Ways to Strengthen Executive Functioning

This is the fourth post in our series about children with ADD/ADHD and supporting our children.  These posts are meant to stimulate your own interest in research and dialogue with your child’s individual educational and health care provider teams, and also to link where I can to current research and current practice in this area, because this can be important in dealing with more mainstream educational and medical models .

Today, we are exploring executive functioning and what this term really means, and how we may strengthen it.  Executive functioning generally refers to a set of cognitive processes that develops and changes over the course of a lifetime of an individual and includes things such as attentional control, inhibitory control, working memory and flexibility in thinking, as well as reasoning, problem solving, and planning ahead.  This is shaped by physical growth and changes in the brain as well as by life experiences.  We often see difficulties with executive functioning in both people with ADD/ADHD, and also in people with addictions.

The sort of normal course of development of these cognitive actions takes place over the lifespan, often in spurts, with growth being particularly marked at the ages of 7-12 months, ages 3-5, ages 8-10 with a spurt around 12 of “goal directed” activities, throughout adolescence with a peak at around age 15 for increased attention to task and an increase in working memory, and then a peak in executive functioning skills in the 20s.  Declines are usually noted around age 70, although I suspect this might be changing with longer life spans.

There are many facets to executive functioning, but here are some varying ideas for areas related to executive functions with possible ways to help your child.  Take what works for you, and use these ideas as possibilities to talk about with your child’s health care and/or educational team.

Working Memory and Recall:  -One study found some teens with ADHD have the working memory of a seven-year old due to executive functioning deficits.  Working memory and recall affects holding facts in your memory and being able to retain them long enough to work with those facts, sequencing of information and getting organized and down on paper, memorizing facts.

  • Possible ways to help:  teaching your older children how to visualize things in their mind’s eye (ages 10 plus, I would say); have your child teach you because in order to teach you will remember things better; play games that teach visual memory (ages 6 plus); make up categories to help remember things; connect emotions and senses to teaching methods (and visualizing)

Activation and alertness – Difficulty in activation of a task, staying alert throughout a task to complete it, finishing work – this can stretch over variability in school work during the day and over the week.  Some days are better than others.

  • Possible ways to help:  make to do lists; make projects by breaking bigger projects down; give clear instructions; hold a steady rhythm;  manage sleep problems through a sleep specialist or clinic; use as graphic organizer; write ideas down in clusters; use manipulatives since physical activity leads to a higher level of mental alertness; use a timer or chime to indicate it is time to start work; if student is drifting off take a “brain break” with Brain Gym type activities or tap on the desk; fidgeting and chewing gum holds real value for increased alertness

Complex problem solving and difficulties with time management – Students with ADD/ADHD may experience trouble with these areas in learning, especially during the teen years as they need to write, memorize, comprehend reading,do algebra, be organized for deadlines for projects and homework with increased time awareness and planning ahead for the future.

  • Possible ways to help:  allow enough time for activities and schedule backwards from due dates or times when you have to be somewhere; practice estimating time; block off time for homework if in traditional school or in homeschooling may need scheduled block of time to finish projects; use weekly or monthly planners; use a master calendar on wall;  work during peak energy times for your child;

Control of Emotions – low tolerance for frustration, emotional blow-ups.  This included difficultly internalizing behavior and difficulty using “self talk” to guide behavior; also usually difficulty in learning from past behavior so misbehavior is often repeated; diminished self-awareness; difficulty inhibiting speech or behavior

  • Possible ways to help:  keep track of when blow-ups happen – many times they are around transitions or when there is a personal crisis (in teens this can especially be true); if a child is on medication it can be when the medication wears off and this would need to be addressed with your child’s health care team; teach your child to go and cool off (easier said than done, I know); help your child learn to recognize internal feelings of anger, rage, frustration and have a plan  in place for when those feelings occur – some schools are using a chart with a gauge of frustration to try to teach children with poor emotional control that not every situation demands the same level of frustration or response and then teach cooling off techniques – breathing, exercise, meditation

Please share with me your best strategies for helping executive challenges.  There are executive functioning specialists who do nothing but work with children and teens with these challenges; perhaps if you have a child with these challenges that is struggling there could be hope in an individualized plan from one of these professionals as well.

