I Love ABA!

Welcome to my Blog!

This blog is about my experiences, thoughts, and opinions on ABA. My career as an ABA provider is definitely a passion and a joy, and I love what I do.

This is a personal blog: The views and opinions expressed here represent my own and not those of the people, institutions, or organizations that I may be affiliated with.

Friday, May 11, 2012

Teaching Non- Verbal Children to Communicate



It’s very common that young children with Autism don't speak or have significant speech delays. Sometimes this is due to medical conditions, such as tongue abnormalities or apaxia. More often this is due to severe deficits in the areas of motivation and social interaction. Speech delays can also be caused by excessive ear infections, which can lead to hearing loss or impair speech processing during times of critical brain development.

The term non-verbal describes an individual who does not use vocal communication ( the clinical term is non vocal, because verbal behavior can include non-expressive communication such as sign language). In most situations these children use ineffective or inappropriate ways of communicating instead of using language.  The majority of the kiddos I have worked with were nonverbal when I first met them. Those kiddos usually communicated by pointing, leading, or the majority of the time: through their behavior. I have observed quite a few toddlers who without saying a word had an entire household catering to their every desire. The parents knew that 2 screams meant “turn the TV on”, a crying fit meant “pick me up”, pushing a sibling meant “I don’t want to play”, and so on.

The goal when working with non-verbal children should be more than getting the child to talk. The goal should be getting the child to communicate effectively. Even children who are verbal don’t always communicate. If I teach a 5 year old to label colors and body parts but she cant tell me when she is hungry, thats a good example of a child who can talk but isn't using language to communicate.

When you think of “non-verbal” think bigger than just being able to speak. How does the child communicate? Does the child appear to be strong in receptive language, even if they cant verbalize? Does the child hum, have verbal stims, sing songs or melodies? Does the child shout when upset or make wordless noises? From my experiences, positive indicators that a nonverbal child will become verbal include verbal stims and echolalia. A child who will echo, sing, or babble, will probably talk.
The behavioral piece of communication is HUGE. It cant be stated enough: Children who cannot communicate or are non-verbal have some of the most persistent and challenging problem behaviors. Why? Well, just imagine that you are placed in an environment where no one speaks your language. If you speak English, everyone else speaks French. If you speak Arabic, everyone else speaks German. Now imagine that you are hungry and must convince these people to feed you. How long would you try pointing and gesturing, before you started pushing people and throwing things?

If a child has no internal motivation to communicate, and isn’t externally required to communicate, then from the child’s perspective its much easier to engage in behaviors. A child who is allowed to fling their plate to the floor during dinner to signify “I'm done” has zero incentive to think up words, form them with their lips, and then speak. Reinforcement is also huge. For a child with Autism to learn to communicate, reinforcement must be present. You might be wondering, “Why do I have to reinforce my child to talk? My other children just started talking, they didn’t require M&M’s to do so”. A characteristic of Autistic Disorder is qualitative impairments in communication. This can mean the child has no language, exhibits speech delays, or has no motivation to use the language they have.


There are  many options for teaching a non-verbal child to communicate (and often a BCBA/Consultant will recommend multiple options at once):

Various Communication Methods

  •      Verbal Behavior Approach (ABA) – There are many different ways to do ABA, and VB is a branch on the ABA therapy tree. VB has a functional language focus. VB captures and builds upon internal motivations, and uses rewards to reinforce communication across verbal operants (mands, tacts, etc). Language is taught as a behavior and each component is broken down. If the child likes ice cream, one of the first things they learn to say is “ice cream”. This way, the child’s motivation to get a desired item is used to pull language out of the child: You say ice cream, you get ice cream. The VB approach also uses repetition, prompting, and shaping to get desired responses. Initially, “buh” is acceptable to request the ball. Over time (and with careful data analysis), the criteria become more demanding until the child can say “BALL”. For a detailed description of VB, see my Verbal Behavior post. 

