American Society of Addiction Medicine

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1 American Society of Addiction Medicine Public Policy Statement: Short Definition of Addiction Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. Adopted by the ASAM Board of Directors 4/12/2011. Copyright American Society of Addiction Medicine, Inc. All rights reserved. Permission to make digital or hard copies of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for commercial, advertising or promotional purposes, and that copies bear this notice and the full citation on the first page. Republication, systematic reproduction, posting in electronic form on servers, redistribution to lists, or other uses of this material, require prior specific written permission or license from the Society. ASAM Public Policy Statements normally may be referenced in their entirety only, without editing or paraphrasing, and with proper attribution to the Society. Excerpting any statement for any purpose requires specific written permission from the Society. Public Policy statements of ASAM are revised on a regular basis; therefore, those wishing to utilize this document must ensure that it is the most current position of ASAM on the topic addressed. _ American Society of Addiction Medicine 4601 North Park Avenue Upper Arcade Suite 101 Chevy Chase, MD TREAT ADDICTION SAVE LIVES PHONE: (301) FACSIMILE: (301) WEBSITE: August 15, 2011

2 Young s Internet Addiction Test Answer the following questions by using this scale: 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Often 5 = Always 0 = Does not apply 1. Do you find that you stay online longer than you intended? 11. Do you find that you find yourself anticipating when you will go online again? 2. Do you neglect household chores to spend more time online? 12. Do you fear that life without the Internet would be boring, empty or joyless? 3. Do you prefer the excitement of the Internet to intimacy with your partner? 13. Do you snap, yell or act annoyed if someone bothers you while you are online? 4. Do you form new relationships with fellow online users? 14. Do you lose sleep due to late night log-ins? 5. Do others in your life complain to you about the amount of time you spend online? 15. Do you feel preoccupied with the Internet when offline, or fantasize about being online? 6. Do your grades or schoolwork suffer because of the amount of time you spend online? 16. Do you find yourself saying just a few more minutes when online? 7. Do you check your before something else that you need to do? 17. Do you try to cut down the amount of time you spend online? 8. Does your job performance or productivity suffer because of the Internet? 18. Do you try to hide how long you've been online? 9. Do you become defensive or secretive when anyone asks you what you do online? 19. Do you choose to spend more time online over going out with others? 10. Do you block out disturbing thoughts about your life with soothing thoughts of the Internet? 20. Do you feel depressed, moody or nervous when you are offline, which goes away when you are back online? Total the numbers for each response to obtain a final score. The higher the score, the greater the level of addiction and the problems Internet usage causes. <20: Uses less than average points: Average on-line user points: Above-average user. Some moderate problems points: Significant problems. Focus on items scored with 4 or 5

3 Resources The Center for Internet Addiction (Kimberly Young): restart: The Center for Internet and Technology Addiction (David Greenfield): Berkeley s Digital Youth Project Children s Hospital Center on Media and Child Health: Family Online Safety Institute: Common Sense Media Google s Internet safety page Examples of telephone/internet provider Internet safety pages support/verizon-familybase-andusage-controls/ Books Alone Together: Why We Expect More from Technology and Less from Each Other, Sherry Turkle (2012) The Big Disconnect: Protecting Childhood and Family Relationships in the Digital Age, Catherine Steiner-Adair (2014) Internet Addiction: A Handbook and Guide to Evaluation and Treatment, Kimberly S. Young & Cristiano Nabuco de Abreu (2010) idisorder: Understanding Our Obsession with Technology and Overcoming Its Hold on Us, Larry Rosen (2013) The App Generation: How Today's Youth Navigate Identity, Intimacy, and Imagination in a Digital World, Howard Gardner & Katie Davis (2014)