Many blessings,

Carrie

 

 

 

 

Holistic Support for Children With ADD/ADHD

So our last post was more suggestions from published studies,  ADD/ADHD educational literature and the US Department of Education regarding general support for educational success.  Today we are going to focus on some of the more holistic options and ideas for general support for the child with ADD/ADHD that I have cross-referenced with just a few studies as I could find them.

The list of complementary therapies parents have used to support ADD/ADHD is long and cannot be adequately listed in one post:  elimination diets, avoiding food allergens and food colorings/preservatives, Omega 3 and other supplements, chiropractic work, craniosacral work, Traditional Chinese Medicine, EEG biofeedback therapy, Occupational Therapy , Physical Therapy, massage, yoga, homeopathy, work with naturopathic doctors.  Other things from a Waldorf perspective may include light or color therapy, sound therapy, anthroposophic medicine, therapeutic eurythmy.

Regular lifestyle choices that many parents who read this blog are familiar with but also supportive to children with ADD/ADHD include regular rhythm, simplification in the environment and outside of the home activities, a great diet of outdoor time and sensory play in the outdoors, warm and natural materials for warmth and play, not burdening smaller children with too many choices.  I am sure there are many other options that exist that I have left out.  Please be sure to leave a comment and let me know what you have used in your family if I have.

In just digging around, here is just a tiny sampling of the links to research I have found that you as a parent could share with your health care or educational team for your child or delve into for yourself.  Parents can sometimes end up spending lots of money on therapies for their child; I think that not everything wonderful has studies behind it, but on the other hand it is  nice to see some do and maybe that is a place to start if you have limited funds and want to look into supportive therapies.

Is there a link between ADD/ADHD and Celiac Disease?

Omega-3 and Zinc Supplementation; the role of zinc 

Case study of chiropractic care and another case study here.  A 2010 systematic review.

EEG Biofeedback (there are many studies out there; this is well-researched.) Here is an example of one study; some studies include only children or teens on Ritalin, so look through and see the study criteria when you look at a study.

Traditional Chinese Medicine efficacy versus Ritalin; meta analysis of acupuncture and its affect on AD/HD

The relationship between Obstructive Sleep Apnea and  AD/HD; outcomes after surgery

Yoga and ADD/ADHD

This is just a tiny, tiny tip of the research out there. I urge you to go onto PubMed’s website and search for yourself under these topics to see what is out there.  Please share with me what complementary choices or lifestyle choices your family has made that you felt had the greatest impact and success for your child with ADD/ADHD.

Blessings,
Carrie

Teaching Children With ADD/ADHD

(The suggestions in this post are more being pulled from research and mainstream literature and really geared more toward a traditional, not homeschooling, environment – although some of these ideas could work quite well there.  They do not represent my independent total ideas of general suggestions, which would include more holistic options as well. However, I feel it is extremely important that parents know what mainstream health care professionals are saying, what research is saying, because if a child is in a traditional school setting particularly I think parents need to have familiarity with what is out there from this perspective.  There are more posts to come in this series in which I hope to detail some other suggestions for teaching)

In our last post, we looked at the neurobiologic differences of children who have ADD/ADHD compared to children who don’t.  However, this often leads to the inevitable question of how to best help children who are experiencing these challenges.  The work of the family due to children who have ADD/ADHD and its often related co-morbidities are real.    And, although not all readers who read this blog homeschool, I think it can feel very difficult in the beginning for the homeschooling parent who is teaching a child with ADD/ADHD where it feels like finding all the answers are on their shoulders.

Here are a few things I would think about regarding teaching and support in general.  Some of these are ideas borne out in studies, some are ideas that parents of children with ADD/ADHD have told me were helpful over the years, and some of my own ideas based on the children I have worked with when I was an actively practicing pediatric physical therapist.

Some very general things:

Exercise – Exercise improves learning in general for all children, and especially  for children with attentional deficits, exercise helps increase neurotransmitter activity.  Here is an example of one study regarding exercise and boys with ADD/ADHD.  Here is one meta-analysis  on this subject from February of 2016.  There is some evidence that exercise in nature is particularly wonderful.

Positive strengths – making a list of your child or student’s positive traits is so important.  It can carry a parent through hard times, it can help to have something to say when a child with ADD/ADHD suffers with low self-esteem or feels rejected socially, and it gives a teacher a place to draw from in teaching.

