Attention Deficit Hyperactive Disorder : The Turmoil Within

March 29, 2008

(the following article was written in partial fulfillment of the requirements for graduate class in psychopathology and counseling class)

TABLE OF CONTENTS

PREFACE

WHAT IS ADHD?

ETIOLOGY OF ADHD

THE NATURE OF THE DISORDER

ADHD SOCIETAL ISSUES

WHAT LIES AHEAD FOR ADHD?

ADHD IN THE PHILIPPINES – WHAT CAN WE DO?

RECOMMENDATIONS TO THE PARENTS OF AN ADHD CHILD IN THE

COUNTRY

REFERRENCES

Preface

I have two unforgettable encounters with Attention Deficit Hyperactive Disorder. I wish I knew then what I know now about this disorder. My past experiences with ADHD provided the faces and the voices as I researched the material, in partial fulfillment of the requirements for my Psychopathology and Counseling Class. I went through the materials while hearing Mike G. at the back of my mind, and the concerned questions of the parents of ADHD children I got to meet earlier this year.

Writing this paper made me want to go back to four years ago and tell Mike G. that now, I understand what he felt and the shame he tried to hide. Writing this paper made me want to retrace several months so I can encourage a worried father that his ADHD son has a good future ahead of him – but this will entail more understanding and sacrifice on his part. If I knew then what I know now, I would have offered lavish praises to a mother who sacrificed her growing career in Singapore to be with her son who has ADHD.

What I encountered here are the issues they continually face. How their child is going to be properly diagnosed? What can they do as parents? What does the future hold for their child who cannot control his impulses? While I cannot tell all their stories – I would like to write about Mike. The very first person that showed me what it is like to live in an ADHD world.

I met Mike G. when I was working as a Counselor at the 1994 Summer Educational Program of the Worldwide Church of God in Orr, Minnesota. Mike, who was from Pennsylvania, came into Dorm 5B along with 23 other teens to form part of the population of 288 teens for that session. With his thick eyeglasses and his gangly frame and his preponderance for reading sci-fi fictions, he did not leave such an impression – just a 16 –year old with the need for regular medications. Part of the instructions I received from the camp nurse was a duty to remind Mike to consistently take his medications everyday right after our breakfast.

I did not stumble into this ADHD secret until after the first week, when I had to check again all their medical forms and see how they would be divided for their 4-day canoe trip to the boundary waters of Canada and US. Based on what I have seen and what they can do, I still would have to assess their medical fitness from the forms duly accomplished before they came. Mike’s medical form caught my attention because of the large four capital letters written on it at the bottom: “ADHD – Attention Deficit Hyperactive Disorder.”

Due to my medical ignorance on the topic – I was amazed how someone could be sick because he is not getting enough attention. And so during the rest of the camp – I paid Mike a lot of attention and gave him tons of encouragement and praises – thinking that I was helping this teen get over whatever it was that was making him sick.

Little did I know that the medication he was took everyday right after breakfast, was necessary for him to take an active part at camp – otherwise, he was just going to be totally hyperactive and would not be able to focus at all.

Later on, I would realize that it was something would call for more than a thorough encouragement from a youth worker like me no matter how well intentioned one can be.

The second encounter with ADHD occurred early this year – on January 10,1999. I was asked by a physical therapist friend to give a pep talk to parents of children with ADHD. At that time, I still knew very little of what it was like for them

as parents of ADHD children – so I focused my little talk on how God sends encouragement to us even in very specific ways. Since I did not have much experience to draw upon, I told them about my encounter with Mike and the lessons I learned from not knowing what ADHD was all about.

That is why this paper is not for medical professionals though the sources have been medical books and medical centers’ websites and the like. Same reason why this paper is not for psychiatrists who may have already some deeply ingrained concepts and procedures for treating ADHD.

Rather…

This paper is for those wanting to understand what parents go through and the stigma they initially feel when their child is diagnosed with ADHD.

This paper is for youth workers who may have to deal with teenagers struggling to find wholeness in their quest for meaning and significance in their lives.

This paper is for fathers and mothers everywhere who are seeking some answers without the condemnation of those who are in ignorance.