  •    Speech Therapy- For every 10 clients I see, probably 6-7 are also receiving speech therapy. Many parents think that ST is the only way to get a non-verbal child talking. SLP's work with conditions such as stuttering, language impairment, feeding/swallowing, etc. (for more information see www.asha.org). I have worked with kids who made huge gains from ST, and I have also worked with kids who did not. They had been receiving ST for years, and after a few months of ABA they started talking. Its important as a consumer to pursue speech and language professionals who have experience with Autism or behavior management. Its also important to look at the intensity of services being offered. Many of my kiddos who get speech therapy only receive 1-1.5 hours a week. For a nonverbal, lower functioning child with Autism, that may not be enough therapy to produce significant gains. If your child is currently receiving speech therapy and experiencing success and making great progress, I highly suggest encouraging collaboration between the ABA team and the SLP. Approaching communication with a team approach and having everyone on the same page can only help your child.

  •  Sign Language- Always combine labeling with sign language so the child hears the correct word, as well as learns the sign. When considering sign language you want to think about the child’s age and fine motor skills. If a child has poor fine motor abilities and cannot make multiple, intricate signs to communicate then sign language isn’t a good choice. Age is important because you want to think about how big that child’s world is. If the child is only 2 and spends all day at home with Mom or Dad, then sign language is probably a good choice. However if the child is 11 and goes to school, after school care, karate practice, and then home, then all of the people the child has regular contact with must know the child’s signs. If the child walks up to a teacher on the playground and signs for her “red notebook”, will the teacher understand? If the child doesn’t get a prompt response to their sign language, they may stop signing. Also a very common error I see with non- verbal kiddos who have learned ASL is getting stuck on the sign "more". Many professionals and parents teach the child to sign "more", and unfortunately the sign then gets generalized. The child will randomly walk up to people and sign for more, and no one knows what they want. More of what?? Imagine how frustrating this must be to the child. If you decide to teach your child to sign "more", always pair it to the specific item they are requesting.
  •  Picture Exchange Communication System- With the PECS system the child learns to communicate by exchanging photos of items to receive the actual item. PECS are simple to use, can be transported across environments, and can eventually be very elaborate. You can teach a child to request in full sentences using PECS, to request multiple items, to describe their day, to have a conversation, etc. An advantage that PECS has over sign language is the cards or photographs are easy for anyone to understand. With signing if a child makes a sign sloppily then people don’t know what they want. With PECS you can use pictures or actual photographs of the items, depending on what works best for the child. Another advantage to a PECS system over signs, is communication between peers. The average 3 year old may not recognize the sign for "play", but they may understand that a photo of a dollhouse means "Do you want to play with the dollhouse?. A disadvantage of PECS that parents report to me can include: difficult to keep up with all the various photos/pictures, and the childs interests change so frequently it requires changing the cards very often.

  • Assisted Communication Devices- An assisted communication device will create speech for the child by speaking in a simulated voice. The child inserts cards, types, or pushes buttons, and the machine speaks. Since these are  technological devices they do require the child have the cognitive ability to independently operate them to be effective. However, if you have access to an Ipad there are some really great communication apps (such as Proloquo 2 Go) that nonverbal kiddos can use to communicate with just a few swipes of their fingers. An advantage of an AAC is they can be used with individuals of varying physical capability, because they can be modified or adapted if the child has vision difficulties, cant type, or has hearing loss. An AAC can be transported easily and allows the child to quickly communicate wants, thoughts, opinions, and needs. Some of these devices can be programmed however they need to be, with very specific information that would be hard to put on a photo (such as a lengthy knock-knock joke). Other devices are more basic and difficult to program for detailed conversations, or elaborate back and forth exchanges.  I know a few kiddos who were able to get communication devices (including Ipads) provided by the school system, so that may be a resource worth looking into if you are unable to afford to purchase a device....some of them can get pretty expensive.  

