Parent-Child Interaction Therapy



Introduction to IoWA-PCIT ManualThe IoWA-PCIT manual builds on 50 years of research on attachment theory and behaviorism. It also builds on intervention research based on attachment theory or behaviorism, manuals used in these research projects, my clinical experience providing attachment and behavioral interventions, and my experience training therapists in these interventions. Details regarding the theoretical underpinnings and rationale for the IoWA-PCIT protocol are described in Troutman (2015). The intervention described in this manual is primarily targeted to children aged 2 to 7 referred for concerns about disruptive behavior (e.g. tantrums, noncompliance, and aggression), attachment, and/or problems in parent-child interaction. By making some age-appropriate adaptations, the intervention can be applied to somewhat younger children (between the ages of 1 and 2) and somewhat older children (between the ages of 7 and 10) with these presenting concerns. With diagnosis-specific adaptations, the intervention can be used with children presenting with disruptive behavior who have been diagnosed with Autism Spectrum Disorder, Post-traumatic Stress Disorder, Reactive Attachment Disorder, and/or Attention Deficit Hyperactivity Disorder. The intervention can also be used with children who are involved in the child welfare system as the result of physical abuse and/or neglect.The behavioral and attachment interventions that have influenced the development of this manual are discussed briefly below. I have learned from each of the interventions and protocols cited and highly recommend them. I am a firm believer in therapists finding a protocol that “fits” them and the families for whom they provide interventions. While I hope this protocol will fit you and the families you work with, it is important to know there are a number of other excellent protocols available if this protocol is not a good fit. I consider the protocols I cite below to be some of the best.Interventions based primarily on attachment theoryThe IoWA-PCIT protocol builds on previous interventions based on attachment theory and the excellent manuals for these interventions. First, it builds on the attachment intervention for irritable infants developed by Dymphna van den Boom PEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gZGVuIEJvb208L0F1dGhvcj48WWVhcj4xOTg4PC9Z

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ADDIN EN.CITE.DATA (D. van den Boom, 1988, 1989, 1994; D van den Boom, 1995). Dr. van den Boom’s model of using coding of parent responsiveness to infant distress to guide parent coaching was especially important to the development of this manual. Another van den Boom (1988, 1989, 1994, 1995) strategy adapted for this model is the use of observations about the parent’s effective strategies for soothing the infant in order to increase sensitive responsiveness by using the infant’s response to reinforce the parent’s efforts. Her emphasis on the steps involved in responding sensitively (i.e. observe, interpret, choose response) also influenced the coaching strategies used in IoWA-PCIT. This protocol also builds on the following attachment theory-based interventions: Watch, Wait, and Wonder ADDIN EN.CITE <EndNote><Cite><Author>Cohen</Author><Year>1999</Year><RecNum>570</RecNum><DisplayText>(Cohen et al., 1999)</DisplayText><record><rec-number>570</rec-number><foreign-keys><key app="EN" db-id="w5w5zw927sar0bezxdkpfrv4509twsezr502" timestamp="0">570</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cohen, N.</author><author>Muir, E.</author><author>Lojkasek, M.</author><author>Muir, R.</author><author>Parker, C.</author><author>Barwick, M.</author><author>Brown, M.</author></authors></contributors><titles><title>Watch, wait and wonder: Testing the effectiveness of a new approahc to mother-infant psychotherapy.