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A Systematic Review of Vocational Interventions for Young Adults With Autism Spectrum Disorders
A Systematic Review of Vocational Interventions for Young Adults With Autism Spectrum Disorders
Source: Pediatrics
BACKGROUND AND OBJECTIVE: Many individuals with autism spectrum disorders (ASDs) are approaching adolescence and young adulthood; interventions to assist these individuals with vocational skills are not well understood. This study systematically reviewed evidence regarding vocational interventions for individuals with ASD between the ages of 13 and 30 years.
METHODS: The Medline, PsycINFO, and ERIC databases (1980–December 2011) and reference lists of included articles were searched. Two reviewers independently assessed each study against predetermined inclusion/exclusion criteria. Two reviewers independently extracted data regarding participant and intervention characteristics, assessment techniques, and outcomes, and assigned overall quality and strength of evidence ratings based on predetermined criteria.
RESULTS: Five studies were identified; all were of poor quality and all focused on on-the-job supports as the employment/vocational intervention. Short-term studies reported that supported employment was associated with improvements in quality of life (1 study), ASD symptoms (1 study), and cognitive functioning (1 study). Three studies reported that interventions increased rates of employment for young adults with ASD.
CONCLUSIONS: Few studies have been conducted to assess vocational interventions for adolescents and young adults with ASD. As such, there is very little evidence available for specific vocational treatment approaches as individuals transition to adulthood. All studies of vocational approaches were of poor quality, which may reflect the recent emergence of this area of research. Individual studies suggest that vocational programs may increase employment success for some; however, our ability to understand the overall benefit of supported employment programs is limited given the existing research.
Interventions for Adolescents and Young Adults With Autism Spectrum Disorders
Interventions for Adolescents and Young Adults With Autism Spectrum Disorders (PDF)
Source: Agency for Healthcare Research and Quality
Few studies have been conducted to assess treatment approaches for adolescents and young adults with ASD, and as such there is very little evidence available for specific treatment approaches in this population; this is especially the case for evidence-based approaches to support the transition of youth with autism to adulthood. Of the small number of studies available, most were of poor quality, which may reflect the relative recency of the field. Five studies, primarily of medical interventions, had fair quality. Behavioral, educational, and adaptive/life skills studies were typically small and short term and suggested some potential improvements in social skills and functional behavior. Small studies suggested that vocational programs may increase employment success for some individuals. Few data are available to support the use of medical or allied health interventions in the adolescent and young adult population. The medical studies that have been conducted focused on the use of medications to address specific challenging behaviors, including irritability and aggression, for which effectiveness in this age group is largely unknown and inferred from studies including mostly younger children.
Long-term oxytocin administration improves social behaviors in a girl with autistic disorder
Long-term oxytocin administration improves social behaviors in a girl with autistic disorder
Source: BMC Psychiatry
Background
Patients with autism spectrum disorders (ASDs) exhibit core autistic symptoms including social impairments from early childhood and mostly show secondary disabilities such as irritability and aggressive behavior based on core symptoms. However, there are still no radical treatments of social impairments in these patients. Oxytocin has been reported to play important roles in multiple social behaviors dependent on social recognition, and has been expected as one of the effective treatments of social impairments of patients with ASDs.
Case presentation
We present a case of a 16-year-old girl with autistic disorder who treated by long-term administration of oxytocin nasal spray. Her autistic symptoms were successfully treated by two month administration; the girl’s social interactions and social communication began to improve without adverse effects. Her irritability and aggressive behavior also improved dramatically with marked decreases in aberrant behavior checklist scores from 69 to 7.
Conclusion
This case is the first to illustrate long-term administration of oxytocin nasal spray in the targeted treatment of social impairments in a female with autistic disorder. This case suggests that long-term nasal oxytocin spray is promising and well-tolerated for treatment of social impairments of patients with ASDs.
A Sensitive Approach to Studying ASDs: Teasing Out Relationships between Autism and Maternal Smoking
A Sensitive Approach to Studying ASDs: Teasing Out Relationships between Autism and Maternal Smoking
Source: Environmental Health Perspectives
Both genetic and environmental factors have been implicated in autism spectrum disorders (ASDs), which affect an estimated 1 in 88 children. One such environmental factor, prenatal exposure to tobacco smoke via maternal smoking, has been associated with ASDs in some studies but not others. A new study reports evidence of a positive association between maternal smoking during pregnancy and higher-functioning ASD subtypes [EHP 120(7):1042–1048; Kalkbrenner et al.].
