Developmental coordination disorder and dyspraxia

What is DCD?

Developmental coordination disorder (DCD) is the term used to describe a range of difficulties 6-8% of children experience with posture, movement and coordination, without there being a specific medical reason for these difficulties. These difficulties are severe enough to adversely affect their everyday function and school activities.

There are a number of other terms or labels used for the difficulties experienced by children including low muscle tone, minimal neurological disorder, and clumsy child syndrome.  The trouble with each of these labels is that make an assumption about the cause of the difficulties the child has - whereas the underlying cause is not known.

What is dyspraxia? 

The term dyspraxia is sometimes used as an alternative term for DCD.  
 
There are no formal criteria for a diagnosis of dyspraxia.  This makes it very confusing: different people use the term dyspraxia in different ways.  

It is also the reason why a diagnosis of dyspraxia is not recognised by many pediatricians and school authorities. 

The information provided by the dyspraxia support group websites tend to list a range d by a child who has been diagnosed as having dyspraxia, including poor emotion regulation, attention, short-term and working memory and other cognitive difficulties.

Including all these different developmental difficulties into one diagnosis has its drawbacks because it prevents clear thinking about the different factors contributing the everyday difficulties the child is experiencing. 
 
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What causes DCD? 

DCD is not really a single disorder with a known cause, a typical developmental pathway or known outcome.
 
it is now generally accepted that children with DCD have atypical brain development that affects the way they learn new skills. They appear to have difficulties forming internal representations (also called internal models) that  form the basis learning, planning and coordination of motor skills.  
 
In addition children with a diagnosis of DCD often have difficulties related to self-regulation, anxiety, attention and working memory which impact on their learning of new skills.
 
Together this means that in order to help a child with DCD it is necessary to understand all the factors that contribute to poor motor performance so that a suitable plan of action can be implemented to help the child. 
 
4y carrying bucket.jpg

Why a child with DCD has poor coordination 

DCD is a specific motor learning developmental disorder

It is now generally accepted that children with DCD do not create internal representations of the subroutines involved in performing everyday actions in the same way as typically developing children do. 

Internal representations are the blue prints within the brain that link information from the body sensors (muscles, joints, eyes) with the motor commands for activating muscle contraction at the right time, in the right order with the right amount of force for an action. 

Children with DCD do not make effective use of everyday experience for building a large bank of internal representations to guide and plan movements. They often require additional guided practice to learn new skills in order to develop the internal representations / models that will form the basis for future performance of the skill.   

The many representations needed for an everyday task

Take for example picking up a plastic beaker of water to take a drink. This looks like a fairly simple task - reach, grasp and lift.

But think about it carefully.  The amount of pressure you apply to the beaker and the speed that you lift it all depend on making judgments about how flexible/soft the beaker is and how full it is. 

If the beaker is made of thin plastic, it is important not to grip the sides too hard. If it is full you need to lift it more carefully so as not to spill the water, and you also need to adjust your grip so that it does not slip out of your hand. 

Each of these aspects of pick-up-and-drink-from-a-beaker action is controlled by an internal representation.

Cutting out a circle with a pair of scissors

Many children with DCD / dyspraxia have difficulties cutting out a circle with a pair of scissors. 

The pictures below show how one child's skill at this task improves over time. In the first frame she is 4 years old and having difficulties positioning and holding the paper. One year she cuts out a circle with confidence - mostly because she has learned to to hold the paper closer to the line of cutting. 

Two things have happened in the intervening year and many hours of cutting experience. The first is that with age and experience her ability to plan her actions so that the two hands work together to cut along the line.

The second is that at 5 years she expects to produce a good end product. She now pays attention to outcome and uses her mistakes to improve her accuracy each time she cuts out a circle. 

Read more: Cutting with scissors: refining control through experience  

R 3y 9m scissor cutting 24.jpgR 5y 3m  cutting circle 3.jpg

 

Helping a child with DCD

Research has shown that providing a child with additional guided practice improves performance of everyday and school related tasks. In other words, individualised coaching in the learning of new tasks pays off. 

Parents play a vital role in such coaching. Some coaching will require setting aside specific time for practice. But in many instances it can and should form part of a family's everyday activities.

Once you understand the requirements for a task and why a child has difficulty performing a task, building help into your interactions with your child pays off in terms of your child's ability to be independent, self-confidence and ability to participate with peers in the playground. 

