenoic acid (EPA; P < .005), and the omega-3 index (EPA+DHA; P < .04). Total omega-6 fatty acids also showed a positive correlation with reading.
Results were similar for working memory. Scores for Recall of Digits Forward were significantly and positively associated with DHA (P < .003), DPA (P < .04), EPA (P < .005), the omega-3 index (P < .001), and total omega-3 (P < .004).
In both reading and working memory, there was a slight negative association with the shorter-chain omega- 3 stearidonic acid (P < .04 in both cases).
The associations held up even after adjustment for sex and socioeconomic status (P = .002 for EPA; P = .001 for DHA; P < 0.001 for omega-3 index).
Peer Pressure?
These data "look fairly comparable" with preliminary results from studies of general population groups in other European countries, said Dr. Richardson. "The omega-3 status in children and younger adolescents seems to be lower than in any other age group, which probably reflects their dietary habits," said Dr. Richardson.
Indeed, in this current study, parent reports showed that almost 9 of 10 children (88.2%) failed to meet current UK dietary guidelines of eating 2 portions of fish per week.
According to Dr. Richardson, the dietary habits of school-aged children are heavily influenced by peer pressure.
"More attention needs to be paid to this," she said. "Omega-3s are critical nutrients but are at suboptimal levels in the diet of most people in developed countries. In addition to their key roles in cardiovascular health and immune function, the long-chain omega-3 (EPA and DHA) are needed for normal brain structure and brain function — so I think we should be concerned that they are not in the diet in sufficient quantities for optimal mental performance and well-being."
She added that "there's enough evidence out there to show that people would be well advised to get enough long-chain omega-3 into their diets one way or the other, whether it's through functional foods or supplements or just by eating fish and seafood."
It's always best to get omega-3 and other nutrients from the diet, but information from the study on children's fish-eating habits showed that they "just weren't doing it," said Dr. Richardson.
Because the study was restricted to children whose first language was English, the findings may not apply to ethnic minority groups, particularly given that important genetic influences on omega-3 fatty acid metabolism and status are known to vary with ancestry.
Dr. Richardson and her colleagues have already embarked on a follow-up DOLAB study to try to replicate the results of this previously published intervention study. "We are focusing on the lowest fifth of readers, the bottom 20% of the normal population range. That was where we found a treatment effect of 600 mg of DHA a day vs placebo."
Most Benefit
Reached for a comment, Jeannine Baumgartner, PhD, nutrition scientist, Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa, said the study "is a technically sound piece of research."
"This study extends the current knowledge on omega-3 fatty acid nutrition and child developmental outcomes, specifically on reading ability, which is often a predictor of continued academic achievement."
The study results also might help explain the results of the DOLAB trial that reported significant effects of DHA supplementation on reading ability and parent-rated behavior in the children whose initial reading performance was below the 20th percentile, said Dr. Baumgartner.
"The significant association between reading ability and omega-3 fatty acid status reported in this cross-sectional analysis from the DOLAB screening indicates that these children were likely to have the lowest omega-3 fatty acid status and therefore to benefit most from supplementation."
Dr. Baumgartner pointed out that previous studies investigating the effects of omega-3 fatty acids supplementation on cognitive and behavioral outcomes in healthy children have had mixed results; that unlike other nutrients, a cutoff for omega-3 fatty acid deficiency is not yet defined; and that many of the children in the current study did not meet recommendation for fish consumption.
"These findings, together with the finding that lower omega-3 fatty acid status was associated with poorer reading ability and parent-rated behavioral problems, highlight the importance of eating 2 servings of fish, particularly fatty, per week," she said. "However, in cases where increasing the fish consumption is not an option, omega-3 fatty acid supplementation can be a good alternative."
More research is needed to determine what level of supplementation has a beneficial effect on cognition and behavior in healthy schoolchildren, as well as to investigate dietetic influences that may affect omega-3 fatty acid metabolism, added Dr. Baumgartner.
Funding for this trial was provided by Martek Biosciences Inc, which also provided product and placebo. Dr. Richardson acts as an occasional paid consultant for companies and organizations involved in producing, selling, or promoting foods or supplements containing omega-3.
PLoS ONE. Published June 24, 2013. Abstract
 
Medscape Medical News © 2013  WebMD, LLC

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Cite this article: Low Omega-3 in Kids Linked to Behavior, Cognitive Deficits. Medscape. Jul 23, 2013.
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Introduction

Hi, welcome.  If you are new please send me a note and introduce yourself.  I look foward towards hearing from you and connecting on Google+.
 
I work in mental health as an administrator, counselor and crisis worker.  Part of my time is spent as a hostage negotiator and crisis worker for the police department. 
 
There are things that are important in life that I really enjoy.  Well written posts, critical commentaries, some poetry and books by Christopher Moore. 
 
Below is one of my favorite poems from Yehuda Amachai. 
 
In This Valley

In this valley which many waters
carved out in endless years
so that the light breeze may now
pass through it to cool my forehead,
I think about you. From the hills I hear
voices of men and machines wrecking and building.

And there are loves which cannot
be moved to another site.
They must die at their place and in their time
like an old clumsy piece of furniture
that’s destroyed together with
the house in which it stands.

But this valley is a hope
of starting afresh without having to die first,
of loving without forgetting the other love,
of being like the breeze that passes through it now
without being destined for it.
 
 
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Warning--any person and/or institution and/or Agent and/or Agency of any governmental structure including but not limited to ALL Governments or private mediums or corporations or individuals also using or monitoring/using this website or any of its associated websites, you do NOT have my permission to utilize any of my profile information nor any of the content contained herein including, but not limited to my photos, and/ or the comments made about my photo's or any other "picture" art posted on my profile. You are hereby notified that you are strictly prohibited from disclosing, copying, distributing, disseminating, or taking any other action against me with regard to this profile and the contents herein. The foregoing prohibitions also apply to your employee(s), agent(s), student(s) or any personnel under your direction or control. The contents of this profile are private and legally privileged and confidential information, and the violation of my personal privacy is punishable by law and will be strictly enforced. 

Education
  • George Fox University
    Psychology, 1987 - 1990
  • Heritage University
    Counseling
  • University of Phoenix
    Healthcare Business
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Gender
Male
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Employment
  • Central Washington Comprehensive Mental Health
    Director
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Yakima, WA
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