The authors collected information on maternal smoking and other factors from the birth certificates for 633,989 children born in 1992, 1994, 1996, and 1998 in 11 U.S. states. They linked these data with surveillance data from the U.S. Centers for Disease Control and Prevention’s Autism and Developmental Disabilities Monitoring network and identified 3,315 of the children who were subsequently diagnosed with an ASD by age 8 years.
About 13% of all the mothers smoked during pregnancy, compared with about 11% of mothers with children diagnosed with an ASD. Maternal smoking has been associated with both lower education and reduced access to health care, factors that might increase the likelihood that ASDs go undiagnosed among children of women who smoked during pregnancy. When the authors corrected for this potential bias using outcome misclassification sensitivity analyses, a weak positive association emerged between maternal smoking and cases classified as “ASD not otherwise specified,” which were assumed to be higher-functioning ASDs such as Asperger’s disorder. The association was not found for lower-functioning (that is, more severe) ASDs.
The authors write that their findings concerning ASD subgroups should be interpreted with caution because the accuracy of subgroup classification may have varied depending upon mothers’ access to evaluation services, and because it was not bas ed on direct clinical observation. They also note that positive associations may reflect the presence in higher-functioning subgroups of children with co-occurring disorders (such as attention deficit/hyperactivity disorder) that can be affected by nicotine exposure.
Strengths of the study include the large sample size, the population-based design with standardized identification of ASD cases, and the use of sensitivity analyses to evaluate potential sources of bias. The authors conclude that the observed association between maternal smoking during pregnancy and higher-functioning ASDs warrants further research.
Psychiatric comorbidities in asperger syndrome and high functioning autism: diagnostic challenges
Psychiatric comorbidities in asperger syndrome and high functioning autism: diagnostic challenges
Source: Annals of General Psychiatry
Several psychiatric conditions, both internalizing and externalizing, have been documented in comorbidity with Asperger Syndrome (AS) and High Functioning Autism (HFA). In this review we examine the interplay between psychiatric comorbidities and AS/HFA. In particular, we will focus our attention on three main issues. First, we examine which psychiatric disorders are more frequently associated with AS/HFA. Second, we review which diagnostic tools are currently available for clinicians to investigate and diagnose the associated psychiatric disorders in individuals with AS/HFA. Third, we discuss the challenges that clinicians and researchers face in trying to determine whether the psychiatric symptoms are phenotypic manifestations of AS/HFA or rather they are the expression of a distinct, though comorbid, disorder. We will also consider the role played by the environment in the manifestation and interpretation of these symptoms. Finally, we will propose some strategies to try to address these issues, and we will discuss therapeutic implications.
Diagnostic History and Treatment of School-aged Children with Autism Spectrum Disorder and Special Health Care Needs
Diagnostic History and Treatment of School-aged Children with Autism Spectrum Disorder and Special Health Care Needs
Source: National Center for Health Statistics
Key findings
Data from the 2011 Survey of Pathways to Diagnosis and Services
- The median age when school-aged children with special health care needs (CSHCN) and autism spectrum disorder (ASD) were first identified as having ASD was 5 years.
- School-aged CSHCN identified as having ASD at a younger age (under age 5 years) were identified most often by generalists and psychologists, while those identified later (aged 5 years and over) were identified primarily by psychologists and psychiatrists.
- Nine out of 10 school-aged CSHCN with ASD use one or more services to meet their developmental needs. Social skills training and speech or language therapy are the most common, each used by almost three-fifths of these children.
- More than one-half of school-aged CSHCN with ASD use psychotropic medication.