More about understanding and coaching motor skills

How Nick practises walking through the house without bumping into things - an example of parent coaching

Children with DCD and dyspraxia often have hypermobile joints and associated muscle weakness

About 20% of people have joints that are more mobile than usual. This is because the capsule and ligaments that hold the joint together are more pliable (they can be more easily stretched) than usual. The muscles are also more pliable and more easily stretched than usual. The body parts are only loosely held together which means that the muscles have to work harder to hold the body steady and move it against the ever present downward pull of gravity. 

Joint hypermobility affects the way a child learns to move and often results in the child developing inefficient pattens of movement and posture. Although the child's joints and muscles are very flexible, some muscles such as the hamstrings and iliotibial band may be very tight and this affects sitting posture and also hampers the child's performance of agility and balance tasks.

Children with joint hypermobility also often have poor endurance.

The muscle weakness and tightness and the poor endurance can be substantially improved by a programme of exercises tailored to meet the child's specific needs and abilities.

 

Children with DCD and dyspraxia also often have a diagnosis of “low muscle tone”

Children are said to have low muscle tone when they have poor posture and difficulty sitting erect and keeping the trunk steady when moving the arms.

In most cases the cause of these difficulties is muscle weakness and poor endurance usually associated with joint hypermobility.

It is important to recognise the muscle weakness as this can improved by a programme of exercises to strengthen weak muscles, improve endurance and train more effective postural control.  

Read more about low muscle tone

roan 5y eagg and spoon.jpg    
  

 

4y transferring soil into a bucket.jpg

DCD often co-occurs with other developmental disorders 

Children with DCD frequently have co-occurring developmental difficulties which impact on the child's everyday function and capacity for learning. 

Recognizing each specific area of difficulty  and how it impacts on learning of movement skills, attention and behaviour in general is very important.  It makes it easier to understand the child's behaviour and also allows parents and teachers to address each area of concern in an appropriate way. 

Co-occurring difficulties include:

  • Attention difficulties: these may be related to anxiety and poor emotional self-regulation. 
  • Poor emotion self–regulation: which is often related to having an anxious nature 
  • Poor working memory which makes it difficult for the child to remember instructions and keep a goal in mind.
  • A very cautious nature which is associated anxiety and hypersensitivity to sensory stimuli, and often allergies and asthma 
  • Joint hypermobility and associated weakness with associated muscle weakness "low muscle tone" and poor levels of fitness
For more on related difficulties see CanChild: DCD Related Disorders
 

Movement difficulties a child with DCD may experience  

Usually a child is given a diagnosis of DCD because he or she is having difficulties with the control, organization and planning of posture and movements.

However, these children often have associated difficulties with the attention and thinking skills needed for organizing themselves, staying on task, persisting with a task, and remembering and learning a new task. .  

Together these difficulties impact on the child's ability to complete everyday tasks and learn new skills, such as:

  • Balance and agility activities - such as hopping, skipping, climbing on the jungle gym
  • Ball skills - catching, throwing and kicking
  • Getting dressed - particularly buttons and laces
  • Sitting still and upright at a table
  • Eating with a knife and fork
  • Building with construction toys
  • Handwriting is slow and untidy, the child complains of discomfort in the shoulder and hand and dislikes writing, complains that it is boring    More about handwriting
  • Slow to learn to ride a bicycle
  • Slow to learn to swim
  • Games and PE at school - tires quickly, cannot keep up with the other children

What is the cause of DCD?

In many cases the reason why a child develops DCD is not known.  The cause may lie in atypical development of the brain. 

The effective control of all our actions and thoughts depends on the different areas of the brain working together in a coordinated fashion.  In the young baby the connections between the different parts of the brain are present, but not well developed. Over time, as the child’s brain grows and develops these connections become much more clearly defined and specific, and as a result child becomes able to perform more complex tasks which involve doing more than one thing at a time.

The richness and complexity of these connections is influenced by the particular way in which the individual child’s brain develops and the way in which the child engages and interacts with the social and physical environment. Our brains are shaped by the variety and range of our experience.  

Some researchers believe that children with DCD do not create these links between the different brain areas in the same way as typically developing children – everyday experience is not enough, they seem to require additional help.   