This paper is for someone whose life may have been unalterably changed by that ADHD diagnosis.

Hear his voice.

“For many of us, that So many of us are recovering addicts of one kind or another. Addictions seem to go with ADD, although not all ADDers get caught up in it. Some are lucky. Some of us carry scars – physical, emotional, and maybe even viral-, which last longer than the addiction.

And some never recover at all.

Overcoming that is as much of a resurrection as can be had in this life.

In many ways, ADD management is a lot like addiction recovery. Even if there are no “chemicals” involved, it still comes down to managing behavior. The meds help, but they cannot work without a commitment to management.

Commitment to management has to also include a commitment to a “higher source” of power.

For me, it includes a commitment to God.

I wish that the people who run churches could know how much we need them. We are the ones who made the Sunday School teachers flinch. As adults, we are the ones who ask the questions that “believers just aren’t supposed to ask”. We have

trouble with authority, structure and rules… all of which pretty much define the state of Christianity today. Yet we need what the church has to offer.

We need the acceptance, even when we are not real acceptable.

We need the accountability.

We need the hope.

We need the resurrection”

Together, let us seek some answers.

What is ADHD?

Attention Deficit Hyperactive Disorder is one of the more researched and studied of all psychological disorders of childhood today. Yet, despite the advances achieved in medical researches worldwide and the voluminous materials, there still exist gaps between diagnosis, treatment or management, and support for ADHD sufferers and their caregivers. Various medical tests are still being done to connect all the gaps and integrate all the ramifications involved in recent findings.

ADHD has been defined as one of the externalizing behaviors used in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)(American Psychiatric Association, 1994) to connote negativistic behaviors that co-occur during childhood. These behaviors are collectively called the Attention-Deficit and Disruptive Behavior Disorders. The Diagnostic Statistical Manual of Disorders or DSM-IV gave the definition of ADHD as follows:

A: Either (1) or (2)

1. six or more of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level.

2. six or more of the following symptoms of hyperactivity-impulsitivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

C. Some impairment from the symptoms is present in two or more settings (e.g. at school or at home).

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Etiology of ADHD

Over the years, a lot of factors have been thought of as the contributing factors that caused ADHD. Some of these factors were diet, toxins, allergies, prenatal and birthing injuries and even parenting practices. The past decade of research has led to the inescapable conclusion that ADHD (Barkley 1994) is not primarily a disturbance in attention as its name suggests. It is however a delay in the development of response inhibition. Recent medical evidences cited from further ADHD studies (Duff, 1999) are beginning to scientifically consider ADHD, a genetically caused neurological disorder manifested in abnormal brain morphology. This abnormal morphology is associated with disregulation and underarousal of the frontal lobes of the brain. Such disregulation and underarousal may lead to inefficiency in the abilities necessary for self-regulation and organization of behavior. Disturbances of which, present profound challenges for ADHD sufferers with regards to future-oriented behavior across time. In a series of medical studies conducted in 1996, (Crawford and Barabasz, 1996) the hypothesis that the frontal lobe dysfunction is present in the ADHD cases was proven, when an experiment was done on a select group of 10 children that met the criteria for age, medication and non-participation in neurotherapy and clear diagnosis of ADHD. In this experiment, each child was hooked up to an EEG monitor and performed four specific tasks:

1. The child looked at a picture of flowers in the field

2. The child listened to a tape-recorded story about dolphins with closed eyes

3. The child had to solve simple addition and subtraction problems

4. The children read silently to themselves.

All four tasks entailed concentration and the EEG measurement would indicate the attentiveness of the children toward each task.

The result of the study showed that the ADHD children “had greater right than left hemisphere low alpha activity at frontal sites while listening to a story, and at temporal 1, and central sites while doing arithmetic” (Crawford and Barabasz, 1996). However children without ADHD did not show any differences at all.

The difference in the EEG magnitudes reveal that the “right fronto-centro-temporal region is not as cognitively activated when compared with the left hemisphere of children without ADHD.

