Noah Becomes A Big Brother

Noah's little brother, Luke Everett Warden arrived on April 11, 2011. Chris and I had decided to keep news of Noah's pending sibling private until after his birth, and celebrate the arrival of new life once he came. Luke is a little miracle of his own, surviving a car accident with me last fall. God has a plan for everything and he wanted Luke here. Noah isn't quite sure what to make of little Luke yet. But hopefully with time they'll be the best of friends. From the moment I looked at Luke I had this little voice almost say, he's your little lion, he will be here to help Noah, to protect him to guide him. So that's what I call him my little lion. Not to mention that he has this blond hair, a surprise to both his daddy and I.

Luke Everett Warden "Our Little Lion"

I must admit my emotions are running high. I feel so blessed to have both boys in my life, yet I significantly twinged when I witnessed Baby Luke being able to suck on his fingers and hands at only four days old, something that Noah cannot do at nearly two and a half years old. There are obvious differences between the two babies I have brought home. And I suppose I fear Noah's future more now than I ever did before. I had nothing to measure it against. Now I see exactly what Noah should have been doing at this tiny age. It's so bittersweet, but I feel so robbed of Noah's babyhood. I had no idea that babies ate and went to sleep, I only knew a fitful distraught baby that never soothed to anything.

We saved Luke's cord blood and tissues with the hopes that someday we'll be able to use them to help Noah in his recovery. A very expensive task we took on to store these stem cells, yet we felt that we couldn't just throw this potential opportunity away for Noah in the future. It may make a huge difference in his life one day. This is something has significantly put us in even further debt, but I figure it can't get much worse than where we are, we basically have nothing anyway. And I thank goodness that there was one last open charge card for such a thing. We really have no idea how we're going to pay for it, or even the annual storage fee, but we felt like we couldn't let this opportunity to pass us by if it could indeed help Noah. They are currently doing sibling stem cell trials for cerebral palsy and expect clinical trials to be over in two years or less. Luke's tissues provided 855.40 million cells that we could save. And I pray with every ounce of my soul that someday somehow, Luke will have provided the medicine we needed to change Noah's life. What an amazing thought that a younger brother could make such a difference in his older brother's life.

Noah is doing much better with his illness. I think we are over the worst, yet I am watching him, guarding him, to assure that he doesn't have a relapse. He's on a second round of antibiotics, since it's a bit harder for him to clear his lungs than children that are mobile. I'm sure the days ahead will be a bit stressful as I figure out how to balance two boys, both that are not self-sufficient in anyway. I've had to put therapies on hold because I know that I cannot get both boys to therapy on my own, I have no help. Chris and my mother both return to work, and there is only me. God must have a plan, and I hope that he tells me what direction I'm supposed to go in. I feel a bit like a fish out of water - Just taking each day as it comes it's all I know how to do. It's all I've been able to do for the last two years, and I continue to ride this roller coaster called life. Mine isn't easy. Maybe it never will be, I don't know. But I'm still hoping God shoots those special arrows my mother was telling me about, those special arrows that come with just a little help to assist me along the way.

There is no doubt that things will be difficult, but it is my hope that there will be far more joy on the way. I'm hoping that little Luke will help Noah in ways therapy may not be able to. It's like I'm experiencing this completely high joy from Luke joining our family, to this really high low looking at Noah feeling the loss of all his motor skills, a helpless mom as I watch on as he simply can only lay on the floor and look up at me and smile. I long for God to help me now more than ever. Please help me heal my Noah. Please grant us all some sort of a resemblance of a normal life, please just give us an easier path, please hear my prayer. I keep asking, and asking and asking some more. Noah is the most precious little boy ever. He lights up dark corners of my days with a smile and laughter so big, he is so deserving of the blessings to be able to walk, and talk and sit or even crawl. I long to watch both my boys run together someday side by side. Please God let it be so.


Love,



Noah's Miracle by Stacy Warden is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.

Still Sick...

