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Home – Child Mental Health Blog

Behavior Problems and Screen Time: What Causes What?

Posted: June 2nd, 2014 by David Rettew

There have been many studies that have demonstrated links between excessive childhood screen time and negative outcomes including attention problems and aggression. Most of them imply causation but generally can’t prove it because the studies don’t measure child behavior before the screen time occurs.  Yes playing Minecraft for 6 hours per day might cause problems, but it could also be true that kids whose have attention problems are drawn more to the bells and whistles of video games. A recent study published in the journal Pediatrics examined this question in relation to poor infant self-regulation and media usage at age 2.Ipad in crib

The study comes from the Early Childhood Longitudinal Study – Birth Cohort and included 7450 children from the community, oversampled for higher rates of ethnic minorities. Infants were assessed for the regulatory abilities at an age of 9 months using a shortened version of the Infant Toddlers Symptom Checklist.  Items involving fussiness, needing constant attention, and sleep problems loaded onto the overall score of regulation problems.  Media usage was measured at age 2 by simply asking caregivers about average media use.  Regression analyses were performed to examine the link between infant regulatory abilities and media use, controlling for other potential confounds.  The authors examined the data both quantitatively (i.e. using the actual numbers of media time) and categorically dividing toddlers into groups that watched more or less than 2 hours per day (based on the AAP guidelines of two hours per day maximum of screen time).

Overall, a small but statistically significant link was found between infant regulatory abilities and age-two media use. The analyses showed that children with poorer regulatory skills (which was about 39% of the sample) consumed approximately 14 more minutes (9 minutes when adjusted for other variables) of media per day than those with good regulatory skills. At age 2, children averaged about 2.3 hours of media use per day with 40% of the sample going above the recommended 2 hours per day. The association between dysregulation and media use was stronger for children who remained dysregulated at age 2 and for children from English speaking and lower SES families.

The authors’ conclusions were somewhat unexpected.  Despite showing evidence that dsyregulation might be a cause rather than a result of media use, the authors argued that the amount of use associated with infant dysregulation was too small to account for the finding from other studies that excessive screen time is linked to negative child behavior.   They cautioned about a cycle in which fussier infants are more likely to be placed in front of screens (to give parents a break or occupy them in a safe place) which then in turn exposes them to the negative effects of increased screen time and thus reinforces the initial problem.    While this is certainly a plausible hypothesis, it requires a study that assesses child behavior, parent behavior, and screen time  at multiple time points.   We are still waiting for that one, as far as I know.


Radesky JS, et al.  Infant Self-Regulation and Early Childhood Media Exposure.  Pediatric; online publication April 14, 2014



CDC Launches New Website on Parenting of Young Children

Posted: May 27th, 2014 by David Rettew

by Allison Hall, MD

Allison HallPrincipals of good parenting like paying attention to positive behavior and using time out may sound easy but can be difficult to put into practice.   The Center for Disease Control (CDC) has recently created a website on parenting young children with some excellent explanations, useful forms such as schedules and charts as well as videos which illustrate parenting techniques which are supported by decades of research. The videos, which have a humorous touch, illustrate pitfalls we often tumble into as parents and show concrete examples of how to communicate positively, give clear instructions, create structure, and set rules and use consequences including time out.

The site has a very supportive, non-critical tone.   It recognizes that all children are different and there is no one size fits all method of parenting. The short videos could be an excellent jumping off place for discussing the use of these techniques with parents.

CDC Parenting



Patches of Brain Disorganization Identified in Autism

Posted: May 20th, 2014 by David Rettew

Characterizing the precise pathology in autistic spectrum disorders, let alone other psychiatric disorders, has remained challenging. Postmortem studies of actual brain tissue are rare but have the potential to provide important clues regarding specific abnormalities in neurodevelopment that are not detectable through other means such as neuroimaging. This major study published in the New England Journal of Medicine provides direct and provocative evidence of specific neuronal pathology that may underlie some of the core features of autism. Patch

The authors used RNA in situ hybridization techniques in order to look for gene expression patterns of 25 potential genes that have been implicated in the pathogenesis of autism and mark the presence of particular types of cells at different layers in the cortex. These analyses were performed on areas within the frontal, temporal, and occipital lobes of 11 children with autism and 11 children controls from two established brain banks. Children were between 2 and 15 years of age and the autistic sample was predominantly male.