In a recent study of 570 twins (Duff, 1999) using objectives measures of attentiveness and hyperactivity, genetics was found to have accounted 50% of the observed variance and the hereditability for ADHD at 64%. Various medical researchers have rejected the idea of a multi-factorial polygenic factors (a model of

inheritance in which more than one gene participates in the process of determining a given characteristic), non-familial environment and cultural factors as causal agents of ADHD.

Thus in a developmental –neurological approach to ADHD (Barkley, 1995 p. 64), a larger framework is needed to understand all the implications involved in ADHD. It being a disorder of self-control, willpower and the organizing and directing of behavior toward the future, calls for a multi-model assessment and treatment and management and a strong partnership of medical doctors, parents, teachers and their caregivers.

The Nature of this Disorder

ADHD is such a perplexing disorder that coping in itself presents a unique challenge for parents. One of the more frustrating things about ADHD for parents is that it evolves as the child grows up. What to expect from a growing up child with ADHD will vary from one individual to the other. To make life even more challenging for parents of ADHD children, all of the primary symptoms of ADHD change not only with the child’s growth but also with the situation. Additional problems in the following areas may be likely to happen: intelligence, school performance, physical development, congenital problems, hearing and speech, vision, motor skills, physical appearance and health and medical problems.

Epidemiological studies (Barkley, 1990) indicate that approximately 3-5% of all children in the United States are diagnosed with ADHD. And in recent years, millions more of children have been diagnosed with this disorder.

ADHD Societal Issues

According to the July 18,1994 issue of Time Magazine in an article “Life in Overdrive: Doctors Say Huge Kids and Adults Have Attention Deficit Disorder. Is it for Real?” ADHD affects as many as 3 ½ million American children and it is two to three times more likely to be diagnosed in boys rather than girls. The article goes on to say that there was a 390% increase in the prescription of MPH (known more commonly as Ritalin) from 1990 to 1994.

The rise in the prescription of methylphenidate and other psychotropic medication therapies for ADHD children in recent years stirred up a lot of public and professional concern about the increasing frequency of the diagnosis, and has prompted examination of this complex issue.

The American Medical Association (AMA) Council on Scientific Affairs has concluded that “there is little evidence of widespread overdiagnosis of ADHD or of widespread overprescription of methylphenidate (Goldman, 1998). Yet on the other hand, the International Narcotics Board and the Drug Enforcement Administration warn (Breggin, 1999) that 90% of the world’s methylphenidate is consumed in the United States, and that, 10% to 20% of boys aged 6 – 14 years are being diagnosed and given methylphenidate. The INB and DEA also warned that more high school seniors are abusing the drug than receiving it through physicians, – methylphenidate being one of the nation’s most commonly stolen and diverted substances.

The use of stimulant medication for symptom management of ADHD has become very popular (Duff, Braithwaite, 1999). The use of psychostimulants is definitely without any doubt; the most commonly used medical treatment for children with ADHD. The most common among psychostimulants is the drug called methylphenidate. While dosage of this varies from individual to individual, it is begun at the lowest recommended dose. It is usually administered two or three times daily. Dosage is then increased gradually according to the achieved maximum symptom relief with hopefully, minimal side effects. The effects of the aforementioned medication can be seen in only after 30 minutes of ingestion and lasts up to 4 –6 hours. (Flick, 1996). Aside from methylphenidate which was said to have reduced up to 70% of hyperactivity (Barkley, 1990), other medications such as anti-depressants are being used such as Norpramin or Pertofrane, Tofranil, Elavil, and Prozac being the more commonly prescribed from the aforementioned list (Barkley, 1995). Like the stimulants, the anti-depressants are taken orally once or twice a day. Unlike the stimulants, they do not wash out of the body very quickly and must build up in the bloodstream over longer periods of time. Some of the side effects noted through anti-depressant medications are slower heart rate and may increase the potential for seizures especially for children with seizure history. Normally, an electrocardiogram (EKG) should first be done to test the heartbeat before putting a child on a regular anti-depressant therapy. Other observed effects are the following: dryness of the mouth, some blurring of vision, constipation and near sightedness which can be remedied by lowering the dosage.