4 Basic queries about technology use Challenges: Individuals may engage in multiple activities (e.g., homework and messaging) Can be difficult to distinguish the line between appropriate usage and over usage Technology increasingly reflects the normal setting for social interaction and leisure as well as work/school Ask about technologies used (e.g., tablets, smart phones, computers) Distinguish between school/work and leisure This can sometimes be difficult, for example starting out online for a work or school project can easily morph into spending much more time than necessary, shifting into other activities or both How many hours a week of screen time do you spend altogether? (Note: This probably varies on weekdays and weekends) How much do you engage in: Computer or online gaming Social media Sexual material News or informational (not directly work/school related) Other significant activity How often are you multitasking (e.g., homework and messaging)? How often do you use multiple screens? Do you have a device in your bedroom when you re going to sleep? If Yes, find out about checking through the night. How long a time between using a device and going to bed? If there seems to be an overuse issue, consider these: More detail on daily use (time, device, activity) When did you first go on the Internet? What are the five most important activities (detail these, including function)? How has the Internet changed your life? How do you feel in the face-to-face world? How much online time do you think is normal for a person? How do you compare?

5 Logging Technology Use Situation Feelings Thoughts Activity/ Descript. Planned Duration Actual Duration

6 Online Use Contract Child (fosi.org) Child s Contract I will tell my parents my usernames and passwords, but always keep them private from everyone else. I will not share my personal information or my parents or family s with anyone online. This includes: name, address, telephone number, age or school name. I will not post this information to my profiles even if I think only my friends will see it. I will treat others the way I want to be treated online. I will be respectful and never pick fights or post mean or threatening words. I will tell my parents about the people I meet online, even if they don t ask. I won t answer s, IMs, messages or friend requests from people I don t know and my parents haven t approved. If I see or read things that I think are bad, inappropriate or mean I will show my parents right away. I will tell my parents if I receive pictures or links that I didn t ask for, or that contain inappropriate content, bad, hateful or mean language or anything I think might not be right. I will not do anything a person online asks me to unless my parents say it s ok, especially things I know they wouldn t approve of. I will not call, write to, or meet someone in person who I ve met online unless my parents say ok and come with me. I will talk with my parents or guardians about our rules for going online, including how long I can be online, what sites I can visit, and who I can communicate with while online. I will help my parents learn more about the Internet and understand what I do and where I go online. I know that sometimes my parents will supervise where I go online or use software to restrict some websites but I understand that they are doing this because they want to protect me online. I know that if I break this contract or the Internet rules that my parents and I have discussed they can take away my access to the Internet including my computer and phone until my behavior changes. I, agree to the above. Child s Signature Date I, agree to the above. Parent s Signature Date

7 Online Use Contract Parent (fosi.org) Parent s Contract I know that the Internet is an important resource for my children and that being familiar with it is a necessary skill. It can also be a wonderful place to visit, but I know that I must do my part to help keep my kids safe online. I will get to know the services and websites my child uses. I will set reasonable rules and guidelines for computer use by my children, including how much time they may spend online; I will encourage them to participate in offline activities as well. We will discuss these rules and post them near the computer as a reminder. I will not overreact if my child tells me about something bad he or she finds or does on the Internet. If my child does something that I do not approve of online we will have a calm conversation about my expectations and the reasons for our Internet rules. I understand that just taking away the Internet will not solve the problem. I will try to get to know my child s online friends and contacts just as I try to get to know his or her offline friends. I will try to put the home computer in a family area rather than in my child s bedroom. I will report suspicious and illegal activity and sites to the proper authorities and learn how to report abuse when necessary. I will frequently check to see where my kids have visited on the Internet and I will talk to them if I see something I m concerned about or that I think is inappropriate. I will talk to my children about their social networking profiles; what they can and cannot post, who they should allow as friends and how to behave appropriately in their online interactions. I will learn about parental controls for filtering and blocking inappropriate Internet material from my children. If my child continues to break our Internet rules after we have discussed them I will impose penalties for their actions including taking away his or her computer, cell phone or other devices until the behavior changes. I, agree to the above. Parent s Signature Date I, agree to the above. Child s Signature Date

8 3/1/2016 Vamping Teenagers Are Up All Night Texting - The New York Times FASHION & STYLE Social Media s Vampires: They Text by Night Vamping Teenagers Are Up All Night Texting By LAURA M. HOLSON JULY 3, 2014 Owen Lanahan s parents demand that his cellphone be stored in the kitchen by 10 p.m., but sometimes he sneaks it into his bedroom. That s because he considers late-night hours his me time. Kids my age are very occupied, said Owen, 15, a high school sophomore in Portland, Ore. We have school all day, and see our friends. We get home and we have to do our homework. Then we eat dinner and go to bed. So some nights, mostly weekends, he snuggles under the covers with his laptop, the screen dimmed so his parents won t see, and watches tutorials on YouTube about how to create hip-hop beats with a drum machine. I talk to girls and stuff, he said, usually texting them on his cellphone. Other times he ll upload his music to SoundCloud, and notify his Twitter followers. 1/5