In 10 out of 11 children with autism, compared to 1 out of 11 children without it, the study found focal areas of significant cytoarchitectural disorganization in the prefrontal and temporal cortex but not in the occipital cortex. These areas were referred to as “patches” and tended to be between 5 and 7mm long, often existing right next to unaffected cortex. The dysfunction was found for different types of neurons but not glial cells. While there was variability found in terms of the precise types of cells and cortical layers that were most affected in the autistic group, such a relatively unique and consistent finding is a major step forward towards understand the precise brain differences in children with autistic spectrum disorder.   The data also strongly points to autism beginning in the prenatal period  when cortical layering and cellular differentiation are occurring.

The authors wrote that they were somewhat surprised to see such as similar pathological feature across so many children with autism given its heterogeneous nature. They also note that while the presence of these patches was evident, their study does not suggest a mechanism for how these abnormalities in neuronal migration and differentiation they develop.

For those interested in visualizing these brain changes, the NIMH released a YouTube video that shows what the patches look like.  I would definitely recommend looking at this to better flavor of these intriguing findings.


Stoner R, et al. Patches of disorganization in the neocortex of children with autism. NEJM 2014;370:1209-1219.


Vermont Youth Prescribed Fewer Antipsychotic Medications

Posted: April 28th, 2014 by David Rettew

Newly analyzed data from the Department of Vermont Health Access is revealing important trends regarding psychiatric medication use in Vermont children and adolescents.  The data examines Medicaid insured youth who took at least one medication in various classes (antidepressants, ADHD medications, antipsychotics, etc.) over the course of the year, comparing rates between 2009, 2011, and 2013.  Efforts were made to ensure that children were counted only if the medication was used for psychiatric conditions rather than other causes such as seizures or allergies.   Separate statistics were computed for children within the foster care system.Antipsychotic Meds 2009-2013

One of the highlights is a decrease in the use of antipsychotics among youth.  Among 6-12 year olds, the rate dropped from 3.1% in 2011 to 1.7% in 2013, a 45% drop.  For adolescents, the rate went from 4.8% in 2009 to 3.5% in 2013.  Among foster care children aged 6-12, the rate drop was even more dramatic (17.2% in 2009 to 7.2% in 2013).   Antidepressant rates were relatively flat, while ADHD medications increased somewhat.  For example, the percentage of adolescents aged 13-17 taking ADHD medications such as stimulants increased from 12.10% in 2009 to 14.1% in 2013, while for younger children (6-12 years old) the rate was pretty stable (13.0% in 2009 to 13.4% in 2013).

These data continue to support the conclusion that the pattern of psychiatric medication usage in Vermont youth is different than most parts of the country.  While it is unclear what is responsible for these trends, many efforts have been launched across the state by individuals here at the Vermont Center for Children, Youth, and Families and elsewhere to try an ensure that medications are used carefully and only as a component of a more comprehensive treatment plan that includes many health promotion strategies.

Treatment Gains Persist in Childhood Anxiety Disorders

Posted: April 11th, 2014 by David Rettew

The Child/Adolescent Anxiety Multimodal Study (CAMS) represents one of the largest and most comprehensive studies to date on the comparative efficacy of different types of treatment for anxiety disorders. In the original NIMH funded study, a total of 488 youth with various combinations of separation, generalized, or social anxiety disorder were randomized to treatment groups consisting of 12 weeks of cognitive-behavioral therapy, medication with sertraline, combination medication and CBT, or pill placebo. At the end of the study, combined treatment was found to be superior to either active treatments alone and all treatments were superior to placebo.CAMS

A new study now describes the participants’ level of functioning and symptoms approximately 6 months later.  In the interval from study completion to follow-up, those who responded at the end of the original study were given 6 monthly booster sessions in their assigned modality. They were, however, permitted to add other types of treatment. Those that had originally received placebo were offered treatment if they did not respond to placebo, but were not included in these follow-up analyses.

One piece of good news overall was that, across all treatment groups, about 80% of youth who had originally responded to treatment kept their response at follow-up.  In terms of group differences, those in the combined group continued to do somewhat better than those in the CBT alone or sertraline alone groups on quantitative assessments of symptoms, although with categorical designations of responders versus nonresponders, the rates did not differ statistically.  This was due to the CBT and sertraline groups increasing their response rate (to around 70%) while the combined group kept its response level roughly the same (around 80%). The CBT alone and sertraline alone groups continued not to differ from each other.