Use of machine learning to shorten observation-based screening and diagnosis of autism
Use of machine learning to shorten observation-based screening and diagnosis of autism
Source: Translational Psychiatry
The Autism Diagnostic Observation Schedule-Generic (ADOS) is one of the most widely used instruments for behavioral evaluation of autism spectrum disorders. It is composed of four modules, each tailored for a specific group of individuals based on their language and developmental level. On average, a module takes between 30 and 60 min to deliver. We used a series of machine-learning algorithms to study the complete set of scores from Module 1 of the ADOS available at the Autism Genetic Resource Exchange (AGRE) for 612 individuals with a classification of autism and 15 non-spectrum individuals from both AGRE and the Boston Autism Consortium (AC). Our analysis indicated that 8 of the 29 items contained in Module 1 of the ADOS were sufficient to classify autism with 100% accuracy. We further validated the accuracy of this eight-item classifier against complete sets of scores from two independent sources, a collection of 110 individuals with autism from AC and a collection of 336 individuals with autism from the Simons Foundation. In both cases, our classifier performed with nearly 100% sensitivity, correctly classifying all but two of the individuals from these two resources with a diagnosis of autism, and with 94% specificity on a collection of observed and simulated non-spectrum controls. The classifier contained several elements found in the ADOS algorithm, demonstrating high test validity, and also resulted in a quantitative score that measures classification confidence and extremeness of the phenotype. With incidence rates rising, the ability to classify autism effectively and quickly requires careful design of assessment and diagnostic tools. Given the brevity, accuracy and quantitative nature of the classifier, results from this study may prove valuable in the development of mobile tools for preliminary evaluation and clinical prioritization—in particular those focused on assessment of short home videos of children—that speed the pace of initial evaluation and broaden the reach to a significantly larger percentage of the population at risk.
See: Web-Based Tool Produces Fast, Accurate Autism Diagnosis, Study Suggests
Prevalence of Autism Spectrum Disorders — Autism and Developmental Disabilities Monitoring Network, 14 Sites, United States, 2008
Prevalence of Autism Spectrum Disorders — Autism and Developmental Disabilities Monitoring Network, 14 Sites, United States, 2008
Source: Morbidity and Mortality Weekly Report (CDC)
For 2008, the overall estimated prevalence of ASDs among the 14 ADDM sites was 11.3 per 1,000 (one in 88) children aged 8 years who were living in these communities during 2008. Overall ASD prevalence estimates varied widely across all sites (range: 4.8–21.2 per 1,000 children aged 8 years). ASD prevalence estimates also varied widely by sex and by racial/ethnic group. Approximately one in 54 boys and one in 252 girls living in the ADDM Network communities were identified as having ASDs. Comparison of 2008 findings with those for earlier surveillance years indicated an increase in estimated ASD prevalence of 23% when the 2008 data were compared with the data for 2006 (from 9.0 per 1,000 children aged 8 years in 2006 to 11.0 in 2008 for the 11 sites that provided data for both surveillance years) and an estimated increase of 78% when the 2008 data were compared with the data for 2002 (from 6.4 per 1,000 children aged 8 years in 2002 to 11.4 in 2008 for the 13 sites that provided data for both surveillance years). Because the ADDM Network sites do not make up a nationally representative sample, these combined prevalence estimates should not be generalized to the United States as a whole.
Familial Linkage between Neuropsychiatric Disorders and Intellectual Interests
From personality to neuropsychiatric disorders, individual differences in brain function are known to have a strong heritable component. Here we report that between close relatives, a variety of neuropsychiatric disorders covary strongly with intellectual interests. We surveyed an entire class of high-functioning young adults at an elite university for prospective major, familial incidence of neuropsychiatric disorders, and demographic and attitudinal questions. Students aspiring to technical majors (science/mathematics/engineering) were more likely than other students to report a sibling with an autism spectrum disorder (p = 0.037). Conversely, students interested in the humanities were more likely to report a family member with major depressive disorder (p = 8.8×10−4), bipolar disorder (p = 0.027), or substance abuse problems (p = 1.9×10−6). A combined PREdisposition for Subject MattEr (PRESUME) score based on these disorders was strongly predictive of subject matter interests (p = 9.6×10−8). Our results suggest that shared genetic (and perhaps environmental) factors may both predispose for heritable neuropsychiatric disorders and influence the development of intellectual interests.