Noah is still struggling to get better. His cough is now pronounced, although not tremendously frequent. His appetite has been affected, he looks droopy and sad, sometimes I can catch a short smile or laugh in between the cries and moaning. I understand that he is sick, but I can't understand what he wants me to do when he cries. He can't tell me if he's uncomfortable and needs to sit, or lay down, or if he's hurting. I feel like I'm grabbing at straws, as is Chris and his grandma. All three of us taking turns trying to get Noah back to a good spot. I got him to eat cheesecake, he'll drink bottles really only for his daddy, and then there's nothing like falling asleep in the comfort of your grandma's arms. The fever has stayed down, I just assumed Noah would be more perky by now. I worry about him, hoping that pneumonia is all we're battling. They've checked his mouth, and ears and all... but I always worry what if there is just something else I am missing. This is truly a hard spot to be in, harder than I thought it would be when the time came. The lack of communication for me breaks my heart. I want so badly to talk to him... Even with Chris' help I'm down to mere hours of sleep, I cannot stop thinking about Noah and clinging to every sound on the baby monitor, counting his breaths to make sure he's receiving enough oxygen. Making sure I have a phone nearby should I have to place another emergency call for help. I of course am too still battling this illness, the same one I probably gave to him as much as I tried not to. He loves the taste of his antibiotics, which is great. We have no battles over taking medication. In fact when it's done he even gets a little mad that his dose is over and protests briefly. Like I've just taken away his cotton-candy treat. I worry about him not being able to clear his chest and cough things through like other children his age that are mobile. Without us he's stuck laying on the ground continuously. I'd feel so much more at ease if I could see signs that he was completely improving, but just like me, I'm sure this will take him a while to recover from. My hopes are that he'll battle it off quicker than I have been able to. I could tell Chris was a little sad over dinner tonight, he tries really hard not to dwell on Noah's condition, but it's hard to realize that this will be life-long for Noah and for us. He mentioned he'd do anything to make Noah okay and take away all his problems. And he would, this excellent father with an amazing heart would do anything... just anything for his "little buddy." As I write, they are currently snuggling together. As I can hear Chris whispering in his ears sweet nothings in an attempt to help soothe him to sleep. At the end of the day we don't have much, but one thing we're not short on is the love we have for each other. "Anyone can give up, it's the easiest thing in the world to do. But to hold it together when everyone else would understand if you fell apart, that's true strength." — Christopher Reeves Love, Noah's Miracle by Stacy Warden is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.

104.4 Happens... and then you Pray

I knew I couldn't dodge it forever, I wanted to, oh God how I wanted to for safety's sake. The idea of a seizure is beyond terrifying. Noah developed an illness. He didn't look sick, didn't really act sick. But I knew something was wrong when he didn't laugh at the television and acted really lethargic all day. He was hard to wake from a really late nap, which was completely uncharacteristic for him. So I asked Chris to dig out the thermometer out of our hall closet that I stashed way at the top just in case. Sure enough temperature reading of 102.9 at 8:30pm. My stomach sank. These things always seem to happen at night. So off to the hospital we went in the middle of the night. Noah showed no signs of congestion, so I didn't know if this was an infection or what I was up against. They took his temperature when we got there, and it had decreased by mere points. They finally were able to get a normal reading two hours later, and after a strep test, ear check and xrays it was determined that Noah had developed pneumonia. I was surprised because there was no cough to accompany it, but maybe I caught it so quickly there wasn't a cough to go along with it. We were relased of course at almost 2am in the morning, leaving Chris with only a few hours of sleep to function on. Noah's grandma came with us, as we needed all the hands we could get with an ailing Noah. He's getting so big it takes multiple people to hold and pass him off to. My little village of three...Chris, Grandma and I. They couldn't send me home with medication so I of course panic when Noah wakes up this morning with a temperature of a 103. 1 and rises to 104 within twenty minutes. I called Noah's grandma to see if she could find any place that was open to get Advil or Tylenol. And to fill his antibiotic prescription for me as Noah is too sick to leave the house like this. Of course off she went, even though it left her late to work. When something is seriously wrong with Noah it impacts the whole family in big ways. No one really understands, we don't have respite, or a nurse or nanny. We are it. And Noah isn't just a typical child with an illness. This is the first time I truly wish he wasn't non-verbal. Just be able to tell me what is wrong, he doesn't have to say mamma or dadda, just where does it hurt? Where do you not feel well.... I've gotten Noah's fever down to 102.1 for the most part of the morning and then he just spiked suddenly again to 104.4. His primary care physician said that they thought I should take Noah straight back to the hospital and so off we went again, as I called home the troops since they said we could be staying. The thing about ER visits is there is nothing quick about them. You wait and wait and then wait some more. The verdict is still that Noah had pneumonia and that we will alternate tylenol and advil every three hours to attempt to conquer this fever. And of course at the hospital Noah exhibited his first signs of cough. I probably won't sleep for days now as I watch over him praying that God spares him from seizures and allows me to get him well. I wish I could have post-poned this day longer. But you just can't control every little germ on earth no matter how hard you try. And I've tried hard for 27 long months. I've worked so hard to make sure he stayed as healthy as he possibly could. We are very tired, as we've spent more time at the hospital these last two days than we have slept. It's been a rough week for Chris and I. Please pray that Noah will conquer this quickly, and that seizures continue to stay away. He looks and acts so miserable and I just want to see him eating and smiling back at me again very soon. Love, Noah's Miracle by Stacy Warden is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.

