Chapter 13Developmental Disorders &
Cognitive Disorders
Nature of Developmental Psychopathology: An Overview
Normal vs. Abnormal Development
Developmental Psychopathology
– Study of how disorders arise and change with time
– Disruption of early skills can affect later development
DSM-IV TR has 43 different categories/types
Mental Health vs. Educational categories – IDEA 2004
IDEA 97 Categories - PL 105-17IDEA 97 Categories - PL 105-17IDEA 2004 – (Same)IDEA 2004 – (Same)
Individual Disabilities Education ActIndividual Disabilities Education Act
Blind or Visually Impaired Hearing impaired (includes
deaf) Orthopedic Other Health Impaired Mentally Retarded Specific Learning Disability Autism
Emotional Disturbance Speech & Language Impaired Traumatic Brain Injury Developmental Delay (DD) <
age 9 Needs special education
services
Kentucky Regulations - IDEA
Mental Disability (mild/functional)
Hearing impairments Communication Disorders Visual Impairment Emotional Behavioral
Disability Autism Deaf-Blind
Orthopedic/physically disabled Traumatic Brain Injury Other Health Impaired Specific Learning Disability Multiple Disabilities Developmental Delay (DD)
<age 9
Nature of Developmental Psychopathology: An Overview (continued)
Developmental Disorders
– Diagnosed first in infancy, childhood, or adolescence (43 diagnoses)
– Attention deficit hyperactivity disorder (ADHD)
– Learning disorders
– Autism
– Mental retardation
Attention Deficit HyperactivityDisorder (ADHD): An Overview
Nature of ADHD
– Central features – Inattention, overactivity, and impulsivity
– Associated with numerous impairments
Behavioral
Cognitive
Social and academic problems
Attention Deficit HyperactivityDisorder (ADHD): An Overview (continued)
DSM-IV-TR Symptom Types
– Inattentive type
– Hyperactive type
– Impulsive type
ADHD: Facts and Statistics
Prevalence
– Occurs in 6% of school-aged children
– Symptoms are usually present around age 3 or 4
– 68% of children with ADHD have problems as adults
ADHD: Facts and Statistics (continued)
Gender Differences
– Boys outnumber girls 4 to 1
Cultural Factors
Probability of ADHD diagnosis
– Greatest in the United States
The Causes of ADHD: Biological Contributions
Genetic Contributions
– ADHD seems to run in families
– DRD4, DAT1, and DRD5 genes have been implicated
The Causes of ADHD: Biological Contributions (continued)
Neurobiological Contributions
– Smaller brain volume
– Inactivity of the frontal cortex and basal ganglia
– Abnormal frontal lobe development and functioning
The Causes of ADHD: Biological Contributions (continued)
The Role of Toxins
– No evidence that allergens and food additives are causes
– Maternal smoking increases risk
The Causes of ADHD: Psychosocial Contributions
Psychosocial Factors
– Can influence the nature of ADHD
– ADHD children are often viewed negatively by others
– Constant negative feedback from peers and adults
– Peer rejection and resulting social isolation
– Such factors foster low self-esteem
Biological Treatment of ADHD
Goal of Biological Treatments
– To reduce impulsivity and hyperactivity and to improve attention
Stimulant Medications
– Reduce core symptoms in 70% of cases
– Examples include Ritalin, Dexedrine
Biological Treatment of ADHD (continued)
Other Medications With More Limited Efficacy
– Imipramine and Clonidine (antihypertensive)
Effects of Medications
– Improve compliance and decrease negative behaviors
– Do not affect learning and academic performance
– Benefits are not lasting following discontinuation
Behavioral and Combined Treatment of ADHD
Behavioral Treatment
– Reinforcement programs
To increase appropriate behaviors
Decrease inappropriate behaviors
– May also involve parent training
Behavioral and Combined Treatment of ADHD (continued)
Combined Bio-Psycho-Social Treatments
– Are highly recommended
– Superior to medication or behavioral treatments alone
Learning Disorders: An Overview
Scope of Learning Disorders
– Academic problems in reading, mathematics, and writing
– Performance substantially below expected levels
Learning Disorders: An Overview (continued)
DSM-IV-TR Reading Disorder
– Discrepancy between actual and expected achievement
– Performance significantly below age or grade level
– Cannot be caused by sensory deficits
Learning Disorders: An Overview (continued)
DSM-IV-TR Mathematics Disorder
– Achievement below expected performance