  •  Language Immersion- This is a method typically seen in preschools or daycares that accept very young children with special needs. The classroom immerses the children in language throughout the day with the intention of creating a stimulating environment conducive to speech. Items are clearly labeled, children are engaged in conversation even if they cant talk (“David, is my coat blue? Nod if my coat is blue”), and the teachers spend time working 1:1 with each child on turntaking, eye contact, and joint attention. To me, these classrooms often look similar to the Koegel method, or Pivotal Response Training. Often these types of techniques are implemented by early childhood education teachers, or parents. An advantage of language immersion, or focusing on pivotal skills to enhance communication, is this method can be easy for a parent to implement with their own child. These types of techniques focus on developmental milestones leading to first words, such as babbling, recognizing distinct sounds, imitating actions, responding to receptive commands, and communicating using gestures. Working with the child 1:1 will include lots of intrinsic rewards, and naturally occurring interactions. For example: treat the child’s babble as if they are words, and carry on a conversation with them. Narrate your actions and the child's actions, even if the child doesn't respond to you ("We're walking upstairs now. Lets count the stairs: 1,2,3,4....."). While you are narrating try to make eye contact with the child, build upon shared interests, and make learning fun.

 
The wide array of programs, books, resources, and clinics out there that promise to get children with Autism to talk can be very intimidating and confusing for consumers. Be a critical consumer and look for research proven methods that clearly explain how the treatment works, and what is involved. If you have to buy the treatment or purchase a book before anyone will explain exactly how it works, be suspicious.

 No matter which option you select to teach communication to a kiddo with Autism, in order for it to be effective and consistent across settings and people you must incorporate behavior management. The child must learn that anything less than the communication system will no longer be accepted. That means if you are teaching the child to use sign language to request a cookie, then they are no longer allowed to climb up onto the kitchen counter and get the box of cookies off the top of the refrigerator. Make communicating with you a requirement, or the child wont do it.
The child must also learn that communicating with people leads to good things. If the child just learned to mand for “juice”, then initially every time the child says juice they should get a sip of juice. The child needs to see that communicating with people promptly gets needs and wants met.
 If you have implemented a system of communication for a kiddo with Autism and the results are inconsistent, ask yourself: “Is this communication system the only way the child can get this need/want met?” If the answer is no, that may be why you aren't seeing progress.


**Quick Tip: Early intervention is critical when it comes to targeting speech production and development. You want to start working with the child from a very young age to ensure the best results. However, research shows that all hope is not lost for older children with Autism who are non-verbal. It will be more challenging for an older child to learn to talk, but it is not impossible. The most promising methods for children over the age of 5 include speech generating devices (which do not inhibit language) and developmental approaches that facilitate joint attention.

References:

Kaiser, A. P., Hancock, T. B., & Nietfeld, J. P. (2000). The effects of parent-implemented enhanced milieu teaching on the social communication of children who have autism. Journal of Early Education and Development [Special Issue], 11(4), 423-446.

Kasari, C., Paparella, T, Freeman, S.N., & Jahromi, L (2008).  Language outcome in autism: Randomized comparison of joint attention and play interventions.  Journal of Consulting and Clinical Psychology, 76, 125-137.

Murphy SA. (2005) An Experimental Design for the Development of Adaptive Treatment Strategies. Statistics in Medicine. 24:1455-1481.

Pickett, E., Pullara, O, O’Grady, J., & Gordon, B. (2009).  Speech acquisition in older nonverbal individuals with autism: A review of features, methods and prognosis. Cognitive Behavior Neurology, 22 1-21.

Schlosser, RW, & Wendt O (2008).  Effects of augmentative and alternative communication intervention on speech production in children with autism: A systematic review. American Journal of Speech-Language Pathology • Vol. 17 • 212–230.