According to this document regarding teaching children with ADD/ADHD from the U.S. Department of Education, it is important to assess exactly how, when, and why the child becomes inattentive or disruptive.  Then the teacher can make up a strategy based upon academic teaching, behavior management, and accommodations.

Some general strategies could include:

Older children and teens in the classroom or a noisy environment can use noise cancelling headphones for working or use white noise.  Here is a study from March of 2016 talking about this issue.

Movement can be incorporated by teachers.  Teachers in schools and in homeschools can design their teaching  to have “Brain Breaks” and get up and move every 20 minutes or so.  Brain breaks in the classroom can include any number of activities, but true physical therapy may be needed to deal with increased motor issues, as many children with ADD/ADHD do have motor challenges.

This recent meta-analysis shows that to decrease disruptive behavior during school, consequences and self-regulation techniques provide the best effects (but what “consequences” were used or what self-regulation techniques were used were not specifically explored).

“High Interest” teaching strategies are important – because children and teens with ADD/ADHD have reduced dopamine receptions and transporters in the area of the brain that is involved with reward and motivation, high interest subjects help improve academic performance.  Students with ADD/ADHD often do not learn well with just visual or auditory input – they often need a more hands-on style with visual cueing.

Understand that learning is DEVELOPMENTAL.  If a child or teenager with ADD/ADHD has delayed neurobiologic brain maturation, he or she will not have the learning or memory capacity of students of the same age.  (This is where structural maturation CAN impact function).   Working memory for student with ADD/ADHD, even a teenager, may be limited to about five items or fewer.  So, a lesson in which the student is supposed to remember ten things will not be learned in one lesson.

For children with ADD/ADHD, if you are the teacher, you must be very clear as to your objectives in learning.  This seems to really help children with ADD/ADHD.

As a teacher, you can orally ask questions as you go along and point to visual cues to help assist in answering.  In public schools, some of the methods being used include the teacher giving the student a copy of lecture notes to the student in outline form with key points marked to help the student, or to provide skeletal outlines to provide compensation for poor working memory.  Reducing notetaking for teens is important.

Showing sample completed projects or pages helps.  Reduced written work should be expected.  Having an older child or teen  write the correct answer only or fill in blank often works better than having a child try to write full essays or summaries.

Quality over quantity.  Pick your assignments for your child carefully.

These are general suggestions.  I hope to address helping with language arts and math in future posts to help parents and homeschooling parents.

Blessings,

Carrie

 

Neurobiologic Differences in Children With AD/HD

ADD/ADHD occurs in approximately 11 percent of all children, according to the CDC.  If  you are someone who is blessed to have a child or teenager who has challenges with attention and executive function, there are few things you might want to keep in mind.  Children with ADD/ADHD are NOT alike, and ADD/ADHD is considered, at this point, a complex neurobiological disorder by the medical community .  We say this because of these main medical findings:

Children with ADD/ADHD seem to have reduced cerebral blood flow to some parts in the front of the brain.  These areas typically control attention, impulsivity, sensitivity to rewards and punishments, emotions, and memory.

There is underactivity of specific neurotransmitters in the brain, specifically dopamine and norephinephrine.    This has been shown on PET scans.  There have been several genes linked to ADD/ADHD – two were dopamine receptor genes, along with a dopamine transporter gene.  Remember, dopamine plays a major role in regulating attention, concentration, movement, behavior, response to punishment and reward, learning, working memory, analysis of a task, problem solving, and long-term memory.

Some sections of the brain are smaller in children and teenagers with ADD/ADHD.  This review looks at the specific areas of the brain with volume reduction.

There is a lag in structural brain maturation of children with ADD/ADHD.  ADHD children may more match children 1-3 years younger, with the largest lags in structural maturation seen in older children in one study.

So, if you are parenting or teaching children who have attentional and executive function challenges, understanding these neurobiologic differences many assist you in developing a more cohesive strategy for helping your child.

The other thing to remember is that ADD/ADHD often occurs with other things,  including learning disabilities, Tourette’s Syndrome, anxiety, depression, bipolar disorder, substance abuse, oppositional defiant disorder, conduct disorder, and executive functioning difficulties.  Sleep disturbances are also extremely common, along with challenges in transitions and changes in routine.  There are often multiple challenges to be addressed together in order to lead to success for the child or teen in school and in life.