Another issue raised was that the diagnosis of ADHD while valid for children 4 – 6 years old, have not necessarily been validated to children below 4 years old, (Rappley, Mullan, Alvarez, Gardiner, 1999). One neurologist (Baughman, 1999) laments that “the definition of ADHD has changed over time, samples of children with ADHD who were diagnosed according to DSM-III-R criteria include children who do not meet DSM IV criteria.” What is really sad to note here is that while many people know about ADHD, there is little consistency in the way it is diagnosed or treated. Various medical organizations are pressed for medical guidelines to be used in diagnosing ADHD. The National Attention Deficit Disorder Association based in Ann Harbor, Michigan has published a diagnostic guidelines for mental health practitioners despite their admission of the paradox that exists with regards to ADHD being both over diagnosed and under diagnosed (See Appendix). The NDDA would also concur that “ one of the most critical steps in properly addressing the significant impact that ADHD has on contemporary society is to establish a standard of care for its diagnosis and treatment. While gaps exist in our knowledge about the precise cause of ADHD and controversy abounds about aspects of its diagnoses and treatment, research and clinical experience over the past decades have been sufficient to begin to identify certain principles regarding the evaluation and treatment of ADHD.” (NADDA,1998). Other medical organizations like the American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association and the American Academy of Pediatrics are all beginning to develop their guidelines. Even the makers of Ritalin, Ciba Pharmaceuticals in Summit, New Jersey plans to issue guidelines in the diagnostic assessment and methylphenidate therapy of ADHD children.

These are but some of the growing medical issues surrounding ADHD. In one of the studies conducted (Rappley, Mullan, Alvarez, Eneli, Wang, Gardiner,1999), the reason for he preponderance of ADHD and medication diagnosis was because physicians were responding to the urgent needs of the children and their families for comfort and relief from the turmoil caused by ADHD, particularly issues of safety and development for a hyperactive child. By conferring a diagnosis of ADHD and its medications – they were merely ensuring the safety of these children who are high risk to injuries.

What Lies Ahead for ADHD?

With the established fact that ADHD is associated with underlying neurological dysfunction involving brainwaves(Duff, Braithwaite,1999) researchers have been developing techniques to enable children and adults retrain their brainwaves. This technique which was started in the mid 70’s is called EEG biofeedback, and it is now called neurotherapy. There is a growing medical literature attesting to the effectiveness of neurotherapy for ADHD. Pioneers among the researches done are Richard Silberstein of the Brain Sciences Institute, Barry Sterman of UCLA and Joel Lubar of Tennessee University who have researched neurotherapy for more than 25 years.

While an explanation of the scientific basis for neurotherapy is way beyond the scope of this paper, a simple description of neurotherapy is still in order.

Electronic instruments are used by a person ( sensor is placed on the scalp) to learn to exert control over bodily processes (Cranton,1999) normally controlled automatically and unconsciously. Some examples of EEG are being able to decrease the tension of specific muscles, decrease skin temperature, lower blood pressure and influence brainwave patterns. An electronic device senses the activity and provides the person with the necessary information in signal form. A person thus learns to control by increasing or decreasing the firing of the signal – and hence also learns to increase or decrease the bodily function that specific signal represents. This learning is associated with neuromodulatory control(Duff, Braithwaite,1999).

Neurotherapy seems to be the most promising treatment for ADHD sufferers today. Despite its record of proven effectiveness in a variety of conditions like PMS, alcoholism, head injuries and sleep problems, neurotherapy remains relatively unknown ( Cranton, 1999). Sessions lasts for 30 minuts and a regular patient might require 30 – 40 sessions to complete the treatment. The major difference between neurotherapy and medication is that the former promotes self-regulation (Duff,1999) and self-empowerment while the latter promotes dependency. Neurotherapy is more expensive in the long run, but it has no recorded adverse side effects. Patients demonstrating quantitative EEG and behavioral characteristics (Lubar,1999) have more promising results with neurotherapy. For more helpful information on neurotherapy – see appendix 2.

What About ADHD in the Philippines – what can we do?