There may also be a genetic connection. DCD sometimes runs in families  – there is often  a parent, an aunt or uncle in the family who had difficulties with balance, coordination and motor planning as a child.

Some children born very early also have movement difficulties as a result differences in brain development caused by the pre-mature birth. 

Children on the autistic spectrum sometimes have poorly developed motor skills – possibly also related to atypical brain development.

A child who has hypermobile joints with related muscle weakness (sometimes called low muscle tone) often has difficulty acquiring movement skills in the usual way.

Temperament also plays a role in the development of movement-based skills. A child with a very cautious temperament may avoid activities that are new and appear difficult and require that require mental and physical effort. This affects their ability to learn new skills in the usual easy way. 

Can DCD be cured? 

Children with DCD can learn to perform most everyday tasks given the right opportunities and support.  It just takes more practice and learning to pay attention in a special way to compensate for the way in which their brains learn new skills. 

But even when a child with DCD has learned to perform a task quite well, it might take more effort than usual and require added attention and more time. This needs to be remembered particularly in school tasks where time demands can have a very negative impact on a child's ability. 

Some skills that require a great deal of co-ordination make remain a problem - but then these need not be part of the child's life. Team sports and learning to ride a bicycle on rough terrain are examples of activities that can be avoided. 

Handwriting is the one school activity that can cause long term issues, and the child may need access to a keyboard for school work.  

General fitness can be improved and can make a big difference to how the child perceives his or her abilities. Being able to keep up with the other children in the playground is important and running fitness and coordination can usually be improved with a bit of effort. 

Therapy for children with DCD

Children with DCD are often referred for physiotherapy and / or an occupational therapy.  Although there is a lot of overlap between these therapies, each profession tends to focus on certain aspects of the child’s function. 

Physiotherapists tend to focus on posture and gross motor skills as well as strength, flexibility, agility, endurance. 

Occupational therapists usually pay more attention to fine motor control, hand function, handwriting, perception and daily activities.

However, depending on the therapist's interests, skills and training a therapist may cross these boundaries.

Ideally therapy enlists parents' help in providing everyday opportunities for training motor skills

Learning a motor skill takes repeated practice along with persistence and an ability to tolerate failure.  Parents and teachers are best placed to encourage repeated practice as part of everyday life. 

Common intervention approaches include:

CO-OP is a cognitive based approach which has been well researched. The Canchild website has more information on Co-op as well as some good information on DCD

Sensory Integration Therapy (SIT) is an the approach commonly used by occupational therapists. The assumption in SIT is that the problems experienced by children with DCD/Dyspraxia are due to an underlying disorder of the ability to process sensory information.

Neuromotor task training, an approach developed and used in the Netherlands has provided some evidence for its effectiveness.

 

 

CanChild 

for the most 
up to date, evidence based information on DCD

 

Developmental Gym Approach 

The Developmental Gym approach assumes that there are many different factors that impact on the learning and performance op movement tasks - and that all these factors need to be considered when planning physiotherapy intervention for children with movement difficulties.

It differs from other programs in that it does not view a child's thinking, emotional and movement skills as separate entities - but approaches the child as a complex being with a range of needs and functioning in a family environment.

It also differs from cognitive approaches, such as CO-OP in that physical factors such as strength, endurance and flexibility that may be limiting a child's are addressed at the same time as addressing cognitive, emotional, attention and movement planning issues that are hampering a child's movement performance.

It differs from traditional physiotherapy approaches in that the physical factors limiting task performance are not addressed in isolation from the emotional and thinking aspects of movement performance.

Children with DCD often need encouragement to engage in the effortful physical activity needed to be fit for the classroom and playground and able to keep up with their peers.  

The Fit for Action Webspace provides parents with a range of ideas for improving a child's strength, endurance and flexibility, based on the Developmental Gym approach. 

The Handwriting Gym website is a good place to find out more about drawing and handwriting.

 

Comments

Do I Need to Push for What My Girl Needs?