20 comments:

  1. My 5 1/2 year old son with PDD-NOS has been doing ABA since he was 3 1/2 and speech since he was 20 months. He has a neurotypical fraternal twin so I really picked up the differences in language development early on. He did 16 hours for a year, then 18 hours for the next year (with full time kindy), and now 8 hours (with full time school). I never know when he is 'done' with ABA. He is already indistinguishable from his peers, so we decided not to inform his new school about his ASD diagnosis. We did a full assessment with a speechie just before he started Prep which found he had moderate language disorder. ASD was not even queried. His screening tests by speechies and OTs at his very expensive very on-the-ball school did not suggest anything abnormal either, beyond the language diagnosis. The teacher has had some difficulties behaviour wise, which she has put down to language (basically not completing his work). But he is exhausted by the great time demands of ABA and speech on top of his school work. Is it normal for a child to continue ABA each day after school (he does 4 days)? Is there ever a time when speech therapy with mum and a speechie a couple of times a week becomes a better option? I don't know. I want to be able to say I did everything. Just not everything wrong.

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    1. ABA Therapy is considered "done" when the child is no longer exhibiting the deficits that they were at the start of therapy. You say that your son is now recovered (indistinguishable from peers), so it sounds like he doesnt need intensive ABA therapy sessions anymore. If he is having behavioral issues at school then they should conduct a FBA and create a behavior plan to teach him alternative behaviors. Otherwise, those behaviors will continue.

      Its always difficult to know which therapeutic treatments to continue with and which to eliminate. From what you describe about your son it sounds like speech therapy and better behavior management in the school setting are better choices over continuing with ABA therapy.

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  2. Thanks Tameika! As I'm a fan of VB :) would you please explain to me what's the main reason that would lead you to choose the VBA over the others?

    Many Thanks!
    Val

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    1. VB would be the best ABA approach to use because its focus is on verbal behavior. So if the intent is not to use an alternative communication system (like sign language), but rather to get a child to talk, then VB is the best choice. VB is all about language. VB uses motivation and interest to teach a child to mand and echo, which eventually leads to saying full sentences. As each word is taught, the child learns the word in multiple ways. So if the child can echo the word "apple", then they learn to request an apple, to label an apple, to describe an apple, and to read and write the word apple.

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  3. Hi Tameika,

    My son who is 6 1/2 is non verbal. He has verbal stims and echolalia. He was in our local district and now this past September he is enrolled in special Autism school. Never had ABA before. They are all Aba based program. I'm not sure if he is getting VB. he is in a class room of 6 kids. I know they do 40 mins sessions with him at a time. How can I make sure that their approach is VB for my child. I have an IEP coming up. I think that's what he needs. How do I go about asking them to incorporate that into his iEP?
    Please advise!
    Loved your article.
    Thank you!

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    1. Hello, and thanks for checking out my blog!

      A VB approach or VB program will have certain characteristics, such as: language and skill assessment using the VB-MAPP, functional analysis of language deficits (focus is on the child understanding the significance of the words they use, and not just getting the child to talk), VB operants will be taught in a sequential order (mands, tacts, intraverbals, etc), and the data is typically collected by what is called the "Cold Probe" or first trial data.
      I would recommend you ask if the school is using a VB approach and then look over the curriculum and goals to verify that. If they say they are not using a VB approach you may be able to specifically request that they incorporate VB methodology for your son. If your son does not currently have an IEP, then the most you can do is request. The point of the IEP is to put in writing the individual accommodations you want made for your child. So with no IEP, it is up to the school to determine how to teach your son.

      --I just want to quickly add that at almost 7 years old, and having never received ABA, its a good sign that your son is echolalic. Typically kids who exhibit echolalia eventually learn to use language--

      I hope that answered your question, feel free to contact me via email if it did not.

      Good luck!

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  4. What is your opinion on the IPAD? are there any apps that you can recommend?

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    1. I'm sorry I cant be more help, but I'm the last person in America who doesn't have an IPAD! :-)
      BUT I do think they are amazing, and know that they can work wonders in an ABA program.

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    2. Hi Tamika ,I am in the process of adopting an 11 yr old girl with down syndrome. She is non verbal only makes motor boat sounds. I understand she was removed for neglect and has lived in a group home for the last two years.Any hope for gaining some speech? I have a daugughter who I adopted at 5 mo. and is now 19, she had alot of early intervention and i became certified in sigh language togive her sign skills, and she is doing quite well though not everyone can understand her. Possible apraxia. But back to S ierra what do you think?