9 3/1/2016 Vamping Teenagers Are Up All Night Texting - The New York Times Sometimes I look up and it s 3 a.m. and I m watching a video of a giraffe eating a steak, he said. And I wonder, How did I get here? Researchers have long contended that teenagers (along with their stressed-out parents) should get more sleep. According to a recent poll conducted by the National Sleep Foundation, more than half of 15- to 17-yearolds sleep about seven hours a night, 90 minutes less than the minimum recommendation. With myriad electronic ways to socialize, gossip and explore hobbies, tech-addicted teenagers are getting even fewer hours of sleep. Some young people even have a term for it online: vamping, a reference to those other legendary creatures of the night. (Thanks, Twilight and True Blood. ) They document their all-nighters by posting selfies on Instagram from bed, with the hashtags #teen and #vamping. Temitayo Fagbenle, a teenage rookie reporter for WNYC, filed a radio report in May about how her friends were sleep deprived because of social media. You want to seem as cool as possible so you will post something at 2 in the morning, to just be like, Oh, I m part of this cool-kid group, one friend said, before Ms. Fagbenle added, My friends and I see the same thing down our newsfeeds, posts about #breakingnight, also known as #notsleepingatall and #vamping. (There are other, sexual definitions for vamping, but those are unrelated.) The word has even gotten the attention of academics. Social media is about having agency over your own life and vamping is one way to recapture that, said Alice Marwick, an assistant professor at Fordham University who studies the Internet and society. Danah Boyd, a scholar and senior researcher at Microsoft Research, who recently wrote the book It s Complicated: The Social Lives of Networked 2/5

10 3/1/2016 Vamping Teenagers Are Up All Night Texting - The New York Times Teens, offered two reasons for the phenomenon. First, teenagers have a desire to connect and the solitude of night allows for intimate conversation. Second, they are reacting to overbooked schedules packed with sports, music lessons and homework that give them less free time to pursue personal interests. Parents think they are doing good, Ms. Boyd said of teenagers busy schedules. But hanging out is where young people begin to understand social dynamics. She added, Because of the restrictions placed on them, very few interactions are unstructured until their parents go to bed. There may be another reason, as timeless as high school dances and afterschool clubs: peer pressure. A mother of a 13-year-old girl in Seattle (who requested anonymity so as not to embarrass her daughter) said her daughter has difficulty untethering from her social group after dark; she has often caught the girl chatting in the wee hours with at least four friends on Kik, a mobile messaging system. She ll go to bed and I ll check on her an hour later and she ll have her phone, the mother said. I say, How do you keep up? It s stressful, the mother added. And she says, I know! But her daughter finds it wrenching to unplug after dark. The phone beeps and they feel compelled to answer it, the mother said. It s not like reading a book. The book wasn t pinging you every moment, saying, Read me! Read me! You can close the book. Some school officials have taken notice and are trying to help parents set boundaries. James Shapiro, the middle-school director at the Berkeley Carroll School in Brooklyn, gives a talk to parents in which he offers tips, like keeping electronics out of the bedroom at night. When the bedroom door is closed, computers should be off and cellphones should not be in the bedroom, he said. It is too tempting. 3/5