Sadly, ADHD is not addressed as much as it has been in other countries particularly, the United States. Here in the Philippines, the stigma attached to having a child labeled as “different” is more than enough sometimes, for parents and the rest of the family to just keep quiet about the ADHD in the family than to seek professional help. Those who can afford to seek medical and professional help find themselves being given the runaround in most hospitals. One mother confessed that it took more than 2 years before her son was finally diagnosed with ADHD, after spending almost a fortune in hospital visits and consultations. The country has very few child developmentalists who can properly do child-assessments, which are very necessary for the management and treatment of ADHD among young children. Those who can afford “treatment” may have to content themselves with whatever medication the doctors can prescribe. Another thing that plague parents of ADHD children is guilt. Parents who can afford children-group therapy would send their children to more therapies than the child could handle (Yap,1999) thinking that more therapy is better for the child. Those who cannot afford to do anything are also riddled with guilt because the unfortunate condition of the offspring is seen as “punishment” for the wrong deeds done in the past.

What is clearly needed here in the Philippines is a focused attention on ADHD and the diagnosis measurement needed. A campaign for information dissemination of the ADHD attributes would help parents come out of their miseries and admit their helplessness in dealing with this situation. Several attempts to find any WebPages or websites about ADHD in the Philippines yielded zero hits. What was truly astounding is that there is no center, clinics, hospitals, whether private or government owned that care to address ADHD here in this country. Hospitals and clinics specializing in pediatrics can form a professional network of medical practitioners that can help perform a multi-modal assessment of ADHD here in the Philippines. Finally, a network of parents of ADHD should be established like a support group where various parental concerns and issues could be freely discussed.

My Recommendations to the Parents of an ADHD Child in the Philippines

Learning about ADHD was a very eye opening experience. It was sobering when one realizes all the implications that take place when a precious child has been diagnosed with this neurological disorder. One can only imagine the turmoil inside the hearts and minds of the parents – and even the young person with ADHD, not knowing why things were happening the way they are happening around him. One ADHD wrote how it felt to suffer from this disorder by saying “ In my case, I wasn’t purposefully obnoxious or unruly, I was just full of energy and had a hard time restraining myself when a thought popped into my head. When I thought
something, I did it (or said it). As a parent of an ADHD child, please get as much information as you can. This may not as easy as your American counterparts where there is easy access to the information. You may search the Internet and use key words related to your search such as “ADHD, treatment, diagnosis” and the like. What you will be able to read from the information highway will be current and would reflect the present researches done that otherwise might not be available just yet from a local library or bookstore. There are sites that will give you other links where you can read about the struggles of other parents and their success stories. There are even Christian websites for ADHD and they offer encouraging information and even Bible Studies for parents in special situations like ADHD.

After the personal information gathering comes the disclosure. Please seek the help and emotional support of others around you. There may be Christian counselors and church workers who may be able to help you personally deal with issues you face as a parent of an ADHD child. It is time that we address ADHD in our midst. It is a neurological disorder that is in no way, connected to your past and you’re parenting style. It is a neurological disorder, which can be modulated through environmental factors. Keep up your hope. You do not have to be alone in your struggle with ADHD – because there are millions of parents worldwide that have been given this special task by God to take care of His ADHD children. And you are one of them.

References:

American Psychiatric Association (1994). Diagnostic and Statistical Manual for Mental Disorders (4th ed.). Washington, DC: Author.

Duff,Jacques.(1999). The Etiology of Attention Deficit Hyperactivity Disorder: Evidence of a neurological basis and treatment implications. Behavioural Neurotherapy Clinic

http://www.adhd.com.au/ADHDaeti.html

Crawford,H.J., & Barabasz, M.(1996 ) Quantitative EEG Magnitudes In Children With and Without Attention Deficit Disorder During Neurological Screening and Cognitive Tasks” . Child Study Journal, 26(1),71-86.

Barkley, R.A. (1994). Foreword: ADHD In the Schools Assessment and Intervention Strategies. The Guilford Press, New York

Barkley, R.A. (1995). Taking Charge of ADHD : The Complete, Authoritative Guide for Parents. The Guilford Press, New York

Barkley, R.A.(1990). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York: Guilford Press

Rappley M, Mullan P, Alvarez F, Eneli I, Wang J, Gardiner J.(1999). Diagnosis of Attention-Deficit/Hyperactivity Disorder and the Use of Psychotropic Medication in Very Young Children. Archive of Pediatric Adolescent Medicine, 153: 1039-1045.