The authors concluded that successful treatment of anxiety disorders results in a sustained response over the next 6 months for most individuals. They speculated that the lack of separation between groups over time may be related to the naturalistic design and the greater use of combination medication and therapy treatment among many subjects.

These results offer solid evidence that the vast majority of youth with anxiety disorders can improve significantly with different treatments and can maintain those gains at least over the next 6 months.  Their finding that the separations between groups erodes somewhat over time mirrors similar studies of other disorders where patients are followed naturalistically after the randomization stops. Overall, there is evidence that combination treatment can be the fastest path to improvement, although single modality treatment using evidence based practices may catch up.  Current treatment recommendations continue to be that childhood anxiety disorders should be treated with cognitive-behavioral therapy on its own or with medications for more severe cases.

Piacentini J, et al.  24- and 36- week outcomes for the child/adolescent anxiety multimodal study (CAMS).  JAACAP 2014;53(3)297-310

Study Finds Link Between In-Utero Acetaminophen Use and Child ADHD

Posted: April 1st, 2014 by David Rettew

A recent study in JAMA Pediatrics caused quite a bit of a stir in finding a possible link between acetaminophen taken during pregnancy and later childhood ADHD.   Acetaminophen has been one of the few medications that has been thought to be pretty safe to use during pregnancy and thus has been the “go to” agent for pain, fever, and other indications, especially given the known risks of some of the alternatives such as NSAIDS.  Now, however, some people aren’t so sure.Tylenol

The study used data from the Danish National Birth Cohort and assessed over 64,000 pregnant mothers.  The amount of acetaminophen use was measured from computer-assisted telephone interviews.  Child behavioral data was collected at age 7 using scores from the Strengths and Difficulties Questionnaire as well as medical records indicating a child took stimulant medications or had an ADHD diagnosis (in this study it was actually ICD hyperkinetic disorder but it is very similar).  Hazard ratios, similar to odds ratios, were calculated to compare the risk of ADHD between acetaminophen exposed and non-exposed mothers, controlling for some potential confounding factors such as maternal infections, inflammation, and maternal mental health.

The study found that majority of mothers did use acetaminophen at some time point during pregnancy.  Compared to mothers who did not use acetaminophen at all, the risk of ADHD in the offspring of mothers who did was significantly elevated, with hazard ratios ranging between 1.13 and 1.37 depending on how ADHD was measured. As an example, elevated scores related to hyperactivity were found in 5.7% of children whose mothers took any acetaminophen during pregnancy versus 4.3% of children who mothers did not. There was also some evidence that higher overall acetaminophen use and use during later pregnancy was associated with higher ADHD risk.

The authors concluded that in utero acetaminophen exposure was associated with increased rates of ADHD or ADHD-like behaviors and they urged further study to verify the findings.  The journal also featured an accompanying editorial which  recommended that  clinical practice not be fundamentally changed from this single non-controlled study.

The media, for the most part, also seemed to get that message and generally did a decent job of not going overboard with their headlines or text.  This was probably good given that everyone seemed to cover the study about a month ago (even I got asked to comment for ABC news).  Clearly, the biggest potential concern is the very real possibility that it is the factors that cause a pregnant mother to take acetaminophen, and not the drug itself, that underlies the link with ADHD.  While the authors took some steps to account for this possibility, they acknowledged that they could not completely control for it.  As there is also some preliminary data linking things like inflammation and infections during pregnancy and child behavioral problems, some restraint prior to changing recommendations seems appropriate.   It is one thing to try something that at best is harmless to see if a health benefit can be obtained (even in the absence of great data), but it is quite another scenario when those actions (or lack of action) may make things worse.   We will have to see, with the message now perhaps being that no medications, over the counter or not, should be taken casually while pregnant.

What might be the mechanism behind this association?  Nobody knows, but the authors did speculate about the possibility that acetaminophen might alter sex or thyroid hormone levels.



Liew Z, et al.  Acetaminophen Use During Pregnancy, Behavioral Problems, and Hyperkinetic Disorders.  JAMA Pediatrics. 2014:online publication.