The Gait-Trainer Has Arrived

Noah has had a good week, he seems to be really enjoying his new Organic Pedia Smart, and I was lucky enough to score Medicaid assisting us with purchasing it on a regular basis through a local nutrition company. I wish they'd help with his pureed foods and such, but it sounds like we're on our own until he hits age five or is on WIC. I caught a cold, my first in years and I've been petrified I'd pass it to Noah. I'm so thankful for Chris and my mom's help. I don't know what I would do without them, they make trying to guard Noah from this germ a lot easier. I of course have scrubbed my skin off to no end after every kleenex use, trying not to breathe in his direction and am chasing all door handles and anything I can think of in the house with disinfectant toilettes. Nothing paranoid about me, but I know that if Noah gets sick it would be a million times worse for him that it is for me... not that I'm a bit happy about feeling as terrible as I do. But I'm in way prepared to fret over seizures, and an illness for him. Noah got his gait trainer today. A Blue Rifton Pacer. The verdict is still out. It's new. I don't know if he knows what do to yet. It will be a work in progress. And maybe when the weather gets nicer we can get outside and use it a bit more. We don't have a lot of indoor options with our current set-up. His head and trunk control still lacks so he kind of drapes himself over it and doesn't push off with his feet at all. He kind of looks like a limp rag doll. My heart ached for a bit. Not because he didn't automatically take off, it's just getting used to the idea that equipment like this is even necessary for him. This certainly isn't the dream you have for your child to be strapped to all these gadgets and apparatus. Noah also got to trial the cuddlebug. It's purple, but at least it's not pink. It weighs about 45-50lbs, not so cool. And it doesn't collapse down well to get it in and out of vehicles. Those seem to be the automatic drawbacks. And even though it has a sun visor I wish it were a little bit bigger as it won't catch as much sun as some of his stroller canopies do. I like that it's soft and squishy, I think Noah does too. It really feels like you're setting him in a big pillow. It's been crash tested, travel approved, and can also become a seating device. It does look slightly handicapped. But in a way it also kind of looks like a really fancy stroller. Noah seems to like it. He certainly didn't complain at all. We'll have to try it out now for walks or at stores, get a feel if it's a good match. The drawback is if we do really like it, Medicaid will not pay for it. The rehab company stated since they already gave Noah a non-returnable Kid-kart that he hates, that they refuse to purchase a new one for him (even though that purchase was nearly two years ago), Medicaid's position is that the kidcart could be modified as he grows. I asked what our options were and it basically it's to find an outside organization somewhere willing to purchase it (i.e. a church donation). And I keep thinking how am I going to swing that? Somedays you feel like you're begging for help because you don't know what else to do. Our pride and feelings of being self-sufficient were taken from us a long time ago. It's such a hard position to be in. You hate having to ask for help, you really do, it makes you feel like you're nothing. Like you're not mere inches tall as the world looks down on you, waiting to swallow you up as one of "those" that is weaker. Please continue to say a little prayer that Noah can dodge this germ that I'm carrying. And that he learns to stand up in his walker, it would be nice to see him take some steps someday soon. Love, Noah's Miracle by Stacy Warden is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.