</title><secondary-title>Infant Mental Health Journal</secondary-title></titles><periodical><full-title>Infant Mental Health Journal</full-title></periodical><pages>429-451</pages><volume>20</volume><dates><year>1999</year></dates><urls></urls></record></Cite></EndNote>(Cohen et al., 1999); Attachment and Biobehavioral Catch-Up (ABC) ADDIN EN.CITE <EndNote><Cite><Author>Dozier</Author><Year>2008</Year><RecNum>836</RecNum><DisplayText>(M. Dozier, Peloso, Lewis, Laurenceau, &amp; Levine, 2008)</DisplayText><record><rec-number>836</rec-number><foreign-keys><key app="EN" db-id="955xzrtrzpvw0seeex6vf52ne0sza900srvz" timestamp="1309232777">836</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dozier, M.</author><author>Peloso, E.</author><author>Lewis, E.</author><author>Laurenceau, J.</author><author>Levine, S.</author></authors></contributors><titles><title>Effects of an attachment-based intervention on the cortisol production of infants and toddlers in foster care</title><secondary-title>Development and Psychopathology</secondary-title></titles><periodical><full-title>Development and Psychopathology</full-title></periodical><pages>845-859</pages><volume>20</volume><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>(M. Dozier, Peloso, Lewis, Laurenceau, & Levine, 2008); Circle of Security (COS) ADDIN EN.CITE <EndNote><Cite><Author>Hoffman</Author><Year>2006</Year><RecNum>928</RecNum><DisplayText>(Hoffman, Marvin, Cooper, &amp; Powell, 2006)</DisplayText><record><rec-number>928</rec-number><foreign-keys><key app="EN" db-id="955xzrtrzpvw0seeex6vf52ne0sza900srvz" timestamp="1316099854">928</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hoffman, K.</author><author>Marvin, R.</author><author>Cooper, G.</author><author>Powell, B.</author></authors></contributors><titles><title>Changing toddlers&apos; and preschoolers&apos; attachment classifications: The Circle of Security intervention</title><secondary-title>Journal of Consulting and Clinical Psychology</secondary-title></titles><periodical><full-title>Journal of Consulting and Clinical Psychology</full-title></periodical><pages>1017-1026</pages><volume>74</volume><dates><year>2006</year></dates><urls></urls></record></Cite></EndNote>(Hoffman, Marvin, Cooper, & Powell, 2006); Child-Parent Psychotherapy (CPP) ADDIN EN.CITE <EndNote><Cite><Author>Fraiberg</Author><Year>1975</Year><RecNum>1047</RecNum><DisplayText>(Fraiberg, Adelson, &amp; Shapiro, 1975; Lieberman, Ippen, &amp; Van Horn, 2006)</DisplayText><record><rec-number>1047</rec-number><foreign-keys><key app="EN" db-id="955xzrtrzpvw0seeex6vf52ne0sza900srvz" timestamp="1405235133">1047</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Fraiberg, S.</author><author>Adelson, E.</author><author>Shapiro, V.</author></authors></contributors><titles><title>Ghosts in the nursery: A psychoanalytic approach to impaired infant-mother relationships</title><secondary-title>Journal of the American Academy of Child Psychiatry</secondary-title></titles><periodical><full-title>Journal of the American Academy of Child Psychiatry</full-title></periodical><pages>387-421</pages><volume>14</volume><dates><year>1975</year></dates><urls></urls></record></Cite><Cite><Author>Lieberman</Author><Year>2006</Year><RecNum>898</RecNum><record><rec-number>898</rec-number><foreign-keys><key app="EN" db-id="955xzrtrzpvw0seeex6vf52ne0sza900srvz" timestamp="1315884272">898</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lieberman, A. 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ADDIN EN.CITE.DATA (Cohen et al., 1999; M. Dozier, Higley, Albus, & Nutter, 2002; M. Dozier et al., 2008; Mary Dozier, Stoval, Albus, & Bates, 2001) provided empirical support for my clinical observations regarding the value of child-led play but shifted my focus from individual play therapy to dyadic therapy with primary caregivers. Watch, Wait, and Wonder (WWW), Attachment and Biobehavioral Catch-Up (ABC), Circle of Security (COS), Child-Parent Psychotherapy (CPP), Relationship Intervention for Parents ADDIN EN.CITE <EndNote><Cite><Author>Moss</Author><Year>2011</Year><RecNum>923</RecNum><DisplayText>(Moss et al., 2011)</DisplayText><record><rec-number>923</rec-number><foreign-keys><key app="EN" db-id="955xzrtrzpvw0seeex6vf52ne0sza900srvz" timestamp="1316098059">923</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Moss, E.