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    3. Hi & Thanks for commenting!

      For the sake of immediate communication, I would recommend using a form of nonvocal communication such as PECS, sign language, or a communication device. When using any nonvocal form of communication be sure to pair it with language, such as handing the child a picture of an apple while saying "Apple. You want an apple".
      This way you can immediately begin to communicate with her, which will greatly reduce the need for her to engage in problem behaviors to express her wants and needs. Thinking more long term, I would highly recommend you seek out the services of a SLP, either privately or through the childs school. Especially since this is an older child who only has makes sounds. ABA professionals are not speech therapists, so you would want to get a full evaluation and recommendation from a speech professional first. In addition, depending on the needs of the child you may want to look into intensive ABA in the home to work on adaptive behaviors, social skills (since she is coming from a group home setting), and to reinforce language skills. SLP's and ABA teams can work beautifully together when everyone is on the same page and communication is strong. When seeking a speech therapist make sure to ask about their experience with children with Downs Syndrome, and older children who are nonvocal. Good luck to you!

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  5. Hi, we have a 3year old son who only uses the first sound of a word (ray for raisin for example). We have recently started a VB program and since we started trying to get him to say more than just the first sound he has stopped 'talking' as much and has gone back to leading us by the hand when he wants something. Is this a normal phase?

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    1. Hi there!

      Is he receiving enough reinforcement in his VB program? Have you modified the environment so that he can only access items/things he enjoys by using language? If I'm understanding your question, you are saying that before the VB program saying "ray" would get him a raisin. Now with the VB program, he has to say the entire word ("raisin") to get the same thing?

      I can understand why he may be trying to revert back to leading, and not wanting to talk. As demand increases, reinforcement must increase. So maybe for saying "raisin" he now gets a handful of raisins. Or a raisin AND a sip of juice. It sounds like he may need more of a reward to use his language than he is currently getting, and more opportunities to practice the skill.

      Also if you are still allowing him to lead you by the hand after beginning a VB program, thats a no-no. When he tries to lead someone, they need to stop and try and get language from him.
      I wouldn't say its a normal phase for his speech sounds to decrease as the demand increases, UNLESS the reinforcement did not also increase. It could be the demand placed on him has gone up, but what he earns as a reward has not.

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  6. I'm wondering if you can tell me if ABA would be helpful for a child who does not have autism but has global developmental delay due to chromosomal issues.... Nonverbal...

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    1. Hi there,

      ABA has extensive empirical data behind it demonstrating that the techniques can be effective with a variety of issues, challenges, or disabilities. ABA is much broader than Autism. I have worked with clients with a wide range of challenges, from ADHD, to Downs Syndrome, to OCD. So I would say that yes, the techniques and strategies used to teach language in a quality ABA program could definitely be helpful for a child with developmental delays.

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  7. Hi Tameika,
    I love your blog, it is very informative. My daughter is five years old and was diagnosed with Autism in May 2012. She is also nonverbal. When she gets frustrated she can become slef injurious rather quickly which involves biting her hand, hitting herself in the head, head butting something, or scratching her legs. Apparently she has been doing these things a lot at school and they actually sent a note home asking us if she is on medication for it. We are wanting to get her started in ABA services where we live but it has been a long process because our insurance will not pay for it and it takes a while to get the Michelle P. Waiver program that our state has. She is in an "Autism unit" at her school but it seems like its a total shock to them to see a child with Autism have aggressive behavior. I really do not want my child medicated and would much rather try the ABA first. Do you agree?

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    1. Hi Samantha,
      I'm glad you enjoy the blog! I am not anti-medication, but I do like to see other things tried before going straight to medication and I dont like to see medication being the ONLY treatment used.