11 3/1/2016 Vamping Teenagers Are Up All Night Texting - The New York Times When eighth-graders from his school went on a trip to Grand Teton National Park, all smartphones were stored in a large tub. They were chirping vainly, like hyperactive grasshoppers, Mr. Shapiro said. But even with limits, it is tough to patrol teenagers 24 hours a day. Jake Rosen-Birch, 15, a high school sophomore who lives in Washington, D.C., said he takes naps after school so he is wide-awake by midnight, often texting friends on his smartphone about concerts or favorite bands. I ve been on Snapchat all night and not closed my eyes, he said, referring to the popular app where messages vanish after a few seconds. Other times he binge-watches shows on Netflix, most recently episodes of Grey s Anatomy. Does his mother get upset? Yeah, he said. She asks me to go to bed at 10 p.m. If the lights are on she comes in two or three times. Ms. Lanahan, Owen s mother, said she once got up in the middle of the night for a glass of water and noticed that her son s laptop was missing from the hallway bench. That was the first time she found her son in bed, the sheets pitched like a tent, with his laptop and some music equipment. She even bought Owen an old-style Timex clock so he wouldn t use his cellphone as an alarm. All parents are struggling with this, Ms. Lanahan said. But perhaps parents are partly to blame. Ms. Boyd, the researcher who studies Internet and society, said that a popular refrain from teenagers is that parents often don t follow their own advice. If we can t have it, why can you have it? she said teenagers ask of their parents. When you have kids put their cellphones in the drawer, parents should put them in, too. 4/5

12 3/1/2016 Vamping Teenagers Are Up All Night Texting - The New York Times Or maybe teenage behavior hasn t changed, whether it has a new name like vamping or not. I used to have a flashlight and I d read Dickens late at night, said Mr. Shapiro, the school director. I d hear footsteps and turn the flashlight off. He laughed, adding, I was good at feigning being asleep. A version of this article appears in print on July 6, 2014, on page ST1 of the New York edition with the headline: Social Media s Vampires: They Text by Night The New York Times Company 5/5

13 3/1/2016 Do You Google Your Shrink? - The New York Times Do You Google Your Shrink? By Anna Fels April 4, :32 pm Couch is a series about psychotherapy. I knew my psychiatric practice was forever changed the day a patient arrived with a manila folder stuffed with printouts and announced that it contained the contents of a Google search that he had done on me. He pulled out a photo of my mother and me, age 7, that had been published in my hometown newspaper; architectural plans for an addition to my house that was never built but apparently was registered locally by the architect; an announcement about my great-grandfather s becoming editor of Amazing Stories magazine in his old age; and my brother s history as a college activist. I d forgotten that many of these documents existed, and there were others I d never seen or heard about. My patient knew things about me that I didn t know. In psychiatry, there s a long tradition of viewing any personal information about the therapist that the patient stumbles upon as grist for the mill. In other words, it s material that can be processed in the treatment just like any other experience or dream or recollection the patient might have. (A colleague of mine once asked her psychoanalyst why his head was wrapped in gauze, only to have him reply, What are your fantasies as to what it might mean? She never got a straight answer.) But after a few minutes of listening to my patient present his findings, I 1/4

14 3/1/2016 Do You Google Your Shrink? - The New York Times was nearly overwhelmed by feelings both of exposure and of curiosity about his trove. Clearly, this was part of his intent, which would be the subject for many a future session. But I also realized that the relative anonymity of therapists, and all the mystery, power and privacy that attended it, were being swept away. Patients access to huge amounts of information about therapists lives can t help but change both members of the therapeutic dyad. It can have, for instance, a chilling effect on the therapist s work outside the office. As a psychiatrist who occasionally writes and speaks, I now have to think about the impact of these activities on prospective patients. If I write a feminist article, will I end up with only female patients? And what about a therapist s avocations? A friend of mine Googled her therapist and discovered that he was an accomplished singer intensifying her already romantic and idealized transference. On a later occasion, an Internet search revealed that the therapist had participated in a gay musical event. When she asked him about it, he explained that he was not gay and had been helping out some friends, but it had been a confusing piece of information for her and, I suspect, for him. Will he feel as free to sing at the next concert with these friends? The blurring of boundaries between the personal and professional can get quite creepy. A patient told me, in greater detail than I wished to know, about her Match.com date with a psychoanalyst with whom I ve had professional dealings. It was an encounter that almost certainly would not have occurred in the pre-internet-dating era, and it will be hard ever to think of him in quite the same way. Googling, of course, can go in both directions. An emergency room psychiatrist tells me that it s routine to check out new E.R. patients on the Internet before they are seen to determine, at the very least, if they have criminal records. I wonder how we survived without it, she muses. But more 2/4