</author><author>Dubois-Comtois, K.</author><author>Cyr, C.</author><author>St-Laurent, D.</author><author>Bernier, A.</author></authors></contributors><titles><title>Efficacy of a home-visiting intervention aimed at improving maternal sensitivity, child attachment, and behavioral outcomes for maltreated children: A randomized control trial</title><secondary-title>Development and Psychopathology</secondary-title></titles><periodical><full-title>Development and Psychopathology</full-title></periodical><pages>195-210</pages><volume>23</volume><dates><year>2011</year></dates><urls></urls></record></Cite></EndNote>(Moss et al., 2011) and Beatrice Beebe’s research and therapeutic insights PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZWViZTwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+PFJl

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ADDIN EN.CITE.DATA (Beebe, Cohen, & Lachmann, 2016; Beebe et al., 2010; Beebe & Lachmann, 2014) influenced my emphasis on attending to parents’ working models of attachment when providing a dyadic intervention. Research on Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD) provided the concept of “responsive discipline” and ideas about teaching parents to give time-outs in a manner that was consistent with attachment theory ADDIN EN.CITE <EndNote><Cite><Author>van Zeijl</Author><Year>2007</Year><RecNum>798</RecNum><DisplayText>(van Zeijl et al., 2007)</DisplayText><record><rec-number>798</rec-number><foreign-keys><key app="EN" db-id="955xzrtrzpvw0seeex6vf52ne0sza900srvz" timestamp="0">798</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>van Zeijl, Jantien</author><author>Mesman, J.</author><author>Stolk, M.</author><author>Alink, L.</author><author>van IJzendoorn, M.</author><author>Bakermans-Kranenburg, M.</author><author>Juffer, F.</author><author>Koot, H.</author></authors></contributors><titles><title>Differential susceptibility to discipline: The moderating effect of child temperament on the association between maternal discipline and early childhood externalizing problems</title><secondary-title>Journal of Family Psychology</secondary-title></titles><pages>626-636</pages><volume>21</volume><number>4</number><dates><year>2007</year></dates><urls></urls></record></Cite></EndNote>(van Zeijl et al., 2007).Interventions based primarily on behaviorism As indicated by the name, IoWA-PCIT clearly builds on previous PCIT protocols PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FeWJlcmc8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA (Eyberg, 1999; Eyberg & Funderburk, 2011; Girard, 2014; Hembree-Kigin & McNeil, 1995; McNeil, 2004; McNeil & Hembree-Kigin, 2010; Urquiza, Zebell, Timmer, McGrath, & Whitten, 2011). It also builds on other behavioral parent management protocols. Specifically, it builds on Helping the Noncompliant Child ADDIN EN.CITE <EndNote><Cite><Author>McMahon</Author><Year>2003</Year><RecNum>594</RecNum><DisplayText>(McMahon &amp; Forehand, 2003)</DisplayText><record><rec-number>594</rec-number><foreign-keys><key app="EN" db-id="w5w5zw927sar0bezxdkpfrv4509twsezr502" timestamp="1485808977">594</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>McMahon, R.</author><author>Forehand, R.</author></authors></contributors><titles><title>Helping the noncompliant child</title></titles><edition>Second</edition><dates><year>2003</year></dates><pub-location>New York</pub-location><publisher>Guilford</publisher><urls></urls></record></Cite></EndNote>(McMahon & Forehand, 2003), Hanf’s two-stage parent training model ADDIN EN.CITE <EndNote><Cite><Author>Hanf</Author><Year>1969</Year><RecNum>596</RecNum><DisplayText>(Hanf, 1969)</DisplayText><record><rec-number>596</rec-number><foreign-keys><key app="EN" db-id="w5w5zw927sar0bezxdkpfrv4509twsezr502" timestamp="1485809248">596</key></foreign-keys><ref-type name="Conference Paper">47</ref-type><contributors><authors><author>Hanf, C.