Noah's New Gadgets

Noah has had a pretty good week. It was slower than usual for our schedule since some therapy was on spring break this week. Noah and I just watched some of his sprouts grow that I tried to germinate in the house prior to making them fend for themselves outdoors since our nights are still a bit too cold for baby spud survival. I got him a new toothbrush kit, which I'm totally in love with. I wish I had found it months ago for him. It's a vibrating toothbrush and gum stimulator. It doesn't vibrate back and forth like you'd think an adult tooth brush would, but gentle vibrations rather as you brush traditionally. I think it totally makes the need for any Nuk gadget obsolete. Noah actually chases it around in his mouth with his tongue which I have to believe is good exercise for both oral eating and potential speech. But I highly recommend it. I'm very impressed with it. The only draw back is that they don't sell replacement heads yet for the toothbrush, even though it comes with one spare, after that you'd be forced to purchase a brand new pack.

I also found another really cool gadget. It is a soon that screws onto the top of the organic pouch foods, made by Plum Organics. The dispensing soon is fantastic for traveling with. Most children Noah's age could just squeeze the pouch full of food themselves, but since he physically can't do that yet, this attach-on spoon makes it so much easier to feed him in between appointments and therapies, or even at home. I still try to Vitamix what meals I can for him, but realistically we're still dependent on baby food, even though the cost for us is much higher than it would be for most families since Noah cannot eat solids.

We also switched Noah from Pediasure to Organic Pedia Smart. It comes in Vanilla and Chocolate and he seems to really enjoy it. It does taste different than Pediasure, but I think in a rather good way. I'm really excited that he's taking a liking to it, as the ingredients are a lot better for his health long term, and he still isn't a child that will drink juice or plain milk no matter how much I try to encourage it. I'm sure he will eventually, but like with everything with Noah it is just super slow.

Noah seems to be enjoying his newly decorated room, minus the fact that we can't get his stickers to stick properly to his wall. That's really what you get for trying to decorate on a shoe string. Creatively I'm currently trying to figure out ways to get them to stick better without making them permanent like wallpaper. So far I've found that the Creative Memories Scrapbooking Frosted Photo Splits are doing the best job. But just as you get one to stay up, another one falls.

Noah's gait trainer is also destined to arrive April 5th. I'm guarding my excitement as I hope he'll walk in it, but I don't know for sure. I remain hopeful that he'll find a way to walk in it and really have a mobile opportunity during the summer months when we can take his walker outside. I think we only have a couple of neighbors that know that Noah is special needs, so I'm sure as we walk around the block we'll have lots of questions since in a stroller he looks pretty much like an average toddler. There won't be much room to use the walker indoors due to our house design. Please continue to say little prayers that Noah continues to grow stronger, and that with each day he finds more freedom in movement. That he will find a way someday to walk and talk. Love,

Noah's Miracle by Stacy Warden is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.

Happy St. Patrick's Day

Spring is in the air, I can smell it and hear those delicate birds that seem to appear right at the sign of better weather on the horizon, and my rock garden is starting to come alive, baby crocus blooms already risen, just awaiting their tulip companions next to them. Which means I'm that much closer to planting Noah's special garden.

I already planted him some tomatoes, sweet peppers and herbs in the house last weekend. I pray they grow, I'm not great with seeds, I do far better with starter plants, but it was really important to start something from seed this year to me. To watch it grow, and help and nurse it along until it gets healthy and strong and ready to pick. I put Noah's feet in the dirt while I was planting. It didn't go so well, the soil was so soft out of the bag that I think he felt like his feet were sinking and disappearing. I keep trying to open his world to new sensory opportunities, but it was just too much too soon. He cried for a half an hour after wards and I felt terrible that I had tried to offer him a new experience that he simply wasn't ready for.

I found a really great deal on soil, Chris had to travel some distance to retrieve it, but it was nice that we got almost a $4.00 discount per bag, which is great when you're after organic certified soil with very little funds for projects. Chris came back and had to tell me that some soils even contain bat poop, like it was an important fact I needed to know right away. It sure gives a different meaning to what my grandmother used to call chicken high-high. I guess she would have called that bat high-high? In any event, I also found a sign that will read Miracle Garden on a stake that I can put in Noah's little garden. I think it will be the perfect little accessory. The garden will get lots of sun, partial shade and fabulous moonlight.