      Some parents choose ABA or other treatments specifically because they do not want to put their child on medication. In some instances, medication may be necessary or helpful as an addition to other therapies, but it really depends on the child.
      For the SIBs (self-injurious behaviors) you are describing it is imperative that you get some help. If you do not currently have ABA services, I would highly recommend contacting a BCBA just to conduct a functional analyses of the problem behaviors and write a strong behavior plan. You can then share that plan with the school, and if you and the school are both implementing the plan successfully the problem behaviors should decrease. SIBs are always behaviors you want to address right away using a functional approach, because they can so quickly worsen or lead to more severe behaviors.

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  8. Hi Tameika,
    I work with a boy who "uses" PECS. He is bloqued on Phase 3 A (discrimination between the desired item and a non desired item). In PECS, if the child take the wrong picture, the therapist is supposed to give the wrong item, prompt toward the good picture, say "good job" but to not deliver the item, provide a distrator trial and give the opportunity for a new exchange. During mand training, I'm not used to do distractors trials, I just prompt toward the image/ the sign and give a little piece of the desired item and I fade the prompt rapidely during next trials. I used differential reinforcement to teach independant demand. Am I making a mistake in my procedure? Do you think it can be dommagable for this boy if I don't follow precisely the PECS procedure and the distractor trial?
    I hope you'll accept to give me your opinion :).
    Thank you.

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    1. Hi Stephanie,

      PECS Phase 3 is about teaching simple discrimination using 1 trainer (earlier phases use 2), and begins by teaching a highly preferred item with a non preferred item. For errors I would use an error correction procedure (such as model then prompt) or block access to the wrong item, before adding distractor pictures. Comprehension checks should be completed before mastery can be achieved.
      However, PECS protocols (like other teaching protocols) are very individualized to the specific child. So without knowing the child and their learning history it is difficult for me to say what would be the best way to proceed. I strongly advise speaking about this issue with the BCBA on the case, or your direct supervisor.

      Tameika

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  9. Hi Tameika,

    I am interested in using sign language as a communication method. Can you suggest which behavioral instructional strategy would work best and perhaps has some research behind it, in teaching sign language to children with Autism? Or perhaps recommend some research articles where I can begin. I have read in various places that ASL is taught by many methods one of which is called the Direct Experience Method but am not convinced it is equal to direct instruction. I have also considered incidental teaching. Being an ABA student I need to keep the intervention strategy research-based. Perhaps I'm looking in the wrong places or approaching the subject from the wrong perspective. Although sign isn't used much with children in my area it is used quite a bit with DD adults, which is my area of knowledge. I would like to be able to learn a more structured way of teaching sign to the adults I work with. Have you any suggestions? I would greatly appreciate any help.

    BTW, I was very excited to find your blog, you have done a beautiful job with it.

    My best,
    Gwen

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    1. Hi Gwen,

      Thank you very much for your kind words :-)

      Signing is such a vast topic, its far more expansive than I can cover here on a blog site.
      The suitability of signing for a non vocal client will vary from child to child. For some clients, vocal manding was the communication target of choice, and for others PECS was the best for that child. For others, signing (often in a DTT/NET combined format) was used. In each situation, the client's current communication abilities, their ability to imitate motor actions, their environment, and caregiver wishes were all considered. I can say I have worked for companies in the past who very zealot one way or the other (totally against PECS or totally against signs), but I dont think it has to be that drastic of a decision. Its about what will be most functional and meaningful for the client.

      What literature tells us is that communication assistance does NOT reduce or prevent vocal communication, so whether you use an Ipad, PECS book, or signing, to help a nonvocal client all methods (when implemented correctly) have a high likelihood of success.

      There are some great resources out there, here are a few to get you started:

      http://www.behavior-consultant.com/asl-pecs.htm
      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1308282/
      http://www.ncbi.nlm.nih.gov/pubmed/2183678
      http://www.ncbi.nlm.nih.gov/pubmed/3610996
      http://www.ncbi.nlm.nih.gov/pubmed/6643323
      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1311332/

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