DSM-IV-TR Disorder of Written Expression
– Achievement below expected performance in writing
Learning Disorders: Some Facts and Statistics
Prevalence of Learning Disorders
– 5-10% prevalence in the United States
– Highest in wealthier regions of the United States
– About 32% of these students drop out of school
– 5-15% prevalence for reading difficulties
– School experience tends to be generally negative
Fig. 13.1, p. 514
Biological and Psychosocial Causes of Learning Disorders
Genetic and Neurobiological Contributions
– Reading disorder runs in families
– 100% concordance rate for identical twins
– Evidence for subtle forms of brain damage is inconclusive
– Overall, contributions are unclear
Psychosocial Contributions are Largely Unknown
Treatment of Learning Disorders
Requires Intense Educational Interventions
– Remediation of basic processing problems
– Improvement of cognitive skills
– Targeting skills to compensate for problem areas
Data Support Behavioral Educational Interventions
Pervasive Developmental Disorders: An Overview
Nature of Pervasive Developmental Disorders
– Problems occur in Language, Socialization, and Cognition
– Pervasive – Problems span many life areas
Examples of Pervasive Developmental Disorders
– Autistic disorder
– Asperger’s syndrome
The Nature of Autistic Disorder: An Overview
Autism – Significant Impairments
– Social interactions and communication
– Restricted patterns of behavior, interest, and activities
The Nature of Autistic Disorder: An Overview (continued)
Three Central DSM-IV-TR Features of Autism
– Qualitative impairment of social interaction
– Problems in communication
50% never acquire useful speech
– Restricted patterns of behavior, interests, and activities
Autistic Disorder: Facts and Statistics
Prevalence and Features of Autism – 1 in every 500 births
– More prevalent in females with IQs below 35
– More prevalent in males with higher IQs
– Occurs worldwide
– Symptoms usually develop before 36 months of age
Autistic Disorder: Facts and Statistics (continued)
Autism and Intellectual Functioning
– 50% have IQs in the severe-to-profound range
– 25% test in the mild-to-moderate IQ range
– Remaining test in the borderline-to-average IQ range
Reliable indicators of good prognosis
– Language ability and IQ
Causes of Autism: Early and More Recent Contributions
Historical Views
– Bad parenting
– Unusual speech patterns
– Lack of self-awareness
– Echolalia
Causes of Autism: Early and More Recent Contributions (continued)
Current Understanding of Autism
– Medical conditions – Not always related with autism
– Genetic component is largely unclear
– Neurobiological evidence of brain damage
– Substantially reduced cerebellum size
Psychosocial Contributions Are Unclear
Asperger’s Disorder: Part of the Autistic Spectrum
The Nature of Asperger’s Disorder
– Show significant social impairments
– Restricted and repetitive stereotyped behaviors
– May be clumsy
– Often quite verbal
– No severe language and/or cognitive delays
Asperger’s Disorder: Part of the Autistic Spectrum (continued)
Prevalence of Asperger’s Disorder
– Often under diagnosed
– Affects about 1 to 36 persons per 10,000 people
Causes of Asperger’s Disorder Are Somewhat Unclear
Treatment of Pervasive DevelopmentalDisorders: Example of Autism
Psychosocial “Behavioral” Treatments
– Skill building
– Reduction of problem behaviors
– Target communication and language problems
– Address socialization deficits
– Early intervention is critical
Treatment of Pervasive DevelopmentalDisorders: Example of Autism (continued)
Biological and Medical Treatments Are Unavailable
Integrated Treatments: The Preferred Model
– Focus on children, their families, schools, and home
– Build in appropriate community and social support
Mental Retardation (MR): An Overview
Nature of Mental Retardation/Intellectual Disability (new term)
– Disorder of childhood
– Below-average intellectual and adaptive functioning
– Range of impairment varies greatly across persons
Mental Retardation (MR): An Overview (continued)
DSM-IV-TR criteria
– Significantly sub-average intellectual functioning
– Deficits or impairments in present adaptive functioning
– Must be evident before the person is 18 years of age
DSM-IV-TR Levels of Mental Retardation (MR)
Mild MR/ID
– IQ score between 50 or 55 and 70
Moderate MR/ID
– IQ range of 35-40 to 50-55