Firstly I am so happy to have found this page, as opposed to NHS websites that just outline with no feedback. My daughter was diagnosed with DCD in year 1. We really had no idea, looking back I now know there were many signs (falling off a chair placed right in front of her just one example). She is seeing the OT tomorrow and now I want to ensure that she is being sufficiently helped. Year 1 her help was so limited. Does she need clear targets for each term?? Things relating specifically to what she does at school?? Her targets last year seemed so small. Is there any other help apart from the OT assessments that I should be asking for? She currently uses hand gyms whenever she is sat on the mat. Is this enough? I know year two is going to be tough so I need her to have as much assistance as she can get!! She gets so worried, on her irst day back to school she got so confused with where to hang her bag and put her book she broke down. It breaks my heart . Just don't want her to be struggling so . Thanks in advance for any suggestions. Laura

Become a knowledgeable and assertive parent

Dear Laura

Thank you for this very important question at the beginning of the school year. 

My experience of school systems is that you are going to need to be an advocate for you child and push for the support she needs. And the best way you can do this is to become as knowledgeable as possible not least about how the system works and what your child is entitled to. 

I suggest you join the Dyspraxia  Foundation support group whose members know all about getting the school system to work for their children 

Children with DCD are able to learn new skills but it takes dedicated learning opportunities - and the only people who really have the time for this are family.  This is where you need to become knowledgeable about how to help your daughter learn new skills.  

Also make sure that you communicate with your daughter's OT regularly and that she lets you know what you can work on.  Discuss the IEP with her and find out how you can assist with extra training to achieve the goals. 

Talk to your daughter's teacher, find out how she perceives your daughter's difficulties and how she hopes to help her. Classes are big and the demands on the teacher's time are many - some teachers are better at dealing with this than others, some find it overwhelming.   Go gently and nudge a little here and there to help the teacher understand your daughters needs if needs be.

In terms of what is expected of your daughter - a few targets that can reasonably be met is better than a lot that are not achieved.     Discuss this with your OT. It may be that the most important targets for the first term are about your daughter settling in and managing her anxiety so that school is a happy place. 

I would like to know how you get on.

Pam

 

 

 

 

 

Hi

HI MY SON IS 2yrs old and has coordination disorder ....very hard FOR HIM TO DO THINGS..HE JUST GIT
DENIED Ssi ..I try ed every doctor out there for my son still no new no body knows what really
Wrong with my son

Encourage your toddler to be active

Hello 

I am sad to hear that you do not have access to a good child development service which can give you the information you need about your son's developmental delay. 

Perhaps you can locate a physiotherapist or occupational therapist who specializes in children to do an assessment and perhaps refer you to a specialist pediatrics clinic. 

In the meantime, your son will benefit from being encouraged to be as active as possible - start with the things he can do and then see if you can get him to do a little more. If he can walk, encourage him to walk in different places, on soft surfaces, in sand, in puddles, on rough surface, in the garden or park.  If he can only sit - well then let him sit on the floor and play with him there so that he has to reach and turn and move across the floor to reach you or the "toys" that you can find in your home - plastic cups and bowls, cardboard boxes,  plastic bottles etc etc.  toddlers like to make towers, unpack, pack up, throw, knock over, push and pull things. The trick is to find out what your child likes doing and then spend time playing with him.

Pam 

 

 

 

Tremor in right hand

Hi I work with a grade two boy with a slight tremor in his right hand. His handwriting is acceptable when writing short paragraphs but the tremor is more visible and his writing speed much slower when writing longer one and two page stories. Do you have specific advice or exercises that may be beneficial? Many thanks.

tremor in right hand

Hello and thank you for your question. 

There may be a number of reasons why a child has a tremor but the most common one is an essential  tremor. This runs in families and can effect one or many parts of the body. I hope the child has been seen by a paediatric neurologist to establish the underlying cause. It is important that everyone - the child. family,  teacher and occupational therapist all understand that the child cannot control the tremor. 

If it is a familial tremor there is nothing much you can do about the tremor itself. it tends to get worse when the child is tired or stressed. It  may be useful to start thinking about the use of a keyboard and a referral to an occupational therapist is useful to assess this, 

 Children with a tremor tend to use more force on the pencil to control their movements - and this is one of the reasons they get tired and the quality of the writing gets poorer. 

 It helps to ensure that the child is using an effective pencil grip that allows for finger action to move the pencil tip. This will provide the best starting point for helping the child use the fingers as effectively as possible even when applying additional pressure,  But remember that an effective grip is not always a perfect dynamic tripod grip!