</author></authors></contributors><titles><title>A two-stage program for modifying maternal controlling during mother-child (M-C) interaction</title><secondary-title>Western Psychological Association</secondary-title></titles><dates><year>1969</year></dates><pub-location>Vancouver, British Columbia</pub-location><urls></urls></record></Cite></EndNote>(Hanf, 1969), Incredible Years ADDIN EN.CITE <EndNote><Cite><Author>Webster-Stratton</Author><Year>1982</Year><RecNum>597</RecNum><DisplayText>(Webster-Stratton, 1982)</DisplayText><record><rec-number>597</rec-number><foreign-keys><key app="EN" db-id="w5w5zw927sar0bezxdkpfrv4509twsezr502" timestamp="1485809433">597</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Webster-Stratton, C.</author></authors></contributors><titles><title>Teaching mothers through videotape modeling to change their children&apos;s behavior</title><secondary-title>Journal of Pediatric Psychology</secondary-title></titles><periodical><full-title>Journal of Pediatric Psychology</full-title></periodical><pages>279-294</pages><volume>7</volume><number>3</number><dates><year>1982</year></dates><urls></urls></record></Cite></EndNote>(Webster-Stratton, 1982) and behavioral parent training protocols based on Patterson’s model ADDIN EN.CITE <EndNote><Cite><Author>Patterson</Author><Year>1982</Year><RecNum>595</RecNum><DisplayText>(Patterson, 1982)</DisplayText><record><rec-number>595</rec-number><foreign-keys><key app="EN" db-id="w5w5zw927sar0bezxdkpfrv4509twsezr502" timestamp="1485809046">595</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Patterson, G.</author></authors></contributors><titles><title>Coercive family process</title></titles><dates><year>1982</year></dates><pub-location>Eugene, Oregon</pub-location><publisher>Castalia Publishing Company</publisher><urls></urls></record></Cite></EndNote>(Patterson, 1982).Similarities of IoWA-PCIT manual and previous PCIT manualsAccording to Eyberg ADDIN EN.CITE <EndNote><Cite ExcludeAuth="1"><Author>Eyberg</Author><Year>2005</Year><RecNum>1107</RecNum><DisplayText>(2005)</DisplayText><record><rec-number>1107</rec-number><foreign-keys><key app="EN" db-id="955xzrtrzpvw0seeex6vf52ne0sza900srvz" timestamp="1480540535">1107</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eyberg, S.</author></authors></contributors><titles><title>Tailoring and adapting Parent-Child Interaction Therapy to new populations</title><secondary-title>Education and Treatment of Children</secondary-title></titles><periodical><full-title>Education and Treatment of Children</full-title></periodical><pages>197-201</pages><volume>28</volume><number>2</number><dates><year>2005</year></dates><urls></urls></record></Cite></EndNote>(2005), the core defining features of PCIT include: 1) Parent and child are seen in joint sessions focused on increasing positive interactions, 2) The focus of the coaching is modifying patterns of interaction by shaping the behaviors of both the parent and the child, 3) The therapist coaches the parent in positive parenting skills, and 4) The therapist coaches the parent during two types of interactions: following the child’s lead and leading the child. While the first three features are characteristic of a number of different interventions, the fourth feature appears to be unique to PCIT and other Hanf-based behavioral interventions. In developing IoWA-PCIT, an effort was made to maintain these four core features of PCIT.Summary of similarities between IoWA-PCIT and other PCIT protocols include:Dyadic Parent Child Interaction Coding System (DPICS) coding at pre-treatment and beginning of coaching sessionsEyberg Child Behavior Inventory (ECBI) at pre-treatment and coaching sessionsCoaching parent in Child-Directed Interaction (CDI) Coaching parent in Parent-Directed Interaction (PDI)Summary of additionsAt the pre-treatment assessment, a clinical assessment of attachment using the preschool separation reunion procedure is added.For CDI sessions, space to record observations relevant to improving security of attachment is added to the CDI coding sheet.Code the coach forms for CDI and PDI sessions are added to improve therapist training and monitoring of therapist coaching. Information on using video review sessions (as needed) to promote treatment retention, skill-building, and/or reflective functioning is added.Optional