I also got confirmation that Noah's gait-trainer has finally made it off of suspended status and was approved. Yes I know I was ready to fall over myself when I got the call. I don't know if I'll be as lucky to get that news with a stander or new chair. Noah has also had his weighted blanket about a week. http://www.affordableweightedblankets.com It makes him really hot, so we had to pack away the feeted fleece jammies, and opt for the cooler spring line. I can't say it's really made a huge difference in his sleeping patterns, but he doesn't hate it. But come summer we won't be able to use it at all since our home has no air conditioning and a window unit is not an option in his front facing room. We all roast sleeping on the top story of this home.

Noah's Weighted Blanket

Now that Noah is getting his gait trainer I suppose I need to look into finding a way to make the house a little bit more handicapped accessible. I really don't know where to start. I guess I see us a bit stranded. I anticipate there is no organization out there that covers the entire amount to come in and put in new floors and get rid of your carpet, and Chris and I don't have two pennies to rub together for such an endeavor, we're just doing the best we can to maintain a roof over our heads and get Noah all the therapy we can.

We also re-decorated Noah's room with little wall stickers and I think it turned out really cute. Noah seems to be calm in there when I change his diaper and clothes so I think he in his own way understands it's his space. I wish he had the ability to come and go and play in there as he chose, but he still spends the majority of his day on a blanket in the family room with me watching TV and doing therapy. The summer gives us a little bit more options because I can take him outside and lay him on his therapy mat and he can watch airplanes go by, watch for butterflies and hear the birds chirping. He also loves to watch the leaves move on our neighbor's massive tree.

Noah had a great St. Patrick's Day, (he gets that from my side...) He sported his green, even ate his Ella's Organic Kitchen Apple, Rutabaga, Spinach meal for lunch which even looked like liquefied shamrocks. He did well at pool therapy, he wasn't as grumpy today. Some of his therapists have encouraged me to explore a local hippo therapy place and cranial sacral therapy to assist Noah in his continued struggle to gain head and trunk control. http://en.wikipedia.org/wiki/Craniosacral_therapy However it doesn't matter if a doctor, or a therapist recommends any and all of these things, as insurance won't help us pay for it. That's such the tough part. You have experts in their field advising you to attempt these therapies, yet you can't afford them out of pocket. It lays heavy on my heart a lot. Because it gives you that inner failure feeling. His therapist gave me all the brochures on them. I haven't sprung it on Chris yet, as I'm not sure he can take much more, he's financially doing his very best to provide for his family in all the best ways. And in his heart I know he wants all we can do for Noah too.

I also researched this little place in Florida that does dolphin therapy.
http://www.islanddolphincare.org Although Noah is too young for it now, and lacks the head control I think he would need at this time. I envision that if Chris and I ever lucky enough to leave home it will be to some place for a type of therapy to help Noah. I most certainly don't see Hawaii, Italy, or New Zealand in our future. Nor do I think we'll get to experience typical vacation family spots. Special needs is life altering, and it alters every single thing in your lives.

Hopefully Noah will take a nap before the corned beef & cabbage dinner is ready, and we'll have a quiet night at home working on vestibular motion and occupational therapy brushing for tactile sensory stimulation. Just a another day in the life...

Love,



Noah's Miracle by Stacy Warden is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.

"The Label"

Noah received his official cerebral palsy diagnosis this week: quadriplegia.

I know it's just a label. I'm sad that Noah will carry any type of label no matter what the verdict would have been, but at the same time I think I've done well not being crushed by the type of cerebral palsy. I've had two years to know that eventually a official label would follow. I admit I had hoped it would be diplegia or even hemiplegia. Somehow I had convinced myself that Noah's chances at sitting, crawling, walking and talking would be greater with either of those two. But it's just a title, a name, a word. It shouldn't define Noah's chances. I just have to keep reminding myself of that. That this does not mean that Noah's reached the end of all he might ever be able to do.