Many blessings,
Carrie

Weeks 29 and 30: Homeschooling Eighth, Fifth, and Kindy

We took a lovely week to be at the sea and had a little holiday.  I spent a little time thinking about our rhythm, which has withstood quite a number of disruptions this year.  We need a strong ending to the school year, so I think I pretty much came upon refining our rhythm to be: me working out early/breakfast; going over our Anglican Spiritual Studies; time for our kindergartener; recess; Main Lesson for our fifth grader; Main lesson for our eighth grader and then a late lunch and more recess.  Several days a week we may have to come back to finish up main lesson kinds of projects and such.  So, it feels comfortable and do-able for the rest of the school year to me at this point and I am hoping to have a great ending to the school year.

Kindergarten:  We have had a grand time with our Spring Circle.  Our story has been Suzanne Down’s “Spring Kite Music” from her book, “Spring Tales”.  Our general rhythm has been baking on Mondays, crafting on Wednesdays, and painting on Fridays with Tuesdays and Thursdays being our days out at Forest Kindergarten.  We have also been making and playing little homemade games – things such as a variation of a homemade Candyland – and other games.  We have been singing and doing a lot of little finger plays for Spring as well.  Such a sweet time.

Fifth Grade – Our fifth grader is finishing up a block that combined Canadian Geography with the Metric System.  Our main project for Canada has been a giant salt dough map where we have been painting provinces, rivers, and marking towns.  We have been using the metric system to go over the height of landmarks, distances between towns, what we would eat in our meals in Canada in grams and liters.  We have been reviewing and practicing a lot with the four math processes, and fractions.  We finished reading the book “Seabird” by Holling C. Holling and have now moved into reading about Hawaii in preparation for our North American Geography block.  We are also working diligently on spelling as well.

Eighth Grade – We finished tracing the events of the Cold War through four decades, mainly through the biographies of Eisenhower, JFK, Nixon, and Reagan.  This included the arms race and the Space Race, the benefits of space exploration and where space exploration is today (and a lovely tie in was seeing the rocket launch on the Florida coast whilst on vacation), the Korean War, the Bay of Pigs invasion and the Cuban Missile Crisis, the Vietnam War and the differences between a president such as Nixon and detente and Reagan’s policies.  Then we moved into the War on Terror and all the different groups and players involved from the Persian Gulf War right up to today.  Our last foray this week is into the Age of Digitality – the history of the Internet and the World Wide Web and challenges of this century.  Our Main Lesson book pages have included amazing writing and art work for this block.  We are looking forward to starting Oceanography tomorrow.  We are starting the first few days by tying in to some of the peoples who traveled the oceans in different watercrafts, and then a little about plate tectonics and a beautiful look at the all the wonders of the ocean floor.  I am very excited about this block!

In World Geography, we finished up Africa and also Russia.  We have reviewed all the geography of Russia, the different ethnic groups within Russia, Russia’s history, and the Trans-Siberian Railroad. The only place we have left to study is Europe, so it feels good we are coming to the end of our year-long geography course.

I am ready to keep forging ahead with our homeschooling year, and also looking forward to get back on planning for first, sixth, and ninth grade. I have actually felt more stumped by first grade lately in planning, but recently came up with some creative ideas that I think will lead to a fun first grade for our littlest.

I would love to hear what you are working on!

Blessings,

Carrie

Spiritual Studies in the Episcopal/Anglican Homeschool

We were on vacation last week, enjoying some sun and sand.  After a rather rough time with the loss of people this fall and a beloved pet especially this spring, it was good to get away for a little bit.  The wonderful thing about vacations is that hopefully one finds time to think (although my joke is always that taking a trip with children is really a holiday, not a vacation! LOL).

At any rate, I was feeling a little consumed by some little words from the Book of Common Prayer found in the Baptismal Rite…In the baptism of a new member, the entire Body of Christ in the parish re-affirms his or her own baptismal vows –  to continue in the tradition of the apostles in fellowship, teaching and communion; to resist evil; to be a good example of Christ’s love in the world, to love and serve all people, to strive for justice and dignity and peace among all people, to respect the dignity of all every human being.  After baptism and chrismation, part of the prayer said by the priest is:

Sustain them, O Lord, in your Holy Sprit. Give them an inquiring and discerning heart, the courage to will and to persevere, a spirit to know and to love you, and the gift of joy and wonder in all Your works.