Severe MR/ID
– IQs ranging from 20-25 up to 35-40
Profound MR/ID
– IQ scores below 20-25
Other Classification Systems for Mental Retardation (MR)
American Association of Mental Retardation (AAMR)
– Defines MR based on levels of assistance required
– Levels of assistance
Intermittent, limited, extensive, pervasive
Other Classification Systems for Mental Retardation (MR) (continued)
Classification of MR/ID in Educational Systems
– Educable (IQ of 50 to 70-75)
– Trainable (IQ of 30 to 50)
– Severe (IQ below 30)
Implications of Different MR/ID Classification Systems
Mental Retardation (MR)/Intellectual Disabilities (ID): Some Facts and Statistics
Prevalence
– About 1-3% of the general population
– 90% are labeled with mild mental retardation
Mental Retardation (MR): Some Facts and Statistics (continued)
Gender Differences
– MR occurs more often in males
– Male-to-female ratio of about 1.6:1
Course of MR
– Tends to be chronic
– Prognosis varies greatly from person to person
Causes of Mental Retardation (MR):Biological Contributions
Hundreds of known causes
– Environmental – Deprivation, abuse
– Prenatal – Exposure to disease or a drug / toxin
– Perinatal – Difficulties during labor
– Postnatal – Head injury
Causes of Mental Retardation (MR):Biological Contributions (continued)
Genetic Research
– Multiple genes, and at times single genes
Chromosomal Abnormalities
– Down syndrome and Fragile X syndrome
Maternal Age and Risk of Having a Down’s Baby
Nearly 75% of Cases Have No Known Cause
Causes of Mental Retardation (MR):Psychosocial Contributions
Cultural-Familial Retardation
– Believed to cause about 75% of MR cases
– Is the least understood
– Associated with
Mild levels of retardation on IQ tests
Good adaptive skills
Causes of Mental Retardation (MR):Psychosocial Contributions (continued)
Difference vs. Developmental Views
– Difference view - Kind and degree of impairment
– Developmental view – Rate of developmental delay
Treatment of Mental Retardation (MR)
Parallels Treatment of Pervasive Developmental Disorders
Teach Needed Skills
– To foster productivity
– To foster independence
– Educational and behavioral management
– Living and self-care skills via task analysis
– Communication training – Often most challenging
Treatment of Mental Retardation (MR) (continued)
Community and Supportive Interventions
– Persons with MR can benefit from such interventions
Summary of Developmental Disorders
Developmental Psychopathology
Attention Deficit Hyperactivity Disorder
– Deficits in attention, hyperactivity, or impulsivity
Learning Disorders
– Deficits in performance below expectations
Summary of Developmental Disorders (continued)
Pervasive Developmental Disorder
– All share deficits in language, socialization, and cognition
Mental Retardation
– Sub-average IQ, deficits in adaptive functioning
– Onset before age 18
Prevention and Early Intervention Are Critical
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Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
New additions Posttraumatic Stress Disorder in Preschool Children Temper Dysregulation Disorder with Dysphoria Callous and Unemotional Specifier for Conduct Disorder Learning Disabilities Non-Suicidal Self Injury Non-Suicidal Self Injury Not Otherwise Specified Language Impairment Late Language Emergence Specific Language Impairment Social Communication Disorder Voice Disorder
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Reclassification Pica: Move to Eating Disorders Rumination Disorder: Move to Eating Disorders Feeding Disorder of Infancy or Early Childhood: Move to
Eating Disorders; Renamed Avoidant/Restrictive Food Intake Disorder
Separation Anxiety Disorder: Moved to Anxiety Disorders
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Disorders to be removed Expressive Language Disorder Mixed Receptive-Expressive Language Disorder Communication Disorder Not Otherwise Specified Rett's Disorder
Reactive Attachment Disorder of Infancy or Early Childhood: Division into Reactive Attachment Disorder of Infancy or Early Childhood & Disinhibited Social Engagement Disorder
Disorder of Written Expression and Learning Disorder Not Otherwise Specified: Subsumed under Learning Disorder
Childhood Disintegrative Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder: Subsumed under Autistic Disorder (Autism Spectrum Disorder)