15 3/1/2016 Do You Google Your Shrink? - The New York Times than legal infractions are revealed by such Internet searches; the patient may turn out to be a V.I.P. or someone with an unsavory past. E.R. psychiatrists even check YouTube for patient postings. The experience of evaluating a patient with fresh eyes and no prior assumptions may, for better and for worse, disappear. Patients electronic histories follow them everywhere and so do doctors. Patients can now, in effect, blackmail therapists by threatening to post negative reviews of them on the Internet if the doctor does not accede to their demands whether for medication, hospitalization or special treatment. A supervising psychiatrist at a teaching hospital told me the frightening tale of a patient with a severe personality disorder seen in the E.R. by a psychiatrist who was just starting his practice. The patient threatened to place and then actually did place a potentially career-destroying evaluation on a physician evaluation website. But the impact of technology on psychotherapy is not all bad; it s even, at times, beneficial. The transparency of information can serve as an antidote to the fusty, authoritarian therapies of the recent past. For some patients, the new access to information about a therapist is liberating. They feel like Dorothy in The Wizard of Oz, pulling back the curtain to reveal that the wizard is a mere mortal. Therapists, it turns out, are just folks like you and me. Their authority is not a given, but something to be earned. Technology can also insert into the often hermetic world of the consulting room a tonic dose of reality, an experience of how the patient actually functions outside the office. My patients arrive in my office and, like gunslingers in a saloon, unload their various electronic devices, laying them on the sofa, often two or even three, before turning them off. But there are times when the phones have to stay on: There s a sick child at home or the boss may call. Hearing in real time patients responses to important figures in their lives gives me an unfiltered glimpse into those relationships. A man who sarcastically belittles his girlfriend to me is surprisingly tender speaking with 3/4

16 3/1/2016 Do You Google Your Shrink? - The New York Times her on his cellphone. An unhappy, self-deprecating executive is suddenly a confident and even commanding figure speaking with one of his subordinates. An aggressive lawyer becomes shy and awkward when speaking with his mother. IN some ways, the relentless electronic interconnectivity of our lives serves to highlight therapy s singular virtues. We are more appreciative of the strange, private dialogue that is the heart of therapy. There are precious few times and spaces left in our society in which people quietly speak to one another in a sustained, intimate conversation. The therapist s office is one of the last safe places. Secrets, reflections, fears or confusion never leave the room. And it is also a refuge. My patients often arrive early just to sit in the waiting room an unusual interlude of quiet. Then there s the session itself. In some ways therapy is, more than ever, the ultimate luxury: To be the focus of a thoughtful person who is listening, caring and helping to make sense of life s chaos is something that the Internet can never provide. Anna Fels is a psychiatrist and faculty member at Weill Cornell Medical College. A version of this article appears in print on 04/05/2015, on page SR8 of the NewYork edition with the headline: Do You Google Your Shrink? The New York Times Company 4/4