Brain enlargement is associated with regression in preschool-age boys with autism spectrum disorders
Brain enlargement is associated with regression in preschool-age boys with autism spectrum disorders (PDF)Source: Proceedings of the National Academy of Sciences
Autism is a heterogeneous disorder with multiple behavioral and biological phenotypes. Accelerated brain growth during early childhood is a well-established biological feature of autism. Onset pattern, i.e., early onset or regressive, is an intensely studied behavioral phenotype of autism. There is currently little known, however, about whether, or how, onset status maps onto the abnormal brain growth. We examined the relationship between total brain volume and onset status in a large sample of 2- to 4-y-old boys and girls with autism spectrum disorder (ASD) [n = 53, no regression (nREG); n = 61, regression (REG)] and a comparison group of age-matched typically developing controls (n = 66). We also examined retrospective head circumference measurements from birth through 18 mo of age. We found that abnormal brain enlargement was most commonly found in boys with regressive autism. Brain size in boys without regression did not differ from controls. Retrospective head circumference measurements indicate that head circumference in boys with regressive autism is normal at birth but diverges from the other groups around 4–6 mo of age. There were no differences in brain size in girls with autism (n = 22, ASD; n = 24, controls). These results suggest that there may be distinct neural phenotypes associated with different onsets of autism. For boys with regressive autism, divergence in brain size occurs well before loss of skills is commonly reported. Thus, rapid head growth may be a risk factor for regressive autism.
A Parent’s Guide to Autism Spectrum Disorder
A Parent’s Guide to Autism Spectrum Disorder
Source: National Institute of Mental Health
This guide is intended to help parents understand what autism spectrum disorder (ASD) is, recognize common signs and symptoms, and find the resources they need. It’s important to remember that help is available.
The Level and Nature of Autistic Intelligence II: What about Asperger Syndrome?
The Level and Nature of Autistic Intelligence II: What about Asperger Syndrome?
Source: PLoS ONE
A distinctively uneven profile of intelligence is a feature of the autistic spectrum. Within the spectrum, individuals with Asperger syndrome differ from patients with autism in their early speech development and in being less likely to be characterized by visuospatial peaks. While different specific strengths characterize different autistic spectrum subgroups, all such peaks of ability have been interpreted as deficits: isolated, aberrant, and irreconcilable with real human intelligence. This view has recently been challenged by findings of autistic strengths in performance on Raven’s Progressive Matrices (RPM), an important marker of general and fluid intelligence. We investigated whether these findings extend to Asperger syndrome, an autistic spectrum subgroup characterized by verbal peaks of ability, and whether the cognitive mechanisms underlying autistic and Asperger RPM performance differ. Thirty-two adults with Asperger syndrome displayed a significant advantage on RPM over Wechsler Full-Scale and Performance scores relative to their typical controls, while in 25 children with Asperger syndrome, an RPM advantage was found over Wechsler Performance scores only. As previously found with patients with autism, children and adults with Asperger syndrome achieved RPM scores at a level reflecting their Wechsler peaks of ability. Therefore, strengths in RPM performance span the autistic spectrum and imply a common mechanism advantageously applied to different facets of cognition. Autistic spectrum intelligence is atypical, but also genuine, general, and underestimated.
See: The Level and Nature of Autistic Intelligence II: What About Asperger Syndrome? (Science Daily)
Recurrence Risk for Autism Spectrum Disorders: A Baby Siblings Research Consortium Study
Recurrence Risk for Autism Spectrum Disorders: A Baby Siblings Research Consortium Study (PDF)
Source: Pediatrics
Objective: The recurrence risk of autism spectrum disorders (ASD) is estimated to be between 3% and 10%, but previous research was limited by small sample sizes and biases related to ascertainment, reporting, and stoppage factors. This study used prospective methods to obtain an updated estimate of sibling recurrence risk for ASD.
Methods: A prospective longitudinal study of infants at risk for ASD was conducted by a multisite international network, the Baby Siblings Research Consortium. Infants (n = 664) with an older biological sibling with ASD were followed from early in life to 36 months, when they were classified as having or not having ASD. An ASD classification required surpassing the cutoff of the Autism Diagnostic Observation Schedule and receiving a clinical diagnosis from an expert clinician.
Results: A total of 18.7% of the infants developed ASD. Infant gender and the presence of >1 older affected sibling were significant predictors of ASD outcome, and there was an almost threefold increase in risk for male subjects and an additional twofold increase in risk if there was >1 older affected sibling. The age of the infant at study enrollment, the gender and functioning level of the infant’s older sibling, and other demographic factors did not predict ASD outcome.