handouts on patterns of attachment are added for therapists to better understand these patterns. These handouts may also be used when discussing attachment with parents.Differences between IoWA-PCIT and other PCIT protocols PCIT strategies described in previous PCIT handouts or therapist manuals were modified, updated, or fine-tuned in order to make them more consistent with current research on attachment theory. The goal of these changes was to: 1) promote security of attachment while addressing behavior problems, 2) improve retention, and 3) address resistance to changing patterns of interaction. Changes from previous PCIT manuals also focused on making handouts for parents easier to teach and easier to learn. Changes to coding sheets focused on incorporating observations of attachment and making the coding sheets more “user-friendly”.Differences in DPICS coding sheetsPre-treatment DPICS coding sheets are simplified by focusing on the coding information most relevant to the pre-treatment assessment. 1) For pre-treatment coding of child-led play, only parent verbalizations are coded (i.e. child compliance with commands is not coded). This change was based on the observation that most PCIT research does not report on child compliance during child-led play and previous PCIT protocols did not track this information. In addition, parent verbalizations are listed in the DPICS priority order on the coding sheet in order to help beginning therapists learn this order. For pre-treatment DPICS coding of parent-led play and clean-up, the only parent verbalizations coded are negative talk and commands. This change was made in order to make it easier to code child compliance with commands which is of primary interest in children referred for disruptive behavior. Differences in CDI teach handoutsCDI handouts are modified to make them more consistent with attachment theory. For example, there are no statements about ignoring crying and or “negative attention-seeking behavior”. A handout on zone of proximal development and scaffolding was added to help parents understand how their supportive presence and use of CDI skills contributes to better behavior during CDI and improvement in their child’s functioning outside of CDI.CDI handouts are modified to make them more attractive and make the skills and rationale for the skills easier to present to parents.Differences in PDI teach handoutsPDI handouts are modified to emphasize the teaching aspect of the PDI protocol and deemphasize the punishment aspect.PDI handouts are modified to make the information easier to present to parents. Differences in coachingModifications to coaching are based on an understanding of how relationships with attachment figures influence working models of attachment. Specifically, the process of coaching is emphasized. Consistent with interventions based on attachment theory, there is an emphasis on the use of parallel process to understand and promote positive change in parents’ working models of attachment. That is, there is an emphasis on providing parents with the type of experiences we want them to be able to provide for their children. There is also a greater emphasis on the use of observations in IoWA-PCIT coaching. The IoWA-PCIT manual includes coding of coaching in order to reinforce the specific types of coaching emphasized in IoWA-PCIT.The other difference in coaching is the IoWA-PCIT model uses an understanding of working models of attachment (pattern of child-parent attachment; parent state of mind) to tailor coaching to working models of attachment.References ADDIN EN.REFLIST Beebe, B., Cohen, P., & Lachmann, F. (2016). The mother-infant interaction picture book. New York: Norton.Beebe, B., Jaffe, J., Markese, S., Buck, K., Chen, H., Cohen, P., . . . Feldstein, S. (2010). The origins of 12-month attachment: A microanalysis of 4-month mother-infant interaction. Attachment & Human Development, 12(1-2), 3-141. Beebe, B., & Lachmann, F. (2014). The origins of attachment: Infant research and adult treatment. New York: Routledge.Cohen, N., Muir, E., Lojkasek, M., Muir, R., Parker, C., Barwick, M., & Brown, M. (1999). Watch, wait