17 References Aboujaoude, E., Koran, L. M., Gamel, N., Large, M. D., & Serpe, R. T. (2006). Potential markers for problematic Internet use: A telephone survey of 2,513 adults. CNS Spectrums, 11, de Abreu, C. N., & Goes, D. S. (2011). Psychotherapy for Internet Addiction. In K. S. Young & C. N. de Abreu (Eds) Internet addiction: A handbook and guide to evaluation and treatment, Wiley. Alloway, R.G., Dawson, C., Alloway, T.P. & Horton, J. (2013). Social networking sites and cognitive abilities: Do they make you smarter? Computers & Education, 63, Bioulac, S., Arfi, L. & Bouvard, M.P. (2008) Attention deficit/hyperactivity disorder and video games: A comparative study of hyperactive and control children. Brand, M., Young, K. S., & Laier, C. (2014). Prefrontal control and Internet addiction: A theoretical model and review of neuropsychological and neuroimaging findings. Frontiers of Human Neuroscience, 8 Chan, P. & Rabinowitz, T. (2006). A cross-sectional analysis of video games and attention deficit hyperactivity disorder symptoms in adolescents. Annals of General Psychiatry, 5, 16. Du, Y., Jiang, W. & Vance, A. (2010). Longer term effect of randomized, controlled group cognitive behavioural therapy for Internet addiction in adolescent students in Shanghai. Australian and New Zealand Journal of Psychiatry, 44, Durkin, K., & Barber, B. (2002). Not so doomed: Computer game play and positive adolescent development. Journal of Applied Developmental Psychology, 23, Engelberg, E. & Sjoberg, L. (2004). Internet use, social skills, and adjustment. CyberPsychology & Behavior, 7, Ferguson, C.J., Garza, A., Jerabeck, J., Ramos, R. & Galindo, M. (2013). Not worth the fuss after all? Cross-sectional and prospective data on violent video game influences on aggression, visuospatial cognition and mathematics ability in a sample of youth. Journal of Youth and Adolescence, 42, Gentile, D.A., Swing, E.L., Lim, C.G. & Khoo, A. (2012). Video game playing, attention problems, and impulsiveness: Evidence of bidirectional causality. Psychology of Popular Media Culture, 1, Greenfield, David N. (1999). The Nature of Internet addiction: Factors in compulsive Internet use. Paper Presented at 107th American Psychological Association Convention, Boston, Massachusetts. Koepp, M.J.; Gunn, R.N.; Lawrence, A.D.; Cunningham, V.J.; Dagher, A.; Jones, T.; Brooks, D.J.; Bench, C.J.; Grasby, P.M. Evidence for striatal dopamine release during a video game. Nature, 393, Kühn, S., Romanowski, A., Schilling, C., Lorenz, R., Mörsen, C., Seiferth, N., Banaschewski, T., Barbot, A., Barker, G.J., Büchel, C., Conrod, P.J., Dalley, J.W., Flor, H., Garavan, H., Ittermann, B., Mann, K., Martinot, J.L., Paus, T., Rietschel, M., Smolka, M.N., Ströhle, A., Walaszek, B., Schumann, G., Heinz, A., and Gallinat, J. (2011). The neural basis of video gaming. Translational Psychiatry, 15. Kuss, D. J., & Griffiths, M. D. (2012). Internet and gaming addiction: A systematic literature review of neuroimaging studies. Brain Science, 2,

18 Orzack, M. H., Voluse, A. C., Wolf, D., & Hennen, J. (2007). An Ongoing Study of Group Treatment for Men Involved in Problematic Internet-Enabled Sexual Behavior. CyberPsychology & Behavior, 9, Park, M., Park, E.J., Choi, J., Chai, S., Lee, J., Lee, C. & Kim, D. (2011). Preliminary study of Internet addiction and cognitive function in adolescents based on IQ tests. Psychiatry Research, 190, Weizman, A. & Weinstein, A.M. (2012). Emerging association between addictive gaming and attention-deficit/hyperactivity disorder. Current Psychiatry Reports, 14, Winkler, A., Dörsing, B., Rief, W., Shen, Y., & Glombiewski, J. A. (2013). Treatment of Internet addiction: A meta-analysis. Clinical Psychology Review, 33, Yoo, H.J., Cho, S.C., Ha, J., Yune, S.K., Kim, S.J., Hwang, J., Chung, A. & Lyoo, I.K. (2004). Attention deficit hyperactivity symptoms and Internet addiction. Psychiatry and Clinical Neurosciences, 58, Young, Kimberly Internet Addiction: The emergence of a new clinical disorder. Paper presented at the 105th annual convention of the American Psychological Association, Toronto, Ontario, Canada Young, K. S. (1998). Internet addiction: The emergence of a new clinical disorder. CyberPsychology & Behavior, 1, Young, K. S. (2007). Cognitive-behavioral therapy with Internet addicts: Treatment outcomes and implications. CyberPsychology & Behavior, 10, Young, K. S. (2001). CBT-IA: The First Treatment Model for Internet Addiction. Journal of Cognitive Psychotherapy: An International Quarterly, 25, Yuan, K., Qin, W., Wang, G., Zeng, F., Zhao, L., Yang, X., Liu, P., Liu, J., Sun, J., Von Deneen, K.M., Gong, Q., Liu, Y., and Tian, J. (2011). Microstructure abnormalities in adolescents with internet addiction disorder. PloS One, 6.

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