Conclusions: The sibling recurrence rate of ASD is higher than suggested by previous estimates. The size of the current sample and prospective nature of data collection minimized many limitations of previous studies of sibling recurrence. Clinical implications, including genetic counseling, are discussed.
Comparative Effectiveness of Therapies for Children With Autism Spectrum Disorders
Comparative Effectiveness of Therapies for Children With Autism Spectrum Disorders
Source: Agency for Healthcare Research and Quality
Efforts toward early intervention for ASDs have been encouraging. Research evidence on the effectiveness of therapies for ASDs has shown promise in some areas, but since this is a young field, these results need to be replicated and expanded. There is some evidence to guide choices among medical interventions (for challenging and repetitive behaviors) and early intensive behavioral interventions. There is little or no comparative evidence on which to make decisions about: medical interventions for social or communication symptoms; most behavioral interventions; and educational, allied health, and complementary and alternative medicine (CAM) interventions. For most interventions, the evidence is insufficient to permit an estimate of their benefits or harms. This does not mean that these interventions are not associated with benefits or harms but that further study is required. Evidence suggests that there is an undefined subgroup of children for whom early and intensive behavioral interventions may elicit robust gains while others may not demonstrate marked improvement.
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Genetic Heritability and Shared Environmental Factors Among Twin Pairs With Autism
Genetic Heritability and Shared Environmental Factors Among Twin Pairs With Autism
Source: Archives of General Psychiatry
Context Autism is considered the most heritable of neurodevelopmental disorders, mainly because of the large difference in concordance rates between monozygotic and dizygotic twins.
Objective To provide rigorous quantitative estimates of genetic heritability of autism and the effects of shared environment.Design, Setting, and Participants Twin pairs with at least 1 twin with an autism spectrum disorder (ASD) born between 1987 and 2004 were identified through the California Department of Developmental Services.
Main Outcome Measures Structured diagnostic assessments (Autism Diagnostic Interview–Revised and Autism Diagnostic Observation Schedule) were completed on 192 twin pairs. Concordance rates were calculated and parametric models were fitted for 2 definitions, 1 narrow (strict autism) and 1 broad (ASD).
Results For strict autism, probandwise concordance for male twins was 0.58 for 40 monozygotic pairs (95% confidence interval [CI], 0.42-0.74) and 0.21 for 31 dizygotic pairs (95% CI, 0.09-0.43); for female twins, the concordance was 0.60 for 7 monozygotic pairs (95% CI, 0.28-0.90) and 0.27 for 10 dizygotic pairs (95% CI, 0.09-0.69). For ASD, the probandwise concordance for male twins was 0.77 for 45 monozygotic pairs (95% CI, 0.65-0.86) and 0.31 for 45 dizygotic pairs (95% CI, 0.16-0.46); for female twins, the concordance was 0.50 for 9 monozygotic pairs (95% CI, 0.16-0.84) and 0.36 for 13 dizygotic pairs (95% CI, 0.11-0.60). A large proportion of the variance in liability can be explained by shared environmental factors (55%; 95% CI, 9%-81% for autism and 58%; 95% CI, 30%-80% for ASD) in addition to moderate genetic heritability (37%; 95% CI, 8%-84% for autism and 38%; 95% CI, 14%-67% for ASD).
Conclusion Susceptibility to ASD has moderate genetic heritability and a substantial shared twin environmental component.
Early Autism Detection: Are We Ready for Routine Screening?
Early Autism Detection: Are We Ready for Routine Screening? (PDF)
Source: Pediatrics
Background: Autism is a serious neurodevelopmental disorder that has a reportedly rising prevalence rate. The American Academy of Pediatrics recommends that screening for autism be incorporated into routine practice. It is important to consider the pros and cons of conducting autism screening as part of routine practice and its implications on the community. We have explored this question in the context of screening from a scientific point of view.
Method: A literature search was conducted to assess the effectiveness of community screening programs for autism.
Results: Judged against critical questions about autism, screening programs failed to fulfill most criteria. Good screening tools and efficacious treatment are lacking, and there is no evidence yet that such a program would do more good than harm.
Conclusions: On the basis of the available research, we believe that we do not have enough sound evidence to support the implementation of a routine population-based screening program for autism. Ongoing research in this field is certainly needed, including the development of excellent screening instruments and demonstrating with clinical trials that such programs work and do more good than harm.