ADHD Diagnosis Rising Nationally, but not in Vermont

Posted: March 5th, 2014 by David Rettew

The diagnosis of ADHD  has been getting a lot of media attention lately over concerns about possible overdiagnosis and overtreatment.  A recent study from the CDC’s National Survey of Children’s Health now provides important national statistics regarding the prevalence of ADHD, as reported by parents, and the trends over time.  Reports from this survey previously found an increase of 22% from 2003 to 2007 with an overall rate of 9.5%.  At that time, 4.8% of U.S children and adolescents were taking an ADHD medication.  This new study provides information up to 2011.ADHD prevalence by state

The data come from a random-digit-dialed telephone survey of parents that was performed in over 75,000 households using both land lines and mobile phones.  Parents were asked about lifetime and current diagnosis of one of their children as well as about severity, age of onset, and treatment.  The overall response rate was 23.0%.  Analyses were weighted to estimate a total prevalence.

Overall, the rate of ever having ADHD among 4 to 17 year olds nationally was 11% (15.1% for boys, 6.7% for girls), representing 6.4 million children. This rate represents an increase of 42% from 2003 to 2011. Of those will current ADHD, 69% were taking medication for it resulting in an overall medication rate of 6.1%, and increase of 28% from 2007.  About half of children with current ADHD were engaged in some kind of counseling.

There was substantial variation in diagnosis rates and medication treatment between the states with several southern states, such as Arkansas and Kentucky among the highest.  The rate in Vermont was 9.4% which was slightly below the national average and a bit lower than neighboring states (with the exception of New York at 7.7%).  These rates compare to 6.9% in 2003 and 9.9% in 2007 (from the prior CDC report), suggesting that unlike other states, the prevalence in Vermont has not increased from 2007 and may actually be going the other direction.   The 2011 Vermont medication rate was 6.6% which is just above the national average.  Thus, compared to other states, a higher proportion of those diagnosed with ADHD in Vermont are receiving medication treatment.

The authors of the study concluded that there has been a substantial rise in ADHD diagnosis over the past decade with approximately 2 million more children and adolescents receiving the diagnosis now, and most taking medications for it.  This increase, they state, is resulting in an additional burden on the health care system, although the authors don’t do any kind of economic analysis of the costs related to untreated ADHD.

This paper comes soon after a very similar report by McDonald and Jalbert in Psychiatric Times that was previous a topic of this blog.  In that study, the rate of stimulant treatment, using a prescription database, was 2% with Vermont being 34th in the nation.   It is difficult to know exactly how to reconcile these two studies.

While providing very useful information regarding overall statistics, trends, and state differences, it is important to remember that the study has no information regarding the accuracy or appropriateness of the diagnosis or treatment.  Thus, you can expect different people to use these numbers to make different conclusions.   A group here is currently working on some data regarding antipsychotic medications among Vermont prescribers that will shed more light on this important topic.


Visser et al., Trends in the Parent-Report of Health Care Provider-Diagnosed and Medicated Attention-Deficit/Hyperactivity Disorder: United States, 2003–2011. JAACAP 2014;53:34-46.

Does Atomoxetine Actually Work? Results from a Recent Meta-Analysis

Posted: February 26th, 2014 by David Rettew

Atomoxetine was FDA approved for ADHD in 2002 and touted as a true alternative to stimulants.  While it remains popular today, many clinicians report less than stellar results in treating the core symptoms of ADHD.  This recent review and meta-analysis by Schwartz and Correll examines all randomized controlled studies of atomoxetine versus placebo. While meta-analyses of this medication have been performed in the past, the authors point out that all were industry sponsored.   This one is not, although one of the authors has received financial support from a number of pharmaceutical companies, including  the maker of atomoxetine, StratteraEli Lily.

The authors reviewed and applied meta-analytic summaries of all double-blind randomized controlled trials of atomoxetine for the treatment of ADHD in children. In total, 25 studies were found that met inclusion criteria up until August 2012, which included a total of nearly 4,000 patients. The average trial was almost 9 weeks in length, and all but two were industry funded. The average atomoxetine dose was 1.17 mg/kg and the average age was around 10.