ADHD
A. Either (1) and/or (2) 1. Inattention 2. Hyperactivity and Impulsivity
B. Several noticeable inattentive or hyperactive-impulsive symptoms were present by age 12.
C. The symptoms are apparent in two or more settings (e.g., at home, school or work, with friends or relatives, or in other activities).
D. There must be clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).
Specifiers: Combined, Predominately Inattentive, Predominately
Hyperactive/Impulsive, Inattentive (Restrictive)
Communication & Learning Disorders
Phonological Disorder: Renamed to Speech Sound Disorder Stuttering: Renamed to Childhood Onset Fluency Disorder Reading Disorder: Renamed to Dyslexia Mathematics Disorder: Renamed to Dyscalculia
Mental Retardation
Mental Retardation: Renamed Intellectual Disability Mental Retardation, Severity Unspecified: Renamed to
Intellectual or Global Developmental Delay Not Further Specified
Autistic (Autism Spectrum) Disorder
Autistic Disorder: Renamed Autism Spectrum Disorder Must meet criteria A, B, C, and D
A. Persistent deficits in social communication and social interaction across contexts
B. Restricted, repetitive patterns of behavior, interests, or activities
C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)
D. Symptoms together limit and impair everyday functioning
Tic Disorders
Tic Disorders Tourette’s Disorder Chronic Motor or Vocal Tic Disorder Transient Tic Disorder Tic Disorder NOS
All proposed to be classified as Neurodevelopmental Disorders
Medical Conditions Related to Delirium
Medical Conditions
– Drug intoxication, poisons, withdrawal from drugs
– Infections
– Head injury and several forms of brain trauma
– Sleep deprivation, immobility, and excessive stress
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Nature of Cognitive Disorders: An Overview
Perspectives on Cognitive Disorders
– Affect learning, memory, and consciousness
– Most develop later in life
Nature of Cognitive Disorders: An Overview (continued)
Three Classes of Cognitive Disorders
– Delirium – Temporary confusion and disorientation
– Dementia – Marked by broad cognitive deterioration
– Amnestic disorders – Memory dysfunctions
Nature of Cognitive Disorders: An Overview (continued)
Shifting DSM Perspectives
– From “organic” mental disorders to “cognitive” disorders
– Broad impairments in cognitive functioning
– Profound changes in behavior and personality
Delirium: An Overview
Nature of Delirium
– Central features – Impaired consciousness and cognition
– Develops rapidly over several hours or days
– Appear confused, disoriented, and inattentive
– Marked memory and language deficits
Delirium: An Overview (continued)
Facts and Statistics
– Affects 10% to 30% of persons in acute care facilities
– Most prevalent in older adults
Those undergoing medical procedures
AIDS patients and cancer patients
– Full recovery often occurs within several weeks
Medical Conditions Related to Delirium (continued)
DSM-IV-TR Subtypes of Delirium
– Delirium due to a general medical condition
– Substance-induced delirium
– Delirium due to multiple etiologies
– Delirium not otherwise specified
Treatment and Prevention of Delirium
Treatment
– Attention to precipitating medical problems
– Psychosocial interventions include reassurance
Focus on coping strategies
Inclusion of patients in treatment decisions
Treatment and Prevention of Delirium (continued)
Prevention
– Address proper medical care for illnesses
– Address proper use and adherence to therapeutic drugs
Dementia: An Overview
Nature of Dementia
– Gradual deterioration of brain functioning
– Deterioration in judgment and memory
– Deterioration in language / advanced cognitive processes
– Has many causes and may be irreversible
Dementia: Initial and Later Stages
Initial Stages
– Memory and visuospatial skills impairments
– Agnosia – Inability to recognize and name objects
– Facial agnosia – Inability to recognize familiar faces
– Other symptoms
Delusions, apathy, depression, agitation, aggression
Dementia: Initial and Later Stages (continued)