Therapies for Children With Autism Spectrum Disorders
Therapies for Children With Autism Spectrum Disorders
Source: Agency for Healthcare Research and Quality
Autism spectrum disorders (ASDs) have an estimated prevalence of 1 in 110 children in the United States. Disorders within the spectrum include Autistic Disorder, Asperger Syndrome, and Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS).
Individuals with ASDs have impaired social interaction, behavior, and communication including lack of reciprocal social interaction and joint attention (i.e., the ability to use nonverbal means such as pointing to direct others’ attention to something in which the child is interested); dysfunctional or absent communication and language skills; lack of spontaneous or pretend play; intense preoccupation with particular concepts or things; and repetitive behaviors or movements. Children with ASDs may also have impaired cognitive skills and sensory perception.
Treatment for ASDs focuses on improving core deficits in social communication, as well as addressing challenging behaviors to improve functional engagement in developmentally appropriate activities. In addition to addressing core deficits, treatments are provided for difficulties associated with the disorder (anxiety, attention difficulties, sensory difficulties, etc.). Individual goals for treatment vary for different children and may include combinations of therapies.
Reducing The Staggering Costs Of Environmental Disease In Children, Estimated At $76.6 Billion In 2008
Reducing The Staggering Costs Of Environmental Disease In Children, Estimated At $76.6 Billion In 2008
Source: Health Affairs
A 2002 analysis documented $54.9 billion in annual costs of environmentally mediated diseases in US children. However, few important changes in federal policy have been implemented to prevent exposures to toxic chemicals. We therefore updated and expanded the previous analysis and found that the costs of lead poisoning, prenatal methylmercury exposure, childhood cancer, asthma, intellectual disability, autism, and attention deficit hyperactivity disorder were $76.6 billion in 2008. To prevent further increases in these costs, efforts are needed to institute premarket testing of new chemicals; conduct toxicity testing on chemicals already in use; reduce lead-based paint hazards; and curb mercury emissions from coal-fired power plants.
Police Interaction With Autistic Persons: The Need For Training
Police Interaction With Autistic Persons: The Need For Training (PDF)
Source: Americans for Effective Law Enforcement, Inc
From a third to a half of all persons with autism have such stunted speech development that they cannot meet their ordinary daily communication needs. Some may repeat others’ words. Unlike mute persons, the difficulty is not physical inability to make sounds, but a neurological and cognitive problem. Some autistic persons have difficulty making and maintaining eye contact with others. A police officer may mistakenly interpret this as “suspicious,” having something to hide, or defiance, when in reality it is not being able to or not knowing how to respond appropriately, or even fear from what, to many, would be a routine social encounter. The result has sometimes, unfortunately, been rapid escalation of the encounter, with ensuing injury or death.
The purpose of this article is to briefly examine some of the circumstances in which police have and will encounter autistic persons in the community. It does not focus on “theories of liability” for unfortunate consequences that may result from such encounters. A small number of court decisions, however, are used as examples. Instead, the focus here is on bringing needed attention to a problem, and hopefully, helping to create awareness of some possible solutions.
Comparative Effectiveness Review: Therapies for Children With Autism Spectrum Disorders (Executive Summary)
Comparative Effectiveness Review: Therapies for Children With Autism Spectrum Disorders (Executive Summary) (PDF)
Source: Agency for Healthcare Research and Quality
Autism spectrum disorders (ASDs) have an estimated prevalence of 1 in 110 children in the United States. Disorders within the spectrum include Autistic Disorder, Asperger Syndrome, and Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS).
Individuals with ASDs have impaired social interaction, behavior, and communication including lack of reciprocal social interaction and joint attention (i.e., the ability to use nonverbal means such as pointing to direct others’ attention to something in which the child is interested); dysfunctional or absent communication and language skills; lack of spontaneous or pretend play; intense preoccupation with particular concepts or things; and repetitive behaviors or movements. Children with ASDs may also have impaired cognitive skills and sensory perception.
Treatment for ASDs focuses on improving core deficits in social communication, as well as addressing challenging behaviors to improve functional engagement in developmentally appropriate activities. In addition to addressing core deficits, treatments are provided for difficulties associated with the disorder (anxiety, attention difficulties, sensory difficulties, etc.). Individual goals for treatment vary for different children and may include combinations of therapies.