In terms of results, atomoxetine was found to be superior to placebo overall in treating core ADHD symptoms of all types. A total of 44.1% with atomoxetine versus 21.4% on placebo achieved improved scores on ADHD rating scales of at least 40%, resulting in a number needed to treat of 4. At the same time, however, nearly 40% of patients did not respond to the medication.  In other domains such as oppositional defiant symptoms and overall quality of life, improvement with atomoxetine was unimpressive.  Adverse effects including aggression and suicidal ideation did not differ from placebo while other types of side effects were generally mild but higher with atomoxetine.

The authors concluded that atomoxetine appears to be a safe (at least in the short term) and efficacious treatment for pediatric ADHD, relative to placebo, although a sizable number of patients will continue to have significant residual symptoms. The data indicate the possibility of a bimodal response to atomoxetine with many patients responding well and many others have minimal to no improvement. Overall, atomoxetine appears to be about 1/3 to 1/5 less effective than stimulants, with little to guide us in predicting who those patients will be that either respond well or not at all to the medication.

Do these numbers correspond to your own clinical impression?  For me, I don’t think I have found atomoxetine to be as helpful as this article would suggest, although it is important to note that these studies used atomoxetine as a first-line agent while in general practice many of us are turning to atomoxetine only after stimulants have failed.


Schwartz S & Correll C. Efficacy and safety of atomoxetine in children and adolescents with attention-deficit/hyperactivity disorder: results from a comprehensive meta-analysis and metaregression. J. Am. Acad. Child Adolesc. Psychiatry, 2014;53(2):174–187

Autism Screening – What Will Happen with the New M-CHAT?

Posted: February 17th, 2014 by David Rettew

When it comes to autism screening for toddlers, the Modified Checklist for Autism (M-CHAT) is one of the most widely used and studied instruments available (and it’s free and dowloadable).   While it’s been shown to have both good sensitivity and specificity, there is always room for improvement.  Thus was born the M-CHAT Revised with Follow-up (M-CHAT-R/F).M-CHAT R

What makes the new scale different is not just some changes in the wording of some of the questions but, perhaps more importantly, how the M-CHAT is scored and categorized.  Now, based on what parents write down on the M-CHAT-R/F, the total score is placed into one of three categories – low, medium, and high risk.  What to do for the low and high risk toddlers is pretty straightforward.  Those at high risk should be sent for a more in-depth autism evaluation right away and those at low risk don’t need further action, other than a repeat M-CHAT-R/F if they are not yet 24 months old.

The middle risk kids are a bit trickier.  Now, the instructions are that primary care clinicians are supposed to go through a series of scripted questions that delve into more detail about those items that are raising a red flag for autism.  Such a process could take about 15 minutes or so and potentially could be done by someone other than the physician.  Based on those questions, another score is generated and if that score is also above the cut-off then the full evaluation is recommended.

A recent study of over 16,000 toddlers who presented for well-child checks at 18 and 24 months of age demonstrated the utility of the new instrument.  Nearly 93% of the initial M-CHAT-R scores were negative, defined as a score of less than 3.  Of those screening positive, 63% of them no longer screened positive with the follow-up assessment.   After establishing an optimal cutoff point of three for the M-CHAT-R and then at least 2 for the follow-up, those who remained positive were found to have a 47.3% chance of being diagnosed with autism, with only 5% of the remaining sample assessed to be developing typically.  This detection rate of autism was found to be superior to that of the original M-CHAT.

The million dollar question in my mind, however, is will this new step for immediate risk really happen in a busy primary care office, and what will occur if it doesn’t?

In the published study, it is important to point out that they didn’t ask the PCPs to do that follow-up piece: the research staff did.  This leaves the open question of how feasible it is to ask the primary care community to do these. Interviews containing scripted questions to help make a diagnosis of various psychiatric disorders have been around for decades and are considered “gold standard” measures that are required in research studies.  However, they are uncommonly used in everyday practice by psychiatrists and even more rarely used in primary care settings.  Consequently, it seems quite likely that many primary care clinics will struggle with this new recommended step.  Am I wrong here?

I was so curious about this aspect that I sent an email to the lead author of the M-CHAT, Diana Robins PhD, at George State University.  She replied quickly and acknowledged that this is looking like a real problem.  In fact, she’s is having trouble finding PCPs willing even to participate in a study about putting the new M-CHAT into practice.

If primary care clinicians decide not to adopt this new follow-up procedure, the instrument could lose some of its discriminative power.  If that happens, a number of things could occur.