Later Stages
– Cognitive functioning continues to deteriorate
– Total support is needed to carry out day-to-day activities
– Death due to inactivity and onset of other illnesses
Dementia: Facts and Statistics
Onset and Prevalence
– Can occur at any age, but most common in the elderly
– Affects 1% of those between 65-74 years of age
– Affects over 10% of persons 85 years and older
Dementia: Facts and Statistics (continued)
Incidence of Dementia
– Affects 2.3% of those 75-79 years of age
– Affects 8.5% of those 85 and older
– Rates seem to double with every 5 years of age
Dementia: Facts and Statistics (continued)
Gender and Sociocultural Factors
– Occurs equally in men and women
– Occurs equally across educational level and social class
DSM-IV-TR Classes of Dementia
Dementia of the Alzheimer’s type
Vascular Dementia
Dementia Due to Other General Medical Conditions
Substance-Induced Persisting Dementia
Dementia Due to Multiple Etiologies
Dementia Not Otherwise Specified
Dementia of the Alzheimer’s Type: An Overview
DSM-IV-TR Criteria and Clinical Features
– Multiple cognitive deficits
– Develop gradually and steadily
– Memory, orientation, judgment, and reasoning deficits
– Additional symptoms may include
Agitation, confusion, or combativeness
Depression and/or anxiety
– “Sundowner syndrome”
Dementia of the Alzheimer’s Type: Extent of Deficits
Range of Cognitive Deficits
– Aphasia – Difficulty with language
– Apraxia – Impaired motor functioning
– Agnosia – Failure to recognize objects
Dementia of the Alzheimer’s Type: Extent of Deficits (continued)
– Difficulties with
Planning
Organizing
Sequencing
Abstracting information
– Negative impact on social and occupational functioning
An Autopsy Is Required for a Definitive Diagnosis
Alzheimer’s Disease: Some Facts and Statistics
Nature and Progression of the Disease
– Deterioration is slow during the early and later stages
– Deterioration is rapid during middle stages
– Average survival time is about 8 years
– Onset usually occurs in the 60s or 70s
Alzheimer’s Disease: Some Facts and Statistics (continued)
Prevalence of Alzheimer’s Disease
– About 4 million Americans and many more worldwide
– Prevalence greater in
Poorly educated persons and females
– Prevalence rates are low in some ethnic groups
10 Warning Signs of Alzheimer’s Disease
1. Memory loss that disrupts daily life 2. challenging in planning or solving problems 3. Difficulty completing familiar tasks 4. Confusion as to time and place 5. Trouble understanding visual images and spatial
relationships 6. New problems with words in speaking and writing 7. Misplacing things and losing the ability to retrace steps 8. Decreased or poor judgment 9. Withdrawal from work or social activities 10. Change in mood or personality
See – www.alz.org
Vascular Dementia: An Overview
Nature of Vascular Dementia
– Caused by blockage or damage to blood vessels
– Second leading cause of dementia next to Alzheimer’s
– Onset is often sudden (e.g., stroke)
– Patterns of impairment are variable
– Most require formal care in later stages
Vascular Dementia: An Overview (continued)
DSM-IV-TR Criteria and Incidence
– Cognitive disturbances – Identical to dementia
– Obvious neurological signs of brain tissue damage
– Incidence is about 4.7% of men and 3.8% of women
Other Causes of Dementia:HIV
HIV
– Causes neurological impairments and dementia
– Cognitive slowness, impaired attention, and forgetfulness
– Apathy and social withdrawal
Other Causes of Dementia:Head Trauma
Head Trauma – Accidents are leading cause
– Memory loss is the most common symptom
Other Causes of Dementia:Parkinson’s Disease
Parkinson’s Disease – Degenerative brain disorder
– Affects about 1 out of 1,000 people worldwide
– Motor problems – Central feature of this disorder
Caused by damage to dopamine pathways
– Impairments appear similar to sub-cortical dementia
Other Causes of Dementia:Huntington’s
Huntington’s Disease
– Genetic autosomal dominant disorder
– Manifests initially as chorea, usually later in life