Baughman, F.(1999).Treatment of Attention-Deficit/Hyperactivity Disorder . Letters to the Editor. JAMA, April, Vol. 281,No.16 p.1490.

http://jama.ama-assn.org/issues

Goldman LS, Genel M, Bezman RJ, Slanetz PJ,(1996). For the Council on Scientific Affairs, American Medical Association. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. JAMA.279: 1100-1107.

Breggin ,P.(1999). Treatment of Attention-Deficit/Hyperactivity Disorder . Letters to the Editor. JAMA, Vol. 281,No.16 p.1490.

http://jama.ama-assn.org/issues

http://www.add.org Guiding Principles for the Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder. The National Attention Deficit Disorder Attention, 1998.

Duff J, Braithwaite,K, Neurotherapy for ADHD. Copyright Behavioral Neurotherapy Clinic. http://www.adhd.com.au/neuro.html

Flick, G.(1996). Power Parenting for Children with ADD/ADHD. A Practical Parent’s Guide for Managing Difficult Behaviors. The Center for Applied Research In Education, New York.

Cranton, E.(1999) EEG Neurotherapy. Mount Rogers Clinic

http://www.drcranton.com/eegbio.htm

Lubar,J. (1999). Position Statement for the treatment of ADD/ADHD with Neurofeedback. http://www.biof.com/position-html

Yap, A. (1999). Interview conducted by the author. Organization of Philippine Therapist and Rehabilitation Center, Manila.

ADDed Thoughts http://add.miningco.com/health/diseases/add/library/weekly/aa033197.htm

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8 Responses to “Attention Deficit Hyperactive Disorder : The Turmoil Within”

  1. eugeniosadrao Says:

    Your ADHD article interested me since i have students who may not ncessaarily be taking medications but naturally do not give enough attention to math discussion. However, they are responsible doing class works. Somehow reading the article give me additonal insights of practicing patience to try other extraordinary strategies to catch my students’ attention. Thanks for the invite to your blog. May God contiually bless your life and family.

  2. oftherock Says:

    Thank you Eugenio for appreciating the article. The parents of these children suffering from ADHD need our care and loving support.


  3. […] Dr. Kenny Handelman: Really interesting read I found today:(the following article was written in partial fulfillment of the requirements for graduate class in psychopathology and counseling class) TABLE OF CONTENTS PREFACE WHAT IS ADHD? ETIOLOGY OF ADHD THE NATURE OF THE DISORDER ADHD SOCIETAL … […]

  4. oftherock Says:

    Thanks Dr. Kenny Handelman for visiting my blog and for linking my article to the ADHD Report Blog Archive. Have a nice day.

  5. sybill41 Says:

    It’s 2:30 A.M, I am a mother with a 7 yr old son showing symptoms of adhd. First, thanks for your concern. 2nd, how i wish there’s something or someone who can give us more support. I am not sure if I can face the challenge. But the more I think about it, the more I get scared knowing myself. But what scares me most is to see my son being wasted because nobody understood except me. I have my own tempers and sometimes out of frustration, i tend to forget that he never meant to cause anything bad. I guess we both need help and yet i’m not sure where to find it…I can go on and on talking about how wonderful is my son..but would anybody care? And if someone would, will it help?..

    I am sorry. Maybe I just feel helpless or desperate. And i just need to let go of whatever i feel.

  6. oftherock Says:

    Thank you for your comment. I could only imagine what you may be going through.

    I have responded to your email and asked you some guideposts to help you find information that would be valuable for the challenges ahead.

    Take care and God bless.


  7. Can neurotherapy be used with problems such as TMJ? ? I would like to investigated the relationship between ADHD and TMJ. I hope you can help!

  8. oftherock Says:

    Hello Tooth-Grinding. I am not in the position to give you an educated response about this. My level of awareness with regard to neurotherapy is very basic.

    Please consult with the proper authorities on the subject.

    Thank you for visiting my site.


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