Those words always strike me as such a dovetail to what I want for my children to receive from our parenting and from our homeschooling.  And this brings me to Anglican Spiritual traditions within homeschooling.  This is actually not an easy subject.  In the Christian homeschooling market, there are many resources for all denominations of Christianity.  Yet, I think perhaps because there is such a strong and large tradition of Anglican and Episcopalian school choices, that at least here in the United States, I cannot find any single resource at all specifically directed to families of the Anglican Communion who are homeschooling.  The few resources I have found and adapted I have commented upon in blog posts in the past.

We learn about the church in community by attending Liturgy and also through activities within our church body. We break bread together on our knees in community, our baptisms are in community, we love in community.  Our children are involved heavily in choir and the Royal School of Church Music program.  Yet, in our home time where we are together as a family and a small home church so to speak , I have to be conscious and mindful.  My goals for right now when we start our school day include:

To open with prayer- which by its very nature, brings in The Book of Common Prayer, the Anglican view of time, the Saints we hold in communion, and the 5 Marks of Mission of the Episcopal Church (for example, this week we celebrate St. Alphege, Archbishop of Canterbury and Martyr, 1012; we celebrate St. Anselm, Archbishop of Canterbury in 1109; and St George, the Patron Saint of England; but we also celebrate John Muir, whose life story fits into one of our mission marks:  “To strive to safeguard the integrity of creation and sustain and renew life on earth”).  During this time, we explore also different paths of mysticism within the Anglican tradition and within the Body of Christ, and icons.

To read the Bible together and discuss intimately.  Some of the books from Cowley Publications, which is a ministry of the Society of St. John the Evangelist, a religious community for men in the Episcopal Church, have been helpful, along with books by author Vicki Black.

Lastly, we will spend a few moments each day discussing any of the following:   the Episcopal Church’s tenets, tenets of good Christian living, famous Episcopalians and Anglicans through biographical format, the Visual and Musical Arts of the Church, the three Creeds we follow, and the history of the Church of England, the Episcopal Church in America  and the Anglican Communion as a whole.

Many blessings and light,

Carrie

 

Weeks 25 -28: Homeschooling Eighth, Fifth and Kindy

These last few weeks have been heartbreaking.  The giant dog that we owned and loved, the best dog we have ever had out of the four dogs we have owned over our nearly twenty-four years of marriage, was diagnosed with bone cancer and died.  So, it has been a time of  great sorrow and now emptiness in our household.

It has also been a time of spring, of new life and new beginnings, and trying to homeschool in the midst of the jumble of emotions and juxtapositions has been a challenge.  We move forward each day, one foot in front of the other, and sometimes that is all that there really is.  In the meantime, we are moving slowly through our blocks, but here are some of the things we have been working on (if you need to see where last were, try this back post:    https://theparentingpassageway.com/2016/03/06/weeks-23-and-24-homeschooling-eighth-fifth-and-kindy/)

Kindy:  Holding a steady rhythm has been a real challenge throughout all the uncommon things going on.  However, we have managed to do braiding, wet felting and knitting; loose parts play; painting and modeling; hiking and biking and being outside in the yard especially.  Our dog really enjoyed that most in her last days especially, even when we all had to carry her outside.

We were doing an Early Spring Circle but now have changed into a circle of “Rabbit’s Adventure” as I have modified it from the book “Movement Journeys and Circle Adventures”.    Our story earlier this month was Suzanne Down’s “Lucky Patrick” and now we have moved to one of my seasonal favorites for spring, also by Suzanne Down, called, “Spring Kite Magic.”

Our preparations for Lent were way behind what we normally did, other than making wet felted eggs and dying eggs.  We missed all the Great Liturgies for Holy Week because I just felt too fragile and sad  (except for the Great Liturgy of Easter),  but I hope to attend the celebrations of Eastertide to the fullest.