Pam

 

AMENDED PLEASE HELP US

Sorry moderators, I forgot one IMPORTANT question in my last post that I submitted, so please would you ignore my previous post, and post this amended version - thank you and sorry for any inconvenience caused.

My son is 13 and has had difficulties all of his life. He has diagnosed ADHD, over-sensitive hearing, hypermobile joints, significant difficulties in processing and modulating all senses (auditory, visual, vestibular ..... ) and the emotional responses to these, fine motor skill difficulties. He has an upcoming appointment for an Aspergers assessment (grandparent has diagnosed Aspergers). School said he has fine motor skill difficulties and shows OCD tendencies. Primary school said he showed autistic tendencies (but I do not have that in writing unfortunately).
He has shown all of these difficulties all of his life.
I started to try to get help for him. Then his dad got involved in a lengthy court case over custody. He said I was "labelling" my child and used this against me in court, so I had to back off getting help for my child as it was EXTREMELY frowned upon in court.
10 years on my son is in secondary and having ENORMOUS difficulties.
School have not even written down all of his medical difficulties, so teachers are unaware.
He is an intelligent person, but is not reaching his full potential and is getting EXTREMELY frustrated and his attitude has changed to school - now he has a "can't be bothered attitude". He has been moved down groups and now is not challenged enough and is bored, and his marks in the groups he has been lowered down to are now getting even worse.
Went to doctors for referral for dyspraxia. She sent us to an OT service that only cater for up to 11 years old (even though I told her that before she sent us there!, as I had done some research).
Assessment went ahead, and OT did NOT do FULL assessment, and has NOT even written in all of the information that both my son and me provided to her.
Result is her report (which school are waiting for), is NOT an accurate reflection of my son. There are numerous errors in it and important stuff has been left out. It is also badly phrased and open to interpretation.
I contacted OT, had a meeting to explain things: I provided a printed copy of what report should contain (based on what did actually happen at assessment). OT (who says one thing and does another) said she would talk to her manager and get back to me.
She also stated "me and my team have worked hard to make reports short so that we can see more children".
5 weeks later !!! she got back to me and said "I've spoken to my manager and she said my report is ok". I have changed some things.
Picked up report ... its the same! (apart from one part about him having difficulty "opening" taps).
Also found out OT "went behind my back" so to speak and sent doctor a letter summarising our meeting when I had asked her to change things, and stated to doctor that I had bought all new evidence along.

Situation is this: report is NOT accurate. Son still needs help. He has a GCSE in June this year, as his school do their first GCSE English paper in Year 9. School are NOT helping. They say he should use an Alphasmart, but he FORGETS to ask for one because he is forgetful. I've asked SENCO to reserve one for him and she says "I can't there's not enough to go around and also people with sprained wrists need them". This has been going on for a long while. I have now managed to BORROW an OLDER version of an alphasmart from outside school.

I have asked the SENCO for my son's IEPs (as he is on School Action Plus) and was told "we don't do IEPs in secondary school". Another time the SENCO said to me "We have no legal obligation to do IEPs". I feel so in the dark about my son's special educational needs - the school are NOT helping even though they get a budget and also get a pupil premium. NO support WHATSOEVER has been provided or is provided for my son for the past 2 and a half years.

I have been writing about some the problems my son has been having in his Homework Diary and the SENCO saw the notes, and photocopied them all. Next day I got a phone call from the Head of Year saying "you obviously have a lot on your chest, you need to come in and discuss things". I asked who with. He said "with the Deputy Head and myself". I said "I'd like the Head there". He said "I'll go back and tell the Deputy that you are not willing to come in and have an appointment then". I said (which is totally out of character because I am normally really timid) "I did not say that, I said I would like the Head there". He said "you'll have to wait a lot longer to see her, she is really busy" (trying to put me off I believe). I said "OK".

I feel I need to explain that the Head of Year and Deputy Head cover things up and sweep things under the carpet (I have experience of it already, and they have already found my son guilty of something that I CATEGORICALLY know that he would not have done).

Since the Head of Year rang I have tried to contact other teachers, and now NO teachers are ringing me back. Effectively they have gone into lock-down so to speak ... another tactic of the school, which I have previous experience of.

When my son sat for the entrance exam to get in the school, the primary SENCO asked for extra time and a separate room for him due to his medical difficulties. These were granted.