  1. Primary care clinicians could just stick to the old M-CHAT (with the loss of the improved instrument resulting in less accurate autism detection)
  2. They could plan to do the follow-up step but often not actually get to it (resulting in a delay of the screening process)
  3. They could group the medium risk kids into the low risk group (which potentially could result in some autistic kids not being formally evaluated until they are older)
  4. They could group the medium risk kids into the high risk group (which could lead to more evaluations and longer waits for kids who would not end up being diagnosed with autism but require formal evaluations to verify this)

None of these options seems ideal and my guess at this point is that the incorporation of the new M-CHAT will be quite slow, especially with this new step in place.  Public health officials interested in autism screening might begin to look for a system that will work without making it too arduous for those who need to implement it.

If you are a primary care clinician that does autism screening, please feel free to comment on what you do now and what you plan to do about the new M-CHAT, if anything.  This one might be worth some follow-up dialogue on how we best should do things around here.


Robins, DL, et al. Validation of the Modified Checklist for Autism in Toddlers, Revised With Follow-up (M-CHAT-R/F).  Pediatrics 2014;133:37–45



Child Mental Health Now Versus the Past

Posted: February 3rd, 2014 by David Rettew

Of note, this post is adapted from a similar one that appeared last week in my Psychology Today blog.

From many headlines today, it is easy to get the impression that children and adolescents are struggling more than ever these days.  At the same time, the mental health system designed to help our kids and their families has been under intense criticism for being either completely inaccessible or for being too accessible when it comes to medication treatment.

Churchman photo -sunrise

Image courtesy of John Churchman and www.brickhousestudios.com

Few would argue that there are serious issues to confront right now.  However, it may also be useful to take a step back and look at how levels of problems now compare to the past.  While good statistics in many areas have not been available for that long, what trends are evident for many important metrics of youth mental health may be surprising.  Here are some examples.

Suicide.  The rate of completed youth suicides (we now try to stay away from the phrase “successful” suicide for obvious reasons) has been steadily declining.  The incidence rose steeply, especially for males, from the 1960s until the early 1990s and has been coming down ever since, according to the Center for Disease  Control (CDC).

Teen Pregnancy Rates.  According to the government’s Office of Adolescent Health, the teen pregnancy rate among adolescent females has been cut in half from 1990 to 2012, across many different ethnic groups.

Delinquency.  The number of youth who are incarcerated have dropped from a high of 381 per 100,000 in 1995 to 225 per 100,000 in 2010 according to a report by the Annie E. Casey Foundation.

Substance Use.  The rate of smoking in teens is at an all-time low, according to the Monitoring the Future study that has surveyed substance use for decades.  Cannabis use is also down from peaks in the 1970s, although has been trending up.  Alcohol use in teens is also at historic lows, according to the National Institute of Drug Abuse.

Psychiatric Disorders.  As has been well covered in many venues, there have been significant increases in the rates of many psychiatric disorders, including ADHD, autism, and bipolar disorder.  What is less clear, however, is the degree to which these numbers reflect an actual increase in behavior versus other factors such as an improved detection rates or a lowering of the diagnostic threshold.  A study by Achenbach and coworkers several years ago that looked at quantitative levels of child behavior problems using the same instrument over a 23 year time span found some increases in overall levels from the 1970s to the early 1990s which then began to fall by the end of the millennium.

Child Abuse and Bullying.  Reports from the Crimes Against Children Research Center shows a steady decline in the rate of child abuse since the early 1990s, particularly physical and sexual abuse as well as violent victimization at school.  The reports utilize government data from the National Child Abuse and Neglect Data System.

When it comes to Vermont, many of these metrics look even better in weighing our place relative to other states, especially when it comes to teen pregnancy and youth incarceration. One notable exception, however, is adolescent cannabis use.

There are still many things to work on to help children and their families thrive when it comes of behavioral wellness.  At the same time, however, we also need to recognize that compared to other time periods (particularly the early 1990s for some strange reason), kids today are really not behaving that terribly and now doesn’t look like a terrible time to be a kid.


Achenbach, T.M., Dumenci, L., & Rescorla, L.A. (2003). Are American children’s problems still getting worse? A 23-year comparison. Journal of Abnormal Child Psychology, 31, 1-11.

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