Fifth Grade: We finished our Greek Mythology and we finished our math block of the Ancient Americas/Chocolate, where we focused on all four math processes, the stories of Toltec and Mayan mythology, and cooking with chocolate.  My original inspiration for this block was from Marsha Johnson, and you can find her notes on her “Magic of Waldorf” website, but I built on it quite a bit from there.  We also spent a bit of time this week on the  Ancestral Puebloans of the American Southwest and will swing back around to this when we do North American Geography in a few short weeks.  We kept on with geometry and have worked our way through the six types of triangles, discovering interior angles, the chords of a circle, quadrilaterals, some biographies of Ancient mathematicians and their discoveries,  and will be moving into circles and ellipses this week in conjunction with our new block.  This week we will be beginning a block on the metric system based around the geography and sites of our neighbor, Canada.  We just finished  the read-aloud of Padraic Colum’s Children’s Homer and will be starting Holling C. Holling’s “Seabird”.  My original goal was to make a board game of the journey of Odysseus, but I feel as if we are running out of time and no longer in that place as we have moved on in blocks. We shall see.  Other than that, we have been working on spelling in addition to the math.  I find when we have a math block it is very taxing for our fifth grader and there is not a lot of energy left for as many artistic pursuits, so cooking has been a good adjunct to this block.

Eighth Grade:  We finished the Gilded Age with a summary and a lovely map of the Biltmore Estate that is our regional representation of the architecture of the Gilded Age.  We did talk about Einstein, we discussed Trotsky and Stalin and the Russian Revolution and spent some time comparing totalitarian regimes to our own country and our Bill of Rights, and then moved into the causes, events and outcomes of World War I and read a biography of Woodrow Wilson.  (The causes of World War I tied in nicely into our World Geography course where went back over the history of the Middle East and the Ottoman Empire).

We talked about the outcomes of World War I planting the seeds for World War II, the Jazz Age and the Harlem Renaissance and  some poetry from that time period, drew a picture of the flapper for the Main Lesson Book, discovered the Great Depression and the Dust Bowl, along with more poetry.  This week we are finishing up World War II – we looked at the causes of the war and conditions in Germany, Japan, and Italy;  we are reading a biography of Churchill; I told the stories of FDR, Hitler, Mussolini, Hirohito; we discussed the complete horrors of the Holocaust and the people who were lights within the Holocaust  – for this time around I focused on the role of the Grand Mosque in Paris as a short-term safe haven; we reviewed all the events of the war and the prominent American generals of the war, the horrors of Japanese-American Internment and the reasons the Allies “won”.  We looked at if there were any parallels between WW II and what is happening in our world with the Islamic State. FDR died here in our state, so it is my hope to visit Warm Springs and talk more about FDR’s life.  We are now moving into the aftermath of World War II and the timeline and  development of the events of the Cold War, including Korea, the Cuban Missile Crisis, the Vietnam War – mainly through biography, just as we did in studying World War II.   This week has mainly been the history of this period, including the struggle for Civil Rights, through the biographies of Dwight D. Eisenhower and JFK.

We will also look at the  Space Race, and the era of Reagan and  end with the War on Terrorism and the Age of Digitality before this block is over.  I Our eighth grader read “Breaking Stalin’s Nose” and we discussed it as a piece of literature, and now she is reading JKF’s “Profiles in Courage.”

In World Geography, we finished Oceania and also finished the area of North Africa/Southwest and Central Asia.  We looked thoroughly at the Middle East and its history again, through the modern era, and focused on OPEC and the Creation of Israel.  We read Julia Johnson’s “Saluki, Hound of the Bedouins” and our eighth grader drew a picture from that.  She also made a very large map in which we labeled all the tribes of the Middle East.  We covered the geography and culture of the sub-Saharan African countries and discussed the intertwining of electricity, economic growth and how South Africa has been displaced in economic growth by Nigeria and how it is predicted that Nigeria will be replaced by Ethiopia and possibly the Democratic Republic of Congo (in second place) by 2050 depending upon infrastructure and power.  We also have discussed President Obama’s 2013 initiative, “Power Africa”.    We have Russia and Europe to finish off our World Geography course.  I feel this course has been a very successful one this year and a high school credit will be well-earned for the amount of work it has been.

We are working on math daily as well, and I am looking forward to ending our World History block and moving into Oceanography and Meteorology in April.   Our eighth grader did her presentation on the Junior Ranger Badge/Get Outdoors Program for her 4-H presentation and is looking at options for 4-H next year.  I am also excited about a regional homeschool field trip group that has formed that has over 3,000 members and will be doing all kinds of wonderful field trips this summer.

I hope your spring is springy and sprongy and full of sweetness, always full of light in the shadows –

Carrie