Now my son is in secondary, he is NOT getting any of these reasonable adjustments. Yet, he sees others getting them (including another boy who was in the separate room with him when they both did the entrance exam). He knows the boy and the boy has ONE of the difficulties that my son has.

This is all such a mess and we really need help. I just don't know what to do.

These are my 3 questions:

Question 1:
How do I get this INCORRECT OT report amended, as I cannot pass it on to school (who are waiting for it because they know of its existence because the OT phoned them) nor can I pass it on to anyone regarding any future assessments.

Question 2:
Who is the BEST person to do a FULL assessment for my son re dyspraxia, bearing in mind my son is 13 (nearly 14). We are in Hertfordshire, and have been told they do not assess in this area between the ages of 11 to 18.
PALs advised us getting referred to Gt Ormond St Hospital. Can I ask the doctor to arrange that?
My son DOES need a FULL assessment done - I KNOW he shows numerous symptoms of dyspraxia. School are NOT listening.

Question 3:
What do I do about the school? How do I get the help that my son needs? Bearing in mind my child is already in Year 9 and is doing a GCSE in 4 months time! (He needs extra time and needs a separate room)
Parent Partnership have been suggested, but I understand that they do NOT speak up on your behalf. Unfortunately I need someone who will because I am rather timid (I have my own difficulties too), and also I am not clued up enough about Education Law and entitlements re Special Educational Needs.

Please help because this is having HUGELY detrimental effects on my son's ability to learn, his self-esteem and our family life to the point that I want to take him out of the school that he worked so hard to get in (through academic tests). But I know that this is not a sensible option because he has difficulty making friends and has difficulties dealing with change. Home life is unbearable - it is INCREDIBLY stressful. Homework takes an eternity and causes so much friction.

Please help - thank you :)

I have been where you are

My son has had an horrendous time at high school. I ended up getting him a Statement of Special Needs. The senco used to say we don't do IEP's but as soon as the Local Authority issued a Statement, surprise surprise we had an IEP. Please don't give up and go straight to your Local Authority and ask for a Statutory Assessment to be done on your son. Keep all correspondence from schools, doctors, paediatrician etc and use that as evidence to say that the school aren't listening. My sons school hate us because we proved the SENCO wrong and it has been so hard but keep going. If you need any help/advise contact national autistic society and they will also help. They were absolutely brilliant. Good luck. The stress will be worth it in the end. I had a breakdown from all the stress but I am now going through it all again with my younger son but it has made me a stronger person and more determined than ever that my ASD children will never have to suffer at school again.

Hi My name's Sue and I am mum

Hi My name's Sue and I am mum to H who is 8 who I also believe is dyspraxic and struggles terribly at school, socially, emotionally etc. etc - the reason I am writing is because we are identical to you. First of all a big hug to you - it is tough with a child with all these difficulties - exactly the same as my son and no-one understands this until they are dealing with it. I'm going to share my experience with you in brief, as I can feel your pain - at times it is desperate I know I've been there and go there frequently. As far as schooling is concerned if the school won't support you - you can request a statutory assessment yourself - I did this I was refused initially but then County agreed (we are in the same area as you) and the results were devastating - H is very far behind. I have an 11 page Notice in Lieu presently but I want H statemented - we have a hearing in November. Medically we have all the same issues too - I am on my third paediatrician's opinion - we've now been referred to Great Ormond Street where H will be seen by a paediatrician specialising in neurology. We were referred by our paediatrician but I had to fight for it as I have done to get all of the support I currently now have for him. I don't think the doctor can refer it needs to be a paediatrician but look at GOSH's website under Neurology. H has counselling - he struggles like your son with anxiety, low self esteem etc. and suffers from stomach ache every day. I am happy to share my experience with you - you could be claiming DLA for your son and become his full-time carer - I'm H's carer as a consequence of which I am able to claim Legal Aid for lawyers fees to achieve for him the education he is entitled to.My email address is [email protected] - email me if I can help you I will.

Thank you for provding much needed moral support

Hi Sue

Thank you for responding to Me4ourhealth's post and offering much needed moral support.  It can be very demoralising when one has to fight each step of the way to get support for a child who is being failed by the school system. 

Parents like you pave the way for others. Us professionals also need to listen to mums who say there is something wrong and that something needs to be done about it - because in my experience they are usually right.

Pam

 

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