and wonder: Testing the effectiveness of a new approahc to mother-infant psychotherapy. Infant Mental Health Journal, 20, 429-451. Dozier, M., Higley, E., Albus, K., & Nutter, A. (2002). Intervening with foster infants' caregivers: Targeting three critical needs. Infant Mental Health Journal, 23(5), 541-554. Dozier, M., Peloso, E., Lewis, E., Laurenceau, J., & Levine, S. (2008). Effects of an attachment-based intervention on the cortisol production of infants and toddlers in foster care. Development and Psychopathology, 20, 845-859. Dozier, M., Stoval, K. C., Albus, K. E., & Bates, B. (2001). Attachment for infants in foster care: The role of caregiver state of mind. Child Development, 72(5), 1467-1477. Eyberg, S. (1999). Parent-child interaction therapy: Integrity checklists and session materials. Retrieved from Eyberg, S. (2005). Tailoring and adapting Parent-Child Interaction Therapy to new populations. Education and Treatment of Children, 28(2), 197-201. Eyberg, S., & Funderburk, B. (2011). Parent-Child Interaction Therapy Protocol: PCIT International, Inc.Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to impaired infant-mother relationships. Journal of the American Academy of Child Psychiatry, 14, 387-421. Girard, E. (2014). Adapted PCIT Course of Treatment Manual. Hanf, C. (1969). A two-stage program for modifying maternal controlling during mother-child (M-C) interaction. Paper presented at the Western Psychological Association, Vancouver, British Columbia. Hembree-Kigin, T., & McNeil, C. (1995). Parent-Child Interaction Therapy. New York: Plenum Press.Hoffman, K., Marvin, R., Cooper, G., & Powell, B. (2006). Changing toddlers' and preschoolers' attachment classifications: The Circle of Security intervention. Journal of Consulting and Clinical Psychology, 74, 1017-1026. Lieberman, A. F., Ippen, C., & Van Horn, P. (2006). Child-Parent Psychotherapy: 6-month follow-up of a randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 913-917. McMahon, R., & Forehand, R. (2003). Helping the noncompliant child (Second ed.). New York: Guilford.McNeil, C. (2004). Manual for Parent-Child Interaction Therapy adapted for the SAMHSA Unity Project. McNeil, C., & Hembree-Kigin, T. (2010). Parent-Child Interaction Therapy, Second Edition. New York: Springer.Moss, E., Dubois-Comtois, K., Cyr, C., St-Laurent, D., & Bernier, A. (2011). Efficacy of a home-visiting intervention aimed at improving maternal sensitivity, child attachment, and behavioral outcomes for maltreated children: A randomized control trial. Development and Psychopathology, 23, 195-210. Patterson, G. (1982). Coercive family process. Eugene, Oregon: Castalia Publishing Company.Urquiza, A., Zebell, N., Timmer, S., McGrath, J., & Whitten, L. (2011). Course of Treatment Manual for PCIT-TC. van den Boom, D. (1988). Neonatal irritability and the development of attachment: Observation and intervention. (dissertation), University of Leiden. van den Boom, D. (1989). Neonatal irritability and the development of attachment. In G. Kohnstamm, J. Bates & M. Rothbart (Eds.), Temperament in Childhood: John Wiley & Sons.van den Boom, D. (1994). The influence of temperament and mothering on attachment and exploration: An experimental manipulation of sensitive responsiveness among lower-class mothers with irritable infants. Child Development, 65, 1457-1477. van den Boom, D. (1995). Do first-year intervention effects endure? Follow-up during toddlerhood of a sample of Dutch irritable infants. Child Development, 66, 1798-1816. van Zeijl, J., Mesman, J., Stolk, M., Alink, L., van IJzendoorn, M., Bakermans-Kranenburg, M., . . . Koot, H. (2007). Differential susceptibility to discipline: The moderating effect of child temperament on the association between maternal discipline and early childhood externalizing problems. Journal of Family Psychology, 21(4), 626-636. Webster-Stratton, C. (1982). Teaching mothers through videotape modeling to change their children's behavior. Journal of Pediatric Psychology, 7(3), 279-294. ................
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