Noah had occupational therapy today. I was a bit disappointed that we were supposed to look into a stander today, although the equipment specialist did not show even though we had this date calendared for at least a month. No status on his gait trainer, no status on the cuddlebug that I was assured would take two weeks or less for us to see... I'm a bit disappointed that I feel like the ball is getting dropped once again. Which means more phone calls to make to see if I can get it all coordinated on Noah's behalf. Noah did well at therapy today. He still very much likes his swings and of course I have to take his portable TV along for a distraction. It's almost like his security blanket. It helps him block out other things he can't handle. He only gagged once at therapy today when he was touching the rope to the swing.

We also broke down and purchased Noah a weighted blanket. It arrived today. It's a rather small blanket for being $80, but they are all custom made for each child, and Chris and I are praying that it agrees with Noah and helps with sleeping hours. There are so many other things we need to purchase for Noah, this long list is growing and none of it insurance will go near. He uses this special life jacket with a hood at pool therapy, that we need to order, along with a nemo floaty (which I happened to spot at Target but didn't price). I know the life jacket will be a special order item. I'm trying to get Noah to drink from a sippee cup, but we haven't found one yet that is agreeing with him, and he doesn't want to drink sitting up, he still prefers to be laying down with a regular bottle. He also did really well with handicapped paintbrushes and things in sensory class, things that I don't have at the house to practice with. Things that seem small but that add up to hundreds very quickly.

We looked into litegait training, and our out-of-home therapy center no longer carries it, and families are renting them in home. However that is not an option for us. We cannot afford the $350 monthly, the $250 shipping and the $200 deposit. Not to mention we don't have a therapy treadmill to accompany it. Even if I could find a way to get the money, it sounds like a type of therapy that would be best supervised with a professional. So that one will be going on the back burner.

Noah has also given me the potty lip lately, a prelude before the cry. Which is new. Oddly many have asked me this week if I think Noah is cognitively on target for age two. I don't know. He has no words, no way to play age appropriately. I'd like to think he's just locked in physically and understands it all, but I don't know. I know that with quadriplegia they say there is a higher likelihood of mental impairments that also accompany the physical. I'm just trying not to think about it much. I don't want to overwhelm myself with emotions or thoughts of things that I have no control over. I just have to turn it over to God for now. The worry is exhausting and can even be paralyzing if you let be.

Chris built Noah's garden last weekend. It is exactly how I pictured it to be. Now I am searching to find some OMRI Certified Organic Dirt to put in it, so I can start his little seedlings. And hopefully I can make a little sign to hang from him garden titled Noah's Miracle Garden.

I've been so busy with Noah's appointments that I totally forgot that I needed to think about giving up something for lent. I received all these emails (late) as my computer has been down for sometime, with declarations of intentions for lent. I remember the days when I would give up buying a pair of new shoes... the days when things were beyond easy. I received an email from a friend who also has cerebral palsy declaring they had already given up everything; the ability to self-feed, dress, bathe or care for themselves, asking what more could God expect them to give up? I understand that feeling.. when you say how much more. As I grow older, and travel this special needs journey with Noah I see things differently than I ever did before. For me it's not about giving up chocolate, or my favorite latte, or quitting sweets or not eating white bread... to me it's a time to think about Heart, Soul, Strength and Mind. It's a time for reflection. To spend more time thinking about where I am with God emotionally, to think about spending ten minutes more a day in prayer, finding the strength and courage to persevere, closeting the tears and the pain and finding more faith, remembering to be a person that comforts others in times of great need. Giving up one desire for lent isn't going to bring me any closer to God... but hopefully a collection of other things will. No matter what God is always there, no matter how much I worry, stress, cry or fret over Noah he holds my hand through my day. I feel this silent encouragement, I am trying to listen for I need all the wisdom I can gather.

A Lenten Reflection
Give up complaining——focus on gratitude.
Give up pessimism——become an optimist.
Give up harsh judgments——think kindly thoughts.
Give up worry——trust Divine Providence.
Give up discouragement——be full of hope.
Give up bitterness——turn to forgiveness.
Give up hatred——return good for evil.
Give up negativism——be positive.
Give up anger——be more patient.
Give up pettiness——become mature.
Give up gloom——enjoy the beauty that is all around you.
Give up jealousy——pray for trust.
Give up gossiping——control your tongue.
Give up sin——turn to virtue.
Give up giving up——hang in there!
unknown

Love,


Noah's Miracle by Stacy Warden is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.