– About 20-80% display dementia
– Dementia also follows a subcortical pattern
Other Causes of Dementia:Pick’s Disease
Pick’s Disease
– Rare neurological condition
– Produces a cortical dementia like Alzheimer’s
– Also occurs later in life (around 40s or 50s)
– Little is known about what causes this disease
Other Dementias: Creutzfeldt-Jakob Disease
Creutzfeldt-Jakob Disease
– Affects 1 out of 1,000,000 persons
– Linked to mad cow disease
Other Dementias: Substance-Induced Dementia
Substance-Induced Persisting Dementia
– Results from drug use in combination with poor diet
– Several drugs can lead to symptoms of dementia
– Resulting brain damage may be permanent
Other Dementias: Substance-Induced Dementia (continued)
– Dementia is similar to that of Alzheimer’s
– Deficits may include
Aphasia, apraxia, agnosia
Disturbed executive functioning
Causes of Dementia: The Example of Alzheimer’s Disease
Early and Largely Unsupported Views
– Implicated aluminum and smoking
Causes of Dementia: The Example of Alzheimer’s Disease (continued)
Current Neurobiological Findings
– Neurofibrillary tangles
– Amyloid plaques
– The role of deterministic genes
Beta-amyloid precursor gene
Presenilin-1 and Presenilin-2 genes
– The role of susceptibility genes - ApoE4 gene
– Brains of Alzheimer’s patients tend to atrophy
Causes of Dementia: The Example ofAlzheimer’s Disease (continued)
Current Neurobiological Findings
– Multiple genes are involved in Alzheimer’s disease
– Chromosomes 21, 19, 14, 12, 1
– Chromosome 14
Associated with early onset Alzheimer’s
– Chromosome 19
Associated with a late onset Alzheimer’s
The Contributions of Psychosocial Factors in Dementia
Psychosocial Factors
– Do not cause dementia directly
– May influence onset and course
– Lifestyle factors – Drug use, diet, exercise, stress
The Contributions of Psychosocial Factors in Dementia (continued)
– Cultural factors
Risk for certain conditions vary by ethnicity and class
– Psychosocial factors
Educational attainment
Coping skills
Social support
Medical and Psychosocial Treatment of Dementia
Medical Treatment: Best if Enacted Early
– Few exist for most types of dementias
– Most attempt to slow progression of deterioration
– Do not stop progression of dementia
Medical and Psychosocial Treatment of Dementia (continued)
Psychosocial Treatments - Aims
– To enhance lives of patients and their families
– To teach compensatory skills
– To use memory enhancement devices, if needed
– Psychosocial interventions appear to focus on caregivers
Prevention of Dementia
Reducing Risk of Dementia in Older Adults
– Estrogen-replacement therapy
– Proper treatment of cardiovascular diseases
– Use of anti-inflammatory medications
Other Targets of Prevention Efforts
– Increasing safety behaviors to reduce head trauma
– Reducing exposure to neurotoxins and use of drugs
Amnestic Disorder: An Overview
Nature of Amnestic Disorder
– Circumscribed loss of memory
– Inability to transfer information into long-term memory
– No loss of other high-level cognitive functions
Amnestic Disorder: An Overview (continued)
Causes May Include
– Medical conditions, head trauma, or long-term drug use
DSM-IV-TR Criteria
– Inability to
Learn new information or recall learned information
– Significant impairment in functioning
Amnestic Disorder: An Overview (continued)
The Example of Wernicke-Korsakoff Syndrome
– Damage to the thalamus
– Thiamine (Vitamin B-1) deficiency
– Resulting from stroke or chronic heavy alcohol use
Prevention
– Use of thiamine supplements with heavy drinkers
Research on Amnestic Disorders Is Scant
Summary of Cognitive Disorders
Cognitive Disorders Span a Range of Deficits
– Affect attention, memory, language, and motor behavior
– Causes include
Medical conditions
Drug use
Environmental factors
Summary of Cognitive Disorders (continued)
Most Result in Progressive Deterioration of Functioning
Few Treatments Exist to Reverse Damage and Deficits
Table 13.1, p. 540
Table 13.2, p. 543
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